Category: Nursing

Comparing Statistical Studies Essay

Statistics are all around us, whether or not we notice them being used. From public policy, health, economics, science, culture to which foods a fast-food restaurant is going to serve next can all be influenced by how the results of statistical studies are operationalized and interpreted.

Each chapter of your course text concludes with two ”Focus on” sections that go into depth on important issues of our time. The topics of these sections were chosen to demonstrate the great variety of fields in which statistics plays a role. For this Discussion, you are going to review and compare two statistical studies.

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

To prepare for this Discussion:

• Think about your degree major and your areas of interests, and then concentrate on two of the following ”Focus on” disciplines: Agriculture, Criminology, Economics, Education, Environment, Health & Education, History, Law, Literature, Politics, Psychology, Public Health, Social Science, Sociology, or The Stock Market Comparing Statistical Studies Essay

• Review the readings from this week’s Learning Resources, as well as the complete list of the ”Focus on” topics to choose from

• Choose two of the studies to compare for this Discussion

• For each study, consider the sample population used, errors that could occur in the research process, and how meaningful and important the results of the study are

Post a 2- to 3-paragraph response that includes the following information:

• Identify two ”Focus on…” sections you have chosen to review and provide a brief summary of the content.

• For each topic, discuss whether you think the sample is representative of the population being studied. What criteria did you use to decide this? Comparing Statistical Studies Essay

• Was the sample chosen in a way that is likely to introduce bias? What kinds of errors are likely to be associated with each study? Explain.

• Based on what you read, do you believe that the results of each study are meaningful and important? Explain.

• Based on the responses above, which do you think is the stronger study? Why?

Be sure to support your ideas by connecting them to the week’s Learning Resources or to something you have read, heard, seen, or experienced. Comparing Statistical Studies Essay

NUR 699/ HCA 699 Evidence-Based Practice Project Format

Evidence-Based Practice Project Format

 
Use the following format and headings when constructing your final evidence-based practice project proposal paper for HCA 699.

 

Title page

Abstract (350-500 words)

Contains project title, project director’s name, and affiliation.

Presents a complete and concise overview of all phases of the proposed project.

Section A: Problem Description

Section B: Literature Support

Section C: Solution Description

Section D: Change Model

Section E:
Implementation Plan

Section F: Evaluation

Appendices

Critical Appraisal Checklists

Evaluation Table

Conceptual Models

Timeline

Resource List

Proposal Instruments

Data Collection Tool

Budget

Optional

Approval Forms

Handouts

Evaluation Tools

 
ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

 

HCA 620: Evidence-Based Practice Project Student Example

Table of Contents

Generating Evidence for Evidence-based Practice

Part 1: Introduction

The problem statement ………………………………….……………………….……….3

The evidence-based question ………………………………………..……….……….…4

Part 2:  Assemble relevant evidence & related literature

Locating credible evidence………………………………………………….……………3

Appraise the evidence……………………………………………………….……………4

Part 3:  Implementation of the intervention

Planning of change………………………………………………………………..…….8-9

Clinical protocol and pilot project………………………………………………9-14 & 23

Integration and Maintenance …………………………………………………….…..14-15

Barriers and strategies………………………………………………….……………15-18

Part 4: Conclusion ………………………………………………..…………………………….18

Part 5: References……………………………………………………………………………20-22

Part 6: Appendices …………………………………………………………..…………….……23

Management of Mechanically Ventilated Patients: Pilot Project ……………………23-24

Questions for Patient Ventilator Rounds ………………………………………………..25

Methodological matrix ………………………………………………………………26-28

Prevention In-Service Flyer ………………………………………………………….…29

 

Problem Statement

The development of pneumonia caused by mechanical ventilation is a significant problem in the intensive care units of hospital facilities. Ventilator-associated pneumonia (VAP) is the “most commonly reported healthcare-acquired infection” in patients requiring mechanical ventilation support (Garcia et al., 2009, p. 524). One of the most common reasons for an ICU admission is related to respiratory distress or failure. VAP is described as a form of nosocomial infection which occurs after the first 48 hours of receiving mechanical ventilation (Augustyn, 2007). The length of stay (LOS) for patients developing VAP is higher than those never requiring mechanical ventilation by an increase of approximately six days (Garcia et al. 2009). In intensive care units (ICUs) across the United States (US), ventilator-acquired pneumonia also results in prolonged periods of actual mechanical ventilation, the excess use of antimicrobial products, increased utilization of healthcare resources and costs, and significant increase in morbidity and mortality (Coffin et al., 2008). Garcia et al. (2009) found on average, estimated costs of an additional $11, 897 to $150,841 per individual case were spent. VAP has a significant economic impact on our society, costing hospitals money which potentially could have been saved. NUR 699/ HCA 699 Evidence-Based Practice Project Format.

Numerous risks factors contribute to the development of ventilator-acquired pneumonia as mechanical ventilation presents a unique set of challenges for the patient requiring intubation and ventilator support. Rigorous clinical studies show oral secretions pose an increased risk for developing VAP (Augustyn, 2007). Treatments, strategies and evidence-based interventions have been developed to decrease the risks and reduce the prevalence of VAP. There is evidence indicating the use of oral chlorhexidine and the removal of oral secretions before position changes may diminish the risks of developing ventilator-acquired pneumonia. By reducing the levels of bacteria in the oropharynx there would theoretically be a decrease in the prevalence of nosocomial pneumonia (Houston et al., 2002). Research demonstrates the use of 0.12% chlorhexidine gluconate oral rinse (CHX) pre and postoperatively reduces the incidence of VAP in patients who are intubated greater than 24 hours. NUR 699/ HCA 699 Evidence-Based Practice Project Format.

Foreground Question

In adults supported with mechanical ventilation, what is the effect of oral chlorhexidine use and removal of oral secretions prior to position changing on the development of ventilator-acquired pneumonia?

Review of Evidence and Synthesis of Literature

This is a literature analysis of research reports and literature reviews which studied the effects of removal of oral secretions prior to position change on the occurrence of VAP. A summary of the articles can be found in Appendix C. The studies varied in design; from randomized to non-randomized, placebo, to longitudinal and a pilot study. Strength for each study is noted at Level II on the hierarchy as each one is a randomized or nonrandomized clinical study. The research supports our clinical question and was utilized with the development of additions to be incorporated into the already existing ICU VAP protocol.

The studies focused on in this review consisted of evidence evaluating oral secretion removal and the use of chlorhexidine gluconate oral rinse to prevent VAP. The cost effectiveness of these interventions was found to be significant. Studies showed oral secretions as being the medium to carry pathogens within the oropharyngeal site down into the respiratory track. The literature hypothesized removing oral secretions prior to the position change of a patient can prevent or minimize the movement of organisms into the respiratory tract which lead to VAP development. Some researchers also concluded the significance of chlorhexidine use for reducing nosocomial infections. The combination of both interventions creates a profound effect on reducing VAP occurrences its research importance, which this practice change aims to strongly support. NUR 699/ HCA 699 Evidence-Based Practice Project Format.

The review of literature consists of evidence dating from 1996 to 2008, indicating the need for continued research and close monitoring of clinical practice changes based on the best evidence at the moment. This problem was identified long ago and yet still needs further evidence for best practice. Three articles discuss removing oral secretions prior to position changes of patients which are one of the two independent variables of interest for this review. In one of those studies, VAP was diagnosed in 24 of 159 patients in the control group, but only in five of 102 patients in the study group within the study group receiving oral suctioning prior to all position changes (Chao, Chen, Wang, Lee, & Tsai, 2008). A similar study showed VAP occurrence at 2.6% in the study group and 11% in the control group with probability of < 0.001 (Tsai, Lin, Chang, 2008). Studies by DeRiso et al. (1996) and Houston et al. (2002) each sought to evaluate the efficacy of oropharyngeal decontamination on nosocomial infections in patients undergoing heart surgery using CHX before and after surgery. Both DeRiso et al. and Houston et al. discovered an overall reduced rate of VAP (52% and 69% respectively for each study). The significance level for both studies was less than .01 (use the higher of the two) with the use of CHX with oral suctioning of subjects for these studies. Another related intervention assessed in a similar randomized clinical study was the use of subglottal suctioning by Smulders et al. (2002) and its effect on VAP incidence. This intervention was appropriate for this review of literature; four percent of patients who underwent continuous suctioning developed VAP as compared to 16% in the control group. A common finding in the studies reviewed was the savings in spite of the costs of using CHX and equipment for oral and subglottal secretion removal. The majority of these studies revealed a significantly reduced duration of mechanical ventilation and LOS in the ICU. All research studies in this literature review, with the exception of Tsai et al.’s study, consisted of study groups homogenous in patient samples, which suggest effective randomization. Tsai et al.’s study has patient heterogeneity (of both medical and surgical ICU patients) which may have confounded the results. Also, the results of Chao et al.’s study did yield a significant difference with the distribution of patients having a history of COPD, DM, use of antacids, and surgery. These variables were then evaluated with logistic regression for their relationship in VAP development, and the results of the logistic regression showed no significant impact on the direct development. Overall the reviews are well organized, use appropriate language, and use mostly all paraphrasing. This review summarizes key finding of evidence for clinical practice, and provides similar conclusions like our study regarding interventions to implement in practice. This literature review consisted of all but one study which were experimental in nature and hold “a high degree of internal validity because of the use of manipulation and randomization” (Polit & Beck, 2008, p. 295). Tsai et al.’s study was a time-sequenced, non-randomized quasi-experimental study most vulnerable to threats to internal validity out of all the literature reviewed. But the remaining study participants in the rest of these experimental designs were all randomized after meeting inclusion criteria. Only two studies (by Houston et al. and Tsai et al.) may have had questionable internal validity. Houston et al.’s study group was large but possibly too broad with subjects intubated for too short of a period to have the intervention be significant. This provides evidence for the need to implement such an intervention and continue research. NUR 699/ HCA 699 Evidence-Based Practice Project Format. This may have led to potential Type I and II errors. Tsai et al.’s weakness was the limitation of a non-randomized control study and patient heterogeneity as previously mentioned. In addition, Chao et al. used a staff nurse of the ICU to conduct data collection; because it is her ICU she may want “her unit” to do well with compliance with the study, creating bias. Also, in both this and Smulders et al.’s studies suctioning pressure was discussed. Internal consistency was not documented and this lack of information affects the reliability of the measurement tools. Selection bias does not appear to be a concern in these studies, and there appears to be no threat of history and the groups were mainly homogenous. Overall the internal validity of the research in this literature review is rather strong taking into consideration these few discussed weaknesses. Regarding external validity, the research findings in these studies can easily be generalized to similar mechanically-ventilated ICU adult populations. The patient populations were representative of the typical ICU population and because of this, external validity is strong. Steps were taken to control characteristics which could impact the groups being compared, and any requirements for participants were taken into consideration when developing the sample. The study by DeRiso et al. was double-blinded and placebo-controlled in design techniques, and Smulders et al.’s study reported blinding with the radiologists in regards to reading all X-ray reports. These techniques enhanced the internal validity. The studies were each performed in only one setting, but could very easily be replicated in another ICU environment. Tsai et al. and Chao et al.’s studies had a period during their research which was dedicated to educating staff on the protocol to be implemented to the experimental group. This enhanced intervention fidelity in both studies. Also, the individual collecting the data from Chao et al.’s study group was a trained staff member of the ICU floor, and such actions facilitated a strong reaction with the intervention and validated construct. No incentives were provided to staff members for compliance with Chao et al.’s study, but staff was aware of the fact that the clinical setting was being monitored and data collected based upon their performance. However, normally nurses are not monitored closely and corrected for actions. Education for new changes to protocols is usually brief, and like any change, will take some time for the staff to acclimate to. NUR 699/ HCA 699 Evidence-Based Practice Project Format. There appears to be no apparent threat to construct validity with the discussed literature. However one could argue the researcher’s expectancies for desired outcomes playing an effect. For example, Tsai et al. and Chao et al.’s studies involved the staff received a thorough education and period of time to learn the protocol for the study’s intervention. Knowing the researcher’s expectations, this could “become part of the treatment construct that is being tested” (Polit and Beck, 2008, p. 301). Researchers appropriately balanced all concerns for validity in their study. Planning a Change After critically analyzing the evidence, the nurse develops a plan to apply the findings to a clinical practice. Developing a plan for change includes identifying strategies to gain cooperation and evaluating outcomes. Once it is decided that evidence supports a practice change, the change agent or facilitators must develop and test the improvement. This step requires some preliminary planning and research. Is the innovation practical, the evidence transferable, is the organization ready for change, are outcomes measurable and will is it possible to implement the EBP within the organization (Newhouse, Dearholt, Poe, Pugh & White, 2007) ? If the answers are agreeable, the innovation must be authorized through the appropriate organizational channels. The implementation of an evidence-based practice is considered a quality improvement initiative and does not require the hospital Institutional Review Board approval. The Quality Care Committee, which oversees process improvement, protocol, and policy changes, will review and approve this proposed implementation of evidence-based practice, as part of the initial planning. The planning phase includes assessing the feasibility of change, defining the change, identifying resources, and defining the desired outcomes (Reavy & Tavernier, 2008). NUR 699/ HCA 699 Evidence-Based Practice Project Format. The proposed EBP innovation is to complement the policy for oral care and suctioning of mechanically ventilated patients with a 10% chlorhexidine gluconate oral rinse and increase suctioning to every two hours prior to repositioning. These interventions can also be increased according to the patients’ needs. The expected outcomes of the change are improved patient care, reduced costs related to VAP infection and increased lengths of stay, and the reduction of the incidence of VAP in patients mechanically ventilated for more than 24 hours. The project feasibility is very good, due to the small scale of the intervention, the ease of implementation into protocol already in place, it’s compatibility with the practice environment, and it is simple to test in a small sample (Newhouse, Dearholt, Poe, Pugh & White, 2007). Other aspects contributing to the project’s potential for success is the availability of ample resources including the Quality Care Committee, Clinical Nurse Specialist, ICU Nurse Educator, Unit Preceptors, Clinical Managers, and Infection Control Nurse. Implementation and Evaluation of Change Proposed Project The authors plan to implement changes in current policy of management of ventilated patients as a pilot project at Scottsdale Healthcare Shea ICU. The change will be to add chlorhexidine rinse for oral care every two hours and suctioning of oral secretions prior to repositioning the patient. The data will be collected on all ventilated patients during daily multidisciplinary team vent rounds by the infection control nurse. See Appendix A for pilot project with current changes in policy. We plan to implement the change at Scottsdale Healthcare Shea medical surgical ICU from June 1, 2010 to April 1, 2011.   Implementation Plan To enhance the patient outcome during hospitalization, an evidence-based pilot project will be implemented. As mentioned earlier, the problem of VAP pertains to all ventilated patients in different ICUs, but it is easier to start the pilot project in one unit and expand it to the other ICUs of the Scottsdale Healthcare hospitals after assessing the effectiveness of the plan and making any necessary changes after the evaluation process. NUR 699/ HCA 699 Evidence-Based Practice Project Format. The authors propose to implement the pilot project initially in the ICU of Scottsdale Healthcare at Shea campus. The plan will be presented to the ICU nurse manager, supervisors, infection control nurse, and the clinical educator of the ICU to obtain permission and approval in order to implement the plan. The plan will also be presented to Quality Care Committee May 2010 meeting for their permission for the change. After obtaining permission for the plot project, evidence base education material containing prevalence of VAP rate, its complications, cost, recommended change with use of chlorhexidine gluconate in oral care, and oral secretion suctioning prior to position change will be presented to the staff during ICU Unit Base Committee (UBC). Four more teaching sessions will be provided, two in each day and night shift, so that staff can attend a session which is more convenient to them. All the registered nurses working in ICU will be required to attend one of the teaching sessions. The teaching session or in-service will be on May 20, 2010 from 8 a.m. to 9 a.m. and from 8 p.m. to 9 p.m. These times are chosen to make it convenient for nurses to attend the in-service before going home at the end of their shift. Two more teaching sessions will be provided on May 23, 2010 from 11 a.m. to 12 noon and from 10 p.m. to 11 p.m. Six brochures to notify staff of the in-service dates and times will be prepared and placed in the restrooms, break rooms and in hallways within the unit (Appendix D). A power point presentation along with two poster boards containing evidence based information about VAP prevalence and its outcomes and changes in practice will be prepared and presented to staff during the in-service. One poster board will be placed in break room and the other poster will be placed in meeting room of ICU to enhance teaching. Time for answering any questions will be provided at the end of the teaching session. The teaching will be conducted in an informal way, and the research assistant will be available to re-educate and answer questions for staff as needed. One day shift nurse and one night shift nurse will be prepared by the nurse educator to do the teaching for the rest of the ICU staff. The physicians and respiratory therapists of ICU will also be notified of this evidence based plan so they will be knowledgeable about this VAP pilot project. The resources needed for the implementation of this plan are two poster boards, a power point, and a jump drive to store the teaching material. NUR 699/ HCA 699 Evidence-Based Practice Project Format. Also required would be the chlorhexidine gluconate oral rinse, which would be ordered from pharmacy for each ventilated patient in the intervention group. The other resources needed are the staff education time for the RNs who are teaching the in-service and the staff who is attending the in-service. There are twenty-three day shift RNs and twenty night shift RNs in ICU who will need to attend these in-services, so one hour in-service for each RN will need forty-three hours of education time for registered nurses in addition to five hours of teaching time for the RNs who are teaching these in-services. Most of the cost of this project is the cost of education time for the staff nurses. The two poster boards will cost seven dollars each, a small jump drive for twenty dollars and the power point is free. The cost of chlorhexidine is also negligible when compared with the cost of VAP. This will be the money well spent and pay for itself with shorter length of stay of ventilated patients due to VAP prevention or reduction. This project will save money for the hospital by improving patient outcome and decreasing VAP rates and the hospital length of stay. Having a theoretical framework enhances the worth of the study according to Polit and Beck (2008). This plan will be guided by the Kurt Lewin’s change theory to improve delivery of information to staff. Lewin’s change theory involves a three stage model of change, which are unfreezing, change, and re-freezing (Neil, 2004). The first stage of unfreezing involves the concept of becoming motivated to change or unfreeze from previous practices. In ICU, the staff will be prepared for the change by explaining them the magnitude of the problem, so that they feel the need for the change. They will be notified about the statistics of VAP prevalence and the magnitude of the complications of VAP. These measures will motivate the staff for a change in practice. The second stage of Lewin’s change theory is implementation of the change. This stage is the actual stage of alteration and will be most essential in maintaining consistency with the use of chlorhexidine in oral care and suctioning the patients prior to position change. Support will be provided to staff during this stage by answering their questions and addressing any concerns they have. The registered nurses will implement the learned techniques of using chlorhexidine in oral care and suction patients prior to position change every two hours and as needed for the duration of plot project from June 1, 2010 to April 1, 2011. The multidisciplinary vent round will continue to enforce the change and collect data on ventilated patients. The physicians will also be supported and welcomed for their input in this process. Lewin’s final stage of the change theory is the concept of re-freezing or making the change permanent. In this last stage of change theory, the newly learned changes become habitual for the staff (Neil, 2004). The staff will be reinforced and encouraged to continue to follow the recommended changes at each month’s staff meeting and daily multidisciplinary vent rounds for the duration of pilot project. The staff will also be encouraged for their feedback on this project. They will also be reinforced about this newly learned skill at the annual skills fair and have opportunity to get their questions answered. The future of the healthcare is moving towards pay for performance measures and this teaching plan will lead Scottsdale Healthcare towards delivering a better patient outcome. Evaluation Plan The evaluation of this teaching plan is relatively simple. The infection control nurse keeps the data of VAP rate of all ventilated patients. The data including VAP rate obtained by infection control nurse from vent rounds during the pilot project will be compared with the VAP rate of ventilated ICU patients of this unit from the previous year. The VAP rate during pilot project for the months of June 1, 2010 to April 1, 2011 will be compared with the VAP rate of previous year for the months of June 1, 1009 to April 1, 2010 to promote validity. The types of patients vary by season, and by doing this we increase the likelihood of having a similar patient population which is representative of the months of June to April. These findings will be discussed among the ICU manager, supervisors, clinical educator and infection control nurse in May 2011 upon completion of pilot project. A decision will be taken to adopt the change or reject the change depending on the findings if VAP rate was reduced or not. Dissemination Plan The staff will be will be notified of the project completion in monthly staff meeting in May 2011. The goal of this dissemination plan is to utilize this new research or evidence based information to improve patient outcome. If the finding suggests a decrease in VAP rate during pilot project, the change will need to be implemented to other ICUs of Scottsdale Healthcare. All the nurses at Scottsdale Healthcare ICUs will need to be reached to ensure that everyone can benefit from this information. Since the problem of VAP pertains to all the ICUs of Scottsdale Healthcare hospitals this information needs to be disseminated to the Scottsdale Healthcare Shea CVICU, and eventually to ICUs at Osborn and Thompson Peak campuses. With the permission from the PCC’s chair, the committee will be presented with recommended changes. The project will be presented in detail and the importance of the need for a change in practice for VAP reduction will be stressed with the supporting evidence. Again the goal will be to obtain permission to expand the changes to CVICU of Scottsdale Healthcare Shea. Two to four nurses from each floor can be prepared to teach the rest of the staff on CVICU. In-service time to prepare them will be arranged at a convenient time. The power point presentation containing the teaching material will be made available to all the hospital employees on the Scottsdale Healthcare Shea campus’s Special Care Unit’s web site. This will promote access to the teaching contents for the staff. The other sources of information will be the RNs of ICU who performed the in-service for their staff. A copy of this plan will be made available to the staff through Scottsdale Healthcare Library also. To include Osborn and Thompson Peak in the teaching plan, the Nursing Leadership Committee will be approached, where the nursing managers from all three campuses are available. They will also be approached the same way as mentioned above to disseminate the pilot project recommended changes plan to the two other campuses. The resources, the contents of the VAP teaching plan, and the medium will be made accessible to them as well. A dissemination plan as mentioned above will be carried out in a similar fashion for the other two campuses also. Integration and Maintenance of Change Initiating the changes to the pre-existing protocol would first involve several steps as previously mentioned. There would be a decision on who would be collecting the research data. After the Quality Care Committee approves the change, we would select a research assistant experienced in infection control to collect data and monitor the process during the study. This study would also require a qualified personal to educate the staff on the protocol changes and be available to answer any questions which may arise. The pilot study (see Appendix A) would then take place. Prior to the study, daily rounds are completed on each ventilated patient to collect information for VAP. After implementing this study, this research assistant would accompany the ventilator rounds team and collect information applicable to the study. This would help facilitate monitoring the process and outcomes of the intervention. See Appendix B for examples of major questions included during ventilator rounds. Questions italicized would be additions made to the rounds during the study for data collection purposes. This information on VAP rates and patient length of stay after implementing the new interventions would be put together and submitted to the appropriate committees. Integrating the new policy on the unit, staff will be much more likely to accept and support the new process if they know what to expect at each phase of the change. Additionally, staff members are able to contribute ideas drawn from their varied experience. Staff ideas often improve the process, save money, and avoid potential obstacles (Gotsill & Natchez, 2007). Implementing this change of protocol would involve the cooperation of both the research and hospital staff. Communication between both groups is crucial, and a key concept of implementing a practice change. Providing updates to the Quality Care Committee, Infection Control Team, unit manager, and the staff throughout the study would be crucial. Quarterly feedback to the staff alone will help visually show their cooperation in this study and the beneficial outcomes yielded from the implementation change. Barriers and Strategies of Change           The work environment healthcare professionals face daily is demanding. Nurses manage heavy workloads and high acuity patients along with staffing shortages and cost cuts, which reduce all available resources. This creates challenges to implementing new policies, protocols, or evidence-based practice (EBP). Some of the potential barriers to implementing EBP clinical changes can be categorized as individual, organizational, environmental, and communication based barriers (Udod & Care, 2006) . Although it appears to be an impossible task, there are many strategies to help gain cooperation from the individuals responsible for implementing change. A few strategies are managerial support, clearly written research, exposure to real-life case studies, role modeling, staff engagement opportunities, and psychosocial support (Udod & Care; Thompson, Bell & Prevost, 1999) . NUR 699/ HCA 699 Evidence-Based Practice Project Format. Potential Barriers to Implementing EBP Healthcare professionals have reported a variety of barriers to implementing EBP. Nurses can be skeptical, especially if they have misperceptions, fears, or anxiety that prevents them from having a clear vision when implementing change (Melnyk & Fineout-Overholt, 2005). Individual barriers include a lack of competence of nurses and managers regarding the implementation of EBP strategies, a lack of academic skills, and an inability to apply research to practice as evidenced by the large research-practice gap that exists in the profession (Udod & Care, 2006). Overwhelming workloads may also leave nurses drained, lacking motivation, confidence, awareness, and time (Thompson, Bell & Prevost, 1999). Melnyk and Fineout-Overholt state that barriers to EBP implementation and adherence are oftentimes related to individual attitudes. A lack of confidence in the plan or its creator, an inability to visualize a positive outcome, or doubt in one’s own skills are a few examples (2005). Some individual barriers can be associated with the organization. However, nurses must overcome other organizational barriers. Examples are administrative constraints such as a lack of funding for skill development, opposing managerial priorities, or a lack of support from management and administration (Udod & Care, 2006). Other workplace barriers are difficulty accessing journals and evidence to support EBP, peer pressure to continue traditional practices, patient demands for widely prescribed treatment, and heavy patient loads which prevent learning and EBP implementation (Melnyk & Fineout-Overholt, 2005). Nursing professionals face environmental barriers, as well, in the implementation of EBP. EBP can be affected by government policy or may be controlled by laws and legislation. An example is the use of medical marijuana for nausea and anorexia in cancer patients, which is illegal in many states. Coworkers and managers with different agendas in the workplace can be considered an environmental barrier to change. Occasionally an organization has such a fast moving culture of change, it leaves nurses too overwhelmed to cope (Udod & Care, 2006). Finally, there are communication barriers in every aspect of life. The implementation of EBP can be affected by a lack of appropriate collaboration and communication between every level of provider involved including researchers, nurses, educators, managers, and administrators (Thompson, Bell & Prevost, 1999). Communication errors and barriers can occur in the educational programs and training for EBP, the interpretation of research, and in publications and presentations (Melnyk & Fineout-Overholt, 2005). This issue can be further complicated with the addition of multidisciplinary involvement, which requires another level of communication to be successful. Strategies for Successful Implementation of EBP The implementation of EBP provides for safer, more cost-effective care with patient-specific interventions. In order to accomplish this, organizations must employ a plan to gain cooperation from the individuals who are responsible for implementing the EBP. Successful implementation requires organizational change and buy-in. The most important strategy for EBP implementation is ensuring the support of the organization and management. This will assist in eliminating constraints, allow for budgeting and possibly funding for education and incentives, and provide encouragement and persuasion as the organization forms its opinion about the EBP implementation (Newhouse, Dearholt, Poe, Pugh & White, 2007). Nurses and physicians cite the desire for clearly written research reports and exposure to case studies where EBP resulted in improved outcomes. Providing appropriate education and tools for EBP implementation and ensuring access to evidence will reinforce and help providers understand the benefits (Melnyk & Fineout-Overholt, 2005). Psychosocial support is an important strategy, which simply means nurses are enabled and encouraged to perform the desired change. This is accomplished with good education, clear-cut expectations, reinforcement, acknowledgement, and rewards. Another similar strategy is role modeling nursing practice. This is done by demonstrating commitment and supporting the cause for advancing the EBP, while performing or educating staff about the desired change. Staff involvement is important when implementing change. Strategies can include encouraging nurse participation in a journal club or other collaborative opportunity to share evidence. Super users, trainers, champions or stakeholders, whatever title one chooses, can be trained to coach staff and provide collegial support and role modeling. Staff can also share in leadership and decision-making, give their feedback and opinions, and contribute new ideas regarding EBP implementation through Shared Leadership, focus groups, and surveys. This allows the organization to measure nursing staff knowledge, attitudes, and beliefs and identify implementation challenges (Melnyk & Fineout-Overholt, 2005). Conclusion The evidence in totality supports this practice change. This implemented change would include the variables of interest discussed previously in the literature review and pilot plan. The benefits of such an intervention change have the potential to support EBP and nursing practice. Contrary to the misperceptions many nurses have about EBP, it does not take away from the nurses’ clinical expertise. EBP integrates the best care with research evidence, patient’s individualized needs, preferences and circumstances (Polit & Beck, 2006). It also allows for exceptions in clinical setting and resource constraints. EBP can also be used as a problem-solving strategy in clinical care by taking away decisions based on custom, authority, opinion, or ritual (Polit & Beck). NUR 699/ HCA 699 Evidence-Based Practice Project Format. References American Association of Critical-Care Nurses. (2005). AACN procedure manual for critical             care, (5 th ed.). St. Louis, MO: Elsevier Saunders. American Association of Critical-Care Nurses (rev. 1 0/07). AACN Practice alert: Oral care in the critically ill. Retrieved June 3,2008 from http://www.aacn.orgIWD/PracticeIDOCS/Oral_ Care_in_the_ pdf(Augustyn B 2007 Ventilator-associated pneumonia: Risk factors and p (Augustyn B 2007 Ventilator-associated pneumonia: Risk factors and prevention)Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39. Retrieved from http://web.ebscohost.com.library.gcu.edu:2048/ehost/search ? (Chao Y C Chen Y Wang K K Lee R Tsai H 2008 Removal of secretions prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: A clinical controlled study)Chao, Y. C., Chen, Y., Wang, K. K., Lee, R., & Tsai, H. (2008). Removal of secretions prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: A clinical controlled study. Journal of Clinical Nursing, 18, 22-28. doi:10.1111/j.1365-2702.2007.02193.x (Coffin S E Klompas M Classen D Arias K M Podgorny K Anderson D JYokoe D S 2008 Strategies to prevent ventilator-associated pneumonia)Coffin, S. E., Klompas, M., Classen, D., Arias, K. M., Podgorny, K., Anderson, D. J.,…Yokoe, D. S. (2008). Strategies to prevent ventilator-associated pneumonia. Infection Control and Hospital Epidemiology, 29, 31-40. doi:10.1086/591062 DeRiso, A., Ladowski, J., Dillon, T., Justice, J., & Peterson, A. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. CHEST, 109 (6), 1556-1561. (Garcia R Jendresky L Colbert L Bailey A Zaman M Majumder M 2009 Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48-mont study)Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48-month study. American Journal of Critical Care, 18, 523-532. doi:10.4037/ajcc2009311 Gotsill, G., & Natchez, M. (2007). From resistance to acceptance: How to implement change management. Training & Development , 61 (11), 24-27. Retrieved from http://web.ebscohost.com.library.gcu.edu:2048/ehost/search (Hsieh H Tuite P 2008 Prevention of ventilator-associated pneumonia: What nurses can do)Houston, S., Houghland, P., Anderson, J., LaRocco, M., Kennedy, V., & Gentry, L. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. American Journal of Critical Care, 11, 567-570. McEwen, M., & Wills, E. M. (2007). Theoretical basis for nursing (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins. NUR 699/ HCA 699 Evidence-Based Practice Project Format Neil, J. (2004, June 04). Unfreeze-change-refreeze or square-blob-star model of change. Retrieved April 10, 2010, from http://wilderdom.com/theory/UnfreezeCgangeRefreeze.html Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, K. (2007, December 1). Organizational change strategies for evidence-based practice. The Journal of Nursing Administration, 37 (12), 552-557. (Polit D F Beck C T 2008 Nursing research: Generating and assessing evidence for nursing practice)Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Willkins. Reavy, K., & Tavernier, S. (2008, April). Nurses reclaiming ownership of their practice: Implementation of an evidence-based practice model and process. The Journal of Continuing Education in Nursing, 39 (4), 166-172. Smulders, K., Hoeven, H., Pothoff, I. W., & Grauls, C. V. (2002). A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. CHEST , 121 , 858-862. Thompson, P., Bell, P., & Prevost, S. (1999, February). Overcoming barriers to research-based practice. MedSurg Nursing, 8 (1), 59-63. Tsai, H. H., Lin, F. C., & Chang, S. C. (2008). Intermittent suction of oral secretions before each positional change may reduce ventilator-associated pneumonia: A pilot study. The American Journal of the Medical Sciences , 336 , 397-401. doi:10.1097/MAJ.0b013e31816b8761 Udod, S., & Care, W. (2006, October). Setting the climate for evidence-based nursing practice: What is the leader’s role? Canadian Journal of Nursing Leadership, 17 (4), 64-75. NUR 699/ HCA 699 Evidence-Based Practice Project Format. Appendix A Management of Mechanically Ventilated Patients: Pilot Project Goals/outcomes The patient will maintain adequate breathing pattern to provide appropriate oxygenation and acid / base balance while providing respiratory muscle rest. The incidence for VAP will be reduced due to EBP pilot project interventions. Definitions Acid/base balance = determined by pH values from arterial blood gas VAP = Ventilator Associated Pneumonia RCP = respiratory care practitioner EBP = evidence based practice Assessment Assess and document breath sounds every four (4) hours and as needed. Monitor and verify ventilator settings every two (2) hours and as needed. Assure that ventilator alarm volumes are audible at all times. Monitor arterial blood gases per physician order. Notify physician as needed. Interventions Wash hands with antiseptic soap and water or apply alcohol-based hand gel before and after performing interventions. The patient will be assigned to a hospital bed allowing maximum visibility at all times. Utilize oral airway if patient is obstructing oral endotracheal tube. Suction as needed; document amount, color and character of tracheal secretions. (Utilize humidified oxygen set-up to maximize mobilization of secretions.) Reposition every two hours and as needed (unless contraindicated), suction oral   Appendix A Continued secretions prior to position change. Elevate head of bed to at least 30 degrees (unless contraindicated). Use oral cleaning and suction system. Brush teeth and tongue a minimum of once every 12 hour shift. Provide oral care every 2 hours with chlorhexidine rinse. Perform oral suctioning every two hours and prior to position change. Document and report to physician significant changes in pulmonary status and secretions through collaboration of RCP and RN. Culture tracheal secretions per physician’s order. Keep Ambu-bag mask and adapter with patient at all times for transport and/or emergency. If the patient exhibits signs/symptoms of respiratory distress or ventilator alarm sounds and problem cannot be quickly identified, disconnect patient from the ventilator, manually ventilate, and call for appropriate assistance. Reduce anxiety by: Explaining all procedures to the patient. Providing alternative methods of communication while intubated. Re-assuring the patient that extraneous alarms are normal and do not usually indicate an emergency situation. Indicate appropriate medical personnel are always close by. Placing the “nurse call” button within patient’s reach. Administering sedatives/analgesics as ordered. Weaning – Follow specific weaning/extubation orders per respiratory protocol or as written by the physician. NUR 699/ HCA 699 Evidence-Based Practice Project Format   Supportive Data See Reference list Appendix B Questions for Patient Ventilator Rounds   Patient Care Question Answer from Staff Hospital day number Number of days ventilated Oral care Q2 Use or Chlorhexidine with oral care* Removal of secretions prior to position changes* Head of bed 30 degrees Repositioning Every 2 hours       SUP prophylaxis DVT prophylaxis Sedation vacation White Blood Cell Count Temperature (max/low in 24 hours)   “*” indicates interventions added to the current existing protocol     Appendix C Methodological Matrix and Evaluation Matrix Author Pub Yr Country Theory Dependent Variables Independent Variables Study design Sample size Sampling Method How data collected DeRiso, A. Ladowski, J.Dillon, T. Justice, J.Peterson, A. 2002 USA Quanti-tative   nosocomial infections   chlorhexidine gluconate oral rinse   Prospective randomized placebo-controlled double-blind experiment 353 Randomized surgical patients undergoing heart surgery data analyzed of patient outcomes after interventions complete Houston, S. Hougland, P. Anderson, J. LaRocco, M. Kennedy, V Gentry, L. 1996 USA Quanti-tative nosocomial pneumonia chlorhexidine gluconate oral rinse NUR 699/ HCA 699 Evidence-Based Practice Project Format Prospective Randomized case-controlled 561 Randomized surgical patients undergoing heart surgery Observation &Self report   Appendix C Methodological Matrix and Evaluation Matrix Continued       Author Pub Year Country Theory Dependent Variables Independent Variables Study Design Sample Size Sampling Method How data collected Smulders, K., Hoeven, H., Pothoff, I. W., & Grauls, C. V.       2002 Nether- lands     None Incidence of VAP; duration of mechanical ventilation; length of ICU stay; length of hospital stay; and mortality Intermittent suctioning of subglottic secretion with 100mg Hg for 8 sec. duration and 20 sec. interval. A randomized clinical Trial N = 150   Study group= 75   Control gp= 75 Random assignment of patients into experimental or control group, who were admitted to ICU over 13 month period and were expected to receive mechanical ventilation >3 days

Observation &

Self report

Chao, Y. C.,

Chen, Y.,

Wang, K. K.,

Lee, R.,

& Tsai, H

 

 

2008

Taipei, Taiwan

Not listed in Article but assumed by reader= Germ Theory of

Louis Pasteur

Pulmonary infection causing VAP

Removal of secretions prior to position change

2-group comparison randomized study

Control group= 159

 

Study group= 102

Random ICU patient admission.

Patients 18 yrs of age or older.

On a ventilator for more than 24 hours.

 

(Those with pneumonia before intubation or within 48 hours after intubation were excluded)

Observation &

Self report from staff

Appendix C

Methodological Matrix and Evaluation Matrix Continued

Author

Pub Year

Country

Theory

Dependent Variables

Independent

Variables

Study Design

Sample

Size

Sampling Method

How data collected

H-H Tsai,

F-C Lin,

S-C Chang

 

 

 

 

 

2008

Taiwan

None

VAP occurrence and incidence

Intermittent suction of Oral Secretions before each position change

NUR 699/ HCA 699 Evidence-Based Practice Project Format

Quasi-exp. Non-randomized

Pilot Study

Study group= 227

 

Control group= 237

All patients admitted to ICU who did not have:

endotracheal intubation (EI) and mechanical ventilation

(MV) more than 3 days prior to ICU admission, presence of tracheostomy, pneumonia before ICU admission, non-ventilated, EI & MV < 48 Hours, ICU admission less than 48 Hours.   Self-report and observation by senior staff         Appendix D VAP Prevention In- Service Flyer VAP Prevention In-service for New Interventions!   Mandatory for All Nursing Staff in ICU. Please attend one of the following:

Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Investigated Disease Process

A major depressive disorder, also referred to as depression, is a condition affecting 16.1 million adults in the United States each year (Anxiety and Depression Association of America, 2016). As a leading cause of disability in the world, depression is considered a common anxiety disorder that affects 1 in 13 adults globally (World Health Organization [WHO], 2016). The 2016 Florida Behavioral Risk Factor Surveillance System (BRFSS) state and county data report, which is used to estimate the prevalence of personal health behaviors that contribute to morbidity and mortality among adults in Florida, concluded that approximately 9.2% of adults in Miami Dade County suffer from depression, compared to a 11.3 % in the state of Florida. (Philip, 2016)  The condition affects men and women alike; yet is most prevalent among women.

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

Major depression limits an individual’s ability to perform daily activities. Based on the Diagnostics and Statistical Manual of Mental Disorders (DSM-IV) (4
th
ed.), major depressive episodes occur for a period of two weeks or longer, reflects a change in a person’s daily functioning, and changes a person’s mood or loss of interest (National Institute of Mental Health, 2017).m Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

This paper will: (1) identify depression (the pathophysiology, standard of practice, and factors that contribute to a patient’s ability to manage depression); (2) analyze depression and how it affects patients, families, and populations (financial costs associated with depression for patients families, and the populations from diagnosis to treatment); and (3) promote best practices for managing depression in my current healthcare organization (including three strategies used to implement best practices for managing depression and the appropriate method of evaluating the implementation of each of the strategies).

A1. Pathophysiology of Depression

Unfortunately, the pathophysiology of depression has not been clearly defined. There appears to be a correlation between neurotransmitter availability, receptor regulation, and affective symptom sensitivity (Verdujin et al., 2015). Meta-analyses support the major depressive disorders are affected by specific pathophysiological mechanisms, such as inflammation, vitamin D, neurotrophic growth, and hypothalamic-pituitary-axis (Verdujin et al., 2015).  Results suggests that an “upregulation of inflammation” in the brain may be associated with the development of depression (Moylan, Mae, Wray, & Beck, 2013). With a decrease in monoamines and an increase in tryptophan catabolites, the brain has difficulty withstanding the toxins presented. It was also suggested that hyperactivity of the hypothalamic-pituitary-axis may be another factor contributing to depressive disorders. When the neurogenesis is impaired and hippocampus volumes are reduced, there appears to be a malfunctioning of the glucocorticoid receptor (Verdijin et al., 2015). Based on the increases and decreases within the brain, it is presumed that recurring episodes can be determined via the cortisol levels.

Patients with depressive disorders may present with normal appearance or display physical symptoms which may vary including weight loss or gain and poor hygiene. Other symptoms of depression may be present, such as: psychomotor retardation, flattening or loss of reacting, and/or psychomotor restlessness or agitation (Olfson, Blanco, & Marcus, 2016).

A2. Standard of Practice

A variety of screening instruments, pharmacotherapy, psychotherapy, electroconvulsive therapy, and stimulation techniques are used for treating patients with depressive disorders (Olfson, Blanco, & Marcus, 2016). According to the Florida Agency for Health Care Administration (2015), questionnaires and rating scales are used as diagnostic assessment evaluation for clinical determination. Although many patients who suffer from depression will end up using a combination of therapies, it is not unusual to begin treatment exclusively with psychotherapy, as it is the least invasive. Ultimately treatments are chosen based on provider recommendation, patient preference, and symptom observations.

No laboratory studies are available at this time to diagnose depression; however, laboratory results are often used to exclude potential medical conditions that may present similar symptoms. All changes made to medication regimen are based on information provided in rating scales and questionnaires. These standards of practice are generic for Broward County and the state of Florida.

National standard of practice is very similar as it involves comprehensive assessment based on detailed history, physical examination and mental state examinations for proper establishment of diagnosis. Formulation of treatment plan involves deciding about treatment setting, medications and psychological treatments to be used. Treatment options for management of depression can be broadly be divided into antidepressants, electroconvulsive therapy (ECT) and psychosocial interventions. (Gautam, 2017)

A2a. Pharmacological Treatments

Evidenced-based pharmacologic therapies utilized in my community are similar to those used nationwide. If nonpharmacological treatments are available, PCPs should ask patients who are initiating depression treatment about preferences for medications or psychotherapy because the ability to address a patient’s treatment preference has been shown to be related to the likelihood of entering depression treatment and better treatment outcomes (Unutzer, 2012) Some forms of treatment drugs that have proven effectiveness include: selective serotonin reuptake inhibitors (SSRIs); serotonin/norepinephrine reuptake inhibitors (SNRIs); atypical antidepressants; tricyclic antidepressants; monoamine oxidase inhibitors; and St. John’s wort (Olfson, Blanco, & Marcus, 2016). All of these medications work by balancing neurotransmitters in the brain that affect both mood and emotions.

Inquiry of evidence was conducted at a local Mental Health / Rehab facility with the authorization from management. Physicians provided a prescribing report which displayed that the majority patients with the diagnosis of depression were prescribed  SSRIs. Many reports and studies emphasize the fact that SSRIs are recommended as first line medication of choice because of the decreased side effect and their higher safety profiles. With use of medications it is important to provide patients with education about the side effects they may encounter such as gastrointestinal disturbances, increased appetite and 
weight
 gain, loss of sexual desire and other sexual problems such as 
erectile dysfunction
 and decreased orgasm, agitation, irritability and suicidal ideation. Special emphasis should be made to the adverse effects of stopping medications without the supervision of the prescribing physician.

Pharmacological treatments are not typically provided independently. Often times, patients are provided with consistent and faster results when medication is combined with psychotherapy. Patients with major depressive disorders who do not respond to drug therapies, have a high risk of suicide and medical morbidity or mortality, and need rapid antidepressant response, electroconvulsive therapy (ECT) is recommended. The Food and Drug Administration (FDA) has also approved the use of transcranial magnetic stimulation for treating major depression. For patients who have attempted and failed four medications or ECT treatments, the FDA has also approved the use of vagus nerve stimulation.

 

A2b. Clinical Guidelines

Assessment
.

Management of depression involves comprehensive assessment based on detailed history, physical and mental state examinations. Obtaining history from all sources including family and or caregivers can be extremely helpful. These patients may present with a combination of symptoms of which include but are not limited to: loss of interest or pleasure, decreased energy, fatigue, reduced concentration and or attention, reduced self-esteem and or self-confidence, ideas of guilt and unworthiness, pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite(Blobel, 2015). Assessment should also focus on evaluation for physical illnesses known to play a role in the development of depression for example diabetes mellitus, thyroid disease or known malignancies. Previous surgical history and use of prescription medications and history of substance abuse should also be taken into consideration.

Diagnosis.

Patients are screened utilizing one or more of the following patient-reported instruments: Patient Health Questionnaire-9; Beck Depression Inventory or Beck Depression Inventory-II, Zung Self-Rating Depression Scale, or the center for Epidemiologic Studies-Depression Scale (Agency for Health Administration in Florida, 2015; Olfson, Blanco, & Marcus, 2016). The Hamilton Depression Rating Scale can also be performed by a professional to indicate depression severity. As previously stated no laboratory studies are available to diagnose depression. Laboratory results are often used to rule out medical diagnoses as a contributor to symptoms of depression.

 

Patient Education.

Education should be made readily available for the patient and all involved in their care by the prescribing provider. Providers should also refer patient’s information on agencies and organizations that also have resources available such as: The National Institute of Mental Health: Depression; Medline Plus, Depression and Bipolar Support Alliance (DBSA), and Families for Depression Awareness.

Education should include information on the different types of depression and risk factors for each. The signs and symptoms of depression and different ways to treat but most importantly information on crisis intervention. Education provided to patients should be provided in a format which is suitable for patient age, education level and specific depression diagnosis if applicable.

A2c. Standard Practice of Disease Management

In 2015 the Florida Medicaid drug therapy management program for behavioral health published the Florida best practice psychotherapeutic medication guidelines for adults. This guideline states a specific goal of beginning the process of symptomatic, syndromal, and functional recovery. The guideline addresses assessment and four different levels of treatment. Treatment options should be discussed with patient and initiation of monotherapy with SSRI’s. (Agency for Healthcare Administration State of Florida, 2015)

In Miami-Dade County, Florida practitioners in the community together with the CDC have been following documented approaches thru a series of promising practices. These are documented approaches to improving community health and quality of life. In the collaborative care for the management of depressive disorders a model is laid out where the responsibilities for providers is listed. Highlights include the routine screening for depression, the initiation of treatment and coordination of treatment amongst different providers. (The Community Guide)

The American Psychiatric Association (APA) supports the combination of psychotherapy and medications to treat patients with moderate to severe depression (2016).  According to the National Institute of Mental Health (2017), 44% of individuals with depression receive treatments with medication and a health professional’s services; however, 37% of individuals are left untreated in the United States.

International rates are more alarming. There has been more than an 18% increase (approximately 300 million) in people worldwide who are diagnosed with depression (WHO, 2017a). Without the proper care, many of these individuals globally are not treated for depression and result in illness and disabilities. Evidence-based psychotherapeutic treatments, such as: interpersonal psychotherapy, cognitive-behavioral therapy; problem-solving therapy; and/or behavioral activation are the first line of treatment used when possible.

A3. Managed Disease Process

The goal in the treatment of depression is for the patient to achieve remission and/or to have complete relief of symptoms. Patients should be able to verbalize adequate coping skills for managing their depression as well as resources available to them in moments of crisis. The most important aspect would be for the patients reintegration to the community by returning to work, school and resuming previous functional and social abilities.

The characteristics of a patient with a managed depression disease process would include presenting with less labile moods, increased interest or pleasure with their activities, higher energy levels, improved concentration and attention span, an increase in self-esteem as well as self-confidence. These patients will not present with ideas of un-worthiness nor will they engage in acts of self-harm, suicide or harm to others. More regular sleep patterns and an increase in appetite are also good signs of a managed depression disease process.

There is a need to educate patients with depression on successful treatments of the condition. As patients become aware of their condition and understand the signs and symptoms to look out for, he/she may seek treatment earlier in the care of a relapse. Educating patients on the different treatments they are receiving, medication effects, side effects, and anticipated results is very important as it may play a vital role in a patient course of action.

Involving the patient, family and care providers in this critical process is imperative as it is not uncommon for symptoms to get worse before improvement is noted. Knowing what to expect and what needs to be reported increases the likely hood for treatment compliance and adherence. Access and transportation to all healthcare providers and services for regular follow up visits, medication and crisis management if need be.

A3a. Disparities

Many different types of disparities exist in healthcare on a national/local level and across all specialties. Racial disparities among community-dwelling elderly also exist in the United States (Akincigil. Olfson, Siegel, Zurlo, Wakup & Crystal, 2012).  African Americans were less likely to receive a diagnosis and treatment for depression from a health care provider than Hispanic Whites (Akincigil, et al., 2012). A study conducted by Ankur Patel, M.D., with Penn State College of Medicine, concluded that there are significant racial/ethnic and economic disparities regarding mental health services. This conclusion was made after analyzing the race, age, payer, length of stay, average hospital cost, region and income of more than 450,000 hospitalizations during the 5-year period with a primary diagnosis of depression. “Depression is also known to be associated with difficulties in role transitions (e.g. low education, high teen child-bearing, marital disruption, unstable employment) and poor role functioning (e.g., low marital quality, low work performance, low earnings). (Gautam, 2017)

Most of these are also associated with poor access to stable insurance or funds to cover treatment and medication or alternative therapies for the disease process. WHO states that prevalence of depression varies by WHO region, from a low of 2.6% among males in the western pacific region to 5.9% among females in the African region. The differences in rates for depression across countries have been linked to cultural differences and/or the social effects that expression of the disorder may bring. In China for example the diagnosis of depression is made less frequently than in other Countries. One attribute has been, according to Xu Jun-Mian, M.D., the widespread access Traditional Chinese Medicine. (Jun-Mian, 1987)

A4. Managed Disease Factors

There are a variety of social, psychological, and biological factors that contribute to depression (WHO, 2017b). Managing of this disease is ongoing as patients can suffer from relapse in recovery. Life altering events, an increase in stress or even changes to daily routines are factors that contribute to the impaired management of the disease.

Financial resources are one of the factors that aid in managing this disease. Many times, treatment options require multi-disciplinary continuation of care, combination therapies along with polypharmacy. Some of these therapies may not be covered by healthcare insurance and having access to financial resources creates limitless opportunities for the treatment options.

A person who is depressed can suffer from a variety of other conditions which lead to or are the cause of the depression. Maintaining control of those diseases will contribute towards the successful management of depression. Patients need to be available to have access to their providers regularly for follow up and medication management. Having means of transportation and or plans in place to be compliant with appointments aids in management of depression.

Lastly patients need to be able to understand their condition and the treatment plans in order to manage it effectively. Treatment plans change with progression or regression of the disease therefore patient involvement of care plan contributes to disease management in a positive way.

A4a. Unmanaged Disease Factors

Depending on the stage of the illness, the frequency and severity of the symptoms will vary. It is important to assess reasons why access to care is compromised so that the underlying reason can be taken care of. Lack of financial resources can lead patients to problems with medication and therapy compliance. This can be a problem for patients who lack insurance. Those who are insured may also struggle with affording the co-payments or services that have been denied or are simply not covered by the insurance. Social service consults may prove to be useful as there are many communities that have resources in place for individuals without access to care or programs patients may qualify for that can ease the financial burden of care maintenance. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

It is important for providers to factor in circumstances that may prove challenging such as those who live in rural areas, have problems with mobility or co morbidities that require them to stay at home. Providers in conjunction with patient and or family should come up with a plan to facilitate access to adequate follow up care.

Teaching provided and communications have to be reinforced in a language and educational level that can be understood. Not having access to disease resources and crisis prevention contacts can be detrimental for patient and dangerous to those who surround them as well. Teaching and resources should also be provided to caregivers of patients with emphasis on crisis intervention.

A4ai. Unmanaged Disease Characteristics

A patient who has unmanaged depression, may experience one or more of the following: persistent sadness or anxiety, feelings of hopelessness, irritability, loss of interest and energy, difficulty concentrating or sleeping, and/or thoughts of suicide (National Institute of Mental Health, 2018).

Patients, Families, and Populations

Depression affects patients, families and their communities on a daily basis. According to the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (2016), 7.6% of individuals 12 and over were identified with depression in 2012.  Based on physician visits, 10.3% of patients indicated a prevalence of depression on their medical record. Unfortunately, there were a total of 42,773 suicide deaths in 2014 from individual’s who suffered from depression (CDC, 2016).  These numbers affect families and communities across the country and the world. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Patients

           
These individuals present with symptoms that affect everyone who comes in contact with them on a daily basis.  The patient’s interpersonal and personal relationships also suffer due to the loss of interest and energy.

Families

           
For one they can be at risk for harming themselves or others around them. Because patients may lose interest in regular activities, they may no longer want to participate of play an active role as a part of the family. Special attention should be given to new mothers presenting with depression as they are at a much higher risk of harming themselves and or their newborns.

 

Populations

The difficulty concentrating or sleeping can become a challenge for them and affect performance in the workplace which in turn affects the community. Individuals with depression especially when unmanaged have an impact not only on their family but communities as a whole.

B1. Costs

Patient

           
For patients, the cost of depression can vary depending on the different types of treatments received. If a patient has medical insurance they may pay a reduced amount or simply co pays for therapy, medications and medical visits. Some insurances may not cover all medications or alternative therapies which increases the out of pocket expense.

Families

           
Families may feel the burden of the cost of depression in different ways. Because family structures and routines vary so much so can the actual costs. Things that may affect these costs are the age of patient with depression, the severity of the condition, need for medications and therapies, and insurance availability to name a few. For one monies will be used to pay for the patient treatments. Another way that families are impacted by the cost is directly related to the patient as many times they can become less productive at work or require caregivers to stay with the patient as well. One of the biggest factors would be the availability of medical insurance to help with offsetting some of the cost. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Populations

Depression can lead to a variety of financial burdens for individuals and their families. Kessler (2012) identifies how depression can affect employment status, childbearing, marital timing and stability, education or lack thereof, parental and marital functioning, financial success, absences from work, comorbid disabilities, and suicidal instances. There are approximately 7% of employees in the United States that have been diagnosed with major depression (Kuhl, 2018). Among those who suffer from depression, it has been estimated that total economic burden has been $210.5 billion annually. Whether the financial cost has been directly or indirectly related to depression, an enormous amount of money is spent on providing care, treatment and interventions, and daily living of individuals suffered from depression.

Best Practices Promoting

Mount Sinai Medical Center (MSMC) was established in 1949. Today, Mount Sinai is a 672-bed hospital with a number of satellite centers throughout Miami-Dade County. MSMC is the largest private independent not-for-profit teaching hospital in South Florida. The Primary Care Center at Mount Sinai Medical Center Family Medicine physicians provide primary care and comprehensive medical evaluations to adults and focus on disease prevention and health promotion. My plan is to promote best practice within the organization for the diagnosing and

treatment of depression. To begin with I feel it is important to empower providers with knowledge and equip them with the educational resources, evidence based information and skills needed to diagnose, treat, and provide care for patients suffering from depression. One way to do so will be via professional development seminars. These seminars will focus on the importance of routine outpatient screening for depression using a scale. Another practice to be implemented is to require primary care providers and clinics to document the initial and subsequent diagnosing scales. Lastly the importance of following up with patients and their caregivers, ensuring that they have the educational resources and are compliant with their plan of care. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

C1. Implementation Plan

Professional developments on depression can be provided as a health care organization. Providers to attend these sessions include but are not limited to doctors, therapists, nurses, and case managers. In order to ensure all health care professionals within the organization have the knowledge about the identification and treatment practice, education will be provided detailing diagnosing tools and standards of care. The objective will be for attendees to verbalize the signs and symptoms of the disease, measurement tools used for diagnosing, treatment options, and managing effective care.

The health care organization will incorporate a mandatory audit for the screening of depression. Scales such as the PHQ2/PHQ9, will become routine during examinations once information is input in Electronic Health Records (EHR) it will be easy to ensure screenings are being performed. Running reports to monitor the patients trends in the depression scoring and identifying patients who did not have the screening performed will allow providers to identify individuals who are at risk and assess the need for intervention. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Once diagnosed it is important to keep track of these patients to ensure that their plan of care is being followed and that the implementation is being executed. It is important to incorporate a systematic approach for identifying, diagnosing, educating patients, providing evidence-based treatments, and providing a close follow-up are used (Unutzer & Park, 2012). Patients who require adjustment of treatment plans, referrals to specialist, or adjunct therapy can be provided education and or resources needed that will maximize their rehabilitation potential. With a system in place to track progression and enforce follow up

 
 

C2. Evaluation Method

The effectiveness of the three strategies provided can be evaluated individually based on the following:

A professional development workshops effectiveness can be evaluated by providing attendees with a pre-workshop questionnaire to assess their knowledge on symptoms and treatment of depression. A post-intervention workshop questionnaire will assess if the objectives of the workshop were met. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Mandatory screening for depression can be evaluated by having a checklist for health care providers to indicate that the patient has completed a screening annually. Another way providers can track mandatory screening of depression is by running reports thru EHR system that will alert which patients are missing the screen.

To ensure effectiveness of tool to track progression and enforce follow up of disease, patient rating scales should be compared each visit to ensure the patient is responding appropriately to the treatments they are receiving. Auditing the charts of these patients to ensure that they are all receiving care and services that are required as well as reinforcing teaching and providing resources if applicable.

Conclusion

With over 300 million individually worldwide suffering from depression, it is important to diagnose, treat, and provide care for these individuals. Mental health disease, can often be overlooked and left untreated; however, research supports that severe cases of depression can lead to suicide. Therefore, it is important for healthcare organizations to understand the importance of providing evidence-based treatments and promoting best practices to ensure patients are receiving the necessary and appropriate care. Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

References

Agency for Health Care Administration. (2015). Florida best practice psychotherapeutic

medication guidelines for adults. University of South Florida. Retrieved from

http://www.medicaidmentalhealth.org/_assets/file/Guidelines/Web_2015-

Psychotherapeutic%20Medication%20Guidelines%20for%20Adults_Final_Approved1.p

df

Akincigil, A., Olfson, M., Siegel, M., Zurlo, K.A., Wakup, J.T., & Crystal, S. (2012). Racial and

ethnic disparities in depression care in community-dwelling elderly in the United States.

American Journal of Public Health, 102(2), 319-328. doi:10.2105/AJPH.2011.300349

Anxiety and Depression Association of America. (2016). Facts and statistics. Retrieved from

https://adaa.org/about-adaa/press-room/facts-statistics#

Blobel, B. (2015). Psychologist in a PocketTowards Depression Screening on Mobile Phones . Proceedings of the 12th International Conference on Wearable Micro and Nano Technologies for Personalized Health. 211, p. 155. Amsterdam: IOS Press.

Centers for Disease Control and Prevention. (2016). Depression. National Center for Health Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Statistics. Retrieved from
https://www.cdc.gov/nchs/fastats/depression.htm

Conner, E. (2016, Mar 3/11/2018). Racial/Ethnic and Income Disparities in Depression Treatment. New York, NY, USA.

Gautam S, J. A. (2017, January). Clinical Practice Guidelines for the management of Depression. Indian Journal of Psychiatry , 59(5), 34-50.

Jun-Mian, X. (1987, June 1). Some Issues in the Diagnosis of Depression in China. Social and Community Psychiatry Section, 32(5), 368-370.

Kessler, R.C. (2012). Costs of depression. Psychiatric Clinical of North America, 35(1), 1-14.

doi:10.1016/j/psc.2011.11.005 Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Kuhl, E.A. (2018). Quantifying the cost of depression. American Psychiatric Association: Center

for Workplace Mental Health. Retrieved from http://workplacementalhealth.org/Mental-

Health-Topics/Depression/Quantifying-the-Cost-of-Depression

Moylan S, Maes M, Wray NR, Berk M. The neuroprogressive nature of major depressive

disorder: pathways to disease evolution and resistance, and therapeutic implications.

Mol Psychiatry 2013; 18: 595–606.

National Institute of Mental Health. (2017). Major depression. Retrieved from

https://www.nimh.nih.gov/health/statistics/major-depression.shtml

National Institute of Mental Health. (2018). Depression. Retrieved from

https://www.nimh.nih.gov/health/topics/depression/index.shtml

Olfson, M., Blanco, C., & Marcus, S.C. (2016). Treatment of adult depression in the united

states. Journal of American Medical Association, 176(1), 1482-1491.

doi:10.1001/jamaintermed.2016.5057

Philip, C. M. (2016). 2016 Florida Behavioral Risk Factor Surveillance System (BRFSS) Data Report. State of Florida , Department of Health Public Health Research Section Epidemiology and Statistics. Celeste Philip, M.D., MPH.

The Community Guide. (n.d.). Mental Health and Mental Illness: Collaborative Care for the Management of Depressive Disorders. Retrieved March 27, 2018, from The Community Guide: https://www.thecommunityguide.org/findings/mental-health-and-mental-illness-collaborative-care-management-pedressive-disorders Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Unutzer, J., & Park, M. (2012). Strategies to improve the management of depression in primary

care. Primary Care, 39(2), 415-431. doi:10.1016/j.pop.2012.03.010

Verdujin, J., Milansechi, Y., Schoevers, R.A., van Hemert, A.M., Beekman, A.T., & Penninx,

B.W. (2015). Pathophysiology of major depressive disorder: Mechanisms involved in

etiology is not associated with clinical progression. Translational Psychiatry, 5(e649),

1-9. doi:10.1038/tp.2015.137

World Health Organization. (2017a). Depression: Let’s talk. Retrieved from

http://www.who.int/mental_health/management/depression/en/

World Health Organization. (2017b). Depression. Retrieved from

http://www.who.int/mediacentre/factsheets/fs369/en/
 Pathopharmacological Foundations for Advanced Nursing Practice – Depression Essay

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Heart Disease

Heart disease affects the lives of millions of people every year so it is important to understand the characteristics and risk factors associated with this condition.  Risk factors for heart disease fall under two categories: modifiable risks and nonmodifiable risks.  Modifiable risks include things that we can control such as obesity, smoking and high fat intake whereas nonmodifiable risks include things that we cannot control such as gender, heredity and age.  But first, we must understand what heart disease is and how it affects our bodies.  Research suggests that heart disease is a result of damage to the lining and inner layers of the heart arteries.  Plaque begins to build up where there are damaged arteries (What Causes Heart Disease, 2014).  Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay. Factors that can contribute to this damage include smoking, blood vessel inflammation, elevated amounts of sugar in the blood due to insulin resistance or diabetes, high blood pressure and high amounts of fats and cholesterol in the blood.

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

A1. Pathophysiology

Heart disease is a clinical manifestation when the heart can not provide a sufficient amount of blood flow to maintain the metabolic requirements for systemic venous return.  Heart failure is the result of several mechanisms such as pump function disorder, neurohormonal activation disorder and salt-water retention disorder (Palazzuoli, 2010).  It develops when there is an abnormality in cardiac function causing blood to not pump at a healthy rate.  Several factors can contribute to the damage including smoking, high blood pressure, inflammation of the blood vessels, and increased amounts of cholesterol in the blood. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

The average human heart beats almost four million times per year, pumping enough blood to fill an oil tanker during a lifetime.  Composed of striated cardiac muscles, the heart is supplied oxygen and nutrients from the coronary arteries.  Over time, some people experience damage to the cardiac muscles which can lead to a weakening of the heart’s ability to pump blood.  If blood is inadequately being pumped, fluid can build up in the lungs, liver and other vital organs.

There are several conditions that can lead to heart disease including anemia, diabetes, obesity, cardiomyopathy, obstructive sleep apnea and cardiac muscle disease.  Diseases related to the heart valves can also cause heart failure.  Damaged or leaking valves cause the heart to pump harder pump back-flowing blood. Some of the main pathologies of heart disease include over loading of the ventricle with blood during diastole, lowered cardiac output causing an increase in the heart rate, stroke volume decreasing as the ventricle rises at the end of systole, reduced cardiac reserve and hypertrophy (Mandal, 2009) Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

A2. Standard of Practice for Heart Disease

The national standard of practice is driven by the Clinical Practice Guidelines published by the National Guideline Clearinghouse (NGC).  The NGC provides a guideline of recommendations on current evidence based practice to help healthcare workers provide safe and efficient care to patients with heart disease.  These evidence based guidelines have the potential to maximize the outcome of a patient (Petruccelli, n.d.).  In 1933 Sir Thomas Lewis wrote in his textbook on heart disease that “The very essence of cardiovascular medicine is the recognition of early heart failure” (Lewis, 1937).

According to the American College of Cardiology a thorough history and physical should be performed in patients that present with heart disease to identify any cardiac or non-cardiac disorders and/or behaviors that may cause the acceleration of the disease.  Volume status and vital signs as well as patient weight, jugular venous pressure and the presence of orthopnea or peripheral edema should be assessed as they may be signs/symptoms of fluid retention.  Risk scores are obtained upon assessment to estimate the risk of mortality in patients with heart disease Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

For patients presenting with signs/symptoms of heart failure, initial laboratory evaluations include complete blood count, troponin, serum creatinine, urinalysis, serum electrolytes, bun, glucose, fasting lipid profile, liver function tests and thyroid-stimulating hormone.

Because heart disease has a high mortality rate, results in decreased quality of life, increased hospitalizations and an extensive therapeutic routine, new research and evidence based data is constantly being done to improve outcomes of the proposed therapies.  Because this is a chronic condition, the effect of therapies may not be noticeable right away.  The prognosis varies from patient to patient when taking into account co-morbidities, life style and genetic factors.  As a result, not all treatments will work for all patients, making it difficult to generalize one specific treatment regimen as the “go-to” for heart disease. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.  The assessment of specific outcomes of therapy are complicated by the potential differential impact of the many co-therapies (Albert, Boehmer, Ezekowitz, Givertz, Klapholz, Linderfeld,…Walsh, 2010).

The complexity and high prevalence of heart disease in today’s society, has resulted in numerous treatment options and practice guidelines.  Different practice guidelines have been created by various organizations.  The American Heart Association [AHA] along with The American College of Cardiology Foundation [ACCF] have developed one set of practice guidelines and have been producing practice guidelines jointly in the area of cardiovascular disease since 1980.  These guidelines are not only comprehensive but they also address all aspects of prevention, evaluation, therapy (both pharmacological and device) as well as disease management for patient’s diagnosed with heart disease.  These guidelines play a major role in clinical management of the disease process. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

A2a. Pharmacological Treatments

Cardiac Glycosides

Can be used for any severity of heart disease

Slows the ventricular rate

Aldosterone receptor antagonists

Recommended for advanced heart disease

Improves survival and morbidity

Recommended in addition to Ace-inhibitors and beta-blockers

Diuretics (loop diuretics, thiazides and metolazone)

 

Decreases fluid overload

Results in rapid improvement of dyspnea and increased exercise tolerance

Should be taken with ACE-inhibitors and beta-blockers

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Beta-adrenoceptor antagonists (Beta-blockers)

Used as treatment for a severities of heart disease

Reduces hospitalizations, improves function and can slow down progression of the disease

Slow the heart rate, allowing the left ventricle to fill more completely

Angiotensin-converting enzyme inhibitors (ACE-inhibitors)

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

1
st
Line of defense

Helps improve control of heart disease

Reduces need for hospitalization, improving patient quality of life

Assists with electrolyte and water balance by increasing the release of water and salt to urine, lowering blood pressure

Vasodilation improves hemodynamics in heart disease and reduces blood pressure

Angiotensin II receptor blockers

Assists blood vessels to relax and dilate

Helps release water and salt to the urine, lowering blood pressure

Decreases pressure on the left ventricle of the hear must pump against

Anti-thrombotic agents

 

Heart disease is often accompanied by a hypercoagulable state

Reduces the incidence of coronary ischemic events

Inhibits vasodilation

**Drugs to use with caution for patients with heart failure:  lithium, tricyclic anti-depressants, corticosteroids, calcium antagonists, NSAIDs and Class I anti-arrhythmic agents

(Cleland, 2005)

 

The pharmacological treatment for heart disease will vary based on the severity of the disease, the patient’s co-morbidities and the patient’s classification.  The AHA and ACCF classify patients into four classes ranging from A to D, with the stages of heart disease distinguishing risk factors and abnormalities of the cardiac structure as being associated with heart disease.  The pharmacological interventions take into account both. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

As mentioned previously, the practice guidelines for heart disease as set forth by the AHA and ACCF work hand in hand with the standardized pharmacological treatment throughout the United States.  Virginia, and more specifically my community, utilize these practice guidelines in the treatment of heart disease.  Angiotensin-converting enzyme (ACE) inhibitors should be used in the treatment of heart failure related to systolic dysfunction.  ACE inhibitors cause relaxation of the blood vessels and decrease blood volume.  This leads to lower blood pressure and decreased oxygen demand on the heart.  Some examples of ACE inhibitors include Lisinopril, Captopril, Trandolapril and Enalapril which have all been proven in clinical trials to be effective in reducing morbidity and overall mortality rates in patient with heart disease (Flather & Kober, 2000).  Unless otherwise contraindicated, ACE inhibitors should be considered a priority intervention.

Also for patients with heart disease related to systolic dysfunction, beta blockers are recommended, unless a patient is dyspneic at rest with hemodynamic instability, signs or symptoms of congestion or those with a previous intolerance to beta blockers (Bleske, Chavey,…Van Harrison, 2008).  Beta blockers block the action of adrenaline and noradrenaline.  Coreg, Metoprolol, Propranolol and Atenolol have been proven in clinical trials to decrease overall mortality.  When a patient takes beta blockers, the heart beats more slowly and with less force.  This reduces blood pressure and helps blood vessels to expand, improving blood flow. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Aldosterone antagonists are receptor antagonists located at the mineralocorticoid receptor.  They are recommended for patients with heart disease.  Aldosterone receptor antagonists block the effects of hormones produced naturally in the adrenal glands that can cause heart disease to worsen.  They affect the balance of water and salts going into the urine.  They also help lower blood pressure and protect the heart by reducing congestion.  Spironolactone is a nonselective aldosterone antagonist and eplerenone is selective to the aldosterone receptor.  These are the only two aldosterone antagonists commercially available in the United States.  Aldosterone antagonism is recommended for patients with heart disease who also have dyspnea rest as well as for patients post myocardial infarction who have developed systolic dysfunction.

Angiotensin II receptor blockers (ARBs) block the actions of angiotensin II, which is produced in the kidneys.  It prevents angiotensin II from binding with angiotensin II receptors in the blood vessels, causing them to dilate and reduce blood pressure.  ARBs are often used to treat patients with heart disease that cannot tolerate ACE inhibitors, but they can also be added in addition to ACE inhibitors.  Losartan and Valsartan are commonly used ARBs, typically found in the hospital setting.

Diuretics assist the body to get rid of excess fluid by encouraging the kidneys to make more urine.  They are commonly used for patients with heart disease to manage fluid volume overload, which can be acute or chronic.  Diuretics cause the kidneys to put more sodium in the urine.  As the sodium is excreted from the blood, it takes water with it to the kidneys.  They cause wasting of potassium and magnesium.  Getting rid of the excess fluid lessens the load on the heart because there is less fluid to pump around the body, easing congestion on the lungs.

In my community, use of these drugs are standard practice.  There are best practice guidelines which outline the use of each drug, potential side effects and things that patients should look out for to tell their physician.  A nationally tracked indicator of heart disease management includes asking relevant questions to patients upon discharge related to their heart disease medications, specifically about the use of a beta blocker, ACE inhibitor or ARBs.  Pharmacists within the hospital setting are trained to reconcile medication upon admission and discharge to ensure patients are prescribed the correct medication to optimize their treatment regimen.  Patients are given access to My Chart, which allows them to access their medications post hospitalization at any time in case their community pharmacist has any questions.

Providers within the community have access to electronic health records which allow them to see previously prescribed medications, discontinued medications and the physicians reasoning for adding/deleting a particular medication as well as any adverse reactions noted.

Within the hospital, case managers work directly with patients to provide community resources so they are able to get their medications more easily and affordably once discharged.  Physicians will typically write a 30-day prescription for most medications to give a patient ample time to see their primary care physician or community resource. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Extensive efforts to ensure patients have the education and resources needed to remain compliant once discharged to the community, have decreased overall re-hospitalization rates.  It is also important to focus on prevention and education.  My hospital hosts health fairs, blood pressure screenings and community education classes to make people aware of the modifiable risk factors associated with heart disease to try to decrease the risk of heart disease before it gets to the point of having someone hospitalized for heart disease.

A2b. Clinical Guidelines

Quality measures include:

Patients must be given ACE inhibitor angiotensin II receptor blocker. If not, there must be clear documentation of intolerance to both.

Patients must be given adult smoking cessation advice or counseling

Patients given discharge instructions must include:

Activity

Weight Monitoring

Diet

List of discharge medications and dosages

Follow up care

What to do if symptoms worsen

 

Diagnosis

A diagnosis of heart disease takes into account the whole picture of physical findings, symptoms and tests.  Based on these results, the physician will order a chest x-ray, echocardiogram and electrocardiography to analyze heart shape/size and function as well as evaluating the lungs for fluid build-up.  Certain specifics a physician will test for: Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Blood Tests- kidney and thyroid function, cholesterol levels and the presence of anemia

BNP-level of BNP increases as heart disease worsens

Chest x-ray-shows size of the heart and whether there is fluid build-up

Echocardiogram-provides pictures of the heart’s valves and chambers so the physician can study the action of the heart

Doppler Ultrasound-evaluates blood flow across the heart valves

Ejection Fracture-<55% Stress test- the heart is stressed by walking on a treadmill. This will help identify clogged arteries   Patient Education Understanding Heart Disease Causes of Heart Disease Common Questions Nutritional Planning Adapting Your Lifestyle Plan periods of rest Be sure to get plenty of rest, ensuring that you keep your feet up to minimize swelling in the legs Conserve your energy Cutting down on some of your daily activities or using less energy during tasks will help you have more energy to do more tasks throughout your day Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Manage a healthy weight Monitor fluctuations in your weight…fast weight gain can mean fluid retention Reading food labels Avoid to much fluid intake Limiting sodium intake Increasing intake of high potassium foods Dried fruits Fresh vegetables Fresh fruits Fish Fresh meat Stop smoking Smoking causes your heart to work harder to supply the body with enough oxygen Be aware of triggers to smoking Being around smokers Alcohol Emotional stress Maintain up-to-date immunizations Respiratory problems can worsen heart disease, vaccinations can provide immunity against flu and pneumonia Monitor your blood pressure and heart rate Gives you confidence in the treatment you are doing Helps give information to the physician about trends Manage your medicines Take your medication as prescribed to get the best possible outcome Take your medications with you when you go to the doctor A2c. Standard Practice of Disease Management Initiatives in Virginia to prevent and combat heart disease include promoting the use of guidelines for primary and secondary prevention as well as increasing quality care in federally funded healthcare centers.  On the national level, in 1999 the National Coalition for Women with Heart Disease, a patient centered organization, was founded creating a wide support network, educational seminars and advocating for legislation.  In 2002, The Heart Truth campaign was created to raise awareness about heart disease, risk factors and preventative action. The standard of practice of care for the management of heart disease is consistent in Virginia as it is across the nation.  Patients with heart disease may experience signs and symptoms of a heart attack such as angina, vomiting, and extreme fatigue, difficulties breathing and swelling in the feet, ankles, legs and abdomen.  Treatment is based on exhibited symptoms and can be pharmacological and nonpharmacological including lifestyle modifications. No single test can diagnose heart disease.  If heart disease is suspected, the national standard is for a physician to order an electrocardiogram to detect and record the hearts electrical activity.  The test will show how fast the heart is beating and if the beat is regular or irregular.  Another standard of care is performing a stress test to make the heart work harder and beat faster through exercise while testing is completed on the heart.  A stress test can show possible signs and symptoms of heart disease such as abnormal changes in the heart rate, blood pressure, shortness of breath and abnormalities in the hearts rhythm. A chest x-ray is typically ordered to give the physician a picture of the organs and structures within the chest and can reveal signs of heart disease.  Blood tests check the levels of cholesterol, sugars, fats and proteins in the blood.  Abnormal levels can indicate heart disease. If other tests suggest heart failure, the physician would order a coronary angiography using a special dye and x-ray to look inside of the arteries (What Causes Heart Disease, 2014). The State of Virginia can help educate the public about the importance of disease prevention through regular check ups.  They can also assist by providing healthcare workers updates on guidelines and best practices for treating patients at risk and affected by heart disease.  Virginia has also established policies for raising awareness for recognizes the signs and symptoms of heart disease and heart attack and helping hospitals implement system changes to adhere to national guidelines and recommendations for victims of heart disease (Moon, 2008). A3. Characteristics of Heart Disease Heart disease affects approximately 5.1 million people (Heart, 2015).   Common symptoms of heart disease include shortness of breath, weight gain, swelling in the feet, ankles, stomach or legs, fatigue and weakness.  Early diagnosis and treatment can greatly increase the quality and length of life for people affected by heart disease.  Treatment typically includes medications, diet modifications, increased physical activity and smoking cessation. There are four stages of heart disease to describe the evolution of the disease. Stage A refers to people who are at high risk for developing heart failure based on one or more risk factors Stage B refers to patients that show no symptoms of heart failure Stage C refers to patients who have in the past, or currently, show symptoms of heart failure with underlying structural heart disease Stage D refers to patients with end-stage heart disease requiring specialized treatments (Diseases, 1964) When thinking about the characteristics of heart disease, genetics should always be a factor.  Individuals that have a parent that suffered a heart attack are at an increased risk for heart disease.  Although we cannot control our gender, heredity or age, there are several risk factors that can be reduced and/or eliminated to lessen the risk of heart disease. Modifiable risk factors include smoking cessation, maintaining a healthy diet and proper weight control.  As little as 20% of a person’s body weight increases the cholesterol levels in the body (Mandal, 2009). Access to Care-Approximately 7.3 million Americans with heart disease are currently uninsured (Federal Access to Care Issues, 2013).  This makes them less likely to receive appropriate care which results in worsening medical outcomes, including increased mortality rates.  Current advocacy priorities initiated federally include implementing health reform, opposing policies that cut benefits or increase costs under Medicare and Medicaid, supporting funding for community access, expanding access to AEDs and CPR training for high school students, lay rescuers and professional responders, increased public knowledge of lifesaving approaches and increased funding for the National Emergency Medical Services Information System and other EMS programs (Ayanian, 2001). Treatment Options- The goal of treatment is typically the same for men and women with a goal of relieving symptoms, reducing risk factors to slow or stop the buildup of plaque, lowering the potential for blood clot formation, widening plaque clogged arteries and preventing complications related to heart disease.  Treatments include: Lifestyle Changes such as smoking cessation, diet modification, increased physical activity, maintaining a healthy weight, reducing stress and depression.  Medications can help reduce the hearts workload and relieve symptoms, lower cholesterol levels, blood pressure and prevent blood clots and prevent the possibility of a heart or sudden death.  A patient may need surgery to treat heart disease such as angioplasty, CABG, percutaneous coronary intervention and coronary artery bypass grafting.  Cardiac rehab is also part of the national standard of care.  It includes exercise training to teach safe exercising, muscle strengthening and improve stamina as well as education, counseling and training to help the patient understand their condition and identify ways to lower risk for future medical issues related to the heart. Life Expectancy and Outcomes-Since 2004, the death rate related to heart disease has fallen.  In 2013 there were 211 deaths per 100,000 people in Virginia and 223 in the nation.  This gave Virginia the 25 th lowest rate in the country (Measuring Cardiovascular Disease, 2015).  Across the state (Virginia) deaths related to heart disease have continued to fall.  According to US government statistics, there are almost 300,000 deaths each year (Moon, 2008).  Of the total heart disease related deaths each year, 8.6 million are women and is the largest single cause of deaths in women worldwide (Fact Sheets, n.d.).  Heart disease is listed as the underlying cause of death for 31% of all deaths in the United States-that’s almost 2200 deaths per day. A3a. Disparities Health disparities continue to exist for low income populations and minorities.  There is evidence that these groups have earlier onset of heart disease and earlier death associated with the advanced disease related to biological, psychosocial, environmental and behavioral issues.  Programs have been implemented by public health groups nationwide to modify known risk factors, focusing on tobacco cessation, increased physical activity, healthier diets and preventative screening.  There has been minimal progress noted in the heart disease health disparities among low income and minority populations.  People living in low income communities have less access to affordable and nutritious food, parks for physical activity and limited access to health screenings.  Fresh and organic produce tend to more expensive than canned or frozen food.  Disparities are seen with patients that carry Medicare as well as non-Medicare patients. Disparities are also noted on an international level based on a patients’ insurance or noninsured status.  Patients that do not carry insurance and are unable to pay privately, are typically discharged home with minimal prescriptions and no access to home health leaving family members to take care of them. According to the World Health Organization, about 16 million people across the world die of heart disease each year (The World Health Report, 2003).  Due to a lack of resources and education, developing countries are twice as likely to see patient deaths related to heart disease.  Heart disease has no socioeconomic, gender or geographic boundaries. According to The World Health Report, heart disease is the leading cause of death in the European Union, accounts for over 245, 000 deaths in the UK and an estimated 8 million people in Canada have some form of heart disease.  In these countries, the prevalence of hypertension is very high with citizens not being treated.  In low-income countries, there is usually one person that is the primary money maker for the family.  Due to limited financial resources, many are not able to seek the treatment that they need or take the time away from work to seek treatment.  Low-income communities have unequal distribution of goods and little to no access to healthcare services, healthy foods or safe, green outdoor areas for activity.  There is easy access to alcohol, tobacco and unhealthy foods such as fast food. Among African Americans 10.3% suffer from heart disease, 4.9% of Hispanics suffer from heart disease, 3.3% of Asians suffer from heart disease and 5.6% of Caucasians suffer from heart disease (Thom, 2006).  It is estimated that by 2030, over 44% of the United States population will have some form of heart disease.  The American Heart Association’s 2020 Impact Goals include improving the cardiovascular health of Americans by as much as 20% while reducing the mortality rate related to heart disease by 20%. Analysis of data sets reported by the Center for Disease Control showed that adults older than 18 years old, disparities were noted for all risk factors examined.  Mexican American men had the highest prevalence of obesity while African American women without a high school education had a high prevalence of obesity.  Regardless of age or sex, African Americans had the highest prevalence of hypertension while Caucasian and Mexican American men had the highest prevalence of hypercholesterolemia along with Caucasian women (Thom, 2006).  Smokers with family incomes lower than the poverty level is twice as likely than adults in the highest family income group. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay A4a. Factors Contributing to Managing Heart Disease Medication compliance is a huge factor in management of heart disease.  Cost is one of the most common reasons people have for not taking their medications.  For patients having financial issues, the physician may be able to prescribe another medication that is more cost effective.  There are also public and private programs that offer discounted or free medications such as manufacturers’ aid or patient assistance programs.  Income and age will often determine eligibility.  It is estimated that three out of four Americans so not take their medications as directed (Medication Adherence, n.d.).  Poor medication adherence takes the lives of 125,000 Americans annually. Some medication assistance programs that can assist a patient better manage heart disease are: RX Outreach- a charitable nonprofit patient assistance program that provides access to affordable generic and brand name medications FamilyWiz Community Service Partnership-distributes free prescription savings cards and a price look up tool NeedyMeds-a national non-profit resource that helps people locate assistance programs to help them afford medications and healthcare costs Due to the high cost of medications, some patients do not purchase them.  A patient with heart disease can experience many complications if they do not follow their medication regimen as prescribed.  Research has proven that a variety of medications are needed for the best outcomes in the treatment of heart disease.  Each medication treats a different symptom or contributing factor to promote the overall treatment.  Each individual medication cannot do their job correctly if not taken correctly.  In a nutshell, proper use of prescribed medications for the treatment of heart disease has been proven to save lives, prolong life and improve overall heart function. Medication noncompliance can lead to an unmanaged disease process as evidence by the mechanism of action of the medications.  For example, diuretics are prescribed to heart disease patients to help the body to rid itself of excess fluids and sodium via urination.  If a patient is not taking their medications as prescribed, there can be an increased workload of the heart as well as increased buildup of fluid in the lungs, ankles and legs making the condition much worse. Lack of insurance coverage can also affect a patient’s ability to manage their heart disease.  Plans such as Medicare Part B covers for preventative screening every 5 years.  There are no costs for the tests and everyone who has Medicare Part B is covered.  Medicare also covers one visit per year as a preventative service.  For patients that are experiencing heart failure, Medicare offers comprehensive cardiac rehabilitation that includes exercise, education and counseling (Your Medicare Coverage, n.d.).  This program is provided in a hospital outpatient setting or in a doctor’s office. A patient that has private insurance typically will have a rehabilitation plan included as part of their coverage.  For instance, with Anthem, a patient can receive up to sixty visits in a calendar year for rehabilitation services without a prior authorization being needed.  The severity of the illness must meet a predetermined standard for a patient to be approved for inpatient rehab which provides for four to six hours daily of therapy as compared to a skilled facility placement that only would provide one to two hours daily.  The decision of coverage is ultimately determined by the medical director working within the insurance company who receives the case information, reviews it based on the documentation provided and approves coverage limits, amount of days and times based on this information.  Unfortunately, this is not often in line with the physician discharge instructions or the patient/family request.  Often times, these predetermined limits will not provide enough coverage for the patient to get back to a normal state. Some patients do not have traditional insurance or Medicaid.  These patients are also often limited in access to care because they have options in care that are either high in cost or limited.  For example, with hospital based programs, a patient can only see certain physicians and are bundled into managed products.  With managed products, a patient is assigned to a specific physician or medical group and is unable to see an outside physician without a referral.  Appointments are limited and often times done during clinic times so seeing the same physician consistently is rare.  These limited appointments often result in patients having to seek care in the Emergency Room which does not provide ongoing care.  This can result in a breakdown in communication between physicians and a lack of consistency of treatment plans. Without the needed ongoing care, patients can fall between the cracks, with constantly changing treatment and medication regimens and inconsistency of the plan of care.  The frustration of long waits during clinics, different physicians every visit and having to wait get on a waiting list to even get into a clinic can lead to an unmanaged disease process due to a lack of frequent, consistent visits and updated plans of care and treatment regimens based on changes in the disease process. Not having access to proper nutrition can affect a patient’s ability to manage heart failure.  One of the standard modifications recommended is diet modification.  The role of a proper diet is key to lowering cardiovascular risk.  Patients that do not have access to healthy foods such as fruits and vegetables, low sodium items, fish, nuts and soy have a higher risk of death related to heart disease.  Food assistance programs such as SNAP (Supplemental Nutritional Assistance Program), Nutritional Programs for Seniors and WIC (Special Supplemental Nutrition Program for Women, Infants and Children) provide assistance for those in need so they can purchase healthier foods. Proper nutrition is very important when trying to manage heart disease.  Continuing to eat an unhealthy diet can lead to co morbidities that can increase that rate of mortality related to an unmanaged disease process.  For example, high blood pressure is a major risk factor with heart disease so a diet high in sodium will increase a patients’ risk for hypertension.  A high fat intake will increase the likelihood of becoming obese (which puts addition strain on the heart) and developing high cholesterol.  Sugary foods can increase the chance of a patient becoming a diabetic.  Abnormal blood lipids are related to what we eat and have a strong correlation to heart disease, heart attack and ultimately coronary death. 4Ai. Characteristics of a Patient with Unmanaged Heart Disease Patients with uncontrolled heart disease may experience several symptoms such as shortness of breath, rapid heart beat, lethargy, light headedness, swelling in the extremities and chest pain.  They may even experience pain in the jaw, neck or back.  Sometimes a patient with uncontrolled heart disease may experience nausea and vomiting as well as unexplained fatigue. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay For patients with unmanaged heart disease the prognosis depends on the cause and severity of the disease. Complications can include: Kidney Failure Heart disease can reduce the blood flow to the kidneys and cause a patient to need dialysis Heart valve Problems Valves may not function correctly if the pressure in the heart is high due to heart disease Heart Rhythm Complications Arrhythmias can be a complication of heart disease Liver Damage Heart disease can lead to fluid buildup that puts excessive pressure on the liver   How Does Heart Disease Affect Patients, Families and Communities? Heart Disease can be a devastating illness that affects not only patients but their families and community as well. For the patient it can affect their ability to live independently and care for themselves. The patient may not be able to continue working as the physical and emotional stress takes its toll.  This can result in a loss of income, further increasing a patient’s stress level and depression especially if they are not able to care for themselves or their family.  There is also the added anxiety over familial and caretaking concerns such as, “Who will take care of my house and my spouse” and “How will he/she manage without me?” Family members may have to face the possibility of caring for a sick loved one. This can put an emotional and financial strain on the dynamics of the household.  The family will also have to be prepared to deal with the possibility of the sick family member to experience depression and other changes in their emotional state.  Their tolerance for noise and disturbances may be decreased and this may be hard for young children to understand.  They may feel that they have lost a parent or that their parent is behaving differently around them but not understand why. For the community, a patient who has decreased or lost their income, may rely on community and government assistance for medications and healthcare related costs. These costs may be absorbed by the local hospitals or state funded programs such as Medicare. If a patient is not able to provide for their family, they may need to turn to other government based assistance programs such as food assistance programs and housing assistance programs. B1. Financial Costs Patient – In 2010, the cost of heart disease in the United States alone exceeded $444 billion (Feature, n.d.).  Pulling from this total 64% were direct costs, 45% were hospital costs, drugs were 19.5% and physician visits were 14.8%.  The cost of treating heart disease exceeds diabetes treatment. DIRECT MEDICAL COSTS INDIRECT MEDICAL COSTS LONG TERM MAINTENANCE Ambulance Lost Productivity and Income Drugs Diagnostic Testing Continued Testing Hospital Charges Cardiologist Appointments Surgery (if needed) Appointments for Co-Morbidities or Illnesses as a Result of Heart Disease For the patient, heart disease results in many increased costs outside of medications and hospital visits.  For instance, fresh, healthy or organic foods cost more than fast food, frozen or canned foods.  That is why it is hard for many people to adopt a healthier nutritional lifestyle.  A meta-analysis of pricing of healthy versus unhealthy diet patterns found that the healthiest diet patterns cost, on average, ≈$1.50 more per person per day (Thom, 2006).  As a result of the illness and its effects on the body, a patient may have to miss work or work less frequently causing their income to decrease. A patient can help offset some of the costs by researching cheaper medications or generic substitutions, ensure they have adequate health insurance and consider disability insurance to replace some of the lost income. Family – For families of heart disease patients, the financial toll can also be high.  Family members may have to become the sole person responsible for finances within the household.  Family members may also experience some form of loss in income if they are forced to miss work to take their loved ones to physician appointments, hospital visits and for treatments.  For families with children, there is also the additional expense of childcare while the healthy parent is taking the ill parent to appointments. Populations – In the United States, heart disease more Medicare allocation dollars than any other illness.  In 2009 over seven million Medicare beneficiaries experienced over 12.4 million inpatient hospital visits (Treating Congestive Heart Failure, 2014). Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Promoting Best Practices & Evaluation Method The first strategy I would implement to promote best practices would be to implement for a nutritionist to meet regularly with all patients admitted with new or current heart disease.  Part of minimizing recurrent visits to the hospital and implementing a healthier lifestyle is education about proper nutrition.  It is important that patients are given the knowledge about implementing heart healthy eating patterns, proper intake of fruits, vegetables, gains, fish, legumes and sources of proteins low in saturated fat.  The nutritionist would also be responsible for educating the patient of weight management and reduction (if needed) through a balance of physical therapy, monitoring caloric intake and programs to maintain/achieve a healthy BMI. Evaluation-The nutritionist would also be responsible for a one month, three months and six months follow up where the patient can have their BMI checked, weight checked, basic labs taken etc. to gauge their progress and give the patient an opportunity to ask questions and get guidance on any concerns they may have regarding their diet and weight management. The second strategy I would implement for best practice would be psychological assessment and support for patients suffering from heart disease and undergoing cardiac treatment.  Stress, anxiety and other psychological factors can greatly affect a patients’ wellness and cardiac rehabilitation.  I would ensure that a psychologist or psychiatrist met with the patient throughout their hospital stay.  They would not only complete assessments to ensure the patient is psychologically handling their diagnosis but also be available for a patient to discuss any concerns, negative emotions, concerns about post discharge factors such as work and family life as well as discuss any depression they may be experiencing.  The psychologist/psychiatrist would also provide education about stress management, recognizing signs and symptoms of depression as well as helping the patient find mental support resources within the community post discharge. Evaluation-The psychologist/psychiatrist will continue to monitor the patients’ mental health throughout their visit, identifying any variances from upon admission.  They will also meet with the patient upon discharge to complete another assessment to ensure the patient is mentally stable to be discharged.  They will also monitor the patient based on their initial baseline for any negative effects related to new or modified medications The third strategy I would implement is a post heart disease diagnosis care team.  Once a patient is discharged from the hospital, they would be seen by the care team the following day.  The care team would include the physician, nutritionist, social worker, physical therapist, psychologist/psychiatrist and cardiac nurse educator.  The team would follow the patient for one-year post admission to provide support for the patient.  Their initial evaluations would be completed while the patient is in-patient.  Upon discharge, the care team would also provide educational opportunities and support groups for patients to participate in.  The team will also assist the patient with smoking cessation programs and medication management.  Following the patient will allow the care team to monitor and changes in condition while helping the patient get oriented to their new diagnosis and symptom management. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Evaluation-The care team will review and track their patients for compliance with medications, dietary modifications, smoking cessation and overall quality of life.  As symptoms arise, the team will also help the patient with symptom management and teach them the skills needed to live with heart disease on their own.  Evaluation of outcomes would be analyzed overtime to identify areas of opportunity and the potential for team expansion.   References Albert, N., Boehmer, J., Ezekowitz, J., Givertz, M., Klapholz, M., Lindenfeld, J.,…Walsh, M. (2010). Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure (16) 475-539. Retrieved from http://www.heartfailureguideline.org/_assets/document/Guidelines.pdf.   Ayanian, J. Z., & Qiunn, T. J. (2001, May). Health Affairs. Retrieved April 12, 2016, from http://content.healthaffairs.org/content/20/3/55.full   Bleske, B., Chavey, W., Hogikyan, R., Kesteron, S., Nicklas, J., Van Harrison, R. (2008). Pharmacological Management of Heart Failure Caused by Diastolic Dysfunction. American Family Physician. (7)957-964. Retrieved from http://www.aafp.org/afp/2008/0401/p957/html.   Burke, N., Desmeules, M., Georee, R., Lim, M., Luo, W., O’Reilley, D., …Tarride, J. (2009). A review of the cost of cardiovascular disease. Canadian Journal of Cardiology , 25 (6). doi:10.1016/s0828-282x(09)70098-4 Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay     Cleland, J., Dargie, H., Drexler, H., Follath, F., Komadja, M., Swedberg, K., (2005, May 18). Guidelines for the diagnosis and treatment of chronic heart failure: Executive summary. Retrieved March 27, 2016, from http://eurheartj.oxfordjournals.org/content/26/11/1115.full   Diseases of the heart and blood vessels: Nomenclature and criteria for diagnosis (6th ed.). (1964). Boston: Little, Brown. Retrieved March 25, 2016.   Doering, L. V., McKinley, S., Riegel, B., Moser, D. K., Meischke, H., Pelter, M. M., & Dracup, K. (2011). Gender-Specific Characteristics of Individuals with Depressive Symptoms and Coronary Heart Disease. Heart & Lung: The Journal of Critical Care, 40 (3), e4–e14. http://doi.org/10.1016/j.hrtlng.2010.04.002   Fact Sheets. (n.d.). Retrieved April 12, 2016, from http://www.world-heart-federation.org/heart-facts/fact-sheets/   Feature, R. M. (n.d.). Heart Disease: The Cost of Medical Bills and Disability. Retrieved April 12, 2016, from http://www.webmd.com/healthy-aging/features/heart-disease-medical-costs Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay   Federal Access to Care Issues. (2013, July 8). Retrieved April 12, 2016, from http://www.heart.org/HEARTORG/Advocate/IssuesandCampaigns/AccesstoCare/Access-to-Care-Policy-Issues_UCM_443156_Article.jsp#.Vwx7mP72bow   Heart Failure Fact Sheet. (2015, November 30). Retrieved March 24, 2016, from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.html   Lewis, T. (1937). Diseases of the heart, described for practitioners and students. London: Macmillan and, Limited.   Mandal, MD, A. (2009, April 5). Heart Failure Causes. Retrieved March 24, 2016 from http://www.news-medical.net/health/Heart-Failure-Causes.aspx   Measuring Cardiovascular Disease in Virginia – Virginia Performs. (2015, March 16). Retrieved April 12, 2016, from http://vaperforms.virginia.gov/indicators/healthFamily/cardiovascularDisease.php   Medication Adherence – Taking Your Meds as Directed. (n.d.). Retrieved April 07, 2016, from http://www.heart.org/HEARTORG/Conditions/More/ConsumerHealthCare/Medication-Adherence—Taking-Your-Meds-as-Directed_UCM_453329_Article.jsp#.VwYmXP72ZoA   Moon, M.A. (2008). Heart Failure Patients Greatly Overestimate Life Expectancy. Family Practice News, 38 (13). Doi:10.1016/s0300-7073(08)70804-1   Palazuoli, A., & Nuti, R. (2010, April 20). Heart Failure: Pathophysiology and clinical picture. Retrieved March 27, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/20427988   Petruccelli, D. F. (n.d.). JCAHO Core Measures. Retrieved April 8, 2016, from https://c.ymcdn.com/sites/aahfn.site-ym.com/resource/resmgr/Docs/nursingpractice/JCAHO_Core_Measures.pdf.   Thom, T. (2006). Heart Disease and Stroke Statistics–2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 113 (6). doi:10.1161/circulationaha.105.171600   Treating Congestive Heart Failure and the Role of Payment Reform. (2014). Retrieved April 13, 2016, from http://www.brookings.edu/research/papers/2014/05/21-congestive-heart-failure-hospital-aco-case-study#recent_rr/   Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. JACC-Journal of the American College of Cardiology, 128(16). doi:10.1161/cir.0b013e31829e8776   Yoon, J., Fonarow, G. C., Groeneveld, P. W., Teerlink, J. R., Whooley, M. A., Sahay, A., & Heidenreich, P. A. (2016). Patient and Facility Variation in Costs of VA Heart Failure Patients. JACC: Heart Failure.   What Causes Heart Disease? (2014, April 21). Retrieved April 11, 2016, from http://www.nhlbi.nih.gov/health/health-topics/topics/hdw/causes   What Is Being Done at The National Level to Prevent Heart Disease In Women? (n.d.). Retrieved April 03, 2016, from http://www.athensheartcenter.com/what-is-being-done-at-the-national-level   Your Medicare Coverage. (n.d.). Retrieved April 07, 2016, from https://www.medicare.gov/coverage/cardiac-rehab-programs.html Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Pathopharmacological Foundations for Advanced Nursing Practice

Investigated Disease Process

Obesity is defined as having a body mass index or BMI of greater than 30.  Obesity is not considered a disease but is a risk factor for other diseases like heart disease and type 2 diabetes.  One third of American adults are obese with another one third considered overweight (BMI greater than 25 but less than 30).  Parents who are obese often have children who are obese due to genetics and environmental effects:  parents and children usually eat the same foods and have the same exercise habits (McCance & Huether, 2014).

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

Obesity is an epidemic with no simple solution Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.  It is a complex problem that is going to take individuals, healthcare professionals, state and local organizations, policy makers, and community leaders working together to create and maintain a healthy lifestyle and environment.  Resources are available through state and local programs for health recommendations.  Community support for healthy eating and active living in different settings can help reverse obesity.  A lifestyle change is the way to achieve and maintain a healthy weight (“Strategies to Prevent Obesity,” 2015).

A1.  Pathophysiology

           
Obesity is defined as a BMI greater than 30 and is also considered a metabolic disorder.  When an individual with susceptible genes to obesity takes in more calories than they burn off then obesity can develop (McCance & Huether, 2014) Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

There are interactions of many cytokines, hormones, and neurotransmitters which makes the pathophysiology of obesity very complex.  Adipocytes are the cellular basis of obesity and secrete numerous hormones and cytokines called adipokines.  Adipokines help regulate food consumption, the storage and metabolism of lipids, insulin sensitivity, and many others.  Accumulation of visceral fat causes the adipocytes to not function properly and results in changes in the regulation and interaction of the hormones.  These changes in the adipokines and other hormones and neurotransmitters take part in the causes and complications of obesity (McCance & Huether, 2014).

A2.  Standard of Practice

           
Recommended standards for a primary care giver is to calculate a patient’s BMI, using height and weight, on annual visits or more frequently if needed.   This is the first step in identifying those who would need to be counseled on weight lose if the BMI is >25 (overweight) or >30 (obese).  A waist circumference should also be used as a possible indicator for higher risk of type II diabetes and cardiovascular disease.  Waist circumference limit is 40 inches or more for men and 35 inches or more for women.  Lifestyle change is the most important start for weight loss.  Guidelines for weight loss are based on the patient assessment and include:  a) diet, b) physical activity, c) behavioral counseling, d) pharmacological treatments, and e) bariatric surgery.  Patient options and any health issues are included in these guidelines (“New Obesity Guidelines:  Authoritative ‘Roadmap’ to Treatment,” 2013). Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A2a.  Pharmacological Treatments

           
Treatments for obesity are based on developing a weight loss plan to improve the patients’ health and well-being.  After consulting some primary care physician offices, results show that evidence-based pharmacological therapies in my state were comparable to the recommended standard guidelines for weight loss.  Developing a diet plan by reducing calorie intake, increasing physical activity, and adding behavioral counseling are important for a successful weight loss plan.  Individuals with a BMI greater than 30 or greater than 27 with other comorbidities that do not have success in losing weight with diet and exercise may need to add medications to help with the weight loss plan.  The approved medications for long-term treatment for weight loss include, orlistat, lorcaserin, phentermine/topiramate, and naltrexone/bupropion. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. Physicians should consider bariatric surgery in patients with a BMI greater than 40 (“Update on Office-Based Strategies for the Management of Obesity – American Family Physician,” 2016).

Alabama is the 3
rd
ranked state with an obesity rate of 35.7% in 2016 (“State of Obesity:  Obesity data trends and policy analysis,” 2017).  Heart disease, stroke, diabetes, and cancer are the leading causes of death in the United States and obesity is a contributing cause to these diseases.  In Alabama obesity has slowly increased in the past 20 years.  Approximately 45% of Alabama adults do not eat fruit at least once a day.  Almost 26% of Alabama adults eat less than one vegetable a day.  And at least 85% of Alabama adults do not meet the recommendation for physical activity guidelines, 150 minutes of moderate aerobic activity weekly and muscle strengthening exercises at least two days a week (“State of Alabama Community Health Assessment,” 2015).

A2b.  Clinical Guidelines

           
Clinical guidelines for obesity is the assessment and management of the disease.  Patients understanding of the disease and the risk factors involved with obesity are essential for treatments to be successful.  Management of obesity is a lifestyle change that requires specific knowledge and education from the patient and provider. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

The recommended guidelines for the assessment, diagnosis, and patient education of obesity are summarized below.

Assessment

           
A complete medical history should be completed on an initial visit and including a BMI and waist circumference.  Eating and physical habits, family history and any other risk factors or conditions are included in the history to determine the cause of obesity (“Diagnosis – NHLBI, NIH,” n,d.).

A physical exam measuring height and weight to determine the BMI.  The waist circumference is measured to assess the amount of abdominal fat on a patient.  Medical conditions like hypothyroidism, Cushing’s syndrome, and polycystic ovary syndrome can cause obesity, so laboratory tests to check for these conditions are also part of the examination (“Diagnosis – NILBI, NIH,” n.d.).

Diagnosis

           
All adults should be screened for obesity.  BMI and waist circumference should be assessed and recorded at each visit with the health care provider.  Even though the BMI does not measure body fat directly or distinguish muscle from fat, it is the recommended way to diagnose patients who are obese.  The classification ranges for BMI are as follows:  underweight –<1.5, normal – 18.5 to 24.9, overweight –  25.0 to 29.9, obese (stage I) –  30.0 to 34.9, obese (stage II) –  35.0 to 39.9, extreme obesity (stage III) –  40.0 and greater.  Waist circumference greater than 40 in men and greater than 35 in women is defined as abdominal obesity (“Diagnosis and Management of Obesity,” n.d.). Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. Patient Education             Educating the patient on weight loss and the necessity for lifestyle changes increases the chance for a healthier life.  Whether the weight loss is significant or a simple 5-10% of the total body weight, can have health benefits for the patient.  The U.S. Preventive Services Task Force (USPSTF) helped develop an approach to educate and help patients who are ready for preventive obesity counseling called the 5 A’s approach.  1) A ssess the stage of obesity and any comorbidities, eating habits, physical activity, medications that affect weight, and readiness for behavioral change.  2) A dvise the patient of the obesity diagnosis, the many different types of diets for weight loss, the need to decrease calories, the pros and cons of over-the-counter weight loss aids, medications, and surgery, and how important it is for the patient to self-monitor.  3) A gree that if the patient is not ready then discuss again at another visit, when the patient is ready a treatment plan will be developed, set a 10% weight-loss goal with diet/exercise/medication, review all surgery options with the patient if he/she is a candidate for weight-loss surgery. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. 4) A ssist the patient with a diet plan, physical activity guide, and behavioral modification guide, provide the patient with any web resources that are based on the patient needs, help patient determine what method of self-monitoring to use for daily intake of food and physical activity (e.g., mobile app or diary), review food and activity log on follow-up visits and reassess if goal is not met.  5) A rrange follow-up visits, referrals to dietitian/behavioral counselor/weight-management classes, surgeon referral, maintenance counseling to help prevent patient from regaining weight after weight loss (“Diagnosis and Management of Obesity,” n.d.). A2c.  Comparing Standard Practice of Disease Management             Standard practices for obesity management and weight loss treatment are used in primary care clinics in my community.  After questioning several providers in the community, the management of obesity was consistent with the standard guidelines.  A complete medical history and physical assessment is completed on patients.  Obesity is diagnosed according to the BMI and a waist circumference if indicated.  A weight management plan is then developed based on each patient’s specific needs.  Diet, exercise, counseling, pharmacological treatments, and surgery options are all included in this plan. A3.  Managed Disease Process             Characteristics of a patient who has reached their healthy weight loss goal and maintained it include:  a) BMI within normal range, b) at least 60 minutes of daily physical activity, c) healthy diet, d) continued behavioral counseling, e) reduction in risk factors for comorbidities (“Update on Office – Based Strategies for the Management of Obesity – American Family Physician,” 2016). A patient who has managed their weight loss would show the appropriate skills for the continued maintenance of the weight management plan.  They would have access and transportation to get to the health providers and activity centers.  The patient would also have the knowledge to choose the appropriate foods for a healthier diet, and the financial resources for pharmacological treatments or bariatric surgery if needed. Studies show that extremely obese (BMI >40) patients have a significant reduction in life expectancy.  Deaths were mostly due to heart disease, cancer, and diabetes.  Life expectance decreased to approximately 6.5 years for a patient with a BMI of 40-44.9 and 13.7 years for a BMI of 55 and greater (“NIH study finds extreme obesity may shorten life expectancy up to 14 years,” n.d.).  The outcome from a patient with managed weight loss would have increased life expectancy. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A3a.  Care Management Disparities

           
Obesity is a major health issue in the United States and globally.  At least 40 percent of the population between the ages of 45 and 59 in North America, Central America, South America, Western Europe, Eastern Europe, and the Middle East, are overweight or obese (“Obesity Epidemic:  Challenges, Health Initiatives, and Implications for Gastroenterologists,” n.d.).  Differences in populations contribute to the disparities in management of obesity across the nation.  Race, culture, sex, economic status, and place of residence, all account for the differences.

           
Obesity exists in all ethnic and racial groups, all ages, gender, socioeconomic status, and geographical location.  African Americans and Latino populations have higher obesity rates than White populations.  Obesity is a worldwide epidemic (“Special Report:  Racial and Ethnic Disparities in Obesity,” n.d.).  Disparities in health care, limited access to health care, and the quality of the care received can have a crucial impact on the management of obesity.

Racial/ethnic populations have different behaviors that factor in to weight gain.  Compared to non-Hispanic whites, Hispanics and non-Hispanic blacks are less likely to participate in physical activity outside of their occupation.  There is also cultural differences and attitudes concerning body weight, both Hispanic and non-Hispanic black women are more content with their body size than non-Hispanic white women (“Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006-2008,” n.d.).

There are approximately 47.8 percent African Americans that are obese compared to the 32.6 percent of White adults.  Low income or lack of income, accessibility to quality education, access to healthier food, and lack of safer places to participate in physical activities, all contribute to the increased obesity rates in African American communities (“Special Report:  Racial and Ethnic Disparities in Obesity,” n.d.).

There are 42 percent of Latino adults that are obese compared to the 32.6 percent of White adults.  Inequity to healthcare, quality of care, little opportunity to make healthier choices, and limited access to a safe environment for physical activity contribute to the higher obesity rates in Latino communities (“Special Report:  Racial and Ethnic Disparities in Obesity,” n.d.).

Nationally African Americans were at a higher risk for obesity and in the United States Latinos are the fastest growing population with the higher rates of obesity.  It is essential for state and national practices to focus on these disparities in health care to improve the health and well-being of individuals (“Special Report:  Racial and Ethnic Disparities in Obesity,” n.d.).

A4.  Managed Disease Factors

           
There are several factors that can impact a patient’s ability to manage their obesity and reach their weight loss goal.  These factors include access to care, financial resources, and health insurance.  The following factors assist in the patient’s ability to manage their weight loss and maintain a healthy lifestyle:

ORDER A  PLAGIARISM-FREE PAPER NOW

Access to Care – Patients will need to have access to the physician services for obesity management care.  Periodic health assessments by a weight loss health care professional for proper management of the disease is required.  Also access to fitness centers and health food stores to aid in the continuation of a healthier lifestyle.  Accessibility to the services provided, along with commitment to the recommendations will result in weight loss and the ability to maintain it.

 

Financial Resources – Patients who have the financial resources to pay for the physician’s care management, healthier foods, gym memberships, counseling, and any prescription medications needed, show better continuity of care in managing obesity and weight loss.  Better continuance of care for obesity will result in a patient with a well-managed weight loss.

Health Insurance – A patient with health insurance can use the insurance for payment purposes to aid in weight loss management, prescriptions medications, and bariatric surgery for the morbidly obese.  Insured patients result in continuity of care for obesity and results in a well-managed weight loss with the ability to maintain it. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A4a.  Unmanaged Disease Factors

           
The same factors can also impact a patient’s inability to manage their obesity.  The following shows how the factors can affect the patient’s inability to manage their weight loss:

 

Access to Care – Patients will need to have access to the physician services for obesity   management care.  Periodic health assessments by a weight loss health care professional for proper management of the disease is required.  Also access to fitness centers and health food stores to aid in the continuation of a healthier lifestyle.  Patients can have lack of access to these services due to:  a) lack of weight loss providers, b) lack of resources to access the care, c) lack of transportation, d) lack of fitness centers and health food stores in patient area.  Lack of accessibility to the services provided will likely result in a patient that remains obese and is unable to manage any weight loss.

 

Financial Resources – Patients who do not have the financial resources for physician’s management, healthier foods, gym memberships, counseling, prescription medications, or surgery, are likely to result in poor obesity management.

 

Health Insurance – A patient who has no insurance is less likely to seek obesity management care.  Health insurance can help pay for physician visits and prescription medications.  Insurance also pays for bariatric surgery in the morbidly obese.  Lack of health insurance will result in little or no management for the obese patient.

A4ai.  Unmanaged Disease Characteristics

           
Managing weight loss is a lifestyle change that must continue even after the weight loss goal is accomplished.  Some patients have a difficult time maintaining a healthier lifestyle and regain the weight, or they may never lose the weight.  There are many reasons why a patient may not be able to manage their obesity.  Some of the reasons are:  lack of access to care, lack of financial resources for care, and lack of health insurance.

An obese patient has increased risks for type 2 diabetes mellitus, hypertension, heart disease, dyslipidemia, cerebrovascular disease, metabolic syndrome, pulmonary abnormalities, gastrointestinal abnormalities, reproductive disease, psychosocial problems, osteoarthritis, and cancer.  Obesity also prevents some access to care.  For example, MRI machines have weight limits of up to 450 pounds.  Surgical mortality is increased with obesity and some surgeons may choose not to operate due to the associated risk of mortality (“Complications of obesity in adults:  A short review of the literature,” n.d.).  These potential comorbidities and increased risks are all associated with a patient that is unable to manage their obesity.

Patients, Families, and Populations

           
Patients who have managed their obesity and were able to reach a healthy weight are expected to live a happier life.  With a normal BMI, a patient can participate in more physical activities and continue their career with no health-related risks.  There is also less hassle for the family to have to care for the patient who is obese and unable to care for themselves.

Patients who are unable to manage their obesity are more likely to develop one or more of the comorbidities (heart disease, diabetes, or hypertension) associated with obesity.  Due to the increased weight and other related diseases the patient is more likely to be out of work frequently or permanently.  When a patient has no income and no insurance then assistance is needed from family members or friends and is going to cause more undue stress.  Financial problems will also arise from the medical bills incurred due to the obesity and related issues.

Approximately 31% of adults in my community are obese.  The higher prevalence of obesity is among African Americans.  Alabama ranked 5th in the prevalence of obesity in 2012 (“State of Alabama Community Health Assessment 2015,” n.d.).  The local county health department also offers many programs and assistance to those in need.  A supplemental nutrition program for women, infants, and children (WIC) is a program that information on nutrition and healthier foods (“WIC Program | Alabama Department of Public Health (ADPH),” n.d.).

B1.  Costs

           
According to the CDC, obesity and the comorbidities associated with the disease economically affect the health care system. Medical costs are directly affected due to preventive, diagnostic, and treatment services that are associated with obesity.  The costs are indirectly affected due to decreased productivity at work and absenteeism.  In 2008 the estimated costs of care for the obese patient was $147 billion.  Nationwide productive costs related to obesity or absenteeism related to obesity was estimated at $3.38 billion to $6.38 billion (“Adult Obesity Causes & Consequences | Overweight & Obesity | CDC,” 2017)

A study done in 2006 showed that obese people spent an estimated 42 percent more on medical spending than the normal-weight people.  Obesity related medical costs are estimated to be increased by 37 percent.  Increases in annual costs were estimated at 36 percent for Medicare, 47 percent for Medicaid, and 58 percent for private pay patients (“Annual Medical Spending Attributable to Obesity:  Payer and Service-Specific Estimates,” n.d.).

The cost of diagnosing obesity and managing weight loss can vary depending on the management plan.  If the patient is insured and the management plan is covered by insurance, then the only cost would be co-pays and deductibles that must be met by the patient.  For the morbidly obese patient that bariatric surgery is indicated for treatment, then insurance would cover the surgery and follow up appointments.

The cost can be significant for the private paying patients.  A diet clinic in the author’s community (no insurance accepted) has a $60 charge for an office visit.  Other local physician offices have a $75 charge for an office visit for weight management treatment.  Prescriptions medications can also vary in price and insurance may or may not cover the cost.  A prescription of phentermine for thirty days is approximately $22 at a local pharmacy.  Naltrexone/bupropion prescriptions can range from $55 to $200 a month.  And the cost for bariatric surgery can range from $10,000 to over $20,000, depending on which surgery the patient and the physician determine is best.

Best Practices Promotion

           
Best practice promotion in an Obstetrician and Gynecology (OB/GYN) office setting, the author’s practice setting, is to increase patient awareness on the importance of weight control and physical activity during pregnancy and after delivery.  Also by following the current standards of practice for obesity, updating provider knowledge on the current practice guidelines would promote best practices.

C1.  Implementation Plan

           
The current setting this author is mainly involved in is obstetrics patients during pregnancy and up to 6 weeks postpartum.  The three strategies chosen for plan implementation include:

Development of a healthy diet and physical activity plan for patients during pregnancy and after delivery.  A healthy, well-balanced diet and daily physical activity can help a patient maintain a healthy pregnancy and manage weight loss after delivery.

Development of a dietician/nutritionist counselor. The counselor will provide patients with education on current guidelines for care related to managing obesity.  The counselor will also provide each patient a specific diet and activity management plan based on the patient’s specific needs and abilities.

Development of provider and counselor education programs on the most current guidelines for obesity management. The programs will be available online and the providers and counselor will be required to complete the programs annually.Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

C2.  Evaluation Method

           
Evaluation of success of the three strategies stated above are as follows:

The success of the healthy diet and physical activity plan with be shown by the patient maintaining a normal weight gain during pregnancy and returning to the pre-pregnancy weight after delivery.

The success of the counselor will be shown by the patient verbalizing her understanding of obesity guideline education. Also, success will be shown by the patient choosing healthier food options and choosing to participate in daily physical activity. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

The success of the provider and counselor programs will be shown with completion of the online learning. And with chart documentation that shows the standard guidelines for obesity are being met by the providers and counselor.

Resources

Adult Obesity Causes & Consequences | Overweight & Obesity | CDC. (2017, August 29). Retrieved from https://www.cdc.gov/obesity/adult/causes.html

Annual Medical Spending Attributable to Obesity: Payer and Service-Specific Estimates. (n.d.). Retrieved from http://content.healthaffairs.org/content/28/5/w822.full.pdf+html

Complications of obesity in adults: A short review of the literature. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062780/ Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Diagnosis – NHLBI, NIH. (n.d.). Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/obe/diagnosis

Diagnosis and Management of Obesity. (n.d.). Retrieved from http://aafp.org

Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults — United States, 2006–2008. (n.d.). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.html

McCance, K., & Huether, S. (2014).
Pathophysiology: The biologic basis for disease in adults and children, 7th Edition
[Western Governors University]. Retrieved from Retrieved from
https://wgu.vitalsource.com/#/books/9780323088541/

New Obesity Guidelines: Authoritative ‘Roadmap’ to Treatment. (2013, November 12). Retrieved from http://www.medscape.com

NIH study finds extreme obesity may shorten life expectancy up to 14 years. (n.d.). Retrieved from
https://www.nih.gov/news-events/news-releases/nih-study-finds-extreme-obesity-may-shorten-life-expectancy-14-years

 

Resources

 

The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033553/ Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Special Report: Racial and Ethnic Disparities in Obesity. (n.d.). Retrieved from https://stateofobesity.org/disparities/

State of Alabama Community Health Assessment 2015. (n.d.). Retrieved from http://www.alabamapublichealth.gov

The State of Obesity: Obesity data trends and policy analysis. (2017, August 31). Retrieved from http://stateofobesity.org

Strategies to Prevent Obesity. (2015). Retrieved from
https://www.cdc.gov/obesity/index.html

Update on Office-Based Strategies for the Management of Obesity – American Family Physician. (2016, September 1). Retrieved from http://www.aafp.org/afp/2016/0901/p361.html

WIC Program | Alabama Department of Public Health (ADPH). (n.d.). Retrieved from http://www.alabamapublichealth.gov/dekalb/wic.html Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Nursing theories essay examples

Importance of Nursing Theory

Nursing theory was largely neglected after Florence Nightingale first defined nursing in 1860 with her writing of
Notes on Nursing: What it is, What it is Not
(Zborowsky, 2014). Nursing theory and models grew exponentially beginning in the 1950’s (McCrae, 2012). Early nurse theorists recognized the need to distinguish the profession from medicine and the traditional “handmaiden status”; the path to accomplish this is through theory by establishing nursing as a “thinking profession (McCrae, 2012) nursing theories essay examples. Continuing to develop nursing theory and define the nursing profession is what will protect and define nursing as a profession rather than a discipline.

BUY A PLAGIARISM-FREE PAPER HERE

The purpose of this paper is to explore the importance of nursing theory for the nursing profession, to discuss Kristen Swanson’s Theory of Caring, how this theory meets all four recognized relationships of the nursing metaparadigm and its application to the role of nurse practitioner.

Importance of Nursing Theory for the Nursing Profession

Nursing theory is essential to the profession of nursing on many levels. Theories help to define the discipline and play an important role in research and  concept development helping to discover more facets of nursing for research (Im and Chung, 2012). Generating theory consolidates the nursing profession and ensures new roles are created and founded on “critically appraised science base” (Power, 2016, p.42) Nursing is never static; roles are expanding providing care once done by doctors. Nursing theory ensures a close linkage to research making implementation at the practice level more practical as well as providing the evidence base needed for further theoretical development (Warelow, 2013). Theory is crucial in propelling the profession of nursing and to “protect and preserve the focus and clarity of nursing’s distinct contribution to health care” (Wilson et al. 2015, p.146). In today’s multidisciplinary setting of healthcare, the nursing profession continues to strive to define and maintain its professional boundaries as well as expand its body of knowledge (Warelow, 2013).

The study of nursing theory aids in application of theory to everyday practice and patient/client interactions. Through study of nursing theory, graduate students reflect upon experiences from their practice and how application of theory aided in treatment of patients or how the lack of knowledge in theory hindered the person-nurse relationship. According to Hatlevik (2011), the teaching of nursing student in using reflective skills directly influences coherence of theoretical knowledge to practice.

Swanson’s Theory of Caring

Kristen Swanson first introduced the Theory of Caring with the introduction of Five Caring Processes in 1991 with the publishing
Empirical Development of a Middle Range Theory of Caring
, later expanding and reorganizing the caring processes in 1993 and 1998 (Wands, 2011;  Amendolair,2012). The five caring processes identified are
maintaining belief, knowing, being with, doing for, and enabling.

The process of maintaining belief is a “fundamental belief in persons and their capacity to make it through events and transitions and face a future with meaning” (Wands, 2011 p.182). Nurses who maintain belief in their patients help patients find belief in themselves that they can get through whatever circumstance, by offering hope to them. “Knowing is the anchor that moors the beliefs of nursing/nursing to the lived realities of those served (Swanson, 1991, p.164)” (Amendolair, 2012, p.15). Knowing is learning and attempting to understand events and how they affect the person (Wands, 2011). Swanson’s third caring process is being with;  be with the patient, giving time to the patient and offering presence. Offering of one’s self and time conveys a message to the patient that they matter (Wands, 2011). Preserving life and dignity through caring actions is the fourth process of doing for (Amendolair, 2012). Doing for is not just the action, but predicting what the person would do if they could do it for themselves. Lastly, Swanson defines enabling as “to facilitate the other’s capacity to grow, heal, and/or practice self-care (p.164)” (Wands, 2011, p.184). Enabling equips the patients with the tools and empowerment to care and provide for themselves. These processes provide the foundation of Swanson’s Theory of Caring as well as the research of caring (Wands, 2011).

Theory of Caring and the Nursing Metaparadigm

The widely accepted metaparadigm concepts introduced by Fawcett are person, nurse, environment, and health (Alimohammadi, Taleghani, Mohammadi & Akbarian, 2014). Swanson’s five processes presented in the theory of caring meets all facets of the metaparadigm; person and health, person and environment, health and nurse, and person, environment and health. Maintaining belief and being with fulfills the person-environment-health metaparadigm, knowing is the person-environment, health-nurse can easily be related to doing for, and enabling fulfills the person-health concept of Fawcett’s nursing metaparadigm.

Maintaining belief and being with is a fundamental process in the person-environment-health relationship. Maintaining belief in the person is to encourage and give hope that the person can and will transition out of the current situation (Amendolair, 2012). Being with is arguably the most misunderstood process for nurses but is the most important (Wands, 2011). Spending one-on-one time by being emotionally present with the patient builds a trusting relationship encouraging the patient and nurse’s reception and giving of information from the other (Wands, 2011). These concepts lend to the metaparadigm by acknowledging the person, establishing trust, providing hope and being emotionally present helping to enhance the interaction the nurse has with the person-health-environment. These two processes are holistic in nature by maintaining belief and being with recognizing the person as a whole and all the facets of; the person, their health and their environment. This relationship is always interacting; one affects the other and so on.

Knowing is learning and appreciating the lived experiences of the patient. Knowing relates to the person-environment through subcategories Swanson describes in 1998. These subcategories are avoiding making assumptions, thoroughly assessing, seeking cues, centering on the person who is receiving care and engaging personhood (Wands, 2011). Avoiding assumptions relies on the nurse to have a good understanding of self and their own beliefs as to not make assumptions of the person but rather “knowing the other from place of meaning and deliberate intention” (Wands, 2011). The nurse needs to thoroughly assess and seek cues that can help the nurse understand the person-environment relationship. How does the patient present? Does the body language match verbal cues? These are just a sample that can lead the nurse to examine deeper the person-environment metaparadigm and understand the patient and their life events. Through this investigation and knowing, the nurse can better understand how to empower the patient to manipulate the environment to meet their immediate health and wellness needs.

Doing for is the most recognized process by nurses (Wands, 2011). The health and nurse metaparadigm is relatable in the process of doing for. This is the tasks of nursing, the act of doing for the patient when they cannot do it for themselves leading to a better state of health. Doing for requires more than just technical skills, it requires experience and scientific evidence-based knowledge to support the decisions and actions taken. “Care that is, doing for is comforting, anticipatory, protective of the other’s needs, and performed competently and skillfully (Swanson, 1991, p.164)” (Wands, 2011).

Enabling as defined by Swanson is empowering the patient to cope with their illness by teaching, explaining, supporting, and providing feedback about the illness in turn enabling them to make decisions about their care (Amendolair, 2012). The person is then educated about resources and empowered to make changes that are necessary to improve health and promote wellness. Empowerment through enabling supports the person and helps them find meaning and strength to move forward with their decisions, no matter what that decision may be.

Caring, being the central phenomena of nursing, is supported by Swanson’s theory of caring (Ahern, Corless, Davis & Kwong, 2011). Theory can feel abstract and not easily translated to practice, leading to practitioners to experience a disconnect from caring science theory and caring practice (Ranheim, Karner & Bertero, 2012). Swanson’s theory of caring, being a middle-range theory, lends itself to easy implementation and application to the interaction of nurse practitioners and their patients.

Application of Swanson’s Theory of Caring for Nurse Practitioners

Understanding caring as the central phenomena of nursing is an integral part of becoming a successful nurse practitioner. By using Swanson’s five caring processes a nurse practitioner (NP) practices patient-centered care. Patient-centered care ultimately enables and empowers the patient to make necessary decisions and actions that will promote well-being. Establishing a trusting, respectful relationship through maintaining belief, knowing, being with, doing for, and enabling is an important part of the patient-NP relationship. The NP-patient relationship is characterized by the willingness of NPs to talk with patients and to attentively listen(knowing and being with) to create treatment regimens (doing for) while providing teaching and health promotion (enabling) all the while maintaining belief in the patient.

In my own professional experience I have used the five processes of Swanson’s theory of caring. In 2004, I was the nurse taking care of a new mother that had suffered with HELLP that ultimately led to fetal demise. She was transferred into our ICU after the birth of her stillborn baby. Knowing I had recently experienced this myself, I was assigned to the mother. I could connect with her in ways others felt they could not. I was able to offer her and her family hope through maintaining belief that she will get through this. Knowing her by learning what her fears were, her dreams for the baby were and what she wanted in the future. Being with was simply holding her hand or a hug and crying with her. Doing for her the things she could not at the time due to IV lines and weakness. Enabling her, by providing resources to help with child loss and grief and a journal to express her anger, sadness, and hopelessness. Through all of this, I was able to help her not bring closure, as I believe there is no closure when losing a child, but I rather equipped her with tools to help her to try to make sense of what happened.

Ahern et al. (2011) cared for a 38-year old Caribbean woman that had undergone several invasive and diagnostic procedures relating to a neoplasia. While suffering depression and the recent loss of her parents, she received a diagnosis of high-grade dysplasia. After missing two appointments she arrived at the clinic and expressed her fears and anxiety related to the diagnosis and pain of the procedure. The procedure was explained in depth to her hoping to ease her fears. Unfortunately, she was unable to finish the procedure. The authors surmise that if a holistic advanced nurse practice model had been utilized, there may potentially been a different clinical outcome. Swanson’s theory of caring and its five care processes: maintaining belief, knowing, being with, doing for, and enabling became part of the clinics holistic approach for their advanced practice nurse model.

Conclusion

Theory can feel abstract and not easily applied to everyday practice. The graduate prepared nurse offers patients care through full understanding of theory and its implications in caring for the person. McCrae (2012) states the ability to generate and apply theory is what lends to a legitimate profession. Swanson’s theory of caring, being middle-range, is evidence based through interactions of patients and professional nurses. Offering empirical evidence, in today’s evidence-based health care system her theory lends itself to easy application.  “Theory is central in developing nursing knowledge and to asserting nursing as a professional occupation” (Power,2016, p.45).

Nurse practitioners implement caring theory by maintaining belief, knowing, being with, doing for, and enabling resulting in a holistic approach to patient-centered care. Upon reflection and examination of the five processes of Swanson’s theory of caring and the nursing metaparadigm, the author acknowledges that all five processes are related to each of the four metaparadigms. Not unlike the nursing metaparadigm, all five processes build upon each other; no process is independent of the other.

References

Ahern, R. L., Corless, I. B., Davis, S. M., & Kwong, J. J. (2011). Infusing Swanson’s Theory of caring into an advanced practice nursing model for an infectious diseases anal dysplasia clinic.
The Journal Of The Association Of Nurses In AIDS Care: JANAC
,
22
(6), 478-488. doi:10.1016/j.jana.2011.06.010

Alimohammadi,N., Taleghani, F., Mohammadi,E., & Akbarian,R. (2014). The nursing metaparadigm concept of human being in Islamic thought.
Nursing Inquiry 21
(2), 121-129. doi:10.1111/nin.12040

Amendolair, D. (2012). Caring model: putting research into practice.
International Journal for Human Caring 16
(4), 14-21.

Im, E. & Chang, S.J. (2012). Current trends in nursing theories.
Journal of Nursing Scholarship 44
(2), 156-164. doi:10.1111/j.1547-5069.2012.01440.x

Hatlevik, I.K.R. (2011). The theory-practice relationship: reflective skills and theoretical knowledge as key factors in bridging the gap between theory and practice in initial nursing education.
Journal of Advanced Nursing 68
(4), 868-877. doi:10.1111/j.1365-2648.2011.05789.x

McCrae,N. (2012). Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care.
Journal of Advanced Nursing 68
(1), 222-229. doi:10.11111/j.1365-2648.2011.05821.x

Power, L. (2016). Nursing theory and the delivery of compassionate care.
Nursing Standard 30
(24), 41-46.

Ranheim, A., Karner, A. & Bertero, C. (2012). Caring theory and practice-entering a simultaneous concept analysis.
Nursing Forum 47
(2), 78-90. doi:10.1111/j.1744-6198.2012.00263.x

Wands, L.M. (2011). Caring for veterans returning home from middle eastern wars.
Nursing Science Quarterly 24
(2), 180-186. doi:10.1177/0894318411399450

Warelow, P.J. (2013). Changing philosophies: a paradigmatic nursing shift from Nightingale.
Australian Journal of Advanced Nursing 31
(1), 36-45.

Wilson, R., Godfrey, C.M., Sears, K., Medves, J., Ross-White, A. & Lambert, N. (2015). Exploring conceptual and theoretical frameworks for nurse practitioner education: a scoping review protocol.
JBI Database of Systemic Reviews and Implementation Reports
.
13
(10), 146-155. doi:10.11124/jbisrir-2015-2150

Zborowsky, T. (2014). The legacy of Florence Nightingale’s environmental theory: nursing research focusing on the impact of healthcare environments.
Health Environments Research and Design Journal 7
(4), 19-34.

 

 

Grand Theorist Report

There are many grand nursing theories that have helped to set the foundation for the nursing profession. Faye Abdellah was one of the first pioneers for shaping nursing as a profession using her framework for Patient-Centered Approaches to Nursing. Abdellah’s theory is easy to apply to nursing practice in a healthcare institution because her framework is readable and clear (McEwen & Wills, 2014). In addition, another rationale for implementing her theory into practice at a healthcare institution is the fact that it clearly addresses the four metaparadigms—person, environment, health, and nursing. In this paper, we will discuss the theorist Faye Abdellah, her theory on Patient-Centered Approaches to Nursing, and how this theory can be integrated into practice at a healthcare institution.

Description of Theorist

Faye Abdellah was born in New York City on March 13, 1919. Abdellah decided at a very young age she wanted to pursue a career in nursing. She received her original certification in nursing from Fitkin Memorial Hospital. She continued her study of nursing at Columbia University getting her BA in Nursing along with her doctorate degree, which focused on psychology and education (Dewey, 2016).

Abdellah was highly influential in the profession of nursing. She was the Chief Nursing Officer and Deputy United States Surgeon General until 1993, and she was ranked as a Rear Admiral. She retired in 2000 from her last position as Dean of the Graduate School of Nursing at the Uniform Services University of Health Sciences (McEwen & Wills, 2014). As a whole, throughout her career Abdellah received many academic honors for her achievements in nursing. Her main focus was to reshape nursing as a profession by encouraging nurses to look past a physical illness or diagnosis and see “patients as people with a complex of emotional and psychological needs” (Dewey, 2016, n.p.). Clearly, this concept of looking at patients as more complex beings significantly helped to influence and shape her Patient-Centered Approaches to Nursing.

Category of Theory

Abdellah’s Patient Centered Approaches to Nursing is considered a grand nursing theory that is based on human needs. She believed that patients should be seen as ‘people’ who have individual unique needs that require personalized care from nurses. Furthermore, Abdellah developed her theory based on how she practiced while providing care to patients—which is what helps to make the theory highly applicable. McEwen & Wills (2014) further explain that Abdellah’s theory is applicable not only in the hospital setting, but also in the community setting.

Assumptions Underlying the Theory

Abdellah’s original theory did not have any stated assumptions; however, as time passed she did add the following six assumptions related to: 1) change and anticipated changes that impact the nursing profession, 2) the importance of how social enterprises and social problems are related, 3) how poverty, racism, pollution, education, etc. impact health and health care delivery, 4) changes in nursing education, 5) continuing education for nurses, and 6) development of nursing leaders (McEwen & Wills, 2014).

In addition, it is important to clearly define the metaparadigm concepts/assumptions underlying the theory as well. Abdellah’s Patient-Centered Approaches to Nursing is all encompassing, and the metaparadigms addressed in the theory are related to person, environment, health, and nursing.

 

 

Person

Person is defined as the patient needing care. McEwen & Wills (2014) explain that Abdellah’s theory views the patient as the “individual who needs nursing care and who is dependent on the health care provider” (p. 141). When using Patient-Centered Approaches to Nursing, it is important to know that Abdellah emphasized the significance of individualized care and knowing the person’s needs.

Environment

When using Abdellah’s theory, it is important to know that the environment from the patient’s standpoint is interconnected to include not only the physical environment, but also external factors that impact the patient such as social problems, poverty, racism, etc. These are all factors within the environment that affect the health of patients and how they approach health care delivery (McEwen & Wills, 2014).

Health

Health can be viewed as a better state of being. The purpose of Abdellah’s theory is to identify problems that are negatively impacting patients and eliminating these problems. Later we will discuss Abdellah’s 21 Nursing Problems and nursing’s responsibility to identify these problems.

Nursing

Nursing is considered “a service to individuals and families to society, which helps people cope with their health needs” (McEwen & Wills, 2014, p. 141). Nursing is expected to identify nursing problems and work collaboratively with the healthcare team to ensure that patients get desired outcomes.

 

 

Major Concepts of the Theory

The major concepts related to Abdellah’s theory involve using ten steps to identify and develop treatment to nursing problems related to patients. Abdellah explains that there are 21 basic nursing problems related to patients, and it is important for nurses to know these identified nursing problems so they can use them while trying to identify what needs to be the plan of care. Below is an abbreviated version of Abdellah’s 21 Nursing Problems.

Abdellah’s 21 Nursing Problems

Maintenance of Hygiene and Comfort

Recognition of physiological responses to conditions

Maintenance of Nutrition for Body Cells

Promotion of activity, exercise, rest, etc.

Maintenance of normal body functions

Achievement of spiritual goals

Promotion of Safety

Appropriate sensory function

Maintenance of Therapeutic Environment

 

 

Maintenance of Proper Body Mechanics

 

Identification and acceptance of positive and negative expressed and reacting appropriately

 

Awareness of physical, emotional, and developmental needs

 

Appropriate Oxygenation

 

Understand relationship between emotions and illness

 

Acceptance of optimal goals despite physical & emotional limitations

 

Appropriate Elimination

 

Maintenance of appropriate verbal and nonverbal communication

 

Willing to use community resources

Maintenance of Fluid & Electrolyte Balance

Development of positive interpersonal relationships

Recognition that social problems impact illness

(McEwen & Wills, 2014)

Clearly, it is very important to know the 21 Nursing Problems because these are the problems nurses must link to their findings while using the ten steps for identification and development of a nursing care plan. The ten steps build upon each other from learning about the basics of a patient, then getting more specific to identify the exact nursing problem(s) that need to be addressed. Below are the ten steps that nurses must follow to successfully develop a plan of care and reach expected patient outcomes.

Ten Nursing Skills to Identifying Problems & Developing a Treatment Plan

1.      Get to know the patient

6. Validate conclusions with patient

2.      Define relevant and irrelevant information

7. Observe and Evaluate Patient

3.      Develop generalizations

8. Evaluate patient & family reaction to plan— incorporate family in care if possible

4.      Identify a therapeutic nursing plan

9. Nursing’s perception of patient’s problems

5.      Test generalizations and modify plan if needed

10. Discuss & develop a nursing care plan

(McEwen & Wills, 2014)

Understanding how to use the 21 Nursing Problems along with the Ten Nursing Skills is important for nurses to grasp in order to see the full potential of this nursing theory for patients. Each of the Ten Nursing Skills needs to be followed so nurses can individualize care plans and work collaboratively with the patient and family to improve the patient’s state of health.

Major Propositions

The major proposition of Abdellah’s theory focuses on looking at the patient as a human being, not an illness.  While her theory touches on many factors, it primarily focuses on patient centered care (McEwen & Willis, 2014).  Due to its broad nature, it is testable in principle such as patient satisfaction and nursing care.

How has it been used?

In the past, Abdellah’s theory has been used in nursing education and nursing research.  In nursing education, her theory has been used to organize lectures and curricula by categorizing nursing problems based on the patient’s needs and developing a classification of nursing skills and treatment (McEwen & Willis, 2014).  Abdellah’s nursing theory has also been used in research such as patient-centered approach to nursing, evolution of nursing, perspectives on nursing theory, public policy impacting on nursing care of older adults, and preparing nursing research for the 21
st
century to name a few (McEwen & Willis, 2014).

Action Plan

It would behoove this institution to adopt Abdellah’s theory as a foundation of practice.  The following action plan could be used as daily practice for all nurses to not only hone their critical thinking skills, but to also give more person centered care (PCC).  PCC is important and has been a focus for many healthcare institutions for years.  In 1969, Edith Balint described person centered care as “understanding the patient as a unique human being” (Santana et al., 2017, p. 430).  Many healthcare systems are adopting a PCC to help gauge high quality care.

This action plan would focus around the Person-Centered Nursing (PCN) Framework developed by McCormack and McCance.  The PCN Framework comes from research focusing on PCC with older people and the experience of caring in nursing (McCance, McCormack, & Dewing, 2011).  The PCN Framework is comprised of four steps.

The first is prerequisites, which focuses on the professional competence of the nurse and his or her commitment to their job.  The nurse needs to be able to demonstrate their beliefs and values and know himself or herself before they can move on.  The second step is the care environment.  This includes if the nurse and the service line are an appropriate fit, making sure the nurse is equipped with the skills and the knowledge to take care of patients.  It is important that the heath care system is organized and can offer a supportive system for its employees so that they can safely deliver patient care and have effective relationships with one another.  Third is person-centered process, which can be thought of as one of the most important steps.  This step includes care that is focused on cultural competence, employee and patient engagement, staff being present, and providing holistic care.  The fourth and final step is outcomes.  This is known as the central component of the PCN Framework and where we can tie it all together.  This includes patient and nurse satisfaction, feeling of well being, and obtaining a therapeutic work environment (McCance et al., 2011).

Integration

A PCC Team would need to come together to develop current data within their hospital.  Data would include patient satisfaction scores, nurse satisfaction scores, readmission rates, and a basis of patient-centered care knowledge among nurses by developing a questionnaire for them to fill out.  The PCC Team would them form a class for all currently employed nurses with an in depth explanation of the PCN Framework and what each step includes.  Role-playing and case studies could be used in order to help staff put PCC into play in a practice setting.  This portion would be integral to the roll out of PCC because it helps nurses to see the importance of person-centered care within their own healthcare setting and would help them to deliver higher quality care (McCance et al., 2011).  Once staff is completely trained, leaders will be able to put the PCN Framework into action.  According to McCance et al.,  “using the Framework ‘in action’ within the workplace as a tool to evaluate care during handovers or during analysis of critical events, both positive or negative; and using the Framework to assess the experience of patients being cared for in each site” (para. 17) we can evaluate the outcomes listed previously: patient satisfaction scores, nurse satisfaction scores, and readmission rates.  It would be important to reevaluate the nurses after one year with the same questionnaire that was handed out at the beginning of the PCN Framework roll out.  The PCC Team would be able to assess their effectiveness in delivering the information and the data from the satisfaction scores and readmission rates would give them the ability to verify how well the PCN Framework works.

After data is collected, the PCC Team would move forward in presenting the information to all new hire nurses and developing a curriculum for preceptors to be able to teach the PCN Framework and to help to develop new nurses within it.  It would be important to continue with the PCC knowledge questionnaire so the PCC Team can continue to evaluate the efficiency of their team.  After one year of new hire education, the team will then collect satisfaction scores and readmission rates to submit to the Board of Directors for the healthcare institution so that the PCN Framework can be presented as a standard of practice in all hospitals within the healthcare institution.

In conclusion, health care costs are rising at an exponential level and due to this rise; patients and their insurance companies are expecting higher-grade care.  Nursing as profession needs to move towards a more patient centered approach.  Without this approach, nursing is just assumed to be medicine and patients will continue to feel that they have no place in their care team.  Currently, patients are being told what medications they should take, when they should take it, and who will be overseeing their care.  In order to reduce readmission rates and subsequently cut costs, patients need to have ample say in their treatment plan and should be able to have open conversations with their caregivers about how they feel about their illness and their plan of care.  If they feel their nurses are competent in their skills and that they truly care about their wellbeing, patients will feel safer and more willing to speak up when they do not understand something and will trust in their care plan to continue it after discharge, thus reducing their risk of readmission.

 

References

Dewey, J. P. (2016). Faye Abdellah.
Salem Press Biographical Encyclopedia
. Retrieved from

http://eds.b.ebscohost.com.lopes.idm.oclc.org/eds/detail/detail?vid=4&sid=b8238afd-f12d-4800-89ca-ff4e2c58d36d%40sessionmgr101&bdata=JnNpdGU9ZWRzL

WxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=113931050&db=ers

McCance, T., McCormack, B., & Dewing, J. (2011, May 2). An exploration of person-centeredness in practice.
The Online Journal of Issues in Nursing
,
16
. http://dx.doi.org/10.3912/OJIN.Vol16No02Man01

McEwen, M., & Willis, E. M. (2014).
Theoretical Basis for Nursing
(4 ed.). Philadelphia: Lippincott Williams & Wilkins.

Santana, M. J., Manalili, K., Jolley, R. J., Zelinsky, S., Quan, H., & Lu, M. (2017, September 30). How to practice person-centred care: A conceptual framework.
Health Expectations
, 429-440. http://dx.doi.org/http://dx.doi.org.lopes.idm.oclc.org/10.1111/hex.12640

 

1.

Grand nursing theories that are based on human needs include all but one of the following. Which is not considered to be a part of needs-based theories?

A)

Focus is on the client.

B)

Client is considered biopsychosocially.

C)

Individual parts of the client are considered.

D)

Interventions are prescribed to meet client needs.

 

 

2.

Florence Nightingale developed a model for nursing practice that was inductively derived based on her experiences during a time of war. What is the model considered by most nursing scholars?

A)

Philosophy

B)

Practice theory

C)

Schema

D)

Research theory

 

 

3.

One of the concepts of Nightingale’s model included the following five points: pure air, pure water, efficient drainage, cleanliness, and light. In which concept are these five points included?

A)

Social considerations

B)

Personal cleanliness

C)

Ventilation and warming

D)

Health of house

 

 

4.

The nurse theorist Virginia Henderson developed which theory?

A)

The Principles and Practice of Nursing

B)

Patient-Centered Approaches to Nursing

C)

The Self-Care Deficit Nursing Theory

D)

The Behavioral System Model

 

 

5.

In the theory by Virginia Henderson, The Principles and Practice of Nursing, she defines nursing and considers her definition of nursing which of the following?

A)

A concept

B)

A model

C)

An assumption

D)

An axiom

 

 

6.

One nurse theorist and her colleague listed 10 steps in identifying the client’s problems and 10 nursing skills to be used in developing a treatment typology. Who is this nurse theorist?

A)

Betty Neuman

B)

Dorothy Johnson

C)

Faye Abdellah

D)

Florence Nightingale

 

 

7.

The nurse theorist Dorothea E. Orem developed which nursing theory?

A)

Patient-Centered Approaches to Nursing

B)

The Self-Care Deficit Nursing Theory

C)

The Principles and Practice of Nursing

D)

The Behavioral System Model

 

 

8.

Included in The Self-Care Deficit and Nursing Theory by Orem, there are three nested theories. Which is not one of the nested theories?

A)

Self-care

B)

Nursing system

C)

Family system

D)

Self-care deficit

 

 

9.

The nurse theorist Dorothy Johnson developed which nursing theory?

A)

The Behavioral System Model

B)

The Principles and Practice of Nursing

C)

The Self-Care Deficit Nursing Theory

D)

Patient-Centered Approaches to Nursing

 

 

10.

In the theory developed by Dorothy Johnson, The Behavioral System Model, she incorporated all but one of the following into her theory. Which one is not included?

A)

Systems theory

B)

Human behavior

C)

Stress

D)

Family

 

 

11.

Which of the following theories was founded on general systems theory, stress theory, and stress and coping theory?

A)

The Neuman Systems Model

B)

The Self-Care Deficit Model

C)

Patient-Centered Approaches to Nursing

D)

The Principles and Practice of Nursing

 

 

12.

In the model by Betty Neuman, she focused on system theory, human needs of protection, or relief from stress. Which of the following was emphasized by her theory?

A)

Humans have a need for dynamic balance that the nurse can provide.

B)

The healthful house is a vital concept.

C)

Nurses should care for the patient until the patient can care for self.

D)

Behaviors should be organized around specific goals.

 

Abraham Maslow

Question

Maslow focused his theory of motivation on the hierarchy of human needs (Hergenhahn & Olson, 2011). The hierarchy of human needs is divided into two different categories: deficiency needs and growth needs. Deficiency needs or basic needs, are the needs at the bottom of the pyramid, these needs must be met before it becomes possible for a person to move into the growth area (Buskirk-Cohen, April 24, 2012). Growth needs or Meta needs, are the higher needs, these needs may emerge once the basic needs are met (Buskirk-Cohen, April 24, 2012).   The hierarchy of needs is then broken down into five subcategories: physiological needs, safety needs, belongingness and love needs, esteem needs, and self-actualization needs (Hergenhahn & Olson, 2011).

Physiological needs are the most basic cluster of needs in the hierarchy of needs; this includes the needs for water, food, oxygen, sleep, elimination, and sex (Hergenhahn & Olson, 2011). Safety needs are the second cluster of needs in the hierarchy of needs; these needs include the need for order, security, and predictability (Hergenhahn & Olson, 2011). Belongingness and love needs are the third cluster of needs in the hierarchy of needs; these needs include the needs for affiliation with others and for the feeling of being loved (Hergenhahn & Olson, 2011). Esteem needs are the fourth cluster of needs in the hierarchy of needs; these needs include the need for status, prestige, competence, and confidence (Hergenhahn & Olson, 2011). The last cluster in the hierarchy of needs is the self- actualization, this is the highest level which can only be reached if the preceding need levels have been met; the self-actualizing individual operates at full capacity and is B-motivated rather than D-motivated (Hergenhahn & Olson, 2011). A D-motivated, or deficiency motivation, person is a person that is influenced by the absence of the things such as food, love, or esteem; these people are characterized as people who are not self-actualizing (Hergenhahn & Olson, 2011).  B-motivated people are people who have met the level of self-actualization; these people include values such as truth, goodness, beauty, justice, and perfection (Hergenhahn & Olson, 2011).

According to the personality theories workbook, Cindy was malnourished baby, she did not receive much love when she was a baby, and her living conditions were not the safest in the world. Cindy’s pediatrician noticed that Cindy was not the correct weight during her first checkup, babies are usually supposed to lose some weight when they stay in the hospital and then they are supposed to regain that weight and sometimes more by the time they are two weeks old (Ashcraft, 2009). But the pediatrician noticed that four week old Cindy did not gain additional weight after leaving the hospital (Ashcraft, 2009). Noticing these things about Cindy, she obviously was not meeting the first need of physiological need of being fed and being taken care of.

Children and Youth Services were then called and Cindy was put into a foster home. The foster home she was placed into did not really care for Cindy either; they were in it for the compensation checks (Ashcraft, 2009). The foster parent’s showed her little affection, never holding her and never talking to her (Ashcraft, 2009). At age twelve months, Cindy would cringe as someone’s touch, having gotten very little during her first year of life; she barely got any interaction with people and she had a lack of love from her biological family and her foster parents (Ashcraft, 2009).

When Cindy lived with her mom, she had a very unstable life. Cindy was around drugs because her mom was a drug addict; her mom did not have a home for the two of them to live in so they went from house to house (Ashcraft, 2009). Cindy would be taken to the pediatrician by her grandmother, who was sickly and elderly, one time Cindy was so dehydrated to the point that she was in medical danger (Ashcraft, 2009). This is an example of Cindy not meeting the safety needs in the hierarchy of needs.

After the year of going through all of that, the caseworker put Cindy into a foster family that was loving, caring, lived in a nice neighborhood, and loved Cindy. Cindy was at first hesitant about them because she was never given that much attention, but the foster family understood what she went through and took everything slow until Cindy was ready for the affection that they were willing to give her. She then met the three basic needs of physiological needs, safety needs, and belongingness and love needs. Cindy is now a happy and confident four year old that lives with this family.

 

 

Work Cited

Ashcraft, D. (2009).
Personality theories workbook.
(5
th
ed.). Belmont, CA: Wadsworth

Pub Co.

Biskirk-Cohen, Allison. April 17, 2012.

Hergenhahn, B.R., & Olson, M.H. (2011).
An introduction to theories of personality.
(8

ed.).

 

 

 

Nursing Theories and Theorists

In this guide for
nursing theories
, we aim to help you understand what comprises a nursing theory and its importance, purpose, history, types or classifications, and give you an overview through summaries of selected nursing theories.

What are Nursing Theories?

Defining Terms

History of Nursing Theories

The Nursing Metaparadigm

Person

Environment

Health

Nursing

Components of Nursing Theories

Phenomenon

Concepts

Definitions

Relational Statements

Assumptions

Why are Nursing Theories Important?

Purposes of Nursing Theories

In Academic Discipline

In Research

In Profession

Classification of Nursing Theories

By Abstraction

Grand Nursing Theories

Middle-Range Nursing Theories

Practice-Level Nursing Theories

By Goal Orientation

Descriptive Theories

Factor-Isolating Theory

Explanatory Theory

Prescriptive Theories

Other Ways of Classifying Nursing Theories

List of Nursing Theories and Theorists

Florence Nightingale

Hildegard E. Peplau

Virginia Henderson

Faye Glenn Abdellah

Ernestine Wiedenbach

Lydia E. Hall

Joyce Travelbee

Kathryn E. Barnard

Evelyn Adam

Roper, Logan, and Tierney

Ida Jean Orlando

Jean Watson

Marilyn Anne Ray

Patricia Benner

Kari Martinsen

Katie Eriksson

Myra Estrin Levine

Martha E. Rogers

Dorothea E. Orem

Imogene M. King

Betty Neuman

Sister Callista Roy

Dorothy E. Johnson

Anne Boykin and Savina O. Schoenhofer

Afaf Ibrahim Meleis

Nola J. Pender

Madeleine M. Leininger

Margaret A. Newman

Rosemarie Rizzo Parse

Erickson, Tomlin, and Swain

Gladys L. Husted and James H. Husted

Ramona T. Mercer

Merle H. Mishel

Pamela G. Reed

Carolyn L. Wiener and Marylin J. Dodd

Eakes, Burke, and Hainsworth

Phil Barker

Katharine Kolcaba

Cheryl Tatano Beck

Kristen M. Swanson

Cornelia M. Ruland and Shirley M. Moore

References

What are Nursing Theories?

Nursing theories
 are organized bodies of knowledge to define what nursing is, what nurses do, and why do they do it. Nursing theories provide a way to define nursing as a unique discipline that is separate from other disciplines (e.g., medicine). It is a framework of concepts and purposes intended to guide the practice of nursing at a more concrete and specific level.

Nursing, as a profession, is committed to recognizing its own unparalleled body of knowledge vital to nursing practice—nursing science. To distinguish this foundation of knowledge, nurses need to identify, develop, and understand concepts and theories in line with nursing. As a science, nursing is based on the theory of what nursing is, what nurses do, and why. Nursing is a unique discipline and is separate from medicine. It has its own body of knowledge on which delivery of care is based.

ADVERTISEMENT

Defining Terms

Development of nursing theory demands an understanding of selected terminologies, definitions, and assumptions.

Philosophy.
 Beliefs and values that define a way of thinking and are generally known and understood by a group or discipline.

Theory
. A belief, policy, or procedure proposed or followed as the basis of action. It refers to a logical group of general propositions used as principles of explanation. Theories are also used to describe, predict, or control phenomena.

Concept.
 Concepts are often called the building blocks of theories. They are primarily the vehicles of thought that involve images.

Models.
 Models are representations of the interaction among and between the concepts showing patterns. They present an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice.

Conceptual framework.
 A conceptual framework is a group of related ideas, statements, or concepts. It is often used interchangeably with the 
conceptual model
 and with 
grand theories
.

Proposition.
 Propositions are statements that describe the relationship between the concepts.

Domain
. Domain is the perspective or territory of a profession or discipline.

Process.
 Processes are a series of organized steps, changes or functions intended to bring about the desired result.

Paradigm.
 A paradigm refers to a pattern of shared understanding and assumptions about reality and the world; worldview or widely accepted value system.

Metaparadigm.
 A metaparadigm is the most general statement of discipline and functions as a framework in which the more restricted structures of conceptual models develop. Much of the theoretical work in nursing focused on articulating relationships among four major concepts: person, environment, health, and nursing.

History of Nursing Theories

The first nursing theories appeared in the late 1800s when a strong emphasis was placed on nursing education.

In 1860, Florence Nightingale
 defined nursing in her “Environmental Theory” as “the act of utilizing the environment of the patient to assist him in his recovery.”

In the 1950s, there is a consensus among nursing scholars that nursing needed to validate itself through the production of its own scientifically tested body of knowledge.

In 1952, Hildegard Peplau
 introduced her 
Theory of Interpersonal Relations
 that puts emphasis on the nurse-client relationship as the foundation of nursing practice.

In 1955, Virginia Henderson 
conceptualized the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs, thus her Nursing Need Theory was developed.

In 1960, Faye Abdellah
published her work “Typology of 21 Nursing Problems” that shifted the focus of nursing from a disease-centered approach to a patient-centered approach.

In 1962, Ida Jean Orlando
emphasized the reciprocal relationship between patient and nurse and viewed the professional function of nursing as finding out and meeting the patient’s immediate need for help.

In 1968, Dorothy Johnson
pioneered the 
Behavioral System Model
 and upheld the fostering of efficient and effective behavioral functioning in the patient to prevent illness.

In 1970, Martha Rogers
viewed nursing as both a science and an art as it provides a way to view the unitary human being, who is integral with the universe.

In 1971, Dorothea Orem
 states in her theory that nursing care is required if the client is unable to fulfill biological, psychological, developmental, or social needs.

In 1971, Imogene King‘s
 Theory of Goal attainment states that the nurse is considered part of the patient’s environment and the nurse-patient relationship is for meeting goals towards good health.

In 1972, Betty Neuman
 in her theory states that many needs exist, and each may disrupt client balance or stability. Stress reduction is the goal of the system model of nursing practice.

In 1979, Sr. Callista Roy
viewed the individual as a set of interrelated systems who strives to maintain the balance between these various stimuli.

In 1979, Jean Watson
developed the philosophy of caring highlighted humanistic aspects of nursing as they intertwine with scientific knowledge and nursing practice.

The Nursing Metaparadigm

There are four major concepts that are frequently interrelated and fundamental to nursing theory: person, environment, health, and nursing. These four are collectively referred to as 
metaparadigm for nursing
.

Person, Nursing, Environment, and Health – the four main concepts that make up the nursing metaparadigm.

Person

Person (also referred to as Client or Human Beings) is the recipient of nursing care and may include individuals, patients, groups, families, and communities.

Environment

Environment (or situation) is defined as the internal and external surrounds that affect the client. It includes all positive or negative conditions that affect the patient, the physical environment, such as families, friends, and significant others, and the setting for where they go for their healthcare.

Health

Health is defined as the degree of wellness or well-being that the client experiences. It may have different meanings for each patient, the clinical setting, and the health care provider.

Nursing

The attributes, characteristics, and actions of the nurse providing care on behalf of or in conjunction with, the client. There are numerous definitions of nursing, though nursing scholars may have difficulty agreeing on its exact definition, the ultimate goal of nursing theories is to improve patient care.

You’ll find that these four concepts are used frequently and defined differently throughout different nursing theories. Each nurse theorist’s definition varies in accordance with their orientation, nursing experience, and different factors that affect the theorist’s view of nursing. The person is the main focus but how each theorist defines the nursing metaparadigm gives a unique take specific to a particular theory. To give you an example, below are the different definitions of various theorists on the nursing metaparadigm:

An overview of the nursing metaparadigm of different nursing theories. (Click to enlarge)

Components of Nursing Theories

For a theory to be a theory it has to contain a set of concepts, definitions, relational statements, and assumptions that explain a phenomenon. It should also explain how these components relate to each other.

Phenomenon

A term given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations. Phenomena may be temporary or permanent. Nursing theories focus on the phenomena of nursing.

Concepts

Interrelated concepts define a theory. Concepts are used to help describe or label a phenomenon. They are words or phrases that identify, define, and establish structure and boundaries for ideas generated about a particular phenomenon. Concepts may be abstract or concrete.

Abstract Concepts
. Defined as mentally constructed independent of a specific time or place.

Concrete Concepts
. Are directly experienced and related to a particular time or place.

Definitions

Definitions are used to convey the general meaning of the concepts of the theory. Definitions can be theoretical or operational.

Theoretical Definitions
. Define a particular concept based on the theorist’s perspective.

Operational Definitions
. States how concepts are measured.

Relational Statements

Relational statements define the relationships between two or more concepts. They are the chains that link concepts to one another.

Assumptions

Assumptions are accepted as truths and are based on values and beliefs. These are statements that explain the nature of concepts, definitions, purpose, relationships, and structure of a theory.

Why are Nursing Theories Important?

Nursing theories are the basis of nursing practice today. In many cases, nursing theory guides knowledge development and directs education, research, and practice. Historically, nursing was not recognized as an academic discipline or as a profession we view it today. Before nursing theories were developed, nursing was considered to be a task-oriented occupation. The training and function of nurses were under the direction and control of the medical profession. Let’s take a look at the importance of nursing theory and its significance to nursing practice:

Nursing theories help recognize what should set the foundation of practice by explicitly describing nursing.

By providing a definition of nursing, nursing theory also helps nurses to understand their purpose and role in the healthcare setting.

Theories serve as a rationale or scientific reasons for nursing interventions and give nurses the knowledge base necessary for acting and responding appropriately in nursing care situations.

Nursing theories provide the foundations of nursing practice, helps generate further knowledge, and indicate in which direction nursing should develop in the future (Brown, 1964).

By providing nurses a sense of identity, nursing theory can help patients, managers, and other healthcare professionals to acknowledge and understand the unique contribution that nurses make to the healthcare service (Draper, 1990).

Nursing theories prepare the nurses to reflect on the assumptions and question the values in nursing, thus further defining nursing and increasing knowledge base.

Nursing theories aim to define, predict, and demonstrate the phenomenon of nursing (Chinn and Jacobs, 1978).

It can be regarded as an attempt by the nursing profession to maintain and preserve its professional limits and boundaries.

In many cases, nursing theories guide knowledge development and directs education, research, and practice although each influence the others. (Fitzpatrick and Whall, 2005).

Purposes of Nursing Theories

The primary purpose of theory in the profession of nursing is to improve practice by positively influence the health and quality of life of patients. Nursing theories are also developed to define and describe nursing care, guide nursing practice, and provide a basis for clinical decision making. The accomplishments of nursing in the past led to the recognition of nursing in academic discipline, research, and profession.

In Academic Discipline

Much of the earlier nursing programs identified the major concepts in one or two nursing models, organized the concepts and build an entire nursing curriculum around the created framework. The unique language in these models was typically introduced into program objectives, course objectives, course descriptions, and clinical performance criteria. The purpose was to explain the fundamental implications of the profession and to enhance the status of the profession.

In Research

Development of theory is fundamental to the research process where it is necessary to use theory as a framework to provide perspective and guidance to the research study. Theory can also be used to guide the research process by creating and testing phenomena of interest. To improve the nursing profession’s ability to meet the societal duties and responsibilities, there need to be a continuous reciprocal and cyclical connection with theory, practice, and research. This will help connect the perceived “gap” between theory and practice and promote the theory-guided practice.

In Profession

Clinical practice generates research questions and knowledge for theory. In a clinical setting, its primary contribution has been the facilitation of reflecting, questioning, and thinking about what nurses do. Because nurses and nursing practice are often subordinate to powerful institutional forces and traditions, the introduction of any framework that encourages nurses to reflect on, question, and think about what they do provide an invaluable service.

Classification of Nursing Theories

There are different ways to categorize nursing theories. They are classified depending on their function, levels of abstraction, or goal orientation.

By Abstraction

There are three major categories when classifying nursing theories based on their level of abstraction: grand theory, middle-range theory, and practice-level theory.

Levels of Nursing Theory According to Abstraction nursing theories essay examples

Grand Nursing Theories

Grand theories are abstract, broad in scope, and complex, therefore requiring further research for clarification.

Grand nursing theories do not provide guidance for specific nursing interventions but rather provide a general framework and ideas about nursing.

Grand nursing theorists develop their works based on their own experiences and the time they were living explaining why there is so much variation among theories.

Address the nursing metaparadigm components of person, nursing, health, and environment.

Middle-Range Nursing Theories

More limited in scope (as compared to grand theories) and present concepts and propositions at a lower level of abstraction. They address a specific phenomenon in nursing nursing theories essay examples.

Due to the difficulty of testing grand theories, nursing scholars proposed using this level of theory.

Most middle-range theories are based on the works of a grand theorist but they can be conceived from research, nursing practice, or the theories of other disciplines.

Practice-Level Nursing Theories

Practice nursing theories are situation specific theories that are narrow in scope and focuses on a specific patient population at a specific time.

Practice-level nursing theories provide frameworks for nursing interventions and suggest outcomes or the effect of nursing practice.

Theories developed at this level have a more direct effect on nursing practice as compared to more abstract theories.

These theories are interrelated with concepts from middle-range theories or grand theories. nursing theories essay examples.

By Goal Orientation

Theories can also be classified based on their goals, they can be 
descriptive
 or 
prescriptive
.

Descriptive Theories

Descriptive theories are the first level of theory development. They describe the phenomena and identify its properties and components in which it occurs.

Descriptive theories are not action oriented or attempt to produce or change a situation. nursing theories essay examples.

There are two types of descriptive theories: 
factor-isolating theory
 and 
explanatory theory
.

Factor-Isolating Theory

Also known as category-formulating or labeling theory.

Theories under this category describe the properties and dimensions of phenomena.

Explanatory Theory

Explanatory theories describe and explain the nature of relationships of certain phenomena to other phenomena.

Prescriptive Theories

Address the nursing interventions for a phenomenon, guide practice change, and predict consequences.

Includes propositions that call for change.

In nursing, prescriptive theories are used to anticipate the outcomes of nursing interventions.

Other Ways of Classifying Nursing Theories

Classification According to Meleis

Afaf Ibrahim Meleis (2011), in her book 
Theoretical Nursing: Development and Progress
, organizes the major nurse theories and models using the following headings: needs theories, interaction theories, and outcome theories. These categories indicate the basic philosophical underpinnings of the theories.

Needs-Based Theories.
The needs theorists were the first group of nurses who thought of giving nursing care a conceptual order. Theories under this group are based on helping individuals to fulfill their physical and mental needs. Theories of Orem, Henderson, and Abdella are categorized under this group. Need theories are criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position  nursing theories essay examples.

Interaction Theories.
 These theories placed the emphasis of nursing on the establishment and maintenance of relationships and highlight the impact of nursing on patients and how they interact with the environment, people, and situations. Theories of King, Orlando, and Travelbee are grouped under this category.

Outcome Theories
. These theories describe the nurse as controlling and directing patient care by using their knowledge of the human physiological and behavioral systems. Nursing theories of Johnson, Levine, Rogers, and Roy belong to this group.

Classification According to Alligood

In her book, 
Nursing Theorists and Their Work, 
Raile Alligood (2017) categorized nursing theories into four headings: nursing philosophy, nursing conceptual models, nursing theories and grand theories, and middle-range nursing theories.

Nursing Philosophy
. Is the most abstract type and sets forth the meaning of nursing phenomena through analysis, reasoning, and logical presentation. Works of Nightingale, Watson, Ray, and Benner are categorized under this group.

Nursing Conceptual Models
. Are comprehensive nursing theories that are regarded by some as pioneers in nursing. These theories address the nursing metaparadigm and explain the relationship between them. Conceptual models of Levine, Rogers, Roy, King, and Orem are under this group.

Grand Nursing Theories. 
Are works derived from nursing philosophies, conceptual models, and other grand theories that are generally not as specific as middle-range theories. Works of Levine, Rogers, Orem, and King are some of the theories under this category nursing theories essay examples.

Middle-Range Theories.
 Are precise and answer specific nursing practice questions. They address the specifics of nursing situations within the perspective of the model or theory from which they are derived. Examples of Middle-Range theories are that of Mercer, Reed, Mishel, and Barker.

List of Nursing Theories and Theorists

You’ve learned from the previous sections the definition of nursing theory, its significance in nursing, and purpose in generating a knowledge base for nursing. In this section, we’ll give you an overview and summary of the various published works in nursing theory (in chronological order). Deep dive into learning about the theory by clicking on the links provided for their biography and comprehensive review of their work.

Florence Nightingale

See Also: 
Florence Nightingale: Environmental Theory and Biography

Founder of Modern Nursing and Pioneer of the 
Environmental Theory. 

Defined Nursing as “the act of utilizing the environment of the patient to assist him in his recovery.”

Stated that nursing “ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selectiozn and administration of diet – all at the least expense of vital power to the patient.”

Identified five (5) environmental factors: fresh air, pure water, efficient drainage, cleanliness or sanitation, and light or direct sunlight nursing theories essay examples.

Hildegard E. Peplau

See Also: 
Hildegard Peplau: 
Interpersonal Relations Theory

Pioneered the 
Theory of Interpersonal Relations

Peplau’s theory defined Nursing as “An interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.”

Her work is influenced by Henry Stack Sullivan, Percival Symonds, Abraham Maslow, and Neal Elgar Miller.

Helps nurses and healthcare providers develop more therapeutic interventions in the clinical setting.

Virginia Henderson

See Also: 
Virginia Henderson: Nursing Need Theory 

Developed the 
Nursing Need Theory

Focuses on the importance of increasing the patient’s independence to hasten their progress in the hospital.

Emphasizes the basic human needs and how nurses can assist in meeting those needs.

“The nurse is expected to carry out a physician’s therapeutic plan, but individualized care is result of the nurse’s creativity in planning for care.” nursing theories essay examples.

Faye Glenn Abdellah

See Also: 
Faye Glenn Abdellah: 
21 Nursing Problems Theory

Developed the 
21 Nursing Problems Theory

“Nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs.”

Changed the focus of nursing from disease-centered to patient-centered, and began to include the care of families and the elderly in nursing care.

The nursing model is intended to guide care in hospital institutions, but can also be applied to community health nursing, as well.

Ernestine Wiedenbach

Developed 
The Helping Art of Clinical Nursing
 conceptual model.

Definition of nursing reflects on nurse-midwife experience as “People may differ in their concept of nursing, but few would disagree that nursing is nurturing or caring for someone in a motherly fashion.”

Guides the nurse action in the art of nursing and specified four elements of clinical nursing: philosophy, purpose, practice, and art.

Clinical nursing is focused on meeting the patient’s perceived need for help in a vision of nursing that indicates considerable importance on the art of nursing nursing theories essay examples.

Lydia E. Hall

See Also: 
Lydia Hall: 
Care, Cure, Core Theory

Developed the 
Care, Cure, Core Theory 
also known as the “
Three Cs of Lydia Hall.
“

Hall defined Nursing as the “participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.”

The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

The “care” circle defines the primary role of a professional nurse such as providing bodily care for the patient. The “core” is the patient receiving nursing care. The “cure” is the aspect of nursing which involves the administration of medications and treatments.

Joyce Travelbee

States in her 
Human-to-Human Relationship Model
 that the purpose of nursing was to help and support an individual, family, or community to prevent or cope with the struggles of illness and suffering and, if necessary, to find significance in these occurrences, with the ultimate goal being the presence of hope.

Nursing was accomplished through human-to-human relationships.

Extended the interpersonal relationship theories of Peplau and Orlando.

Kathryn E. Barnard

Developed the 
Child Health Assessment Model
.

Concerns improving the health of infants and their families.

Her findings on parent-child interaction as an important predictor of cognitive development helped shape public policy nursing theories essay examples.

She is the founder of the Nursing Child Assessment Satellite Training Project (NCAST) which produces and develops research-based products, assessment and training programs to teach professionals, parents and other caregivers the skills to provide nurturing environments for young children.

Borrows from psychology and human development and focuses on mother-infant interaction with the environment.

Contributed a close link to practice that has modified the way health care providers assess children in light of the parent-child relationship.

Evelyn Adam

Focuses on the development of models and theories on the concept of nursing.

Includes the goal of the profession, the beneficiary of the professional service, the role of the professional, the source of the beneficiary’s difficulty, the intervention of the professional, and the consequences.

A good example of using a unique basis of nursing for further expansion.

Nancy Roper, Winifred Logan, and Alison J. Tierney

A Model for Nursing Based on a Model of Living

Logan produced a simple theory, “which actually helped bedside nurses.”

The trio collaborated in the fourth edition of The Elements of Nursing: A Model for Nursing Based on a Model of Living and prepared a monograph entitled The Roper-Logan-Tierney Model of Nursing: Based on Activities of Daily Living.

Includes maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping, and dying.

Ida Jean Orlando

See Also: 
Ida Jean Orlando: 
Nursing Process Theory

She developed the
 Nursing Process Theory.

“Patients have their own meanings and interpretations of situations and therefore nurses must validate their inferences and analyses with patients before drawing conclusions.”

Allows nurses to formulate an effective nursing care plan that can also be easily adapted when and if any complexity comes up with the patient.

According to her, persons become patients requiring nursing care when they have needs for help that cannot be met independently because of their physical limitations, negative reactions to an environment, or have an experience that prevents them from communicating their needs.

The role of the nurse is to find out and meet the patient’s immediate needs for help.

Jean Watson

See Also: 
Jean Watson: Theory of Human Caring

She pioneered the 
Philosophy and Theory of Transpersonal Caring.

“Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health.”

Mainly concerns on how nurses care for their patients, and how that caring progresses into better plans to promote health and wellness, prevent illness and restore health.

Focuses on health promotion, as well as the treatment of diseases.

Caring is central to nursing practice and promotes health better than a simple medical cure.

Marilyn Anne Ray 

Developed the 
Theory of Bureaucratic Caring

“Improved patient safety, infection control, reduction in medication errors, and overall quality of care in complex bureaucratic health care systems cannot occur without knowledge and understanding of complex organizations, such as the political and economic systems, and spiritual-ethical caring, compassion and right action for all patients and professionals.”

Challenges participants in nursing to think beyond their usual frame of reference and envision the world holistically while considering the universe as a hologram nursing theories essay examples.

Presents a different view of how health care organizations and nursing phenomena interrelate as wholes and parts in the system.

Patricia Benner

Caring, Clinical Wisdom, and Ethics in Nursing Practice

“The nurse-patient relationship is not a uniform, professionalized blueprint but rather a kaleidoscope of intimacy and distance in some of the most dramatic, poignant, and mundane moments of life.”

Attempts to assert and reestablish nurses’ caring practices during a time when nurses are rewarded more for efficiency, technical skills, and measurable outcome.

States that caring practices are instilled with knowledge and skill regarding everyday human needs.

Kari Martinsen

Philosophy of Caring

“Nursing is founded on caring for life, on neighborly love, […]At the same time, it is necessary that the nurse is professionally educated.”

Human beings are created and are beings for whom we may have administrative responsibility.

Caring, solidarity, and moral practice are unavoidable realities.

Katie Eriksson

Theory of Carative Caring

“Caritative nursing means that we take ‘caritas’ into use when caring for the human being in health and suffering […] Caritative caring is a manifestation of the love that ‘just exists’ […] Caring communion, true caring, occurs when the one caring in a spirit of caritas alleviates the suffering of the patient.”

The ultimate goal of caring is to lighten suffering and serve life and health.

Inspired many in the Nordic countries, and used as the basis of research, education, and clinical practice. nursing theories essay examples.

Myra Estrin Levine

See Also:
 
Myra Estrin Levine: Conservation Model for Nursing

According to the 
Conservation Model
, “Nursing is human interaction.”

Provides a framework within which to teach beginning nursing students.

Logically congruent, is externally and internally consistent, has breadth as well as depth, and is understood, with few exceptions, by professionals and consumers of health care.

Martha E. Rogers

See Also: 
Martha Rogers: 
Theory of Unitary Human Beings

In Roger’s 
Theory of Human Beings
, she defined Nursing as “an art and science that is humanistic and humanitarian.

The Science of Unitary Human Beings contains two dimensions: the science of nursing, which is the knowledge specific to the field of nursing that comes from scientific research; and the art of nursing, which involves using the science of nursing creatively to help better the life of the patient.

A patient can’t be separated from his or her environment when addressing health and treatment.

Dorothea E. Orem

See Also: 
Dorothea E. Orem: 
Self-Care Theory

In her 
Self-Care Theory,
 she defined Nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.”

Focuses on each individual’s ability to perform self-care.

Composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems, which is further classified into wholly compensatory, partially compensatory and supportive-educative.

Imogene M. King

See Also: 
Imogene M. King: Theory of Goal Attainment

Conceptual System and Middle-Range Theory of Goal Attainment

“Nursing is a process of action, reaction and interaction by which nurse and client share information about their perception in a nursing situation” and “a process of human interactions between nurse and client whereby each perceives the other and the situation, and through communication, they set goals, explore means, and agree on means to achieve goals.”

Focuses on this process to guide and direct nurses in the nurse-patient relationship, going hand-in-hand with their patients to meet the goals towards good health.

Explains that the nurse and patient go hand-in-hand in communicating information, set goals together, and then take actions to achieve those goals. nursing theories essay examples.

Betty Neuman

See Also:
 
Betty Neuman: Neuman’s Systems Model

ADVERTISEMENTS

In 
Neuman’s System Model
, she  defined nursing as a “unique profession in that is concerned with all of the variables affecting an individual’s response to stress.”

The focus is on the client as a system (which may be an individual, family, group, or community) and on the client’s responses to stressors.

The client system includes five variables (physiological, psychological, sociocultural, developmental, and spiritual) and is conceptualized as an inner core (basic energy resources) surrounded by concentric circles that include lines of resistance, a normal line of defense, and a flexible line of defense.

Sister Callista Roy

See Also:
 Sister Callista Roy:
 Adaptation Model of Nursing

In 
Adaptation Model, 
Roy defined nursing as a “health care profession that focuses on human life processes and patterns and emphasizes promotion of health for individuals, families, groups, and society as a whole.”

Views the individual as a set of interrelated systems who strives to maintain balance between various stimuli.

Inspired the development of many middle-range nursing theories and of adaptation instruments.

Dorothy E. Johnson

See Also: 
Dorothy E. Johnson:
Behavioral Systems Model

The 
Behavioral System Model
 defined Nursing as “an external regulatory force which acts to preserve the organization and integration of the patients’ behaviors at an optimum level under those conditions in which the behavior constitutes a threat to the physical or social health, or in which illness is found.”

Advocates the fostering of efficient and effective behavioral functioning in the patient to prevent illness and stresses the importance of research-based knowledge about the effect of nursing care on patients.

Describes the person as a behavioral system with seven subsystems: the achievement, attachment-affiliative, aggressive-protective, dependency, ingestive, eliminative, and sexual subsystems.

Anne Boykin and Savina O. Schoenhofer

The Theory of Nursing as Caring: A Model for Transforming Practice

Nursing is an “exquisitely interwoven” unity of aspects of the discipline and profession of nursing.

The focus and aim of nursing as a discipline of knowledge and a professional service is “nurturing persons living caring and growing in caring.”

Caring in nursing is “an altruistic, active expression of love, and is the intentional and embodied recognition of value and connectedness.”

Afaf Ibrahim Meleis

Transitions Theory

Began with observations of experiences faced as people deal with changes related to health, well-being, and ability to care for themselves.

Types of transitions include developmental, health and illness, situational, and organizational.

Acknowledges the role of nurses as they help people go through health/illness and life transitions.

Focuses on assisting nurses in facilitating patients’, families’ and communities’ healthy transitions nursing theories essay examples.

Nola J. Pender

See Also:
 
Nola Pender: Health Promotion Model

Health Promotion Model

Describes the interaction between the nurse and the consumer while considering the role of the environment in health promotion.

Focuses on three areas: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes.

Describes the multidimensional nature of persons as they interact within their environment to pursue health.

Madeleine M. Leininger

See Also: 
Madeleine M. Leininger: Transcultural Nursing Theory

Culture Care Theory of Diversity and Universality

Defined transcultural nursing as “a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness, or death in culturally meaningful ways.”

Involves learning and understanding various cultures with regard to nursing and health-illness caring practices, beliefs, and values with the intention to implement significant and efficient nursing care services to people according to their cultural values and health-illness context nursing theories essay examples.

Focuses on the fact that various cultures have different and unique caring behaviors and different health and illness values, beliefs, and patterns of behaviors.

Margaret A. Newman

Health as Expanding Consciousness

“Nursing is the process of recognizing the patient in relation to the environment, and it is the process of the understanding of consciousness.”

“The theory of health as expanding consciousness was stimulated by concern for those for whom health as the absence of disease or disability is not possible . . . “

Nursing is regarded as a connection between the nurse and patient, and both grow in the sense of higher levels of consciousness.

Rosemarie Rizzo Parse

Human Becoming Theory

“Nursing is a science and the performing art of nursing is practiced in relationships with persons (individuals, groups, and communities) in their processes of becoming.”

Explains that a person is more than the sum of the parts, the environment and the person are inseparable, and that nursing is a human science and art that uses an abstract body of knowledge to help people.

Centered around three themes: meaning, rhythmicity, and transcendence.

Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain

Modeling and Role-Modeling

“Nursing is the holistic helping of persons with their self-care activities in relation to their health . . . The goal is to achieve a state of perceived optimum health and contentment.”

Modeling is a process that allows nurses to understand the unique perspective of a client and learn to appreciate its importance.

Role-modeling occurs when the nurse plans and implements interventions that are unique for the client.

Gladys L. Husted and James H. Husted

Created the 
Symphonological Bioethical Theory

“Symphonology (from ‘symphonia,’ a Greek word meaning agreement) is a system of ethics based on the terms and preconditions of an agreement.”

Nursing cannot occur without both nurse and patient. “A nurse takes no actions that are not interactions.”

Founded on the singular concept of human rights, the essential agreement of nonaggression among rational people that forms the foundation of all human interaction.

Ramona T. Mercer

Maternal Role Attainment—Becoming a Mother

“Nursing is a dynamic profession with three major foci: health promotion and prevention of illness, providing care for those who need professional assistance to achieve their optimal level of health and functioning, and research to enhance the knowledge base for providing excellent nursing care.”

“Nurses are the health professionals having the most sustained and intense interaction with women in the maternity cycle.”

Maternal role attainment is an interactional and developmental process occurring over time in which the mother becomes attached to her infant, acquires competence in the caretaking tasks involved in the role, and expresses pleasure and gratification in the role. (Mercer, 1986) nursing theories essay examples.

Provides proper health care interventions for nontraditional mothers in order for them to favorably adopt a strong maternal identity.

Merle H. Mishel

Uncertainty in Illness Theory

Presents a comprehensive structure within which to view the experience of acute and chronic illness and to organize nursing interventions to promote optimal adjustment.

Describes how individuals form meaning from illness-related situations.

The original theory’s concepts were organized in a linear model around the following three major themes: Antecedents of uncertainty, Process of uncertainty appraisal, and Coping with uncertainty.

Pamela G. Reed

Self-Transcendence Theory

Self-transcendence refers to the fluctuation of perceived boundaries that extend the person (or self) beyond the immediate and constricted views of self and the world (Reed, 1997).

Has three basic concepts: vulnerability, self-transcendence, and well-being.

Gives insight into the developmental nature of humans associated with health circumstances connected to nursing care.

Carolyn L. Wiener and Marylin J. Dodd

Theory of Illness Trajectory

“The uncertainty surrounding a chronic illness like cancer is the uncertainty of life writ large. By listening to those who are tolerating this exaggerated uncertainty, we can learn much about the trajectory of living.”

Provides a framework for nurses to understand how cancer patients stand uncertainty manifested as a loss of control.

Provides a new knowledge on how patients and families endure uncertainty and work strategically to reduce uncertainty through a dynamic flow of illness events, treatment situations, and varied players involved in the organization of care nursing theories essay examples.

Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth

Theory of Chronic Sorrow

“Chronic sorrow is the presence of pervasive grief-related feelings that have been found to occur periodically throughout the lives of individuals with chronic health conditions, their family caregivers and the bereaved.”

This middle-range theory defines the aspect of chronic sorrow as a normal response to the ongoing disparity created by the loss.

Phil Barker

Barker’s Tidal Model of Mental Health Recovery 
is widely used in mental health nursing.

Focuses on the fundamental care processes of nursing, is universally applicable, and is a practical guide for psychiatry and mental health nursing.

Draws on values about relating to people and help others in their moment of distress. The values of the Tidal Model are revealed in the Ten Commitments: Value the voice, Respect the language, Develop genuine curiosity, Become the apprentice, Use the available toolkit, Craft the step beyond, Give the gift of time, Reveal personal wisdom, Know that change is constant, and Be transparent.

Katharine Kolcaba

Theory of Comfort

“Comfort is an antidote to the stressors inherent in health care situations today, and when comfort is enhanced, patients and families are strengthened for the tasks ahead. In addition, nurses feel more satisfied with the care they are giving.”

Patient comfort exists in three forms: relief, ease, and transcendence. These comforts can occur in four contexts: physical, psychospiritual, environmental, and sociocultural.

As a patient’s comfort needs change, the nurse’s interventions change, as well.

Cheryl Tatano Beck

Postpartum Depression Theory

“The birth of a baby is an occasion for joy—or so the saying goes […] But for some women, joy is not an option.”

Described nursing as a caring profession with caring obligations to persons we care for, students, and each other.

Provides evidence to understand and prevent postpartum depression.

Kristen M. Swanson

Theory of Caring

“Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.”

Defines nursing as informed caring for the well-being of others.

Offers a structure for improving up-to-date nursing practice, education, and research while bringing the discipline to its traditional values and caring-healing roots.

Cornelia M. Ruland and Shirley M. Moore

Peaceful End-of-Life Theory

The focus was not on death itself, but on providing a peaceful and meaningful living in the time that remained for patients and their significant others.

The purpose was to reflect the complexity involved in caring for terminally ill patients.

Leading Educational Theories in Nursing

Nursing theories can be applied to many different circumstances. However, the leading nursing programs, including the program at Duquesne University, incorporate the grand theories into the master’s in nursing curriculum. Grand theories are considered the theoretical framework that supports the principles and key concepts of nursing.

Self-Care Nursing Theory

Introduced by Dorothea Orem, the Self-Care Nursing Theory (also known as the Self-Care Deficit Nursing Theory) focuses on the nurses’ role in supporting the patients’ ability to be self-sufficient and responsible for their own care. The theory is based on the idea that people must be knowledgeable about their health problems to provide adequate self care. The theory is made up of three interconnected theories: the theory of self-care, the theory of self-care deficit and the theory of nursing systems.

Orem said she based her theory on her practice as a nurse and contemporary nursing literature and thought. During her career, she published several books that explored and expanded her theory, including 
Guides for Developing Curricula for the Education of Practical Nurses
 and 
Nursing: Concepts of Practice
.

Culture Care Theory

As a nurse, Madeleine Leininger recognized a lack of cultural and care knowledge as a missing component in nursing and patient care. From her experiences, she developed transcultural nursing and the Cultural Care Theory to study and explain the outcomes of transcultural nursing.

Leininger’s theory is focused on providing care that is in harmony with a patient’s cultural beliefs, practices and values. In the 1960s, she coined the phrase “culturally congruent care,” which is the primary goal of transcultural nursing. Some of the basic tenets of transcultural nursing include an understanding of the following:

Cultural care diversity and universality, which refers to the differences and commonalities between different cultures.

Cultural and social structure dimensions, which includes factors that include religion, social structures and economics that set cultures apart. nursing theories essay examples.

Cultural care preservation or maintenance, which relates to nursing care activities that help specific cultures to retain the core cultural values related to healthcare.

Humanistic Nursing Theory

Also called the holistic approach, the Humanistic Theory looks to meld mental and emotional health with physical health. The theory is based on the idea that patients grow in healthy and creative ways. This approach to nursing, created by APRNs Josephine Paterson and Loretta Zderad, looks at each patient as an individual who needs personalized care.

Paterson and Zderad developed five phases of nursing, called phenomenological nursing, to accompany the Humanistic Theory:

Nurses prepare for “coming to know” or start investigating a case.

Nurses create an “I-You” relationship so they can understand their patients and use their intuitive knowledge.

Nurses apply scientific knowledge and begin a subject-object or “I-It” relationship, which allows nurses to reflect on their own experiences and put them into context for the current situation.

Nurses synthesize their knowledge to become a source of continually evolving information.

Nurses transform from the “many to the paradoxical one” to apply knowledge to a practical clinical setting.

Theory of Interpersonal Relations

The Interpersonal Relations Theory, developed in 1952 by Hildegard Peplau, focuses on the importance of the nurse-patient relationship. Nurses are able to prove better care to their patients if they build a strong relationship based on mutual respect. Peplau’s theory evolves in three phases:

Orientation: The nurse-patient relationship is initiated by a patient’s needs. The nurse helps the patient get acquainted with the treatment process and answers questions.

Working: As the nurse-patient relationship develops, the patient concentrates on expressing reactions to the illness and becomes an active participant in care.

Termination: The nurse helps the patient follow through on care that has been provided and return to a normal productive life.

During the different phases, the nurses take on many roles, including resource person, teacher, surrogate and counselor.

Need Theory

Developed by Virginia Henderson, an RN who was inducted into the American Nurses Association’s Hall of Fame, the nursing Need Theory focuses on a nurse’s role in assisting patients to maintain health, recover from injuries or achieve a peaceful death. In her work, she continually stressed nursing’s duty to focus on helping the patient rather than the doctor.

Henderson, considered the mother of modern nursing care, outlined four basic needs—psychological, physiological, social and spiritual — that are required for patients to live independently:

Psychological needs including communicating and handling fears.

Physiological needs    including eating and sleeping.

Spiritual needs including worship and faith.

Social needs including recreational activities.

Among Henderson’s noted works was 
Nursing Research: Survey and Assessment 
and 
Nursing Studies Index
, published in 1964 and 1972 respectively.

 

Application of Nursing Theory

Nursing theory helps makes sense of our complex healthcare system and has provided the foundation that defines the nursing profession by organizing thoughts and ideas identified by nursing theories (Karnick, 2016). Concepts offer an understanding of theories and combine evidence based practice towards clinical practice to improve patient health outcomes. Theory can further provide a framework to create a positive work environment by implementing strategies defined in a theory set out to improve work environments. Nurse retention directly reflects a cohesive positive work environment revolving around a supportive health care team and management system outlined in Jean Watson’s Theory of Human Caring (Twigg and McCullough, 2014).

Jean Watson’s Theory of Human Caring was published in 1979. This theory is designed to care for another person utilizing the 10 Caritas meaning to “cherish” or give special loving attention to someone. This theory can assist nurse leaders with a framework to create a positive work environment for health care team members aiding in nurse retention rates. The basis of this theory is recognizing a “caring moment” to establish an authentic caring relationship with another person. The formation of an authentic relationship is a sacred encounter connecting both parties on a spiritual and emotional level enabling a positive impact for one another. When allowing oneself to be authentically present in a “caring moment,” Watson believed this sets the tone for daily connections made with each other through communication, therapeutic touch, and any type of interaction where a person feels cared for. Leaders are empathetic and compassionate towards their health care team members by practicing the Carita of love, kindness, and equanimity to facilitate staff retention (Norman, Rossillo, and Skelton, 2016).

As more patients require health care services, the nursing shortage and the inability to retain staff threatens our health care system since hospitals are unable to provide staff to meet these needs. The purpose of this paper is utilizing Jean Watson’s Theory of Human Caring to encourage and effect staff retention. The layout of the paper includes a description of the issue or concern, the application of selected nursing theory to issue or concern, and finally, the conclusion.

Description of Issue or Concern

The United States continues to face a nursing shortage crisis and is unable to meet the demands projected for years to come. The World Health Organization estimates an average nurse shortage by 2020 of 285,000 and 500,000 by 2025 (Twigg and McCullough, 2014). The statistics presented are alarming and concerning. Whenever an insufficient number of nurses are available to produce high quality of care in a hospital setting, the effects of a nursing shortage are noticed. The nursing shortage is a result of an imbalance in supply and demand credited by demographics, qualifications, and availability of nurses willing to perform work (Hellerava, and Adambarage, 2015). The nursing shortage combined with the inability to retain staff poses economic factors and poor-quality healthcare care being delivered. Not only does this influence individual health organizations and the health care industry, but this crisis affects the patients who are at the receiving end of patient care nursing theories essay examples.

According to the Bureau of Labor Statistics, nursing is the leading profession for employment growth between 2010 and 2020. Due to the retirement of the baby boomer generation, the healthcare reform, and the ever-changing economy will cause healthcare to continually assess various methods to retain nursing staff. By 2020, half a million nurses will retire. Nurses who are unable to retire will face an overwhelming prediction of being unsatisfied in the workplace. Retention rates for these nurses are very poor (Dotson, Dave, Cazier, and Spaulding, 2014).

The individual hospital and corporation are affected by decreased retention rates due to financial burdens. Hiring a new nurse can cost a hospital an estimated 62,000 to 67,000 dollars in 2002. Inflation caused an average of 82,000-88,000 dollars spent on hiring a nurse in 2007. The costs were considerably higher if a new graduate nurse was hired since they are required to take additional classes and training to provide safe practice. Of the nurses hired, 10% of the new hire population will quit. An average of 17% to 85% of the new graduate nurses hired will quit. A 1% change in turnover or retention has the ability to save or cost a hospital an average of 373,200 dollars, according to Woten (2017).

The effects of nurse turnover and the inability to retain staff is noticed during patient care. Decreased nurse retention rates cause the rest of the nursing staff to be short-staffed each day. This requires one nurse to endure the responsibility desired for two nurses correlating with a decrease in quality of care. One study compared years with sufficient staff versus insufficient staff that yielded results linking a decrease in medication errors, falling incidents, and adverse event incidents when enough staff was present during a shift. Nurse turnover damages patient satisfaction and organizations due to lack of continuity of care, additional time required to manage fellow employees, and a loss in staff productivity. As more experienced nurses are reaching retirement and inexperienced nurses continue to have high turnover, the medical floors are experiencing inadequate skills, limited knowledge, and unfavorable patient care causing an issue and concern relating to poor health care (Hayes et al., 2012) nursing theories essay examples. Nurse turnover triggers unsafe patient care.

The most common reason related to nurse turnover is organizational factors. Nurses were more likely to stay if they had a positive relationship with a nurse leader in their organizational structure. Positive nurse leaders empower fellow health care team members by providing access to resources and information, providing support when needed, and offering learning opportunities to develop confidence that guides nursing practice. If inconsistencies arise in the workplace, the health care team members believe their goals will be unfulfilled causing them to quit (Goodare, 2017). Twigg and McCullough (2014) state nursing leaders provide a positive work environment by encouraging and supporting team members to perform to the best of their ability. An example might include when nurse leaders recognize team members when the nurse exceeds the expectations of the hospital. Positive work environments also consist of nursing autonomy, flexibility of scheduling, shared governance of the workplace, and continuous mentoring and support of health care teams.  A leader that is present and willing to be a part of authentic relationship with his or her health care team begins the process of nurse retention and satisfactory working conditions.

The nursing shortage and inability to retain staff is causing many healthcare systems to have unsafe patient ratios. They are unable to supply the demand needed to provide safe patient care. The concern of the nursing profession is safe working environment which the patient safety and positive patient outcomes being the center of focus in nursing practice. The hospitals and organizations are affected by the financial burden, patients are affected by poor quality healthcare, and nurses are all effected by unsafe nurse-patient ratios caused by nurse turnover; which is detrimental to health care. The statistics are alarming and a strategy needs to be implemented to retain staff. Nursing literature states an influential nurse leader who values support, encourages, empowers, and believes in authentic relationships is paramount to nurse retention.

Application of Selected Nursing Theory to Issue or Concern

Jean Watson’s Theory of Human Caring is based on concepts such as caring, “caring moments,” and a transpersonal authentic relationship. A “caring moment” transpires into an authentic transpersonal relationship where the 10 Caritas are applied to care for another person. The 10-Caritas used to explain and define caring include practicing equanimity, being physically and emotionally present, intentional assisting with basic needs, establishing a trusting authentic relationship, being culturally sensitive, engaging in a learning experience to create a “wholeness,” by creating an environment revolving around holism and humanism (Norman, Rossillo, and Skelton, 2016).

Research proposes a positive nurse leadership and environment is more effective towards nurse retention than increasing salaries (Twigg and McCullough, 2014). Implementing Watson’s Theory of Human Caring from a nurse leader standpoint is a possible strategy to decrease nurse turnover rate. Caring occurs when the nurse leader encompasses the 10-Caritias previously defined to empower his or her health care team.

Norman, Rossillo, and Skelton (2016) state practicing love, kindness, and equanimity that is empathetic and compassionate towards a team member’s needs is providing a safe work environment. Team members are always aware of a nurse leader’s actions, and when both party’s views and values and beliefs are aligned, an authentic relationship to ensue. For example, a nurse leader enforcing a zero-tolerance relating to workplace bullying is practicing this Carita by protecting his or her health care team from verbal or physical abuse.  Tending to health team members basic needs may mean being a team player when help is needed or providing learning opportunities and resources to allow a nurse to become confident in his or her knowledge and skills nursing theories essay examples. A positive leader will even go above and beyond and model an exemplary attitude and caring approach portrayed by Watson’s theory to motivate other team members to display a caring demeanor. Nurse leaders who recognize fellow nurses that display kindness, love, and equanimity in nursing practice are more satisfied with his or her work environment. Any kind act or encouraging words will never go unnoticed.

At a hospital, a nurse leader is utilizing Jean Watson’s theory if he or she is interacting with healthcare team members and developing a sacred encounter. A sacred encounter can transpire by communication, therapeutic touch, or any action where a team member feels cared for by the offering person. Each team member is positively affected creating a deeper human connection. A team member feels cared for when the nurse leader is authentically present and actively listening to his or her concerns and issues during these encounters. Trust and rapport are built between the two parties. Being able to create authentic caring relationship with healthcare team members allows them to feel supported which increases nurse retention and quality of care delivered in nursing practice (Norman, Rossillo, and Skelton, 2016).

Future research conducted would be to include if a caring nurse leadership approach that increased nurse retention caused a hospital to reach magnet level status. Tai, Wai, and Bame (2017) state magnet hospitals are the result of qualified nurse retention, better quality of patient care, acceptable patient satisfaction, and decreased mortality rate. Magnet level hospitals have acceptable nurse-patient ratios that decrease adverse events and patient mortality providing a safer environment for patient care. Are hospitals reaching a magnet level status due to sufficient staffing caused by a positive nurse leader being able to retain his or her staff?

Conclusion

           
As the nursing shortage and staff retention continues to become more visible in the workplace, it is imperative that the nursing profession utilizes theory as a framework to follow. Jean Watson’s Theory of Human Caring can be incorporated and guide clinical practice by including the 10 Caritas empowering other healthcare team members. The purpose of applying the Human Caring theory is to improve patient healthcare and outcomes, decrease the financial burden the hospital faces, and create a positive working environment with sufficient safe staffing ratios. The theory is built on the concepts of caring, caring moments, and transpersonal caring relationships that a nurse leader must feel comfortable being a part of. To care for someone, is the ability to be aware of a “caring moment” and seizing the opportunity to build an authentic relationship with fellow healthcare team members. This essentially builds trust and rapport and increases job satisfaction that leads to increased nurse retention rates.

As I reflect over the new knowledge gained from my research efforts, I have learned that theory will always provide the foundation for which the nursing profession has been established. Nurses will continue to be satisfied as management remains present and acknowledges the hard work that is put out to create and provide safe patient care. Empowering others utilizing Jean Watson’s Theory of Human Caring is incredibly important to fulfill the goals of health care team members to motivate them to stay within the hospital nursing theories essay examples. Being able to positively manage health care team members is necessary to ensure job satisfaction and reduce turnover and nursing shortages.

   

References

Dotson, M., Dave, D., Cazier, J., &Spaulding, T. (2014). An empirical analysis of nurse retention: What keeps rns in nursing.
The Journal of Nursing Administration, 44
(2), 111-116. doi: 10.1097/NNA.0000000000000000034

Goodare, P. (2017). Literature review: Why do we continue to lose our nurses.
Australian Journal of Advanced Nursing, 34
(4), 50-56. Retrieved from eds.b.ebscohost.com.proxy.chamberlain.edu:8080/eds/detail/detail?vid=2&sid=8d62a810-605f-4be1-a743-c7fccea99

Hayes, L., Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., Laschinger, S., & North, N. (2012) Nurse turnover: A literature review- an update.
International Journal of Nursing Studies, 49(
7), 887-905. doi: 10.1016/j.ijnurstu.2011.10.001

Hellerava, K., & Adambarage, A. (2015). The nursing shortage impact on job outcome.
Journal of Competitiveness, 7
(3), 75-94. doi: 10.7441/joc.2014.03.06

Karnick, P. M. (2016). Evidence-based practice and nursing theory. 
Nursing Science Quarterly,
 
29
(4), 283-284. doi:10.1177/0894318416661107 nursing theories essay examples

Norman, V., Rossillo, K., & Skelton, K. (2016). Creating healing environments through the theory of caring.
AORN Journal, 104
(5), 401-409. doi: 10.1016/j.aron.2016.09.006

Tai, T., Wai, C., & Bame, S. (2017). Organizational and community factors associated with magnet status of u.s. hospitals.
Journal of Healthcare Management, 62
(1), 62-76. Retrieved from http://proxy.chamberlain.edu/8443/login?url=https://search-proquest-com

Twig, D., & McCullough, K. (2014). Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings.
International Journal of Nursing Studies, 51(
1), 85-92. doi: 10.1016/j.ijnurstu.2013.05.015

Woten, M. (2016). Recruitment and retention of healthcare personnel: Nursing Residency.
CINAHL Nursing Guide
. Retrieved from eds.a.ebscohost.comproxy.chamberlain.edu: 8080/eds/detail/detail?vid=0&sid=5db30734

 

Nursing Theories and Their Works

 

Florence Nightingale (“Environmental Theory”)

Nursing as “act of utilizing the environment of the patient to assist him in his recovery”

Nightingale’s Concepts:

Person: Patient who is acted on by nurse; Affected by environment; has reparative powers nursing theories essay examples.

Environment: Foundation of theory; Included everything, physical, psychological, and social

Health: Maintaining well-being by using a person’s powers; Maintained by control of environment

Nursing: Provided fresh air, warmth, cleanliness, and good diet, quiet to facilitate person’s reparative process

 

Virginia Henderson (“The Nature of Nursing”)

“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. She must in a sense, get inside the skin of each of her patients in order to know what he needs”.

 

Dorothea Orem (“Self-Care Model”)

Nursing is “ an art, a helping service and a technology”

The theory includes:

Self care
– practice of activities that individual initiates and perform on their own behalf in maintaining life ,health and well being

Self care agency
– is a human ability which is “the ability for engaging in self care” -conditioned by age developmental state, life experience sociocultural orientation health and available resources nursing theories essay examples.

Therapeutic self care demand
– “totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions”

Self care requisites
-action directed towards provision of self care.

 

Sister Calista Roy (“Adaptation Model”)

Nursing is “a theoretical system of knowledge that prescribes a process of analysis and action related to the care of the ill or potentially ill person”

Five Interrelated Essential Elements:

Patiency- The person receiving care

Goal of nursing- Adapting to change

Health-Being and becoming a whole person

Environment

Direction of nursing activities- Facilitating adaptation

 

Betty Neuman (“Health Care Systems Model”)

–     Nursing is “a unique profession in that is concerned with all the variables affecting an individual’s response to stressors, which are intra, inter, extra personal in nature” nursing theories essay examples.

–     The model represents the client within the system perspective, holistically and multi-dimensionally. It illustrates the components of five interacting client variables; physiological, psychological, developmental, sociocultural and spiritual in relation to environmental influences upon the client as a system consisting of basic structure, lines of resistance and lines of defense.

 

Martha Rogers (“Unitary Human Beings”)

Nursing is “a humanistic science dedicated to the compassionate concern with and maintaining and promoting health, preventing illness, and caring for and rehabilitating the sick and disabled”

 

Imogene King (“Goal Attainment Theory”)

Nursing is “a helping profession that assists individuals and groups in society to attain maintains and restores health. If this is not possible, nurses help individual die with dignity”

Open systems framework nursing theories essay examples.

Human beings are open systems in constant interaction with the environment

Personal System

individual; perception, self, growth, development, time space, body image

Interpersonal

Society

Personal System: Individual; perception, self, growth, development, time space, body image

Interpersonal: Socialization; interaction, communication and transaction

Society: Family, religious groups, schools, work, peers

The nurse and patient mutually communicate, establish goals and take action to attain goals

Each individual brings a different set of values, ideas, attitudes, perceptions to exchange

 

Hildegard Peplau (“Interpersonal Relations Model”)

Based on psychodynamic nursing

using an understanding of one’s own behavior to help others identify their difficulties

Applies principles of human relations

Patient has a felt need

Peplau’s Concepts

Person: An individual; a developing organism who tries to reduce anxiety caused by needs; Lives in instable equilibrium

Environment

Health: Implies forward movement of the personality and human processes toward creative, constructive, productive, personal, and community living

Nursing: A significant, therapeutic, interpersonal process that functions cooperatively with others to make health possible

 

Jean Watson (“Philosophy and Science of Caring”)

Caring can be demonstrated and practiced

Caring consists of carative factors nursing theories essay examples

Caring promotes growth

A caring environment accepts a person as he is and looks to what the person may become

A caring environment offers development of potential

Caring promotes health better than curing

Caring is central to nursing

 

Lydia Hall (“Care Core and Cure Theory”)

The “Core, Care, and Cure” Theory was developed in the late 1960’s.  She postulated that individuals could be conceptualized in three separate domains: the body (care), the illness, (cure), and the person (core).

Hall believed patients should receive care ONLY from professional nurses. Nursing involves interacting with a patient in a complex process of teaching and learning. Hall was not pleased with the concept of team nursing–she said that “any career that is defined around the work that has to be done, and how it is divided to get it done, is a “trade” (rather than a profession).

 

Ida Jean Orlando (“Deliberative Nursing Process”)

The deliberative nursing process is set in motion by the patient’s behavior

All behavior may represent a cry for help. Patient’s behavior can be verbal or non-verbal.

The nurse reacts to patient’s behavior and forms basis for determining nurse’s acts.

Perception, thought, feeling

Nurses’ actions should be deliberative, rather than automatic nursing theories essay examples.

Deliberative actions explore the meaning and relevance of an action.

 

Katherine Kolcaba (“Comfort Theory”)

Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental)

 

The Importance of Nursing Theory

Nursing theory can be defined as a rigorous yet creative structure of ideas that emanate a purposeful, tentative, and systematic view of healthcare phenomena. Nursing theories incorporates many theories; with this culmination an introduction of action is placed into model practice. These theories are used to define, revolutionize, and disseminate current nursing knowledge and advance healthcare into the next era. Utilizing these theories provide for a plan for reflection and gives certainty for which the plan should be headed. With each new situation encountered, the framework of nursing theory provides an order for management, research, and decision making. These theories also provide a structure of communication for nurses amongst one another and with other healthcare professionals within the team. Nursing theories assist the nurse in developing goals, beliefs, and values. nursing theories essay examples.

Foundations of theory are and will remain an important aspect of nursing and advanced practice nursing education. Today, theory play an even larger role in nursing with increased emphasis on nursing research and evidence-based practices for advanced practice nurses. With this being said, it is expected of nurse practitioner graduates to demonstrate competencies in skills and knowledge in order to provide safe and quality care to a diverse population of patients in a very complicated health care system.

With increase in acuity of patients, hospitalization length decreasing, and the boom of healthcare technology and specialization, the need for highly experienced nurses have increased. With this increase in need, the responsibility and complexity of current nursing practice requires constant, long term career development. According to the AACN, many Master’s level nursing programs were reported to have wide varying clinical practicum requirements, didactic course work experiences, and titling. Unfortunately, in certain instances, new graduates from these nursing programs reportedly had no direct care experiences in their chosen master’s programs such as adult health, community health, and child health (AACN, 2011). nursing theories essay examples.

From Novice to Expert, a theory formulated by Patricia Benner, is probably one of the simplest nursing theories to understand. Benner’s theory proposes that in gaining and developing skills, a nurse must pass through five proficiency levels: as a novice, an advanced beginner, competent, proficient, and lastly, an expert. Advancing through each level reflects a movement from dependence on abstract principles to the application of past concrete experiences. As a nurse advances through each step, she builds upon the previous step and gains clinical expertise with each advancement (Benner, 1982).

In Benner’s first stage of clinical competence, the novice or beginner has little to no experience in circumstances in which they are expected to perform in. There is lack of confidence in demonstrating safe practice and the requirement of continuous verbal and physical cues are present. Practice is within an extended period of time and the individual is unable to make and use discretionary, independent judgement. An example of this would be a nursing student in the first year of clinical education; upon observation, the observer will witness limited and inflexible behavior in the clinical setting. Novices lack the ability to predict and ascertain what may occur in certain patient situations, i.e., mental status change, this knowledge may be obtained once a novice nurse has gained experience working with patients who have had similar symptoms (1982 nursing theories essay examples.

The next stage of clinical competence, advanced beginner, the nurse demonstrates slightly acceptable performance due to prior experiences in actual situations. The nurse is competent and skillful in certain areas of practice, requiring minimal verbal and physical cues with continued knowledge development. These are nurses who have obtained a first job, acquired experiences which allow them to recognize situations in which they have been previously exposed and have the knowledge combined with the know-how to respond but still lack in depth experience.

Benner’s third stage, Competence, is demonstrated by the nurse who has been practicing in the same job/situation for at least two to three years. The nurse holds the ability to demonstrate efficiency, possesses coordination and confidence in her actions. A plan effectively establishes a perspective and is based on substantial abstract, conscious, logical contemplation of the situation. The deliberate, conscious planning associated with this skill level assists the nurse in achieving efficiency and organization with care completion in an appropriate timeframe with no supporting cues.

For Benner’s next stage, Proficient, the nurse’s perception of a situation is whole rather than in bits and pieces. The proficient nurse understands and views the situation a whole due to the ability to perceive the meaning in terms of long term goals. The Proficient nurse obtains knowledge from experience from typical situations, how to respond to these situations and how to modify plans in response to these situations. The Proficient nurse holds the ability to recognize what is an atypical event/situation. The Proficient nurse perceives decision making as holistic and decision making becomes less arduous due to gained experience nursing theories essay examples.

For Benner’s last stage, Expert, the nurse has the ability to intuitively grasp each situation and event which allows for accurate assessment and addressing of certain problems without unnecessary wasting of consideration, time, and solutions. The Expert nurse functions from a deep understanding of the situation as a whole. Performance becomes flexible and fluid with high proficiency. For situations in which the nurse has had no exposure or experience, a high skilled analytic ability is necessary.

When applying the metaparadigm in Benner’s perspective, the perception is that the person does not enter this world pre-defined but is defined through the course of living life; a self – interpreting being, the view is of the person being a participant in common meanings (Tomey & Allgood, 2002). According to Benner, the person must understand and handle the role of the situation, the body, the personal concern, and temporality. Benner’s focus on health was through the lived experience of being healthy and sick. Benner defined health as objective assessment, with well-being as experienced by health and wholeness. For Benner, environment, or situation, is used to suggest a social atmosphere. This is defined by Benner as the person’s involved interaction, perception, interpretation, and understanding of the situation.

According to Huffstutler, newly graduated nurse practitioners often express feelings of being a “fake” or “imposter, as they make the transition from nurse to nurse practitioner (2006). After exceeding the stages of novice to expert, the newly graduated nurse practitioner must once again gain experience and get established in a “new” situation and role. Huffstutler suggests strategies for new nurse practitioners to develop during this transitional phase is to be aware of the transition. Self-reflection and calm inward looking may assist with this transitional process. The novice nurse practitioner should acknowledge initial lack of command as a nurse practitioner.

As I review this theory and its stages, I have the ability to ascertain where my methods and practice arise from. Applying Benner’s stages, I had no knowledge, I gained knowledge, I developed confidence, and I became an expert. As a nurse, it is crucial that we recognize and are able to differentiate between cultures and the many different views of healthcare, amongst life and death and are able to work within these frameworks to provide the best and most effective quality of care for our patients nursing theories essay examples.

References

American Associations of Colleges of Nursing (2011). The Essentials of Master’s Education in Nursing. Retrieved from 
http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf. 

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley, pp. 13-34.

Huffstutler, S. Y. (2006). The Impostor Phenomenon in New Nurse Practitioner Graduates. 
Topics in Advanced Practice Nursing EJournal,
 6(2).

Tomey, A. M., & Allgood, M. R. (2002). Nursing Theorists and Their Work.
International Journal of Nursing Studies,
 42(1), 114.
http://dx.doi.org/10.1016/j.ijnurstu.2004.05.009
 nursing theories essay examples

Jean watson human caring theory sample essays

Jean Watson’s Theory of Human Caring

Jean Watson’s Theory of Human Caring is a middle range theory that focuses on the patient and nurse connection.  It focuses on caring authentically patient as a whole, which means caring about the patient’s mind, spirit and body, so the process of healing can continue at an ideal level.  Described as a model of caring that includes art and science; a framework that intersects and embraces with art, science, spirituality, humanities and a new dimension of body spirit and mind medicine. Jean watson human caring theory sample essays. Watson believes her theory is one that is open to the changing practice of nursing.  By applying abstract concepts of faith, hope, love, caring, and trust to nursing can help stratify the concept of human caring (Williams 2011).

BUY A PLAGIARISM-FREE PAPER HERE

Comprised of 4 major conceptual elements; clinical Caritas processes, caring moment/caring occasion and caring consciousness and transpersonal caring relationships.  The clinical Caritas processes emerges from Watson’s own caritas reason that involves trust, love, faith, hope, selflessness, caring, spirituality, energy and understanding.

Nurses must find it within themselves to say and explore on who they are to offer ideal care.  If the nurse is aware of what it takes to care for their patient, it will take them on an experience that not only benefits the nurse but the patient.  The nurse anticipates the needs of the patient and ensures that those needs are reached. Caring moment/caring occasion focus on the nurse experiencing something greater than themselves.  The feeling could be spiritual and encourage the nurse to make connections with the patient that would have never been there.  It could open areas for the new possibilities for a human connection at a deeper level that of physical interactions (Watson 2009).  The function of caring consciousness means the nurse needs awareness of the dynamics of life and human phenomena.  Watson’s goal is to let the nurse know that every person can connect by the healing process of energy. Jean watson human caring theory sample essays.

Watson’s praxis leads itself in providing a different dimension of nursing explored rarely as the art of caring. Developing this theory structured the concept.  Caring is a part of nursing and the nurse needs to understand the power of human caring.  When reading this theory, it is clear and states the patient care is an ordeal that leads to a healing process for the patient.  In an acute setting a patient consumed by fear and anxiety, it takes a caring nurse to find those symptoms and help the patient resolve it.

The relationship that the model describes is between patients and nurse that is intensely deep and intertwined in the eyes of Watson.  Theoretical basis for nursing practice is in the transpersonal relationships that focus on the patient as the cherished other.  Based on the general concept that patients rely on nurses for spiritual care, psychosocial and comfort.  The relationship possesses healing power for the patient. with connection of human beings. Jean watson human caring theory sample essays. A caring model provides a capacity that nurses are to understand how caring behaviors can aid with development of a relationship with patients that puts them at ease and feeling secure.  This theory is significant in developing caring behaviors (Watson 2009).

The concept of caring is very broad, with the Watson’s theory of Human Caring, it seems to help nurses understand more about the process of human caring.  The theory is easy to follow and introduced a word “caritas” defined in her theory as coming from the Greek word meaning “to cherish and appreciate, giving special attention to, or loving” (Summerell 2015)..

This theory originated with the importance to understanding that the nursing career is an ever evolving work in progress that adapts to our rapid changing nursing practice in society.It responds well to the human dynamics of phenomena that focus on nurse self-care that one can appreciate.  The focus is that Watson wants the nurse  to understand that one must find their spiritual and inner self that will allow them to go beyond their ego to open up to others with sensitivity and compassion.  It also has a potential to influence nursing actions to propel the discipline further into a more holistic context.  Self-care is important in nursing because it brings nurses closer to their spirits, allowing them to feel connections with the entire world and to experience a cosmic love (Sitzman 2007).  One can apply this knowledge to their nursing practice; it has simple tasks and is easily applied in any setting.  With the busy hospital, the nurse can have daily awareness to their practice, by taking a slow deep breath before entering the room to remind them that the need is present for awareness of the present condition.  This theory has concepts that seem to enhance the discipline of nursing. Jean watson human caring theory sample essays.

 

Reference:

Summerell, P. (2015). EB133 Jean Watson’s Caritas Processes: A Model for Transforming the      Nursing Practice Environment.
Critical Care Nurse
,
35
(2), e66-e67.

Sitzman, K. (2007). Teaching-learning professional caring based on Jean Watson’s Theory of         Human Caring.
International Journal For Human Caring
,
11
(4), 8-16.

Watson, J. (2009). CARING SCIENCE AND HUMAN CARING THEORY: TRANSFORMING PERSONAL AND PROFESSIONAL PRACTICES OF NURSING AND HEALTH CARE.
Journal Of Health & Human Services Administration
,
31
(4), 466-482.

 

Williams, I. R., McDowell, J., & Kautz, D. (2011). A caring leadership model for nursing’s           future.
International Journal For Human Caring
,
15
(1), 31-35. Jean watson human caring theory sample essays

 

 

Nursing Theory and Practice

In the early days of nursing, nursing tasks were directed with little regard as to why they are being performed. The development of nursing theory is what gives nursing its basis or structure and it is what distinguishes its practice from other healthcare professions. There are many nursing theorists and theories in existence all of which have been somewhat of an evolutionary development as nursing has grown and each one has some unique attributes. The focus will be on Watson’s Theory of Caring. Watson defines caring as “the ethical and moral ideal of nursing with interpersonal and humanistic skills” (Alligood, 2014, p. 96). Discussion will include the importance of the above theory, a summary of the theory and its application into practice as a family nurse practitioner (FNP). Jean watson human caring theory sample essays.

Importance of Nursing Theory

Evidence-based practice is a large part of Master’s curriculum but more important is the understanding of the relationship between theory, evidence, research and practice is absent in many programs (Donohue-Porter, Forbes, & White, 2011). Meaning that the relationship between theory and practice has been replaced with bringing evidence into practice. While evidence can support decision-making and interventions or action, theory is still the foundation for the evidence. Jean watson human caring theory sample essays. However, if focus is completely on research and evidence, one could argue that it is taking nursing away from the humanistic art that it is and changing it toward more of a medical practice model.

Nursing theory is important because it is what provides basic information and is what guides nursing action (Alligood, 2014, p. 67) and provides direction and purpose. It is what guides nurses and inspires thoughts and actions (Noel, 2010, p. 17). This essentially means that nursing theory is the foundation to nursing practice. Looking at why it is important in a master’s program led me down a path of inquiry and research of the various theories and models of nursing focusing on the nursing meta-paradigm of person, health, environment, and nursing. Then, paying more specific attention to the definition of nursing which is “situated caring shaped by interior and exterior environments” (Jarrin, 2012, p. 3) Jean watson human caring theory sample essays. This is what separates nursing from a “medical model” which essentially is a problem solving, cure based or “fix-it” approach. This translates to patients relying on the advice of the physician, however may lead to clients feeling as if they have no sense of control (Noel, 2010).

One could argue concern for use of theory in practice that many of the nursing theories are older and outdated as they were based on what was actually happening in the world and healthcare during the specific time period they were developed. Another argument is that theory does not give specific guidelines for assessment, diagnosis or intervention (Meleis, 2012).

Summary of Watson’s Theory of Human Caring

Jean Watson developed one of the most recent nursing theorists and in 1979
Nursing: The Philosophy and Science of Caring
was published initially as a textbook for nursing curriculum at the University of Colorado (Alligood, 2014) and reprinted in 2005. Her theory has evolved over the past 30 years and her most recent work was published in 2013 titled
Caring Science, Mindful Practice: Implementing Watson’s Human Caring Theory.
According to Noel, Watson describes caring science as a model that allows us to approach the sacred in our caring-healing work and her writings show the progression of her understanding of caring Jean watson human caring theory sample essays.

Caring overall has many facets and includes physical, psychological, cultural, spiritual and existential aspects (Noel, 2010, p. 17). Watson defines caring as “the ethical and moral ideal of nursing with interpersonal and humanistic qualities, a complex concept involving development of a range of knowledge, skills, and expertise that encompass holism, empathy, communication, clinical competence, technical proficiency, and interpersonal skills” (Alligood, 2014, p. 96). Interpersonal relationships are those based on mutual respect, mutual learning and give and take, meaning that the patient and the nurse learn from each other thus creating a what can be referred to as a shared experience (Noel, 2010).

When looking at the person or human being she views them from a holistic standpoint in where the mind, body and spirit are all connected and the person as a whole is influenced based on ones self-concept. Holistic nursing is described as a practice focusing on the whole person as in the person is not just an illness, it addresses the interconnectedness of the mind, body, spirit, social/cultural, emotions, relationships, context, and environment (“Holistic Nursing,” n.d., para. 1). Therefore in order to heal the person, it is important to look at all of this in determining how they affect ones health.

There are 10 processes to Watsons’ caring theory referred to as “Caritas processes.” Caritas comes from the Latin word meaning “to cherish or give special attention to”. The first three are the foundation for the science of caring and the remaining seven build upon that foundation. She describes nursing as “transpersonal” conveying a human-to-human connection in which both persons are influenced through the relationship and being together in the moment (Alligood, 2014, p. 104). Jean watson human caring theory sample essays. She states that it is important that the nurse find a way to be conscious of Caritas in order to effectively practice within this paradigm.

Nurses and FNP’s, generally look for opportunities to connect with their patients or clients as a way to teach, learn and share. This involves being present or in the moment with the patient, supporting them and building trust as we learn from each other. Watson’s work has been human caring theory sets the framework for current initiatives focused on wellness, health promotion, chronic disease management, case management and crisis intervention.”

Application to Practice

The FNP is set apart from other healthcare disciplines in that the practice is based on promoting overall health and well-being by taking into perspective the whole person, meaning mind, body and spirit and educating the population in making better choices for health and wellness (American Association of Nurse Practitioners, n.d.). Many articles state that the practice of loving kindness is what is most important to patients and families and having it come from the heart, it is the beginning of what can help improve healing relationships and improved patient outcomes (DiNapoli, Nelson, Turkel, & Watson, 2010).

The first Caritas is to practice loving kindness. The practitioner can incorporate this into his or her practice with the affirmation of “Everyday I am here I see that the care is provided with loving-kindness”. Others Caritas processes include decision making, instilling faith and hope, teaching and learning, respect for spiritual beliefs and practices, holistic care, building a helping and trusting relationship, healing environment, promoting expression of feelings and miracles Jean watson human caring theory sample essays. This directly translates to the job description that meets the healthcare needs of the individual and family by providing comprehensive primary care through the lifespan as provided by the University of California, San Francisco (UCSF). As discussed earlier comprehensive care is caring for the whole patient and all of his or her needs.

In my practice as a case manager for a workman’s compensation insurance provider I incorporate this into my practice daily. I have injured worker that I will refer to as Mr. H., who approximately 9 months ago was driving from one work location to another in the scope of his employment and was involved in a very severe head-on collision. He was severely injured and spent several weeks in the hospital and then a rehabilitation facility. His wife was due to have labor induced the day following the accident. While my focus was on planning ahead for the patients potential care needs, I also had the needs of his wife and family to take into consideration. Mr. H. was in the intensive care unit (ICU) and unable to communicate due to the extent of his injuries. I made a trip to the hospital where he was being treated to speak with the ICU staff, treating physicians and also nursing case management in order to collaborate with all parties involved regarding his care and treatments. With this knowledge I was able to educate the patients wife and family on treatment options, recovery and potential future needs. Discussions with his wife prior to his transfer from ICU to rehab included spirituality, instillation of faith and hope, holistic practices and care, helping to promote expression of feelings and practicing loving kindness; thus creating a human-to-human connection and the ability to see beyond the treatments and procedures that lie ahead. This helped to facilitate referrals needed to work on his anger toward the driver who hit him; posttraumatic stress and anxiety related to multiple surgeries and prolonged recovery.

Conclusion

Watson’s theory of caring and the Caritas processes involves knowing, being and doing all at the same time. In many cases theory is not a huge focus in nursing programs and practice as theory-based practice is being replaced by evidence-based practice thus potentially changing nursing into a medical model of practice vs. a nursing model of practice. Watson’s caring theory can help to preserve the practice of nursing as a profession of caring founded upon practicing loving kindness looking at the relationship between mind, body and spirit and how they are connected Jean watson human caring theory sample essays. Nurse practitioners provide care to patients across the lifespan and this care in concentrated on education of the patients by taking into account their beliefs and practices in order to assist them in making choices for improvement of lifestyle and essentially quality of life. The focus is not on treating the patient as a disease or illness, but as a whole person to create a relationship of mutual trust and respect.

This assignment was a growth experience for me and really brought me outside of my comfort zone. In my early years of nursing, I would roll my eyes when discussion of theory came up. I was focused on the procedures and practice, not on the milieu per say. As my experience and knowledge grew, I began to realize that theory is what distinguishes nursing form the other healthcare disciplines and is in itself and art. I recognized this as a hospice case manager where I was forced to focus on the mind body and spirit in order to provide the best care for patients and their families. I chose Watson’s caring theory as this theory is one I now can relate to on a more personal level, and I feel that my research will help to guide me in my future practice as a FNP. Jean watson human caring theory sample essays.

References

Alligood, M. R. (2014).
Nursing theory: Utilization and application
(5th ed.). [Google Books]. Retrieved from https://books.google.com

American Association of Nurse Practitioners. (n.d.). https://www.aanp.org

DiNapoli, P. P., Nelson, J., Turkel, M., & Watson, J. (2010). Measuring the caritas processes: Caring factor survey.
International Journal for Human Caring
,
14
(3), 16-21. Retrieved from https://www.watsoncaringscience.org

Donohue-Porter, P., Forbes, M. O., & White, J. H. (2011). Nursing theory in curricula today: Challenges for faculty at all levels of education.
International Journal of Nursing Education Scholarship
,
8
(1), 1-18. http://dx.doi.org/10.2202/1548-923x.2225

Holistic nursing. (n.d.). Retrieved from http://nursing-theory.org/theories-and-models/holistic-nursing.php

Jarrin, O. F. (2012). The integrality of situated caring in nursing and the environment.
Advanced Nursing Science
,
35
(1), 14-24. http://dx.doi.org/10.1097/ANS.0b013e3182433b89 Jean watson human caring theory sample essays.

Meleis, A. I. (2012).
Theoretical nursing: Development and progress
(5th ed.). [Google Books]. Retrieved from https://www.books.google.com

Noel, D. L. (2010, January). Occupational health nursing practice through he human caring lens.
AAOHN Journal
,
58
(1), 17-24. http://dx.doi.org/10.3928/08910162-20091216-02

University of California San Francisco. (n.d.). https://nursing.ucsf.edu Jean watson human caring theory sample essays

Discussion: Therapy for Clients With Personality Disorders

Clients with personality disorders often find it difficult to overcome their problems and function in daily life. Even when these clients are aware that they have a dysfunction with their personality and are open to counseling, treatment can be challenging for both the client and the therapist. For this Discussion, as you examine personality disorders, consider therapeutic approaches you might use with clients.

Learning Objectives

Students will:

Analyze therapeutic approaches to treating clients with personality disorders

To prepare:

BUY A PLAGIARISM-FREE PAPER HERE

Review this week’s Learning Resources and reflect on the insights they provide.

Select one of the personality disorders from the DSM-5.

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 cannot post anonymously. Please check your post carefully before clicking Submit! Discussion: Therapy for Clients With Personality Disorders

By Day 3

Post a description of the personality disorder you selected. Explain a therapeutic approach (including psychotropic medications if appropriate) you might use to treat a client presenting with this disorder, including how you would share your diagnosis of this disorder to the client in order to avoid damaging the therapeutic relationship. Support your approach with evidence-based literature.

Read a selection of your colleagues’ responses.

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

Chapter 20, “Termination and Outcome Evaluation” (Review pp. 693–712)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Note: You will access this text from the Walden Library databases. Discussion: Therapy for Clients With Personality Disorders

Dixon-Gordon, K. L., Turner, B. J., & Chapman, A. L. (2011). Psychotherapy for personality disorders. International Review of Psychiatry, 23(3), 282–302. doi:10.3109/09540261.2011.586992

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

Lorentzen, S., Ruud, T., Fjeldstad, A., & Høglend, P. A. (2015). Personality disorder moderates outcome in short- and long-term group analytic psychotherapy: A randomized clinical trial. British Journal of Clinical Psychology, 54(2), 129–146. doi:10.1111/bjc.12065

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

Paris, J. (2004). Personality disorders over time: Implications for psychotherapy. American Journal of Psychotherapy, 58(4), 420–429. PMID: 15807086

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

Swift, J. K., & Greenberg, R. P. (2015). What is premature termination, and why does it occur? In Premature termination in psychotherapy: Strategies for engaging clients and improving outcomes (pp. 11–31). Washington, DC: American Psychological Association. doi:10.1037/14469-002

Note: You will access this text from the Walden Library databases. Discussion: Therapy for Clients With Personality Disorders

Optional Resources

Dorr, D. (1999). Approaching psychotherapy of the personality disorders from the Millon perspective. Journal of Personality Assessment, 72(3), 407–425. PMID: 10491846

Bach, B., Lee, C., Mortensen, E. L., & Simonsen, E. (2016). How do DSM-5 personality traits align with schema therapy constructs? Journal of Personality Disorders, 30(4), 502–529. doi:10.1521/pedi_2015_29_212

Walden University. (2016). ASC success strategies: Studying for and taking a test . Retrieved from http://academicguides.waldenu.edu/ASCsuccess/ASCtesting

 

Introduction

A personality disorder refers to the mental disorder in which the person suffering from the same have a rigid and unhealthy pattern of thinking coupled with undesired functioning and behaving. People with personality disorder have difficulties perceiving and relating to situations and other people and thus, leading to limitations in relationships and social activities. In most cases, one would not know if he/she is having the personality disorder because the way of thinking and behaving appear natural to them. Even though there are several types of personality disorder; I chose to focus on schizotypal personality disorder (STPD) in this discussion.

Description of schizotypal personality disorder (STPD)

By description, schizotypal personality disorder (STPD) is a type of disorder characterized by the oddities of appearance, unusual perceptual experiences, behaviour, and speech, and anomalies of thinking which are similar as schizophrenia (Hazlett et al. 2015) . People having schizotypal PD usually fear social interaction because they think of others as being harmful.   Patients may also experience extreme anxiety in social situations. Some of the symptoms associated with a schizotypal personality disorder (STPD) include lack of close friends or confidants, being uncomfortable relating to people, anxious in social situations and superstitious. Patients with schizotypal personality disorder are often suspicious and may think others are out to hurt them (Jakobsen et al 2017). Discussion: Therapy for Clients With Personality Disorders

The therapeutic approach for schizotypal personality disorder (STPD)

When it comes to the therapeutic approach for schizotypal personality disorder (STPD), typical antipsychotic drugs and antidepressants would be prescribed for the patient. Atypical antipsychotics are prescribed to lessen anxiety and psychotic-like symptoms. Generally, patients with schizotypal personality disorders benefit from low-dose antipsychotic medications. These drugs act by reducing psychotic-like symptoms while improving day-to-day functioning.  Mainly, I will prescribe Clozapine. Clozapine works by reducing the negative symptoms associated with a schizotypal personality disorder (STPD). The advantage of using clozapine is that it has been shown to be effective treatment even for the patients who have failed to show positive response with the conventional antipsychotic (Argent & Hill, 2014). Nevertheless, clozapine has lower tolerability and therefore, need continuous blood monitoring

The second therapy is the Cognitive-behavioural therapy which focuses on helping the client acquire social skills and manage anxiety.  CBT will also be used to help the person understand how his/her thoughts and behaviours affect each other.  Thirdly, supportive psychotherapy can also be used. The central goal here is to establish an emotional, encouraging and supportive relationship with the patient (Jakobsen et al 2017).

In sharing the diagnosis of schizotypal personality disorder to the client to avoid damaging the therapeutic relationship, it is essential to be firm, consistent, and empathetic. I would first tell the patient before revealing the exact condition that his disorder is treatable. I will also tell the client the different treatment options that are available and then recommend the most appropriate one based on the symptoms. Discussion: Therapy for Clients With Personality Disorders

References

Argent, S. E., & Hill, S. A. (2014). The novel use of clozapine in an adolescent with borderline personality disorder. Therapeutic Advances in Psychopharmacology, 4, 4, 149-155.

Hazlett, E. A., Rothstein, E. G., Ferreira, R., Silverman, J. M., Siever, L. J., & Olincy, A. ( 2015). Sensory gating disturbances in the spectrum: Similarities and differences in schizotypal personality disorder and schizophrenia. Schizophrenia Research, 161, 283-290.

Jakobsen, K. D., Nielsen, J., Jakobsen, K. D., Skyum, E., Hashemi, N., Schjerning, O., Nielsen, J., … Jakobsen, K. D. ( 2017). Antipsychotic treatment of schizotypy and schizotypal personality disorder: A systematic review. Journal of Psychopharmacology, 31, 4, 397-405. Discussion: Therapy for Clients With Personality Disorders

This Evaluation of Marginalized Women: Women with HIV Essay paper should clearly and comprehensively identify the disease or population health problem chosen. The paper should be organized into the following sections:

1. Introduction with a clear presentation of the marginalized group as well as significance and a scholarly overview of the paper. Include Incidence and prevalence statistics.

2. Background of the marginalized group/problem including description, current incidence and/or prevalence statistics current state, local, and national statistics pertaining to the problem.

BUY A PLAGIARISM-FREE PAPER HERE

3. Discuss the socio economic aspects of the marginalized group

4. Discuss social justice and its relationship to health disparities and health care of marginalized group.

5. Discuss ethical issues on marginalized group Evaluation of Marginalized Women: Women with HIV Essay

6. Provide a brief plan of how you will address this marginalized group in your practice once you are finished with school as a primary nurse pracititioner. Provide three actions you will take along with how you will measure outcomes of your actions. Includes at least three evidenced based actions, supported by literature, that the student will take in their own practice and how outcomes will be measured.

7. Conclude in a clear manner with a brief overview of key points of the entire problem. presents major points of the paper with clear direction for action.

group to be researched: WOMEN with HIV in Kentucky, USA.

Please do not include a cover/title page. Please include all references used. Evaluation of Marginalized Women: Women with HIV Essay

Assignment 1: Practicum – Client Termination Summary- WK1064N

Learning Objectives

Students will:

• Develop client termination summaries

To prepare:

• For guidance on writing a Client Termination Summary, review pages 693–712 of the Wheeler text in this week’s Learning Resources.

• Identify a client who may be ready to complete therapy.

BUY A PLAGIARISM-FREE PAPER HERE

The Assignment

With the client you selected in mind, address the following in a client termination summary (without violating HIPAA regulations): SEE ATTACHED CLIENT INFORMATION- USE THIS FOR THE ASSIGNMENT BELOW

• Identifying information of client (i.e., hypothetical name, age, etc.)

• Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end

• Total number of sessions, including number of missed sessions

• Termination planned or unplanned

• Presenting problem

• Major psychosocial issues

• Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)

• Overview of treatment process

• Goal status (goals met, partially met, unmet)

• Treatment limitations (if any)

• Remaining difficulties and/or concerns

• Recommendations

• Follow-up plan (if indicated)

• Instructions for future contact

• Signatures

Assignment 1: Practicum – Client Termination Summary- WK1064N