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KozierandErbsFundamentalsofNursing10thed.pdf
# 153613 Cust: Pearson Au: Berman Pg. No. e Title: Kozier & Erb’s Fundamentals of Nursing 10e
C/M/Y/K Short / Normal
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# 153613 Cust: Pearson Au: Berman Pg. No. d Title: Kozier & Erb’s Fundamentals of Nursing 10e
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Brief Contents UNIT 1 The Nature of Nursing 1 Chapter 1 Historical and Contemporary Nursing
Practice 2
Chapter 2 Evidence-Based Practice and Research in Nursing 26
Chapter 3 Nursing Theories and Conceptual Frameworks 37 Chapter 4 Legal Aspects of Nursing 47 Chapter 5 Values, Ethics, and Advocacy 73
UNIT 2 Contemporary Health Care 88 Chapter 6 Health Care Delivery Systems 89 Chapter 7 Community Nursing and Care Continuity 105 Chapter 8 Home Care 118 Chapter 9 Electronic Health Records and Information
Technology 129
UNIT 3 The Nursing Process 143 Chapter 10 Critical Thinking and Clinical Reasoning 144 Chapter 11 Assessing 155 Chapter 12 Diagnosing 175 Chapter 13 Planning 189 Chapter 14 Implementing and Evaluating 208 Chapter 15 Documenting and Reporting 221
UNIT 4 Health Beliefs and Practices 243 Chapter 16 Health Promotion 244 Chapter 17 Health, Wellness, and Illness 262 Chapter 18 Culturally Responsive Nursing Care 276 Chapter 19 Complementary and Alternative Healing
Modalities 295
UNIT 5 Life Span Development 311 Chapter 20 Concepts of Growth and Development 312 Chapter 21 Promoting Health from Conception Through
Adolescence 328
Chapter 22 Promoting Health in Young and Middle-Aged Adults 353 Chapter 23 Promoting Health in Older Adults 364 Chapter 24 Promoting Family Health 386
UNIT 6 Integral Aspects of Nursing 397 Chapter 25 Caring 398 Chapter 26 Communicating 411 Chapter 27 Teaching 438 Chapter 28 Leading, Managing, and Delegating 462
UNIT 7 Assessing Health 476 Chapter 29 Vital Signs 477 Chapter 30 Health Assessment 513
UNIT 8 Integral Components of Client Care 601 Chapter 31 Asepsis 602 Chapter 32 Safety 640 Chapter 33 Hygiene 669 Chapter 34 Diagnostic Testing 718 Chapter 35 Medications 750 Chapter 36 Skin Integrity and Wound Care 828 Chapter 37 Perioperative Nursing 865
UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904 Chapter 39 Self-Concept 922 Chapter 40 Sexuality 934 Chapter 41 Spirituality 954 Chapter 42 Stress and Coping 972 Chapter 43 Loss, Grieving, and Death 989
UNIT 10 Promoting Physiological Health 1009 Chapter 44 Activity and Exercise 1010 Chapter 45 Sleep 1066 Chapter 46 Pain Management 1086 Chapter 47 Nutrition 1127 Chapter 48 Urinary Elimination 1174 Chapter 49 Fecal Elimination 1210 Chapter 50 Oxygenation 1241 Chapter 51 Circulation 1287 Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308
Further enhance your Clinical Reasoning with the additional resources below. For more information and purchasing options visit www.mypearsonstore.com.
Break Through to improving results
MyNursingLab provides a guided learning path that is proven to help students synthesize vast amounts of information, guiding them from memorization to true understanding through application.
Thinking Like a Nurse in Clinical Thinking Like a Nurse for NCLEX-RN® Success
Align ed to
the
2013 NCL
EX-R N®
Test Plan
Clinical references across the nursing curriculum available.
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eText
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Kozier and Erb’s Fundamentals of Nursing 10e
1 Historic and Contemporary Nursing Practice
2 Evidence-Based Practice and Research in Nursing
3 Nursing Theories and Conceptual Frameworks
4 Legal Aspects of Nursing
5 Values, Ethics, and Advocacy
6 Health Care Delivery Systems
7 The Nurse-Patient Relationship and Therapeutic Communication
8 Home Care
9 Electronic Health Records and Information Technology
10 Critical Thinking and Clinical Reasoning
11 Assessing
12 Diagnosing
13 Planning
14 Implementing and Evaluating
15 Documenting and Reporting
16 Health Promotion
Available for your favorite
electronic device!
NURSE’S DRUG GUIDE Wilson • Shannon • Shields
2016
NURSE’S DRUG GUIDE
Wilson • Shannon • Shields
• Thousands of drugs organized alphabetically
• Indexed by generic and trade drug names
• Complete IV drug information
PEARSON
PEARSON
www.pearsonhighered.com
PEARSON NURSE’S DRUG GUIDE 2016 NURSES AGREE: Pearson Nurse’s Drug Guide provides all the information you need for safe, effective drug administration in any setting!
• Organized alphabetically and indexed by generic and trade drug names
• Dosages across the lifespan from neonate to older adults
• Dosage with adjustments for clinically relevant conditions
• Complete IV preparation and administration information
• Clinically relevant drug interactions with food, herbals, and other drugs
• Pharmacologic and therapeutic classifications for every drug
• Unique glossary of clinical conditions and their related signs and symptoms
• Prototype drugs for each drug classification
• NEW! Black box warnings throughout
Comprehensive Current Clinically Relevant
Available for your favorite
electronic device!
2016
Simplify your study time by using the resources included with this textbook at http://www.nursing.pearsonhighered.com
using your
Begin Thinking LIKE A NURSE
PEARSON RESOURCES
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Brief Contents UNIT 1 The Nature of Nursing 1 Chapter 1 Historical and Contemporary Nursing
Practice 2
Chapter 2 Evidence-Based Practice and Research in Nursing 26
Chapter 3 Nursing Theories and Conceptual Frameworks 37 Chapter 4 Legal Aspects of Nursing 47 Chapter 5 Values, Ethics, and Advocacy 73
UNIT 2 Contemporary Health Care 88 Chapter 6 Health Care Delivery Systems 89 Chapter 7 Community Nursing and Care Continuity 105 Chapter 8 Home Care 118 Chapter 9 Electronic Health Records and Information
Technology 129
UNIT 3 The Nursing Process 143 Chapter 10 Critical Thinking and Clinical Reasoning 144 Chapter 11 Assessing 155 Chapter 12 Diagnosing 175 Chapter 13 Planning 189 Chapter 14 Implementing and Evaluating 208 Chapter 15 Documenting and Reporting 221
UNIT 4 Health Beliefs and Practices 243 Chapter 16 Health Promotion 244 Chapter 17 Health, Wellness, and Illness 262 Chapter 18 Culturally Responsive Nursing Care 276 Chapter 19 Complementary and Alternative Healing
Modalities 295
UNIT 5 Life Span Development 311 Chapter 20 Concepts of Growth and Development 312 Chapter 21 Promoting Health from Conception Through
Adolescence 328
Chapter 22 Promoting Health in Young and Middle-Aged Adults 353 Chapter 23 Promoting Health in Older Adults 364 Chapter 24 Promoting Family Health 386
UNIT 6 Integral Aspects of Nursing 397 Chapter 25 Caring 398 Chapter 26 Communicating 411 Chapter 27 Teaching 438 Chapter 28 Leading, Managing, and Delegating 462
UNIT 7 Assessing Health 476 Chapter 29 Vital Signs 477 Chapter 30 Health Assessment 513
UNIT 8 Integral Components of Client Care 601 Chapter 31 Asepsis 602 Chapter 32 Safety 640 Chapter 33 Hygiene 669 Chapter 34 Diagnostic Testing 718 Chapter 35 Medications 750 Chapter 36 Skin Integrity and Wound Care 828 Chapter 37 Perioperative Nursing 865
UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904 Chapter 39 Self-Concept 922 Chapter 40 Sexuality 934 Chapter 41 Spirituality 954 Chapter 42 Stress and Coping 972 Chapter 43 Loss, Grieving, and Death 989
UNIT 10 Promoting Physiological Health 1009 Chapter 44 Activity and Exercise 1010 Chapter 45 Sleep 1066 Chapter 46 Pain Management 1086 Chapter 47 Nutrition 1127 Chapter 48 Urinary Elimination 1174 Chapter 49 Fecal Elimination 1210 Chapter 50 Oxygenation 1241 Chapter 51 Circulation 1287 Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308
Further enhance your Clinical Reasoning with the additional resources below. For more information and purchasing options visit www.mypearsonstore.com.
Break Through to improving results
MyNursingLab provides a guided learning path that is proven to help students synthesize vast amounts of information, guiding them from memorization to true understanding through application.
Thinking Like a Nurse in Clinical Thinking Like a Nurse for NCLEX-RN® Success
Align ed to
the
2013 NCL
EX-R N®
Test Plan
Clinical references across the nursing curriculum available.
Courses | Hello Instructors | Account | Help & Support
Course Home
Syllabus
Assignment Calendar
Course Content
eText
Class Preparation
Class Master
Submissions
Kozier and Erb’s Fundamentals of Nursing 10e
1 Historic and Contemporary Nursing Practice
2 Evidence-Based Practice and Research in Nursing
3 Nursing Theories and Conceptual Frameworks
4 Legal Aspects of Nursing
5 Values, Ethics, and Advocacy
6 Health Care Delivery Systems
7 The Nurse-Patient Relationship and Therapeutic Communication
8 Home Care
9 Electronic Health Records and Information Technology
10 Critical Thinking and Clinical Reasoning
11 Assessing
12 Diagnosing
13 Planning
14 Implementing and Evaluating
15 Documenting and Reporting
16 Health Promotion
Available for your favorite
electronic device!
NURSE’S DRUG GUIDE Wilson • Shannon • Shields
2016
NURSE’S DRUG GUIDE
Wilson • Shannon • Shields
• Thousands of drugs organized alphabetically
• Indexed by generic and trade drug names
• Complete IV drug information
PEARSON
PEARSON
www.pearsonhighered.com
PEARSON NURSE’S DRUG GUIDE 2016 NURSES AGREE: Pearson Nurse’s Drug Guide provides all the information you need for safe, effective drug administration in any setting!
• Organized alphabetically and indexed by generic and trade drug names
• Dosages across the lifespan from neonate to older adults
• Dosage with adjustments for clinically relevant conditions
• Complete IV preparation and administration information
• Clinically relevant drug interactions with food, herbals, and other drugs
• Pharmacologic and therapeutic classifications for every drug
• Unique glossary of clinical conditions and their related signs and symptoms
• Prototype drugs for each drug classification
• NEW! Black box warnings throughout
Comprehensive Current Clinically Relevant
Available for your favorite
electronic device!
2016
Simplify your study time by using the resources included with this textbook at http://www.nursing.pearsonhighered.com
using your
Begin Thinking LIKE A NURSE
PEARSON RESOURCES
A00_BERM4362_10_SE_FEP.indd 4-5 04/12/14 8:14 PM
# 153613 Cust: Pearson Au: Berman Pg. No. i Title: Kozier & Erb’s Fundamentals of Nursing 10e
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Audrey Berman, PhD, RN Professor
Dean, Nursing Samuel Merritt University
Oakland, California
Shirlee J. Snyder, EdD, RN Former Dean and Professor, Nursing
Nevada State College Henderson, Nevada
Geralyn Frandsen, EdD, RN Professor of Nursing Maryville University St. Louis, Missouri
TENTH EDITION
FUNDAMENTALS OF NURSING
KOZIER & ERB’S
Concepts, Process, and Practice
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Publisher: Julie Levin Alexander Executive Product Manager: Katrin Beacom Program Manager: Melissa Bashe Editorial Assistant: Kevin Wilson Development Editor: Teri Zak Project Manager: Michael Giacobbe Production Editor: Roxanne Klaas, S4Carlisle Publishing Services Manufacturing Buyer: Maura Zaldivar-Garcia Art Director/Cover and Interior Design: Maria Guglielmo Director of Marketing: David Gesell
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Copyright © 2016, 2012, 2008 by Pearson Education, Inc. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright and permission should be obtained from the publisher prior to any prohibited reproduction, stor- age in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. For information regarding permission(s), write to: Rights and Permissions Department, 221 River Street, Hoboken, New Jersey 07030.
Notice: Care has been taken to confirm the accuracy of information presented in this book. The authors, editors, and the publisher, how- ever, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents.
The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with cur- rent recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Library of Congress Cataloging-in-Publication Data Berman, Audrey, author. Kozier & Erb’s fundamentals of nursing : concepts, practice, and process / Audrey Berman, Shirlee Snyder, and Geralyn Frandsen.—Tenth edition. p. ; cm. Kozier and Erb’s fundamentals of nursing Fundamentals of nursing Includes bibliographical references and index. ISBN 978-0-13-397436-2—ISBN 0-13-397436-7 I. Snyder, Shirlee, author. II. Frandsen, Geralyn, author. III. Title. IV. Title: Kozier and Erb’s fundamentals of nursing. V. Title: Fundamentals of nursing. [DNLM: 1. Nursing Process. 2. Nursing Care. 3. Nursing Theory. WY 100] RT41 610.73—dc23 2014018545 10 9 8 7 6 5 4 3 2 1
ISBN-13: 978-0-13-397436-2 ISBN-10: 0-13-397436-7
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Dedication Audrey Berman dedicates this tenth edition to everyone who ever played a part in its creation: to Barbara Kozier and Glenora Erb who started it all and taught me the ropes; to the publishers, editors, faculty authors, contributors, reviewers, and adopters who improved every edition; to the students and their clients who made all the hard work worthwhile; and to all my family and colleagues who allowed me the time and space to make these books my scholarly contribution to the profession.
Shirlee Snyder dedicates this edition to her husband, Terry J. Schnitter, for his unconditional love and support; and to all of the nursing students and nurse educators she has worked with and learned from during her nursing career.
Geralyn Frandsen dedicates this edition to her husband and fellow nursing colleague Gary. He is always willing to answer questions and provide editorial support. She also dedicates this edition to her children Claire and Joe and future son-in-law, John Conroy.
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About the Authors Audrey Berman, PhD, RN A San Francisco Bay Area native, Audrey Berman received her BSN from the University of California–San Francisco and later returned to that campus to obtain her MS in physiological nursing and her PhD in nursing. Her dissertation was entitled Sailing a Course Through Chemotherapy: The Experience of Women with Breast Cancer. She worked in oncol- ogy at Samuel Merritt Hospital prior to
beginning her teaching career in the diploma program at Samuel Merritt Hospital School of Nursing in 1976. As a faculty member, she participated in the transition of that program into a baccalaureate degree and in the development of the master of science and doctor of nursing practice programs. Over the years, she has taught a variety of medical–surgical nursing courses in the prelicensure programs. She currently serves as the dean of nursing at Samuel Merritt University and is the 2014–2016 president of the California Association of Colleges of Nursing.
Dr. Berman has traveled extensively, visiting nursing and health care institutions in Australia, Botswana, Brazil, Germany, Israel, Japan, Korea, the Philippines, the Soviet Union, and Spain. She serves on the board of directors for the Bay Area Tumor Institute and the East Bay American Heart Association. She is a member of the American Nurses Association and Sigma Theta Tau and is a site visitor for the Commission on Collegiate Nursing Education. She has twice par- ticipated as an NCLEX-RN item writer for the National Council of State Boards of Nursing. She has presented locally, nationally, and internationally on topics related to nursing education, breast cancer, and technology in health care.
Dr. Berman authored the scripts for more than 35 nursing skills videotapes in the 1990s. She was a coauthor of the sixth, seventh, eighth, ninth, and tenth editions of Fundamentals of Nursing and the fifth, sixth, seventh, and eighth editions of Skills in Clinical Nursing.
Shirlee J. Snyder, EdD, RN Shirlee J. Snyder graduated from Columbia Hospital School of Nursing in Milwaukee, Wisconsin, and sub- sequently received a bachelor of sci- ence in nursing from the University of Wisconsin–Milwaukee. Because of an interest in cardiac nursing and teach- ing, she earned a master of science in nursing with a minor in cardiovascular
clinical specialist and teaching from the University of Alabama in Birmingham. A move to California resulted in becoming a faculty member at Samuel Merritt Hospital School of Nursing in Oakland, California. Shirlee was fortunate to be involved in the phasing out of the diploma and ADN programs and development of a baccalaureate
intercollegiate nursing program. She held numerous positions dur- ing her 15-year tenure at Samuel Merritt College, including curricu- lum coordinator, assistant director–instruction, dean of instruction, and associate dean of the Intercollegiate Nursing Program. She is an associate professor alumnus at Samuel Merritt College. Her interest and experiences in nursing education resulted in Shirlee obtaining a doctorate of education focused on curriculum and instruction from the University of San Francisco.
Dr. Snyder moved to Portland, Oregon, in 1990 and taught in the ADN program at Portland Community College for 8 years. During this teaching experience she presented locally and nationally on top- ics related to using multimedia in the classroom and promoting eth- nic and minority student success.
Another career opportunity in 1998 led her to the Community College of Southern Nevada in Las Vegas, Nevada, where Dr. Snyder was the nursing program director with responsibilities for the associ- ate degree and practical nursing programs for 5 years. During this time she coauthored the fifth edition of Kozier & Erb’sTechniques in Clinical Nursing with Audrey Berman.
In 2003, Dr. Snyder returned to baccalaureate nursing educa- tion. She embraced the opportunity to be one of the nursing faculty teaching the first nursing class in the baccalaureate nursing program at the first state college in Nevada, which opened in 2002. From 2008 to 2012, she was the dean of the School of Nursing at Nevada State College in Henderson, Nevada. She is currently retired.
Dr. Snyder enjoyed traveling to the Philippines (Manila and Cebu) in 2009 to present all-day seminars to approximately 5,000 nursing students and 200 nursing faculty. She is a member of the American Nurses Association and Sigma Theta Tau. She has been a site visitor for the National League for Nursing Accrediting Commission and the Northwest Association of Schools and Colleges.
Geralyn Frandsen, EdD, RN Geralyn Frandsen graduated in the last class from DePaul Hospital School of Nursing in St. Louis, Missouri. She earned a bachelor of science in nursing from Maryville College. She attended Southern Illinois University at Edwardsville, earn- ing a master of science degree in nursing with specializations in community health and nursing education. Upon completion,
she accepted a faculty position at her alma mater Maryville College, which has since been renamed Maryville University. In 2003 she com- pleted her doctorate in higher education and leadership at Saint Louis University. Her dissertation was Mentoring Nursing Faculty in Higher Education. Her review of literature was incorporated in the Maryville University Guide to Promotion and Tenure.
In service to the university, she has been a member and chair of the promotion and tenure committee for the past 10 years. She is a tenured full professor and currently serves as assistant director
iv
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Point and My Nursing Lab. This is an online resource to assist stu- dents in reviewing content in their nursing fundamentals course. She has authored both the Nursing Fundamentals: Pearson Reviews and Rationales and, in 2007, Pharmacology Reviews and Rationales.
Dr. Frandsen has completed the End-of-Life Nursing Education Consortium train-the-trainer courses for advanced practice nurses and the doctorate of nursing practice. She is passionate about end-of- life care and teaches a course to her undergraduate students. She also teaches undergraduate pharmacology and advanced pharmacothera- peutics. Her advanced pharmacotherapeutics class is taught at the university and online. Dr. Frandsen is a member of Sigma Theta Tau International, the American Nurses’ Association, and serves as a site visitor for the Commission on Collegiate Nursing Education.
of the Catherine McCauley School of Nursing at Maryville. When educating undergraduate and graduate students, she utilizes a variety of teaching strategies to engage her students. When teaching under- graduate pharmacology she utilizes a team teaching approach, plac- ing students in groups to review content. Each student is also required to bring a completed ticket to class covering the content to be taught. The practice of bringing a ticket to class was introduced to her by Dr. Em Bevis, who is famous for the Toward a Caring Curriculum.
Dr. Frandsen has authored textbooks in pharmacology and nursing fundamentals. In the ninth edition of Kozier & Erb’s Fundamentals of Nursing she contributed the chapters on Safety, Diagnostic Testing, Medications, Perioperative Nursing, and Fecal Elimination. In 2013 she was the fundamentals contributor for Ready
About the Authors v
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vi
We wish to extend a sincere thank you to the talented team involved in the tenth edition of this book: the contributors and reviewers who provide content and very helpful feedback; the nursing students, for their questioning minds and motivation; and the nursing instructors, who provided many valuable suggestions for this edition.
We would like to thank the editorial team, especially Kelly Trakalo, executive acquisitions editor, for her continual support, Melissa Bashe, Program Manager, Pearson Nursing, and most of all Teri Zak, development editor, for keeping our noses to the grind-
stone and especially for her dedication and attention to detail that promoted an excellent outcome once again. Many thanks to the pro- duction team of Michael Giaccobe, production liaison, and Roxanne Klaas, production editor, for producing this book with precision, and to the design team led by Maria Siener and Maria Guglielmo, art directors, for providing a truly beautiful design for this textbook.
Audrey Berman Shirlee Snyder
Geralyn Frandsen
Acknowledgments
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vii
Thank You
vii
We would like to extend our heartfelt thanks to our colleagues from schools of nursing across the country who have given their time generously to help us create this learning package. These individuals helped us develop this textbook and supplements by reviewing chapters, art, and media, and by answering a myriad of questions right up until the time of publication. Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, has benefited immeasurably from their efforts, insights, suggestions, objections, encouragement, and inspiration, as well as from their vast experience as teachers and nurses. Thank you again for helping us set the foundation for nursing excellence.
Contributors to the Tenth Edition Sherrilyn Coffman, PhD, RN Professor, Associate Dean Nevada State College Chapter 25: Caring
Elizabeth Johnston Taylor, PhD, RN Associate Professor, Loma Linda University Research Director, Mary Potter Hospice Wellington South, New Zealand Chapter 41: Spirituality
Reviewers of the Tenth Edition Mary Anderson, RN, MSN Chicago State University Chicago, IL
Kathy Anglin, MSN, RN Texarkana College Texarkana, TX
Barbara Celia, EdD, RN Drexel University Philadelphia, PA
Sarah Dempsey, MSN, RN Maryville University St. Louis, MO
Mary Ann Gaster, MEd, MSN Central Carolina Community College Pittsboro, NC
Susan Growe, MSN, RN, OCN Nevada State College Henderson, NV
Helena Gunnell, MEd, BSN, RN Jones County Community College Ellisville, MS
Sandy Gustafson, MA, RN Hibbing Community College Hibbing, MN
Elizabeth Long, DNP, APRN, GNP-BC Lamar University Beaumont, TX
Colleen Marzilli, DNP, MBA, RN University of Texas at Tyler Tyler, TX
Florence Miller, MSN, MPH Chicago State University Chicago, IL
Sharon M. Nowak, MSN Jackson College Jackson, MI
Martha Olson MSN, MS, RN Iowa Lakes Community College Emmetsburg, Iowa
Laura Warner, MSN, RN Ivy Tech Community College Greenfield, IN
Cindy Zeller, MSN, CPNP Frederick Community College Frederick, MD
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viii
The practice of nursing continues to evolve . . . the practice of caring is timeless.
Nurses today must grow and evolve to meet the demands of a dramatically changing health care system. They need skills in sci- ence, technology, communication, and interpersonal relations to be effective members of the collaborative health care team. They need to think critically and be creative in implementing nursing strate- gies to provide safe and competent nursing care for clients of diverse cultural backgrounds in increasingly varied settings. They need skills in teaching, leading, managing, and the process of change. They need to be prepared to provide home- and community-based nursing care to clients across the life span—especially to the increasing numbers of older adults. They need to understand legal and ethical principles, holistic healing modalities, and complementary therapies. And, they need to continue their unique client advocacy role, which demands a blend of nurturance, sensitivity, caring, empathy, commitment, and skill founded on a broad base of knowledge.
Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, addresses the concepts of contemporary professional nursing. These concepts include but are not limited to caring, wellness, health promotion, dis- ease prevention, holistic care, critical thinking and clinical reason- ing, multiculturalism, nursing theories, nursing informatics, nursing research, ethics, and advocacy. In this edition, every chapter has been reviewed and revised. The content has been updated to reflect the latest nursing evidence and the increasing emphasis on aging, wellness, safety, interprofessional practice, and home- and community-based care.
ORGANIZATION The detailed table of contents at the beginning of the book makes its clear organization easy to follow. Continuing with a strong focus on nursing care, the tenth edition of this book is divided into 10 units.
Unit 1, The Nature of Nursing, clusters five chapters that provide comprehensive coverage of introductory concepts of nursing.
In Unit 2, Contemporary Health Care, four chapters cover con- temporary health care topics such as health care delivery systems, community-based care, home care, and informatics.
In Unit 3, The Nursing Process, six chapters introduce students to this important framework with each chapter dedicated to a spe- cific step of the nursing process. Chapter 10 applies critical thinking, clinical reasoning, and the nursing process. A Nursing in Action case study is used as the frame of reference for applying content in all phases of the nursing process in Chapter 11, Assessing; Chapter 12, Diagnosing; Chapter 13, Planning; and Chapter 14, Implementing and Evaluating. Chapter 15 covers documenting and reporting. Starting in this unit and incorporated throughout the book, we refer to the NANDA International diagnoses.
In Unit 4, Health Beliefs and Practices, four chapters cover health- related beliefs and practices for individuals and families from a variety of cultural backgrounds.
Unit 5, Lifespan Development, consists of five chapters that dis- cuss life span and development from conception to older adults.
Unit 6, Integral Aspects of Nursing, discusses topics such as caring; communicating; teaching; and leading, managing, and delegating. These topics are all crucial elements for providing safe, competent nursing care.
Unit 7, Assessing Health, addresses vital signs and health assess- ment skills in two separate chapters, so beginning students can under- stand normal assessment techniques and findings. Chapter 29, Vital Signs, begins to introduce students to the clinical procedures that they need to learn to perform.
In Unit 8, Integral Components of Client Care, the focus shifts to those components of client care that are universal to all clients, including asepsis, safety, hygiene, diagnostic testing, medications, wound care, and perioperative care.
Unit 9, Promoting Psychosocial Health, includes six chapters that cover a wide range of areas that affect one’s health. Sensory percep- tion, self-concept, sexuality, spirituality, stress, and loss are all things that a nurse needs to consider to properly care for a client.
Unit 10, Promoting Physiological Health, discusses a variety of physiological concepts that provide the foundations for nursing care. These include activity and exercise; sleep; pain; nutrition; elimina- tion; oxygenation; circulation; and fluid, electrolyte, and acid–base balance.
WHAT’S NEW TO THE TENTH EDITION • QSEN linkages. The delivery of high-quality and safe nursing
practice is imperative for every nurse. The QSEN competencies were developed to address the gap between nursing education and practice. There are expectations for each of the six QSEN com- petencies and these expectations relate to knowledge, skills, and attitudes. Nursing students are expected to achieve these compe- tencies during nursing school and use them in their professional role as RNs. This edition has incorporated QSEN competencies and specified expectations in QSEN features. The content in these QSEN features will guide students to learn and maintain safety and quality in their provision of nursing care.
• Culturally Responsive Care highlights diversity and special con- siderations in nursing care.
• Evidence-Based Practice focuses on evidence-informed prac- tice to highlight relevant research and its implications for nurs- ing care.
• Home Care Assessment focuses on educating the client, family, and community to recognize what is needed for care in the home.
• Home Care Considerations focus on teaching the client and care giver the proper care at home.
• Safety Alerts correlate to the National Patient Safety Goals and identify other crucial safety issues.
• Updated photo program with more than 150 new photos
Preface
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book the number-one choice of nursing students and faculty. The walk-through at the beginning of the textbook illustrates these fea- tures. A significant addition to this edition is the inclusion of QSEN features that address the competencies and expectations for quality nursing care. Another important feature is the inclusion of a sec- tion on Interprofessional Practice within specific skills. In addition, Evidence-Based Practices boxes replace the Research Notes in rec- ognition that research is not the only way in which nurses determine best practices.
Supplements That Inspire Success for the Student and the Instructor Pearson is pleased to offer a complete suite of resources to support teaching and learning, including:
• TestGen Test Bank • Lecture Note PowerPoints • Classroom Response System PowerPoints • New! Annotated Instructor’s eText—This version of the eText is
designed to help instructors maximize their time and resources in preparing for class. The AIE contains suggestions for class- room and clinical activities and key concepts to integrate into the classroom in any way imaginable. Additionally, each chapter has recommendations for integrating other digital Pearson Nursing resources, including The Neighborhood 2.0, Skills videos, and MyNursingLab.
• Clinical reasoning. The practice of nursing requires critical thought and clinical reasoning. Clinical reasoning is the cognitive processes a nurse utilizes to gather and analyze client data, evalu- ate the relevance of the information, and implement nursing in- terventions to improve the client’s well being.
• Interprofessional practice. The concept of interprofessional practice is identified in specific skills. It reinforces to the student that other members of the health care team may also be perform- ing the specified skill.
• Men in nursing. This edition has increased information about men in nursing from a historical and current perspective in Chapter 1.
• Standards of care. This edition continues to value and update standards of care as evidenced by the latest National Patient Safety Goals, Infusion Nursing Society Standards of Practice, ANA Scope and Standards of Practice, 2014 Hypertension Guidelines; IHI Pressure Ulcer Prevention Guidelines, ANA Safe Patient Han- dling and Mobility Interprofessional National Standards, OSHA/ CDC BBP and Infection Prevention Standards, and Cancer Screening Guidelines.
FEATURES For years, Kozier & Erb’s Fundamentals of Nursing has been a gold standard that helps students embark on their careers in nursing. This new edition retains many of the features that have made this text-
Preface ix
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Chapter 11 • Assessing 157
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DIAGNOSING After analysis, Nurse Medina formulates a nursing diagnosis: Ineffective Airway Clearance related to accumulated mucus obstructing airways.
PLANNING Nurse Medina and Margaret collaborate to establish goals (e.g., restore effective breathing pattern and lung ventilation); set outcome criteria (e.g., have a symmetrical respiratory excursion of at least 4 cm, and so on); and develop a care plan that includes, but is not limited to, coughing and deep-breathing exercises q3h, fluid intake of 3,000 mL daily, and daily postural drainage.
EVALUATING Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.
Margaret O’Brien is a 33-year-old nursing student. She is married and has a 13-year-old daughter and 5-year-old son. She is admitted to the hospital with an elevated temperature, a productive cough, and rapid, labored respirations. While taking a nursing history, Mary Medina, RN, finds that Margaret has had a “chest cold” for 2 weeks, and has been experiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to experience “pain” in her “lungs”.
ASSESSING Nurse Medina’s physical assessment reveals that Margaret’s vital signs are temperature, 39.4°C (103°F); pulse 92 beats/min; respirations 28/min; and blood pressure, 122/80 mmHg. Nurse Medina observes that Mrs. O’Brien’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.
IMPLEMENTING Margaret agrees to practice the deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake and to plan her morning activities to accommodate postural drainage.
Figure 11–1 • Continued
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Features of the Tenth Edition
SPECIAL FEATURES provide the opportunity to link QSEN competencies and to think critically to make a connection to nursing practice. These features provide guidance on maintaining safety and quality of nursing care.
508 Unit 7 ● Assessing Health
PURPOSES • To estimate the arterial blood oxygen saturation • To detect the presence of hypoxemia before visible signs
develop
ASSESSMENT Assess • The best location for a pulse oximeter sensor based on the
client’s age and physical condition. Unless contraindicated, the � nger is usually selected for adults.
• The client’s overall condition including risk factors for development of hypoxemia (e.g., respiratory or cardiac disease) and hemoglobin level
• Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as baseline data
• Adhesive allergy
PLANNING Many hospitals and clinics have pulse oximeters readily available for use with other vital signs equipment (or even as an integrated part of the electronic blood pressure device). Other facilities may have a limited supply of oximeters, and the nurse may need to request it from the central supply department.
DELEGATION
Application of the pulse oximeter sensor and recording of the SpO 2 value may be delegated to UAP. The interpretation of the oxygen saturation value and determination of appropriate responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Measuring oxygen saturation may be within the scope of practice for many health care providers. For example, in addition to nurses, respiratory therapists may check the client’s oxygen saturation before, during, and after treatment. Although these therapists may verbally communicate their � ndings and plan to the health care team members, the nurse must also know where to locate their documen- tation in the client’s medical record.
IMPLEMENTATION Preparation Check that the oximeter equipment is functioning normally.
Performance 1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy. 4. Choose a sensor appropriate for the client’s weight, size, and
desired location. Because weight limits of sensors overlap, a pediatric sensor could be used for a small adult. • If the client is allergic to adhesive, use a clip or sensor
without adhesive.
• If using an extremity, apply the sensor only if the proximal pulse and capillary re� ll at the point closest to the site are present. If the client has low tissue perfusion due to periph- eral vascular disease or therapy using vasoconstrictive medications, use a nasal sensor or a re� ectance sensor on the forehead. Avoid using lower extremities that have a compromised circulation and extremities that are used for infusions or other invasive monitoring.
5. Prepare the site. • Clean the site with an alcohol wipe before applying the sensor. • It may be necessary to remove a female client’s dark nail
polish. Rationale: Nail polish may interfere with accurate measure- ments although the data about this are inconsistent.
• Alternatively, position the sensor on the side of the � nger rather than perpendicular to the nail bed.
Equipment • Nail polish remover as needed • Alcohol wipe • Sheet or towel • Pulse oximeter
The aim of this study by Korhan, Yönt, and Khorshid (2011) was to compare the pulse oximetry values obtained from a finger on re- strained or unrestrained sides of the body. In clinical settings such as intensive care, physical restraints may be indicated to lessen the chances that clients will displace tubes and monitors. However, the most important complication in using physical restraints is impaired circulation. Thus, oxygen saturation from body parts in which cir- culation is impaired can be inaccurate. The research sample con- sisted of 30 hospitalized clients. A significant difference was found between the oxygen saturation values obtained from a finger of an arm that had been physically restrained and a finger of an arm that had not been physically restrained. The mean oxygen saturation
value measured from a finger of an arm that had been physically restrained was found to be 93.40 and the mean oxygen saturation value measured from a finger of an arm that had not been physically restrained was found to be 95.53.
IMPLICATIONS The results of this study indicate that nurses should use a finger of an arm that is not physically restrained when evaluating oxygen sat- uration values. The use of physical restraints is carefully evaluated because there are many possible adverse effects of their use. This study provides one additional physiological consideration: that as- sessment data gathered from a restrained limb may not be accurate.
Evidence-Based Practice Are Pulse Oximeter Readings Accurate If Measured on a Restrained Arm? EVIDENCE-BASED PRACTICE
Measuring Oxygen Saturation S
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Chapter 16 ● Health Promotion 255
This assessment allows the nurse and client to discuss and evaluate the adequacy of the client’s support system together and, if necessary, plan options for enhancing the support system.
Health Risk Assessment A health risk assessment (HRA) is an assessment and educa- tional tool that indicates a client’s risk for disease or injury during the next 10 years by comparing the client’s risk with the mortality risk of the corresponding age, gender, and racial group. The client’s general health, lifestyle behaviors, and demographic data are compared to data from a large national sample. Individual risk reports are based on statistics for the population group that match the individual’s sur- veyed characteristics. The HRA includes a summary of the person’s health risks and lifestyle behaviors with educational suggestions on how to reduce the risk.
Many HRA instruments are available today in paper-and- pencil formats or as computerized forms. Recently, HRAs have be- gun to reflect a broader approach to health as companies use the HRA as a means to begin a health promotion and risk reduction program. Occupational health nurses can identify risk factors and subsequently plan interventions aimed at decreasing illness, absen- teeism, and disability.
HRAs are helpful for assessing individual and group health risks. They are not, however, substitutes for medical care and are not appro- priate for all individuals. For example, people with chronic illnesses such as cancer or heart disease may not obtain accurate risk assess- ments. Certain populations (e.g., very young, older adults, some so- ciocultural groups) may not be fully represented in the population databases and, therefore, the HRA may not project an accurate risk assessment.
Health Beliefs Review Clients’ health beliefs need to be clarified, particularly those beliefs that determine how they perceive control of their own health care status. Locus of control is a measurable concept that can be used to predict which people are most likely to change their behavior (see Chapter 17 ) . Several instruments are available that assess a per- son’s health-belief measures. Assessment of clients’ health beliefs pro- vides the nurse with an indication of how much the clients believe they can influence or control health through personal behaviors. Sev- eral cultures have a strong belief in fate: “Whatever will be, will be.” If people hold this belief, they do not feel that they can do anything
SELF-CARE ALERT
Is exercise a negative term for you? Does it imply something that is boring, routine, and a “must-do”? Instead, think of “physical activity,” which can be a variety of things that increase your activity level (e.g., dancing, tennis, golf, walking the dog).
Lifestyle Assessment Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally as- sessed are physical activity, nutritional practices, stress management, and such habits as smoking, alcohol consumption, and drug use. Other categories may be included. Several tools are available to as- sess lifestyle. The goals of lifestyle assessment tools are to provide the following:
1. An opportunity for clients to assess the impact of their present lifestyle on their health
2. A basis for decisions related to desired behavior and lifestyle changes.
Spiritual Health Assessment Spiritual health is the ability to develop one’s inner nature to its fullest potential, including the ability to discover and articulate one’s basic purpose in life; to learn how to experience love, joy, peace, and ful- fillment; and to learn how to help ourselves and others achieve their fullest potential ( Pender et al., 2011 , p. 104). Spiritual beliefs can affect a person’s interpretation of events in his or her life and, therefore, an assessment of spiritual well-being is a part of evaluating the person’s overall health. See Chapter 41 for more information.
SELF-CARE ALERT
There are two physical arts that blend spirituality and health: t’ai chi and yoga. T’ai chi promotes muscle relaxation through movement. Yoga promotes mobility and flexibility.
Social Support Systems Review Understanding the social context in which a person lives and works is important in health promotion. Individuals and groups, through interpersonal relationships, can provide comfort, assistance, encour- agement, and information. Social support fosters successful coping and promotes satisfying and effective living.
Social support systems contribute to health by creating an en- vironment that encourages healthy behaviors, promotes self-esteem and wellness, and provides feedback that the person’s actions will lead to desirable outcomes. Examples of social support systems in- clude family, peer support groups (including computer-based sup- port groups), community-organized religious support systems (e.g., churches), and self-help groups (e.g., Mended Hearts, Weight Watch- ers). Culturally Responsive Care addresses aspects of social support within the context of culture.
The nurse can begin a social support system review by asking the client to do the following:
• List individuals who provide personal support. • Indicate the relationship of each person (e.g., family member, fel-
low worker or colleague, social acquaintance). • Identify which individuals have been a source of support for 5 or
more years.
Cultural Aspects of Social Support
It is important to understand how various subgroups of U.S. society may define social support. • In the African American community, the family and church
have been major providers of social support. • Hispanic/Latino Americans and Asian Americans view the
family as being a major social support system. • Asian Americans respect older adults and use shame and
harmony in giving and receiving support. • Native Americans live in social networks that foster mutual
assistance and support.
From Health Promotion in Nursing Practice , 6th ed. (p. 220), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011, Upper Saddle River, NJ: Prentice Hall.
PATIENT-CENTERED CARE Culturally Responsive Care
222 Unit 3 ● The Nursing Process
Communication The record serves as the vehicle by which different health profession- als who interact with a client communicate with each other. This pre- vents fragmentation, repetition, and delays in client care.
Planning Client Care Each health professional uses data from the client’s record to plan care for that client. A primary care provider, for example, may order a specific antibiotic after establishing that the client’s temperature is steadily rising and that laboratory tests reveal the presence of a cer- tain microorganism. Nurses use baseline and ongoing data to evalu- ate the effectiveness of the nursing care plan.
Auditing Health Agencies An audit is a review of client records for quality assurance purposes (see Chapter 14 ) . Accrediting agencies such as The Joint Com- mission may review client records to determine if a particular health agency is meeting its stated standards.
Research The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
Education Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
Reimbursement Documentation also helps a facility receive reimbursement from the federal government. For a facility to obtain payment through Medi- care, the client’s clinical record must contain the correct diagnosis- related group (DRG) codes and reveal that the appropriate care has been given.
Codable diagnoses, such as DRGs, are supported by accu- rate, thorough recording by nurses. This not only facilitates re- imbursement from the federal government, but also facilitates reimbursement from insurance companies and other third-party payers. If additional care, treatment, or length of stay becomes necessary for the client’s welfare, thorough charting will help jus- tify these needs.
Legal Documentation The client’s record is a legal document and is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, be- cause information the client gives to the primary care provider is confidential.
Health Care Analysis Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital ser- vices. Records can be used to establish the costs of various services
SAFETY ALERT!
Take safety measures before faxing confidential information. A fax cover sheet should contain instructions that the faxed material is to be given only to the named recipient. Consent is needed from the client to fax information. Make sure that personally identifiable information (e.g., client name, Social Security number) has been removed. Finally, check that the fax number is correct, check the number on the display of the machine after dialing, and check the number a third time before pressing the “send” button.
For purposes of education and research, most agencies allow student and graduate health professionals access to client records. The records are used in client conferences, clinics, rounds, client studies, and written papers. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health profes- sional to protect the client’s privacy by not using a name or any state- ments in the notations that would identify the client.
Ensuring Confidentiality of Computer Records Because of the increased use of EHRs (see Chapter 9 ) , health care agencies have developed policies and procedures to ensure the privacy and confidentiality of client information stored in comput- ers. In addition, the Security Rule of HIPAA became mandatory in 2005. This rule governs the security of electronic PHI. The following are some suggestions for ensuring the confidentiality and security of computerized records:
1. A personal password is required to enter and sign off computer files. Do not share this password with anyone, including other health team members.
2. After logging on, never leave a computer terminal unattended. 3. Do not leave client information displayed on the monitor where
others may see it. 4. Shred all unneeded computer-generated worksheets. 5. Know the facility’s policy and procedure for correcting an entry
error. 6. Follow agency procedures for documenting sensitive material,
such as a diagnosis of AIDS. 7. Information technology (IT) personnel must install a firewall to
protect the server from unauthorized access.
PURPOSES OF CLIENT RECORDS Client records are kept for a number of purposes including communi- cation, planning client care, auditing health agencies, research, educa- tion, reimbursement, legal documentation, and health care analysis.
CLINICAL ALERT!
An accurate client health record provides details about the care a cli- ent has received and the client’s overall response to care. Accurate documentation provides the staff with a means for accountability and reflection on the delivery of client care ( Prideaux, 2011 ). To enhance the accuracy in documenting care, Paans, Sermeus, Nieweg, and van der Schans (2010) identified the PES structure as a guideline for nurs- ing care. The letter P represents the client’s problem or diagnosis. The etiology or cause of the problem is represented by E, and S represents the signs and symptoms the nurse should be assessing. The use of this structure enhances nurses’ ability to exercise clinical reasoning.
SAFETY
INTERPROFESSIONAL PRACTICE reinforces interactions with other members of the health care team.
ENHANCED PHOTO PROGRAM shows procedural steps and the latest equipment.
486 Unit 7 ● Assessing Health
LIFESPAN CONSIDERATIONS Temperature
INFANTS • The body temperature of newborns is extremely labile, and
newborns must be kept warm and dry to prevent hypothermia. • Using the axillary site, you need to hold the infant’s arm against
the chest ( Figure 29–10 ■ ). • The axillary route may not be as accurate as other routes for
detecting fevers in children. • The tympanic route is fast and convenient. Place the infant
supine and stabilize the head. Pull the pinna straight back and slightly downward. Remember that the pinna is pulled upward for children over 3 years of age and adults, but downward for children younger than age 3. Direct the probe tip anteriorly and insert far enough to seal the canal. The tip will not touch the tympanic membrane.
• Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes.
• The tympanic membrane route may be more accurate in determining temperature in febrile infants.
• When using a temporal artery thermometer, touching only the forehead or behind the ear is needed.
• The rectal route is least desirable in infants.
CHILDREN • Tympanic or temporal artery sites are preferred. • For the tympanic route, have the child held on an adult’s lap
with the child’s head held gently against the adult for support. Pull the pinna straight back and upward for children over age 3 ( Figure 29–11 ■ ).
• Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes.
• The oral route may be used for children over age 3, but nonbreakable, electronic thermometers are recommended.
• For a rectal temperature, place the child prone across your lap or in a side-lying position with the knees flexed. Insert the thermometer 2.5 cm (1 in.) into the rectum.
OLDER ADULTS • Older adults’ temperatures tend to be lower than those of
middle-aged adults. • Older adults’ temperatures are strongly influenced by both environ-
mental and internal temperature changes. Their thermoregulation control processes are not as efficient as when they were younger, and they are at higher risk for both hypothermia and hyperthermia.
• Older adults can develop significant buildup of ear cerumen (earwax) that may interfere with tympanic thermometer readings.
• Older adults are more likely to have hemorrhoids. Inspect the anus before taking a rectal temperature.
• Older adults’ temperatures may not be a valid indication of the seriousness of the pathology of a disease. They may have pneumonia or a urinary tract infection and have only a slight temperature elevation. Other symptoms, such as confusion and restlessness, may be displayed and need follow-up to determine if there is an underlying process.
Figure 29–10 ■ Axillary thermometer placement for a child.
Figure 29–11 ■ Pull the pinna of the ear back and up for placement of a tympanic thermometer in a child over 3 years of age; back and down for children under age 3.
Figure 29–12 ■ A pacifier thermometer.
Home Care Considerations Temperature
• Teach the client accurate use and reading of the type of ther- mometer to be used. Examine the thermometer used by the client in the home for safety and proper functioning. Facilitate the replacement of mercury thermometers with nonmercury ones. See page 482 for instructions regarding management of a broken mercury thermometer.
• Observe the client/caregiver taking and reading a temperature. Reinforce the importance of reporting the site and type of ther- mometer used and the value of using the same site and ther- mometer consistently.
• Discuss means of keeping the thermometer clean, such as warm water and soap, and avoiding cross contamination.
• Ensure that the client has water-soluble lubricant if using a rectal thermometer.
• Instruct the client or family member to notify the health care provider if the temperature is 38.5°C (101.3°F) or higher.
• When making a home visit, take a thermometer with you in case the clients do not have a functional thermometer of their own.
• Check that the client knows how to record the temperature. Provide a recording chart/table if indicated.
• Discuss environmental control modifications that should be made during illness or extreme climate conditions (e.g., heating, air conditioning, appropriate clothing and bedding).
• Pacifier thermometers ( Figure 29–12 ■ ) may be used in the home setting for children under 2 years old. The manufacturer’s instructions must be followed carefully since many require adding 0.5°F in order to estimate rectal temperature.
PATIENT-CENTERED CARE
492 Unit 7 ● Assessing Health
Assessing an Apical Pulse
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PURPOSES • To obtain the heart rate of an adult with an irregular
peripheral pulse • To establish baseline data for subsequent evaluation
• To determine whether the cardiac rate is within normal range and the rhythm is regular
• To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to improve heart action
ASSESSMENT Assess • Clinical signs of cardiovascular alterations such as dyspnea
(dif� cult respirations), fatigue/weakness, pallor, cyanosis (bluish discoloration of skin and mucous membranes), palpitations, syncope (fainting), or impaired peripheral tissue perfusion as evidenced by skin discoloration and cool temperature
• Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect heart rate such as digoxin, beta-blockers, or calcium channel blockers)
PLANNING DELEGATION
Due to the degree of skill and knowledge required, UAP are generally not responsible for assessing apical pulses.
Equipment • Clock or watch with a sweep second hand or digital seconds
indicator • Stethoscope • Antiseptic wipes • If using a DUS: the transducer probe, the stethoscope headset,
transmission gel, and tissues/wipes
INTERPROFESSIONAL PRACTICE
Assessing an apical pulse may be within the scope of practice for many health care providers. For example, in addition to nurses, respiratory therapists may check the client’s apical pulse before, during, and after treatment, and physicians often check the api- cal pulse when assessing the chest during examinations. Although these providers may verbally communicate their � ndings and plan to other health care team members, the nurse must also know where to locate their documentation in the client’s medical record.
❶ Second intercostal space. Shirlee Snyder.
IMPLEMENTATION Preparation If using a DUS, check that the equipment is functioning normally.
Performance 1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection pre- vention procedures.
3. Provide for client privacy. 4. Position the client appropriately in a comfortable supine posi-
tion or in a sitting position. Expose the area of the chest over the apex of the heart.
5. Locate the apical impulse. This is the point over the apex of the heart where the apical pulse can be most clearly heard. • Palpate the angle of Louis (the angle between the manu-
brium, the top of the sternum, and the body of the ster- num). It is palpated just below the suprasternal notch and is felt as a prominence (see Figure 29–14 ).
• Slide your index � nger just to the left of the sternum, and palpate the second intercostal space. ❶
CLINICAL ALERT!
When “left” and “right” are used to describe the nurse’s hand place- ment on the client, the terms refer to the client’s right or left side, not the nurse’s.
• Place your middle or next � nger in the third intercostal space, and continue palpating downward until you locate the � fth intercostal space. ❷
• Move your index � nger laterally along the � fth intercostal space toward the MCL. ❸ Normally, the apical impulse is palpable at or just medial to the MCL (see Figure 29–14 ).
6. Auscultate and count heartbeats. • Use antiseptic wipes to clean the earpieces and diaphragm
of the stethoscope. Rationale: The diaphragm needs to be cleaned and disinfected if soiled with body substances. Both earpieces and diaphragms have been shown to harbor pathogenic bacteria ( Muniz, Sethi, Zaghi, Ziniel, & Sandora, 2012 ).
NEW AND ENHANCED FEATURES
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HALLMARK FEATURES
This tenth edition maintains the best aspects of previous editions to provide the most valuable learning experience.
LEARNING OUTCOMES help identify critical concepts.
KEY TERMS provide a study tool for learning new vocabulary. Page numbers are included for easy reference.
MEETING THE STANDARDS end of unit activities provide the opportunity to think through themes and competencies presented across chapters in a unit and think critically to link theory to nursing practice.
NURSING CARE PLANS help you approach care from the nursing perspective.
APPLYING CRITICAL THINKING questions come at the end of select sample Nursing Care Plans to encourage further reflection and analysis.
INTRODUCTION Western medicine is an approach to health that focuses on the use of science in the diagnosis and treatment of health problems. This is in contrast to Eastern medicine , which places greater emphasis on prevention and natural healing. The differences between Western and Eastern medicine are not about geographic location since both Eastern and Western health practitioners exist in almost every part of the world. Most of nursing education in the United States, Canada, Europe, and Australia has been under the umbrella of Western medi- cine. Thus, nurses from these parts of the world are familiar and comfortable with biomedical beliefs, theories, practices, strengths, and limitations. In this chapter the terms conventional medicine , biomedicine , and allopathic medicine are used to describe West- ern medical practices. Fewer nurses have studied Eastern medicine and as a result may lack information or even harbor misinformation about these healing practices.
The term complementary and alternative medicine (CAM) includes as many as 1,800 other therapies practiced all over the world. Many of these have been handed down over thousands of years, both orally and as written records. They are based on the Eastern medical
systems of ancient people, including Egyptians, Chinese, Asian Indi- ans, Greeks, and Native Americans. Other therapies, such as bioelec- tromagnetics and chiropractic, evolved in the United States during the past two centuries. Still others, such as some of the mind–body approaches, are on the frontier of scientific knowledge and under- standing. The CAM therapies described in this chapter are only some of the many used by clients. Nurses must learn about the ones being used by the clients in their specific practice settings.
Complementary medicine refers to the use of CAM together with conventional medicine. Most use of CAM by Americans is complementary. Alternative medicine refers to use of CAM in place of conventional medicine. Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness. It is also called integrated medicine .
The public interest in complementary and alternative therapies is extensive and growing. One has only to look at the proliferation of popular health books, health food stores, and clinics offering heal- ing therapies to realize this. In 1998, the National Institutes of Health established the National Center for Complementary and Alternative
acupressure , 301 acupuncture , 301 allopathic medicine , 295 alternative medicine , 295 animal-assisted therapy , 306 aromatherapy , 299 Ayurveda , 297 balance , 296 bioelectromagnetics , 306 biofeedback , 304 biomedicine , 295 chiropractic , 300
complementary medicine , 295 conventional medicine , 295 curanderismo , 298 detoxification , 306 Eastern medicine , 295 energy , 296 faith , 304 guided imagery , 303 hand-mediated biofield
therapies , 301 herbal medicine , 298 holism , 296
homeopathy , 299 horticultural therapy , 306 humanist , 296 hypnotherapy , 303 imagery , 303 integrative medicine , 295 massage therapy , 301 meditation , 303 music therapy , 305 naturopathic medicine , 300 pilates , 304 prayer , 304
qi , 297 qi gong , 304 reflexology , 301 spirituality , 296 t’ai chi , 304 traditional Chinese medicine
(TCM) , 297 Western medicine , 295 yoga , 302
KEY TERMS
After completing this chapter, you will be able to: 1. Describe the basic concepts of alternative practices. 2. Give examples of healing environments. 3. Describe the basic principles of health care practices such
as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.
4. Explain how herbs are similar to many prescription drugs. 5. Discuss the principles of naturopathic medicine. 6. Identify the role of manual healing methods in health and
illness.
LEARNING OUTCOMES
19 Complementary and Alternative Healing Modalities
7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qi gong, and t’ai chi have in common.
8. Identify types of detoxification therapies. 9. Discuss uses of animals, prayer, and humor as treatment
modalities. 10. Teach clients the uses of and safety precautions regarding
complementary and alternative therapies.
295
CLIENT: Manuela AGE: 55 CURRENT MEDICAL DIAGNOSIS: Still’s Disease Medical History: Manuela has experienced some type of health challenge for most of her adult life. She was diagnosed with adult- onset Still’s disease (AOSD) at about age 35 after several years of tests to try to determine exactly what syndrome her symptoms re- flected. She complained of joint pain, rash, and fevers, which came and went, and she had an enlarged spleen and liver. This disease has many similarities with rheumatoid and autoimmune diseases, but those conditions were all removed from consideration because the tests were negative. AOSD is a chronic condition for which there is no known cure. In addition to joint deterioration, it can progress to affect the lungs and heart. Initial treatment consists of steroids and nonsteroidal anti-inflammatory drugs (NSAIDS). If those are ineffec- tive, other medications such as gold and chemotherapeutics are used; however, they have severe side effects such as kidney damage and bone marrow suppression. The condition worsens when the person is under physical or emotional stress. Manuela
underwent a hip replacement about 4 years ago and recently has had several hospitalizations for respiratory failure. Personal and Social History: Manuela has never married and has lived near or with her parents or siblings for all her life. She has many friends, drives, and has an active social life when she is feeling well. She uses the computer extensively for communication, especially when having visitors or talking by phone is too exhausting. She must follow a strict diet of food and liquids that are easy to swallow and digest. She is a spiritual person but not overly religious. She is quick to laugh and generally has an optimistic outlook, but expresses awareness that her life could end at any time—certainly long before her full life expectancy.
Manuela is a college graduate but has been able to work only part time for most of her life. Recently, she was declared permanently disabled, which allows her access to financial and other support sys- tems. She is creative in adapting her living situation to her disabilities and unwilling to give up her beloved pet dog.
Questions American Nurses Association Standard of Practice #3 is Outcomes Identification: The nurse consults with the client and family in formulating measureable goals consistent with the client’s culture, values, and environment. As you learned in Chapter 16 , Manuela’s needs fall into the category of tertiary prevention in which rehabilitation and movement toward optimal levels of functionality within the individual’s constraints are the focus. 1. What are some outcomes for Manuela that would reflect
this focus? 2. Do you need to know her personal definitions of health and
health beliefs ( Chapter 17 ) before you can work with her to set expected outcomes?
American Nurses Association Standard of Practice #5b is Health Teaching and Health Promotion: The nurse customizes the client’s teaching to promote a healthy environment. 3. What are some aspects of Manuela’s situation that you would
consider incorporating into a teaching plan to maximize a safe environment for her?
American Nurses Association Standard of Professional Performance #13 is Collaboration: Nurses work with the client, family, and other health care providers in planning, implementing, and evaluating care. 4. Which health care team members other than physicians
and nurses would likely be important to include in Manuela’s care plan?
American Nurses Association Standard of Professional Performance #9 is Research . 5. What evidence might you have or seek to support the use
of alternative or complementary treatment modalities in Manuela’s care?
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
4 Meeting the Standards In this unit, we have explored concepts related to health, health promotion, wellness, illness, culture and heritage, and complementary and alternative healing modalities. These topics heighten awareness of the individualistic nature of the relationship between the nurse and the client and the importance of assessing the breadth of factors that affect health decisions and behaviors. In the case described below, you will see how one person demonstrates complicated, interrelated, personal definitions of health and illness influenced by her medical condition, her heritage, and her demographic character- istics (e.g., age and family structure). These definitions and perspectives in turn influence her choices for care and support—including the role of her nurses.
310
Chapter 13 ● Planning 203
BOX 13–2 Benefits of Standardized Interventions
• Enhances communication among nurses and among nurses and nonnurses.
• Makes it possible for researchers to determine the effectiveness and cost of nursing treatments.
• Helps communicate the nature of nursing to the public. • Helps demonstrate the impact that nurses have on health care. • Makes it easier for nurses to select appropriate interventions by
reducing the need for memorization and recall. • Facilitates the teaching of clinical decision making.
• Contributes to the development and use of computerized clinical records.
• Assists in effective planning for staff and equipment needs. • Aids in development of a system of payment for nursing
services. • Promotes full and meaningful participation of nurses in the
multidisciplinary team.
From Nursing Process & Critical Thinking, 5th ed. (p. 253), by J. M. Wilkinson, 2012, Upper Saddle River, NJ: Prentice Hall. Adapted with permission.
LIFESPAN CONSIDERATIONS Nursing Care Plan
OLDER ADULTS When a client is in an extended care facility or a long-term care facility, interventions and medications often remain the same day after day. It is important to review the care plan on a regular basis, because changes in the condition of older adults may be subtle and go unnoticed. This applies to both changes of improvement or deterioration. Either one should receive attention so that appropri- ate revisions can be made in expected outcomes and interventions. Outcomes need to be realistic with consideration given to the cli- ent’s physical condition, emotional condition, support systems, and
mental status. Outcomes often have to be stated and expected to be completed in very small steps. For instance, clients who have had a cerebrovascular accident may spend weeks learning to brush their own teeth or dress themselves. When these small steps are successfully completed, it gives the client a sense of accomplish- ment and motivation to continue working toward increasing self- care. This particular example also demonstrates the need to work collaboratively with other departments, such as physical and occu- pational therapy, to develop the nursing care plan.
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/Indicators Nursing Interventions Rationale
Respiratory Status: Gas Exchange [0402], as evidenced by • Absence of pallor and cyanosis (skin
and mucous membranes) • Use of correct breathing/coughing
technique after instruction
Monitor respiratory status q4h: rate, depth, effort, skin color, mucous membranes, amount and color of sputum. Monitor results of blood gases, chest x-ray studies, and incentive spirometer volume as available. Monitor level of consciousness.
To identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidenced by pallor, cyanosis, lethargy, and drowsiness.
• Productive cough • Symmetric chest excursion of
at least 4 cm
Auscultate lungs q4h. Vital signs q4h (TPR, BP, pulse oximetry, pain).
Inadequate oxygenation and pain cause increased pulse rate. Respiratory rate may be decreased by narcotic analgesics. Shallow breathing further compromises oxygenation.
Within 48–72 hours: • Lungs clear to auscultation • Respirations 12–22/min; pulse, less
than 100 beats/min
Instruct in breathing and coughing techniques. Remind to perform, and assist q3h.
To enable client to cough up secretions. May need encouragement and support because of fatigue and pain.
• Inhales normal volume of air on incentive spirometer
Administer prescribed expectorant; schedule for maximum effectiveness. Maintain Fowler’s or semi-Fowler’s position. Administer prescribed analgesics. Notify primary care provider if pain not relieved.
Helps loosen secretions so they can be coughed up and expelled. Gravity allows for fuller lung expansion by decreasing pressure of abdomen on diaphragm. Controls pleuritic pain by blocking pain pathways and altering perception of pain, enabling client to increase thoracic expansion. Unrelieved pain may signal impending complication.
NURSING CARE PLAN Margaret O’Brien
Continued on page 204
218 Unit 3 ● The Nursing Process
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/ Indicators Evaluation Statements Nursing Interventions**
Explanation for Continuing or Modifying Nursing Interventions
• Freely expresses concerns and possible solutions about work and parenting roles
Partially met. Discussed only briefly on 3–11 shift. Not done on 11–7 shift because of client’s need to rest. (Evaluated 8/27/14, JW)
As client can tolerate, encourage to express and expand on her concerns about her child and her work. Explore alternatives as needed.
It is important that this assessment be made right away, so child care can be arranged if needed.
Note whether husband returns as scheduled. If he does not, institute care plan for actual Interrupted Family Process. (Do on 8/27, day shift) (8/27/14, JW)
*The NOC # for desired outcomes is listed in brackets following the appropriate outcome.
**In this care plan, a line has been drawn through portions the nurse wished to delete; additions to the care plan are shown in italics.
NURSING CARE PLAN For Margaret O’Brien Modified Following Implementation and Evaluation—continued
Applying Critical Thinking 1. From reviewing Margaret O’Brien’s nursing care plan, what general conclusions can you make about the desired outcomes for
Ineffective Airway Clearance and Anxiety? 2. Despite some of the outcomes being only partially met or not met, no new interventions were written for several outcomes. What
reasons might there be for this? 3. For the nursing diagnosis of Anxiety, most of the outcomes are fully met. Would you delete this diagnosis from the care plan at this
time? Why or why not? 4. Since the Evaluation Statements column is generally not used on written care plans, where would auditors or individuals
conducting quality assessments find these data? See Critical Thinking Possibilities on student resource website.
• Implementing is putting planned nursing interventions into action. • Successful implementing and evaluating depend in part on the
quality of the preceding phases of assessing, diagnosing, and planning.
• Reassessing occurs simultaneously with the implementing phase of the nursing process.
• Cognitive, interpersonal, and technical skills are used to implement nursing strategies.
• Before implementing an order, the nurse reassesses the client to be sure that the order is still appropriate.
• The nurse must determine whether assistance is needed to per- form a nursing intervention knowledgeably, safely, and comfortably for the client.
• The implementing phase terminates with the documentation of the nursing activities and client responses.
• After the care plan has been implemented, the nurse evaluates the client’s health status and the effectiveness of the care plan in achieving client goals.
• The desired outcomes formulated during the planning phase serve as criteria for evaluating client progress and improved health status.
• The desired outcomes determine the data that must be collected to evaluate the client’s health status.
• Reexamining the client care plan is a process of making decisions about problem status and critiquing each phase of the nursing process.
• Professional standards of care hold that nurses are responsible and accountable for implementing and evaluating the plan of care.
• Quality assurance evaluation includes consideration of the struc- tures, processes, and outcomes of nursing care.
• Quality improvement is a philosophy and process internal to the institution, and does not rely on inspections by an external agency.
CHAPTER HIGHLIGHTS
Chapter 14 Review
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SETTING THE FOUNDATION FOR CLINICAL COMPETENCE!
STEP-BY-STEP SKILLS An easy-to-follow format helps students understand techniques and practice sequences.
• Includes a complete Equipment list for easy preparation.
• Clearly labeled Delegation boxes assist you in assigning tasks appropriately.
• Easy-to-find rationales give you a better understanding of why things are done.
• Critical steps are visually represented with full-color photos and illustrations.
CONCEPT MAPS provide visual representations of the nursing process, nursing care plans, and the relationships between difficult concepts.
318 Unit 5 ● Life Span Development
CONCEPT MAP Overview of Growth and Development Psychosocial Theories and Theorists
Theories
Freud
personality develops
in five overlapping stages from
birth to adulthood
5 stages: • Oral • Anal • Phallic • Latency • Genital
theorist theorist theorist theoristtheorist
Erikson
stages reflect
positive and
negative aspects of the critical
life periods
8 stages: • Trust vs. Mistrust • Autonomy vs. Shame & Doubt • Initiative vs. Guilt • Industry vs. Inferiority • Identity vs. Role Confusion • Intimacy vs. Isolation • Generativity vs. Stagnation • Integrity vs. Despair
Havighurst
believed
• Growth & development occurs during 6 age periods (infancy to later maturity) • Each age period has developmental tasks • Achieving the developmental tasks helps the individual transition to the next developmental period
Peck
adult development
• Three developmental tasks during old age: • Ego differentiation vs. work-role • Body transcendence vs. body preoccupation • Ego transcendence vs. ego preoccupation
Gould
adult development
7 stages: • 1: 16–18 years • 2: 18–22 years • 3: 22–28 years • 4: 28–34 years • 5: 34–43 years • 6: 43–50 years • 7: 50–60 years
Growth and Development
Psychosocial Development
• Stage 6 (ages 43–50). Personalities are seen as set. Time is accepted
as finite. Individuals are interested in social activities with friends and spouse and desire both sympathy and affection from spouse.
• Stage 7 (ages 50–60). This is a period of transformation, with a real- ization of mortality and a concern for health. There is an increase in warmth and a decrease in negativism. The spouse is seen as a valuable companion ( Gould, 1972 , pp. 525–527).
Temperament Theories Early research on temperament, conducted in the 1950s by Stella Chess and Alexander Thomas, identified nine temperamental qualities seen in children’s behavior ( Table 20–3 ). Temperament is multidimensional leading to the development of a child’s person- ality traits. Temperament has a role in the development of anxiety, depression, attention deficit disorder, and other types of behavior
632 Unit 8 • Integral Components of Client Care
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Sterile gloves are available to protect the nurse from contact with blood and body fluids. Latex and nitrile gloves are more flexible than vinyl, mold to the wearer’s hands, and allow freedom of movement. Since latex should be avoided due to possible allergies, wear nitrile gloves when performing tasks (a) that demand flexibility, (b) that place stress on the material (e.g., turning stopcocks, handling sharp instruments or tape), and (c) that involve a high risk of exposure to pathogens. Vinyl gloves should be chosen for tasks unlikely to stress the glove material, requiring minimal precision, and with minimal risk of exposure to pathogens.
Skill 31–4 describes how to apply and remove sterile gloves by the open method.
Sterile Gloves Sterile gloves may be applied by the open method or the closed method. The open method is most frequently used outside the oper- ating room because the closed method requires that the nurse wear a sterile gown. Gloves are worn during many procedures to enable the nurse to handle sterile items freely and to prevent clients at risk (e.g., those with open wounds) from becoming infected by microorgan- isms on unsterile gloves or the nurse’s hands.
Sterile gloves are packaged with a cuff of about 5 cm (2 in.) and with the palms facing upward when the package is opened. The pack- age usually indicates the size of the glove (e.g., size 6 or 7 1/2 or small, medium, large).
❶ Picking up the first sterile glove.
PURPOSES • To enable the nurse to handle or touch sterile objects freely with-
out contaminating them • To prevent transmission of potentially infective organisms from
the nurse’s hands to clients at high risk for infection
Applying and Removing Sterile Gloves (Open Method)
S K
IL L 3
1 –4
ASSESSMENT Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves. Check the client record and ask about latex allergies. Use nonlatex gloves whenever possible.
INTERPROFESSIONAL PRACTICE
Sterile gloves are used many health care providers. All providers should be comfortable pointing out to each other when any break in sterile technique is detected.
Equipment • Packages of sterile gloves
PLANNING Think through the procedure, planning which steps need to be com- pleted before the gloves can be applied. Determine what additional supplies are needed to perform the procedure for this client. Always have an extra pair of sterile gloves available.
DELEGATION
Sterile procedures are not delegated to UAP.
edge (on the palmar side) with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff. ❶ Rationale: The hands are not sterile. By touching only the inside of the glove, the nurse avoids contaminating the outside.
or • If the gloves are packaged one on top of the other, grasp
the cuff of the top glove as above, using the opposite hand. • Insert the dominant hand into the glove and pull the glove
on. Keep the thumb of the inserted hand against the palm of the hand during insertion. ❷ Rationale: If the thumb is kept
IMPLEMENTATION Preparation Ensure the sterility of the package of gloves.
Performance 1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary.
2. Perform hand hygiene and observe other appropriate infection prevention procedures (see Skills 31–1, 31–2, and 31–3).
3. Provide for client privacy. 4. Open the package of sterile gloves.
• Place the package of gloves on a clean, dry surface. Rationale: Any moisture on the surface could contaminate the gloves.
• Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package. See Skill 31–3.
• Remove the inner package from the outer package. • Open the inner package as in step 4 of Skill 31–3 or accord-
ing to the manufacturer’s directions. Some manufacturers provide a numbered sequence for opening the flaps and folded tabs to grasp for opening the flaps. If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces. Rationale: The inner surfaces, which are next to the sterile gloves, will remain sterile.
5. Put the first glove on the dominant hand. • If the gloves are packaged so that they lie side by side,
grasp the glove for the dominant hand by its folded cuff
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Chapter 15 ● Documenting and Reporting 233
agency’s policies about the type of pen and ink used for recording. In regards to EHRs, changes are made in accordance with the software guidelines. It is important for the nurse to understand the policies and procedures of the health care institution regarding documentation.
Date and Time Document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (e.g., 9:00 am or 3:15 pm ) or according to the 24-hour clock (military clock), which avoids confusion about whether a time was am or pm ( Figure 15–9 ■ ).
Timing Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition indicates; for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. As a rule, documenting should be done as soon as possible after an assessment or intervention. No recording should be done before providing nursing care.
Legibility All entries must be legible and easy to read to prevent interpreta- tion errors. Hand printing or easily understood handwriting is usually permissible. Follow the agency’s policies about handwritten recording.
Permanence All entries on the client’s record are made in dark ink so that the re- cord is permanent and changes can be identified. Dark ink repro- duces well on microfilm and in duplication processes. Follow the
PRACTICE GUIDELINES
Long-Term Care Documentation
• Complete the assessment and screening forms (MDS) and plan of care within the time period specified by regulatory bodies.
• Keep a record of any visits and of phone calls from family, friends, and others regarding the client.
• Write nursing summaries and progress notes that comply with the frequency and standards required by regulatory bodies.
• Review and revise the plan of care every 3 months or whenever the client’s health status changes.
• Document and report any change in the client’s condition to the primary care provider and the client’s family within 24 hours.
• Document all measures implemented in response to a change in the client’s condition.
• Make sure that progress notes address the client’s progress in relation to the goals or outcomes defined in the plan of care.
Figure 15–9 ■ The 24-hour clock.
PM
AM
2400
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300 12 1
2
3
4
5 6
7
8
9
10
11 0100
0200
0300
0400
0500 0600
0700
0800
0900
1000
1100
PRACTICE GUIDELINES
Home Health Care Documentation
• Complete a comprehensive nursing assessment and develop a plan of care to meet Medicare and other third-party payer requirements. Some agencies use the certification and plan of treatment form as the client’s official plan of care.
• Write a progress note at each client visit, noting any changes in the client’s condition, nursing interventions performed (including education and instructional brochures and materials provided to the client and home caregiver), client responses to nursing care, and vital signs as indicated.
• Provide a monthly progress nursing summary to the attending primary care provider and to the reimburser to confirm the need to continue services.
• Keep a copy of the care plan in the client’s home and update it as the client’s condition changes.
• Report changes in the plan of care to the primary care provider and document that these were reported. Medicare and Medicaid will reimburse only for the skilled services provided that are reported to the primary care provider.
• Encourage the client or home caregiver to record data when appropriate.
• Write a discharge summary for the primary care provider to approve the discharge and to notify the reimbursers that services have been discontinued. Include all services provided, the client’s health status at discharge, outcomes achieved, and recommendations for further care.
Chapter 29 ● Vital Signs 481
with severe hypothermia, a hyperthermia blanket (an electronically controlled blanket that provides a specified temperature) is applied, and warm intravenous fluids are given. Wet clothing, which increases heat loss because of the high conductivity of water, should be replaced with dry clothing. See Box 29–3 for nursing interventions for clients who have hypothermia.
Assessing Body Temperature The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Each of the sites has advantages and disadvantages ( Table 29–1 ).
The body temperature may be measured orally . If a client has been taking cold or hot food or fluids or smoking, the nurse should wait 30 minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food, fluid, or warm smoke.
Rectal temperature readings are considered to be very accurate. Rectal temperatures are contraindicated for clients who are undergo- ing rectal surgery, have diarrhea or diseases of the rectum, are immuno- suppressed, have a clotting disorder, or have significant hemorrhoids.
The axilla is often the preferred site for measuring temperature in newborns because it is accessible and safe. Axillary temperatures are lower than rectal temperatures. Some clinicians recommend re- checking an elevated axillary temperature with one taken from an- other site to confirm the degree of elevation. Nurses should check agency protocol when taking the temperature of newborns, infants, toddlers, and children. Adult clients for whom the axillary method of temperature assessment is appropriate include those for whom other temperature sites are contraindicated.
Nursing Interventions for Clients with Fever BOX 29–2
• Monitor vital signs. • Assess skin color and temperature. • Monitor white blood cell count, hematocrit value, and other
pertinent laboratory reports for indications of infection or dehydration.
• Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.
• Provide adequate nutrition and fluids (e.g., 2,500–3,000 mL/ day) to meet the increased metabolic demands and prevent dehydration.
• Measure intake and output. • Reduce physical activity to limit heat production, especially
during the flush stage. • Administer antipyretics (drugs that reduce the level of fever) as
ordered. • Provide oral hygiene to keep the mucous membranes moist. • Provide a tepid sponge bath to increase heat loss through
conduction. • Provide dry clothing and bed linens.
CLINICAL MANIFESTATIONS
Hypothermia • Decreased body temperature, pulse, and respirations • Severe shivering (initially) • Feelings of cold and chills • Pale, cool, waxy skin • Frostbite (discolored, blistered nose, fingers, toes) • Hypotension • Decreased urinary output • Lack of muscle coordination • Disorientation • Drowsiness progressing to coma
Nursing Interventions for Clients with Hypothermia BOX 29–3
• Provide a warm environment. • Provide dry clothing. • Apply warm blankets. • Keep limbs close to body. • Cover the client’s scalp with a cap or turban. • Supply warm oral or intravenous fluids. • Apply warming pads.
this results in frostbite. Frostbite most commonly occurs in hands, feet, nose, and ears.
Managing hypothermia involves removing the client from the cold and rewarming the client’s body. For the client with mild hypo- thermia, the body is rewarmed by applying blankets; for the client
Site Advantages Disadvantages
Oral Accessible and convenient Thermometers can break if bitten. Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery.
Rectal Reliable measurement Inconvenient and more unpleasant for clients; difficult for client who cannot turn to the side. Could injure the rectum. Presence of stool may interfere with thermometer placement.
Axillary Safe and noninvasive The thermometer may need to be left in place a long time to obtain an accurate measurement.
Tympanic membrane Readily accessible; reflects the core temperature; very fast
Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect the reading.
Temporal artery Safe and noninvasive; very fast Requires electronic equipment that may be expensive or unavailable. Variation in technique needed if the client has perspiration on the forehead.
TABLE 29–1 Advantages and Disadvantages of Sites Used for Body Temperature Measurements
496 Unit 7 ● Assessing Health
DRUG CAPSULE
CLIENT WITH CARDIAC MEDICATIONS THAT AFFECT HEART RATE Cardiac glycosides increase cardiac contractility, which increases car- diac output. As a result, perfusion to the kidneys is increased, which increases the production of urine. Cardiac glycosides also decrease heart rate by prolonging cardiac conduction, especially at the AV node.
Digoxin is commonly used for the clinical management of heart failure, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia.
NURSING RESPONSIBILITIES • Take the apical pulse for 1 minute before administering the
dose. If the apical pulse is < 60 beats/min or another specific parameter set by the health care provider, do not administer the dose and retake the pulse in 1 hour. If pulse remains < 60, call the prescriber. Note: If the initial resting pulse is significantly < 60 or the client has symptoms of bradycardia such as dizzi- ness, notify the primary care provider without waiting to retake.
• Monitor electrolyte levels: Low potassium and low magnesium and high levels of calcium place the client at risk for digitalis toxicity. Check the client’s most recent electrolyte laboratory work for safe levels before administering the dose.
• Avoid giving with meals because this will delay absorption. • Monitor for therapeutic drug levels: 0.5–2 ng/mL. Digoxin has a
narrow therapeutic index, which means that there is not much difference between a therapeutic effect and a toxic effect.
• Assess for signs of digoxin toxicity: anorexia, nausea, vomiting, diarrhea, blurred or “yellow” vision, unusual tiredness and weakness.
CLIENT AND FAMILY TEACHING • Explain the reason for taking digoxin and the importance of
medical checkups that may include laboratory work to evaluate the effects and dosage of the drug.
• Teach the client and/or family how to check the radial or carotid pulse for a full minute. Inform them to take the pulse at the same time each day and to write it on the calendar. Provide pulse parameters and tell them when it is appropriate to call the health care provider.
• Caution the client not to stop taking the digoxin without approval of the health care provider.
• Caution the client to avoid over-the-counter drugs, except on the advice of the health care provider, because many can inter- act with digoxin.
• Explain the signs and symptoms of digoxin toxicity and the importance of calling the health care provider.
Note: Prior to administering any medication, review all aspects with a current drug handbook or other reliable source.
Cardiac Glycoside or Digitalis Glycoside Digoxin (Lanoxin)
RESPIRATIONS Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in and out of the lungs.
There are basically two types of breathing: costal (thoracic) breathing and diaphragmatic (abdominal) breathing . Costal breathing involves the external intercostal muscles and other ac- cessory muscles, such as the sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward. By contrast, diaphragmatic breathing involves the contraction and re- laxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement.
Mechanics and Regulation of Breathing During inhalation, the following processes normally occur ( Figure 29–16 ■ ): The diaphragm contracts (flattens), the ribs move upward and outward, and the sternum moves outward, thus enlarg- ing the thorax and permitting the lungs to expand. During exhalation ( Figure 29–17 ■ ), the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed. Normal breathing is auto- matic and effortless. A normal adult inspiration lasts 1 to 1.5 seconds, and an expiration lasts 2 to 3 seconds.
Respiration is controlled by (a) respiratory centers in the me- dulla oblongata and the pons of the brain and (b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen (O 2 ), carbon dioxide (CO 2 ), and hydrogen (H + ) in the arterial blood. See Chapter 50 for details.
Sternum moves outward
Diaphragm contracts
Diaphragm contracts
Ribs move upward and outward
Figure 29–16 ■ Respiratory inhalation: top: lateral view; bottom: anterior view.
268 Unit 4 ● Health Beliefs and Practices
STANDARDS OF LIVING An individual’s standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the ability to seek health care advice and follow health regimens vary among high-income and low-income groups.
Low-income families must prioritize use of their finances, often choosing food and housing over health care. They may have difficulty obtaining time off from work and transportation to health care fa- cilities. Because their present problems are so great and all efforts are exerted toward survival, they may lack an orientation toward actions that help prevent illness.
The environmental conditions of impoverished areas have a bearing on overall health. Slum neighborhoods are overcrowded and in a state of deterioration. Sanitation services tend to be inad- equate, streets strewn with garbage, and pests are common. Fires and violence may be frequent. Recreational facilities are limited, forcing children to play in streets and alleys.
Occupational roles also predispose people to certain illnesses. For instance, some industrial workers may be exposed to carcino- genic agents. High-pressure social or occupational roles predispose to stress-related diseases. Such roles may also encourage overeating or social use of drugs or excessive alcohol.
FAMILY AND CULTURAL BELIEFS The family passes on patterns of daily living and lifestyles to offspring. For example, a man who was abused as a child may physically abuse his own children. Physical or emotional abuse may cause long-term health problems. Emotional health depends on a social environment that is free of excessive tension and does not isolate the person from others. A climate of open communication, sharing, and love fosters the fulfillment of the person’s optimum potential.
Culture and social interactions also influence how a person per- ceives, experiences, and copes with health and illness. Each culture has ideas about health, and these are often transmitted from parents to children. People of certain cultures may perceive home remedies or tribal health customs as superior to and more dependable than the health care practices of North American society. For example, a person of Asian origin may prefer to use herbal remedies and acu- puncture to treat pain rather than analgesic medications. Cultural rules, values, and beliefs give people a sense of being stable and able to predict outcomes. The challenging of old beliefs and values by second-generation cultural groups may give rise to conflict, instabil- ity, and insecurity, in turn contributing to illness. Heritage and cul- tural influences on health are discussed in detail in Chapter 18 .
SOCIAL SUPPORT NETWORKS Having a support network (family, friends, or a confidant) and job satisfaction helps people avoid illness. Support persons also help the individual confirm that illness exists. People with inadequate support networks sometimes allow themselves to become increasingly ill be- fore confirming the illness and seeking therapy. Support people also provide the motivation for an ill person to become well again.
HEALTH BELIEF MODELS Several theories or models of health beliefs and behaviors have been developed to help determine whether an individual is likely to par- ticipate in disease prevention and health promotion activities. These models can be useful tools in developing programs for helping people
Spiritual and religious beliefs can significantly affect health be- havior. For example, Jehovah’s Witnesses oppose blood transfusions; some fundamentalists believe that a serious illness is a punishment from God; some religious groups are strict vegetarians; and religious Jews perform circumcision on the eighth day of a male baby’s life. The influence of spirituality and religion is discussed further in Chapter 41 .
SELF-CARE ALERT
Knowledge of health behaviors does not always translate into action. The nurse should be self-reflective and consider both the personal and professional advantages of examining and minimizing one’s own barriers to ways of becoming a positive role model.
External Variables External variables affecting health include the physical environment, standards of living, family and cultural beliefs, and social support networks.
ENVIRONMENT People are becoming increasingly aware of their environment and how it affects their health and level of wellness. Geographic loca- tion determines climate, and climate affects health. For instance, malaria and malaria-related conditions occur more frequently in tropical rather than temperate climates. Pollution of the water, air, and soil affects the health of cells. Pollution can occur naturally (e.g., lightning-caused fires produce smoke, which pollutes the air). Some man-made substances in the environment, such as asbestos, are con- sidered carcinogenic (i.e., they cause cancer). Tobacco is “hazardous to one’s health,” with rates of cancer higher among both smokers themselves, and those who live or work near people who smoke in their environment.
An environmental hazard is radiation. The improper or exces- sive use of medical x-rays, for example, can harm many of the body’s organs. Another common source of radiation is the sun’s ultraviolet rays. Light-skinned people are more susceptible to the harmful ef- fects of the sun than are dark-skinned people. Ozone molecules in the atmosphere absorb most of the harmful sun radiation but the manu- facture of certain products releases chemicals that damage the ozone layer, increasing the amount of harmful rays that reach the earth’s sur- face. International legislation limiting the production of these chemi- cals can lessen damage to the ozone layer.
The main component of acid rain is sulfur dioxide, produced by ore smelters and related industries. The other components are nitro- gen oxides. These emissions, brought down by the air when it rains, are thought to damage forests, lakes, and rivers.
An environmental hazard that is receiving more attention is an increase in the “greenhouse effect.” The glass roof of a greenhouse permits the sun’s radiation to penetrate, but the resulting heat does not escape back through the glass. Carbon dioxide in the earth’s at- mosphere acts like the glass roof of a greenhouse, and as carbon di- oxide levels increase due to industrial and automobile emissions, the surface temperature of the earth may also be increasing.
Other sources of environmental contamination are pesticides and chemicals used to control weeds and plant diseases. These con- taminants can be found in some animals and plants that are subse- quently ingested by people. In excessive levels, they are harmful to health.
SELF-CARE ALERTS focus on actions nurses can perform to take care of themselves and serve as effective role models for clients and colleagues.
CLINICAL MANIFESTATIONS boxes are a quick resource to learn key signs and symptoms of illness.
PRACTICE GUIDELINES provide instant-access summaries of clinical do’s and don’ts.
Chapter 15 ● Documenting and Reporting 235
Do Not Use Potential Problem Use Instead
U, u (unit) Mistaken for “0” (zero), the number “4” (four), or cc
Write “unit”
IU (for International Unit) Mistaken for IV (intravenous) or the number 10 (ten)
Write “International Unit”
Q.D. QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day)
Mistaken for each other Period after the Q mistaken for “I” and “O” mistaken for “I”
Write “daily” and “every other day”
Trailing zero (X.0 mg)** Lack of leading zero (.X mg)
Decimal point is missed. Write X mg Write 0.Xmg
MS MSO 4 and MGSO 4
Can mean morphine sulfate or magnesium sulfate. Confused for one another
Write “morphine sulfate” or “magnesium sulfate”
*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.
**A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
From Facts About the Official “Do Not Use” List , by The Joint Commission, 2010 . Retrieved from http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf . © The Joint Commission, 2010. Reprinted with permission.
TABLE 15–5 Official “Do Not Use” List*
In 2004, The Joint Commission developed National Patient Safety Goals (NPSGs) to reduce communication errors. These goals are required to be implemented by all organizations accred- ited by the commission. As a result, the accredited organizations must develop a do-not-use list of abbreviations, acronyms, and symbols. This list must include those banned by The Joint Com- mission ( Table 15–5 ).
Correct Spelling Correct spelling is essential for accuracy in recording. If unsure how to spell a word, look it up in a dictionary or other resource book. Two decidedly different medications may have similar spellings; for ex- ample, Fosamax and Flomax.
CLINICAL ALERT!
Incorrect spelling gives a negative impression to the reader and, thereby, decreases the nurse’s credibility.
Signature Each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title; for example, “Susan J. Green, RN” or “SJ Green, RN.” Some agencies have a signature sheet and after signing this signature sheet, nurses can use their initials. With computerized charting, each nurse has his or her own code, which allows the documentation to be identified.
The following title abbreviations are often used, but nurses need to follow agency policy about how to sign their names:
RN registered nurse
LVN licensed vocational nurse
LPN licensed practical nurse
NA nursing assistant
NS nursing student
PCA patient care associate
SN student nurse
Accuracy The client’s name and identifying information should be stamped or written on each page of the clinical record. Before making an entry, check that the chart is the correct one. Do not identify charts by room number only; check the client’s name. Special care is needed when caring for clients with the same last name.
Notations on records must be accurate and correct. Accurate nota- tions consist of facts or observations rather than opinions or interpreta- tions. It is more accurate, for example, to write that the client “refused medication” (fact) than to write that the client “was uncooperative” (opinion); to write that a client “was crying” (observation) is preferable to noting that the client “was depressed” (interpretation). Similarly, when a client expresses worry about the diagnosis or problem, this should be quoted directly on the record: “Stated: ‘I’m worried about my leg.’” When describing something, avoid general words, such as large , good , or nor- mal , which can be interpreted differently. For example, chart specific data such as “2 cm × 3 cm bruise” rather than “large bruise.”
When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line (depending on agency policy). Do not erase, blot out, or use correction fluid. The original entry must remain visible. When using computerized charting, the nurse needs to be aware of the agency’s policy and process for correcting documentation mistakes. See Figure 15–10 ■ for an example.
Write on every line but never between lines. If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other per- son, and sign the notation.
CLINICAL ALERT!
Avoid writing the word error when a recording mistake has been made. Some believe that the word error is a “red flag” for juries and can lead to the assumption that a clinical error has caused a client injury.
Sequence Document events in the order in which they occur; for example, re- cord assessments, then the nursing interventions, and then the client’s responses. Update or delete problems as needed.
DRUG CAPSULE boxes provide a brief overview of drug information, nursing responsibilities, and client teaching to help you understand implications of pharmacotherapy in different situations.
CLINICAL ALERTS highlight special information useful for clinical settings.
CRITICAL THINKING CHECKPOINTS provide a brief case study followed by questions that encourage you to analyze, compare, contemplate, interpret, and evaluate information.
Chapter 22 ● Promoting Health in Young and Middle-Aged Adults 361
Developmental Assessment Guidelines
The Middle-Aged Adult
In these three developmental areas, does the middle-aged adult do the following?
PHYSICAL DEVELOPMENT • Exhibit weight within normal range for age and sex. • Manifest vital signs (e.g., blood pressure) within normal range for
age and sex. • Manifest visual and hearing abilities within normal range. • Exhibit appropriate knowledge and attitudes about sexuality (e.g.,
about menopause). • Verbalize any changes in eating, elimination, or exercise.
PSYCHOSOCIAL DEVELOPMENT • Accept aging body. • Feel comfortable and respect self.
• Enjoy new freedom to be independent. • Accept changes in family roles (e.g., having teenage children and
aging parents). • Interact effectively and share companionable activities with life
partner. • Expand and renew previous interests. • Pursue charitable and altruistic activities. • Have a meaningful philosophy of life.
DEVELOPMENT IN ACTIVITIES OF DAILY LIVING • Follow preventive health practice.
BOX 22–4 Health Promotion Guidelines for Middle-Aged Adults
HEALTH TESTS AND SCREENING • Annual physical examination • Immunizations as recommended, such as a tetanus booster
every 10 years, and current recommendations for influenza vaccine
• Regular dental assessments (e.g., every 6 months) • Tonometry for signs of glaucoma and other eye diseases every
2 to 3 years or annually if indicated • Breast examination annually by primary care provider • Testicular examination annually by primary care provider • Screenings for cardiovascular disease (e.g., blood pressure
measurement; electrocardiogram and cholesterol test as directed by the primary care provider)
• Screenings for colorectal, breast, cervical, uterine, and prostate cancer (see cancer screening guidelines in Chapter 30 )
• Screening for tuberculosis every 2 years • Smoking: history and counseling, if needed
SAFETY • Motor vehicle safety reinforcement, especially when driving at night • Workplace safety measures • Home safety measures: keeping hallways and stairways lighted
and uncluttered, using smoke detectors, using nonskid mats and handrails in the bathrooms
NUTRITION AND EXERCISE • Importance of adequate protein, calcium, and vitamin D in diet • Nutritional and exercise factors that may lead to cardiovascular
disease (e.g., obesity, cholesterol and fat intake, lack of vigorous exercise)
• An exercise program that emphasizes skill and coordination
SOCIAL INTERACTIONS • The possibility of a midlife crisis: encourage discussion of
feelings, concerns, and fears • Providing time to expand and review previous interests • Retirement planning (financial and possible diversional
activities), with partner if appropriate
Critical Thinking Checkpoint
Mark Jones, a 22-year-old construction worker, comes into the health center for a “physical.” He states that the last time he saw a health care provider was during high school, and he is only here today be- cause his employer required that he be examined prior to returning to work. Mr. Jones has been off the job for 2 weeks following an ac- cident in which he fell off a ladder, sustaining multiple contusions and a concussion. He mentions that he and “his buddies” have enjoyed his 2 weeks off from work, and have used the time to “drink beer and chase women.”
1. What questions would you ask Mr. Jones about his usual health promotion activities?
2. How would you ask Mr. Jones about his risk for sexually transmitted infections?
3. What health conditions are young adults at risk for, and how would you explain these to Mr. Jones?
4. What health screening activities would you suggest to Mr. Jones? How would you explain the rationale to him?
5. How would you assess Mr. Jones’s psychosocial development? See Critical Thinking Possibilities on student resource website.
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EXTENSIVE END OF CHAPTER REVIEW
CHAPTER HIGHLIGHTS focus your attention and review critical concepts.
READINGS AND REFERENCES give you a source for evidence- based material and additional information.
TEST YOUR KNOWLEDGE helps you prepare for the NCLEX® exam. Alternative-style questions are included. Answers and rationales are in Appendix A.
Chapter 21 ● Promoting Health from Conception Through Adolescence 351
8. After falling off playground equipment, a 5-year-old is brought to the emergency department with a broken arm. The parents ask for ways to keep her occupied while wearing the cast. Which is the best response by the nurse? 1. “You will need to talk to the primary care provider about
this.” 2. “Let her watch television or do puzzles and other quiet
games.” 3. “Activities that do not involve the use of the arm or risk
damage to the cast are okay.” 4. “She can ride a bike, jump rope, or play with friends if you
watch her closely.” 9. According to Piaget’s theory of cognitive development, the
movement from intuitive reasoning to logical reasoning in school-age children is called the concrete operations phase. Which is an example of this phase? 1. A science-fair project comparing how fast different objects
fall from a set height 2. Feeling responsible for wishing that a sibling would go
away, and now that sibling is ill and hospitalized 3. Understanding how geometric figures might fit into a
futuristic and idealistic world 4. Learning to ride a bike
10. Parents ask the nurse how they will know that their daughter has reached puberty. Which is the best response by the nurse? 1. “The first noticeable sign of puberty in females is
appearance of the breast bud.” 2. “The growth spurt usually begins between ages 10 and 14.” 3. “The apocrine glands, found over most of the body, begin
to produce sweat.” 4. “The adolescent will display significant mood swings.”
See Answers to Test Your Knowledge in Appendix A.
5. Females experience an increase in weight and fat deposition during puberty. Which nursing action is most appropriate to this age group? 1. Give reassurance that these changes are normal. 2. Suggest dietary measures to control weight gain. 3. Recommend increased exercise to control weight gain. 4. Encourage low-fat diet to prevent fat deposition.
6. A night shift nurse notices that a postpartum (after delivery of a baby) client is crying and rubbing her baby’s head. The mother states, “Look how lopsided my little Sam’s head is. It is all my fault. My mom told me that I should have laid down more instead of sitting. Now, Sam’s head is all smashed and funny looking.” Which is the best response by the nurse? 1. “Do you mean to tell me that your mother told you that?
Are you serious?” 2. “The head is soft and changed shape as it moved through
the birth canal.” 3. “I will provide you with materials to read that will clear that up
for you.” 4. “There is no need to cry. His head will return to normal in a
few days.” 7. During a physical examination a 24-month-old child clings to
the parent and cries every time the nurse attempts to touch her. From knowledge of psychosocial development, the nurse makes which conclusion about the child? 1. The child is displaying normal toddler development. 2. The child needs further psychological evaluation. 3. The child is manipulative and should be taken from the
parent to be examined. 4. The child is showing signs of regression.
Suggested Reading Turner, A. M., Kirchoff, A. M., & Capurro, D. (2012). Using
crowdsourcing technology for testing multilingual public health promotion materials. Journal of Medical Internet Research , 14 (3), e79. doi:10.2196/jmir.2063 Nurses have an important task in developing teaching materials for parents to educate them on health promotion strategies to be implemented while raising their children. The key to successful education is the development of these resources in all languages.
Related Research Anderson, K. K., Fuhrer, R., Abrahamowicz, M., & Malla, A. K.
(2012). The incidence of first episode schizophrenia- spectrum psychosis in adolescents and young adults in Montreal: An estimate from an administrative claims data- base, Canadian Journal of Psychiatry , 57 , 626–633.
Cooper, L. A., & Nickerson, A. B. (2013). Parent retrospec- tive recollections of bullying and current views, concerns, and strategies to cope with children’s bullying. Journal of Child and Family Studies , 22, 526–540. doi:10.1007/ s10826-012-9606-0
Homer, C., Armari, E., & Fowler, C. (2012). Bed-sharing with infants in a time of SIDS awareness. Neonatal, Paediatric, & Child Health Nursing , 15 (2), 3–7.
Pirruccello, L. M. (2010). Preventing adolescent suicide: A community takes action. Journal of Psychosocial Nursing and Mental Health Services , 48 (5) 34–41. doi:10.3928/02793695-20100303-01
References American Academy of Pediatrics, Council on Communica-
tions and Media. (2011). Policy statement: Media use by children younger than 2 years. Pediatrics , 128 , 1040–1045. doi:10.1542/peds.2011-1753
American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome (2011). SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment. Pediatrics,128, 1341–1367. doi:10.1542/peds.2011-2285
Ball, J. W., Bindler, R. C., & Cowen, K. J. (2014). Child health nursing partnering with children and families, Upper Saddle River, NJ: Pearson.
Carney, J. V., Hazler, R. J., Oh, I., Hibel, L. C., & Granger, D. A. (2010). The relations between bullying expo- sures in middle childhood, anxiety, and adrenocorti- cal activity. Journal of School Violence , 9 , 194–211. doi:10.1080/15388220903479602
Centers for Disease Control and Prevention. (2000). 2000 CDC growth charts for the United States . Retrieved from http://www.cdc.gov/growthcharts
Centers for Disease Control and Prevention. (2012a). HPV vaccine—Questions and answers. Retrieved from http:// www.cdc.gov/vaccines/vpd-vac/hpv/vac-faqs.htm
Centers for Disease Control and Prevention. (2012b). Youth risk behavior surveillance—United States, 2011. Morbidity and Mortality Weekly Report , 61 (SS04), 1–162.
Centers for Disease Control and Prevention. (2013a). HPV infection remains common among women in the United States, CDC study confirms. Retrieved from http:// www.cdc.gov/hpv
Centers for Disease Control and Prevention. (2013b). Obesity prevalence among low-income, preschool-aged children— New York City and Los Angeles County, 2003–2011. Morbidity and Mortality Weekly Report, 62 (02), 17–22.
de Onis, M. (2011). New WHO child growth standards catch on. Bulletin of the World Health Organization , 89 , 250–251. doi:10.2471/BLT.11.040411
Drummond, D., & Hare, M. S. (2012). Dietitians and eat- ing disorders: An international issue. (2012). Canadian
Journal of Dietetic Practice and Research , 73 (2), 86–90. doi:10.3148/73.2.2012.86
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: W. W. Norton.
Ferro, M. A., & Boyle, M. H. (2013). Self-concept among youth with chronic illness: A meta-analytic review. Health Psy- chology , 32 (8), 839–848. doi:10.1037/a0031861.supp
Fowler, J. W. (1981). Stages of faith: The psychology of human development and the quest for meaning . New York, NY: Harper & Row.
Grummer-Strawn, L. M., Reinold, C., & Krebs, N. F. (2010). Use of World Health Organization and CDC growth charts for children aged 0–59 months in the United States. Morbidity and Mortality Weekly Report , 59 (RR-9), 1–23.
Harlow, K. C., & Roberts, R. (2010). An exploration of the relationship between social and psychological factors and being bullied. Children and Schools , 32 (1), 15–26. doi:10.1093/cs/32.1.15
Hill, S., Young, D., Briley, A., Carter, J., & Lang, R. (2013). Baby be smoke free: Teenage smoking cessation pilot. British Journal of Midwifery , 21 , 485–491.
Kirkland, R. T., & Motil, K. J. (2013). Etiology and evaluation of failure to thrive (undernutrition) in children younger than two years . Retrieved from http://www.uptodate.com/contents/ etiology-and-evaluation-of-failure-to-thrive-undernutrition- in-children-younger-than-two-years
Kohlberg, L. (1981). Essays on moral development: Vol. 1, The philosophy of moral development. San Francisco, CA: Harper & Row.
Kothari, C. L., Wendt, A., Liggins, O., Overton, J., & del Carmen Sweezy, L. (2010). Assessing maternal risk for fetal–infant mortality: A population-based study to prioritize risk reduction in a healthy start community. Maternal Child Health Journal , 15 , 68–76. doi:10.1007/ s10995-009-0561-3
READINGS AND REFERENCES
• Prenatal or intrauterine development lasts approximately 9 calen- dar months.
• The embryonic phase is the 8-week period during which the fertil- ized ovum develops into an organism with most of the features of the human.
• The infant’s weight, length, head and chest circumferences, fonta- nel size and status, vision, hearing, smell and taste, touch, reflexes, and motor development are important indicators of the newborn’s growth and health.
• Infants from birth to 12 months reveal marked growth in size and stature with appropriate nutrition and care: Birth weight doubles by about 5 months and triples by 12 months.
• Rapid weight gain in the first 5 to 6 months of life appears to be related to overweight and obesity in childhood and as an adult.
• During infancy, motor development is notable: At 1 month infants can lift their heads momentarily when prone; at 6 months they can sit unsupported; and at 12 months they can walk with help.
• Fulfillment of the infant’s physiological and psychological needs is required to develop a basic sense of trust. Parents can enhance this sense of trust by being sensitive to the infant’s needs and meeting those needs skillfully, promptly, and consistently, and pro- viding a predictable environment in which routines are established.
• For the infant, cognitive development is a result of interaction be- tween an individual and the environment. The infant needs a variety of sensory and motor stimuli.
• The toddler group, ages 12 months to 3 years, is, according to Erikson, developing a sense of autonomy. Voluntary control in- creases and these children learn to walk and speak. They also learn to control their bladders and bowels, and they acquire all kinds of information about their environment.
• During the preschool years, ages 4 to 5, physical growth slows, but control of the body and coordination increase greatly. The
preschooler’s world gets larger as they meet relatives, friends, and neighbors. They are engaged in Erikson’s task of initiative versus guilt.
• The school-age period starts when children are about 6 years of age. In general, this period from 6 to 12 years is one of significant change. Skills learned during this stage are particularly important in relation to work later in life and willingness to try new tasks.
• During psychosocial development, school-age children face Erikson’s conflict of industry versus inferiority.
• School-age children change from being egocentric to having co- operative interactions, and begin to understand cause-and-effect relationships. According to Piaget, they are in the concrete opera- tions phase of cognitive development.
• Most school-age children progress to the conventional level of moral development and to the mythic-literal stage of spiritual development.
• Rapid growth in height, development of secondary sexual charac- teristics, sexual maturity, and increasing independence from the family are major landmarks of adolescence.
• Peer groups assume great importance during adolescence; they provide a sense of belonging, pride, social learning, and sexual roles.
• Adolescents between the ages of 11 and 15 begin the formal operations stage of cognitive development; they are able to think logically, rationally, and futuristically and can conceptualize things as they could be rather than as they are.
• The adolescent is at Kohlberg’s conventional level of moral devel- opment, and some proceed to the postconventional or principled level.
• Adolescents are at Fowler’s synthetic-conventional stage of spiri- tual development.
• The four leading causes of adolescent death are motor vehicle crashes, other unintentional injuries, homicide, and suicide.
CHAPTER HIGHLIGHTS
Chapter 21 Review
1. The parent of an 8-month-old girl who has been admitted to the hospital with pneumonia is worried about the infant having sudden infant death syndrome (SIDS). The parent stated that “My sister’s baby died at the age of 2 months and all he had was a little cold.” Which is the nurse’s best response? 1. “You don’t need to worry. Your daughter is too old for SIDS.” 2. “Girls are less likely to have SIDS than boys are.” 3. “We don’t know what causes SIDS, so I would try not to
worry about it.” 4. “You must be very anxious; let’s talk about SIDS and what
you are thinking.” 2. Four-year-old Angie, whose grandmother recently died, tells
the nurse, “My grandma has wings just like angels. She flew to heaven yesterday and tomorrow she’ll be back.” Which is the nurse’s best response? 1. “She’s not coming back, honey.” 2. “It is normal for a little one to make believe.” 3. “You must miss your grandma a lot.” 4. “When people get old they die.”
3. Because near-drowning is one of the leading causes of vegeta- tive state in young children, which is the best instruction for the nurse to teach parents? 1. Supervise children at all times when near any source of
water. 2. Enroll children in swimming classes at an early age to ensure
water safety. 3. Make bathroom doors and toilets easily accessible and
appropriate for a toddler’s size. 4. Allow unsupervised play only in “kiddy pools” designated for
young children. 4. Which statement most accurately describes physical
development during the school-age years? 1. Child’s weight almost triples. 2. Child acquires stereognosis. 3. Few physical changes occur during middle childhood. 4. Fat gradually increases, which contributes to the child’s
heavier appearance.
TEST YOUR KNOWLEDGE
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Contents About the Authors iv Acknowledgments vi Thank You vii Preface viii
UNIT 1 The Nature of Nursing 1
Chapter 1 Historical and Contemporary Nursing Practice 2
Introduction 2
Historical Perspectives 2 Women’s Roles 2, Religion 2, War 3, Societal Attitudes 4, Nursing Leaders 6, Men in Nursing 8
Nursing Education 9 Types of Education Programs 9
Contemporary Nursing Practice 13 Definitions of Nursing 13, Recipients of Nursing 13, Scope of Nursing 13, Settings for Nursing 14, Nurse Practice Acts 15, Standards of Nursing Practice 15
Roles and Functions of the Nurse 15 Caregiver 15, Communicator 15, Teacher 15, Client Advocate 15, Counselor 15, Change Agent 15, Leader 15, Manager 15, Case Manager 16, Research Consumer 16, Expanded Career Roles 16
Criteria of a Profession 16 Specialized Education 17, Body of Knowledge 17, Service Orientation 17, Ongoing Research 17, Code of Ethics 17, Autonomy 17, Professional Organization 17
Socialization to Nursing 17 Critical Values of Nursing 18
Factors Influencing Contemporary Nursing Practice 18
Health Care Reform 19, Quality and Safety in Health Care 19, Consumer Demands 19, Family Structure 19, Science and Technology 19, Information, Telehealth, and Telenursing 20, Legislation 20, Demography 20, The Current Nursing Shortage 20, Collective Bargaining 21, Nursing Associations 21
Nursing Organizations 21 American Nurses Association 22, National League for Nursing 22, International Council of Nurses 22, National Student Nurses Association 22, International Honor Society: Sigma Theta Tau 22
Chapter 2 Evidence-Based Practice and Research in Nursing 26
Introduction 26
Evidence-Based Practice 26
Nursing Research 27 Approaches to Nursing Research 27, Overview of the Research Process 29, Research-Related Roles and Responsibilities for Nurses 31
Chapter 3 Nursing Theories and Conceptual Frameworks 37
Introduction 37
Introduction to Theories 37 Context for Theory Development in American Universities 37, Defining Terms 38
The Metaparadigm for Nursing 38
Role of Nursing Theory 38 In Education 39, In Research 39, In Clinical Practice 39
Overview of Selected Nursing Theories 40
Nightingale’s Environmental Theory 40, Peplau’s Interpersonal Relations Model 40, Henderson’s Definition of Nursing 40, Rogers’ Science of Unitary Human Beings 41, Orem’s General Theory of Nursing 41, King’s Goal Attainment Theory 41, Neuman’s Systems Model 42, Roy’s Adaptation Model 42, Leininger’s Cultural Care Diversity and Universality Theory 43, Watson’s Human Caring Theory 44, Parse’s Humanbecoming Theory 44
Critique of Nursing Theory 44
Chapter 4 Legal Aspects of Nursing 47
Introduction 47
General Legal Concepts 47 Functions of the Law in Nursing 47, Sources of Law 48, Types of Laws 48, Kinds of Legal Actions 48, The Civil Judicial Process 49, Nurses as Witnesses 49
Regulation of Nursing Practice 49 Nurse Practice Acts 49, Credentialing 49, Standards of Care 51
Contractual Arrangements in Nursing 52 Legal Roles of Nurses 52, Collective Bargaining 53
Selected Legal Aspects of Nursing Practice 53
Informed Consent 53, Delegation 56, Violence, Abuse, and Neglect 57, The Americans with Disabilities Act 57, Controlled Substances 57, The Impaired Nurse 57, Sexual Harassment 58, Abortions 59, Death and Related Issues 59
Areas of Potential Liability in Nursing 61 Crimes and Torts 62, Privacy of Clients’ Health Information 66, Social Media 66, Loss of Client Property 66, Unprofessional Conduct 66
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xvi Contents
Factors Affecting Health Care Delivery 96 Increasing Number of Older Adults 96, Advances in Technology 96, Economics 96, Women’s Health 96, Uneven Distribution of Services 97, Access to Health Insurance 97, The Homeless and the Poor 98, Health Insurance Portability and Accountability Act 98, Demographic Changes 98
Frameworks for Care 98 Managed Care 98, Case Management 99, Differentiated Practice 99, Case Method 99, Functional Method 99, Team Nursing 99, Primary Nursing 100
Financing Health Care 100 Payment Sources in the United States 100, Insurance Plans 101
Chapter 7 Community Nursing and Care Continuity 105
Introduction 105
The Movement of Health Care to the Community 105
Primary Health Care and Primary Care 106
Community-Based Health Care 107
Community Health 108 Community-Based Frameworks 109, Community-Based Settings 110
Community-Based Nursing 111 Competencies Required for Community-Based Care 111, Collaborative Health Care 111
Continuity of Care 113 Care Across the Life Span 113, Discharge Planning 114, Preparing Clients to Go Home 114, Medication Reconciliation 114, Home Health Care Teaching 114, Referrals 115
Chapter 8 Home Care 118
Introduction 118
Home Health Nursing 118 Unique Aspects of Home Health Nursing 119
The Home Health Care System 119 Referral Process 119, Home Health Agencies 119, Private Duty Agencies 120, Durable Medical Equipment Companies 120, Reimbursement 120
Roles of the Home Health Nurse 120 Advocate 120, Caregiver 121, Educator 121, Case Manager or Coordinator 121
Perspectives of Home Care Clients 121
Selected Dimensions of Home Health Nursing 121
Client Safety 121, Nurse Safety 122, Infection Prevention 122, Caregiver Support 123
The Practice of Nursing in the Home 123 Establishing Health Issues 124, Planning and Delivering Care 124, Resources for Home Health Nursing 125
The Future of Home Health Care 125
Legal Protections in Nursing Practice 67 Good Samaritan Acts 67, Professional Liability Insurance 67, Carrying Out a Physician’s Orders 68, Providing Competent Nursing Care 68, Documentation 68, The Incident Report 68
Reporting Crimes, Torts, and Unsafe Practices 69
Legal Responsibilities of Students 70
Chapter 5 Values, Ethics, and Advocacy 73
Introduction 73
Values 73 Values Transmission 73, Values Clarification 74
Ethics and Morality 75 Moral Development 76, Moral Frameworks 76, Moral Principles 76
Nursing Ethics 77 Nursing Codes of Ethics 78, Origins of Ethical Problems in Nursing 79, Making Ethical Decisions 79, Strategies to Enhance Ethical Decisions and Practice 80
Specific Ethical Issues 80 Acquired Immunodeficiency Syndrome (AIDS) 80, Abortion 80, Organ and Tissue Transplantation 82, End-of-Life Issues 82, Allocation of Scarce Health Resources 83, Management of Personal Health Information 83
Advocacy 83 The Advocate’s Role 83
UNIT 2 Contemporary Health Care 88
Chapter 6 Health Care Delivery Systems 89
Introduction 89
Types of Health Care Services 89 Primary Prevention: Health Promotion and Illness Prevention 89, Secondary Prevention: Diagnosis and Treatment 89, Tertiary Prevention: Rehabilitation, Health Restoration, and Palliative Care 90
Types of Health Care Agencies and Services 90
Public Health 90, Physicians’ Offices 91, Ambulatory Care Centers 91, Occupational Health Clinics 91, Hospitals 91, Subacute Care Facilities 92, Extended (Long-Term) Care Facilities 92, Retirement and Assisted Living Centers 92, Rehabilitation Centers 92, Home Health Care Agencies 93, Day Care Centers 93, Rural Care 93, Hospice Services 93, Crisis Centers 93, Mutual Support and Self-Help Groups 93
Providers of Health Care 94 Nurse 94, Alternative (Complementary) Care Provider 94, Case Manager 94, Dentist 94, Dietitian or Nutritionist 94, Emergency Medical Personnel 94, Occupational Therapist 94, Paramedical Technologist 95, Pharmacist 95, Physical Therapist 95, Physician 95, Physician Assistant 95, Podiatrist 95, Respiratory Therapist 95, Social Worker 95, Spiritual Support Personnel 95, Unlicensed Assistive Personnel 95
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Contents xvii
Chapter 11 Assessing 155
Introduction 155
Overview of the Nursing Process 155 Phases of the Nursing Process 155, Characteristics of the Nursing Process 155
Assessing 159
Collecting Data 159 Types of Data 160, Sources of Data 161, Data Collection Methods 163
Organizing Data 167 Conceptual Models/Frameworks 167, Wellness Models 170, Nonnursing Models 171
Validating Data 171
Documenting Data 171
Chapter 12 Diagnosing 175
Introduction 175
Nanda Nursing Diagnoses 175 Definitions 175, Status of the Nursing Diagnoses 176, Components of a NANDA Nursing Diagnosis 176, Differentiating Nursing Diagnoses from Medical Diagnoses 177, Differentiating Nursing Diagnoses from Collaborative Problems 177
The Diagnostic Process 178 Analyzing Data 178, Identifying Health Problems, Risks, and Strengths 179, Formulating Diagnostic Statements 182, Avoiding Errors in Diagnostic Reasoning 183
Ongoing Development of Nursing Diagnoses 185
Chapter 13 Planning 189
Introduction 189
Types of Planning 189 Initial Planning 189, Ongoing Planning 189, Discharge Planning 189
Developing Nursing Care Plans 190 Standardized Approaches to Care Planning 190, Formats for Nursing Care Plans 192, Multidisciplinary (Collaborative) Care Plans 194, Guidelines for Writing Nursing Care Plans 195
The Planning Process 195 Setting Priorities 195, Establishing Client Goals/Desired Outcomes 197, Selecting Nursing Interventions and Activities 199, Writing Individualized Nursing Interventions 201, Delegating Implementation 202
The Nursing Interventions Classification 202
Chapter 14 Implementing and Evaluating 208
Introduction 208
Implementing 208 Relationship of Implementing to Other Nursing Process Phases 208, Implementing Skills 208, Process of Implementing 209
Chapter 9 Electronic Health Records and Information Technology 129
Introduction 129
General Concepts 129
Computer Systems 130 Management Information Systems 130, Hospital Information Systems 131
Technology in Nursing Education 131 Teaching and Learning 131, Testing 132, Student and Course Record Management 132
Technology in Nursing Practice 132 Documentation of Client Status and Medical Record Keeping 133, Electronic Access to Client Data 135, Practice Management 137, Specific Applications of Computers in Nursing Practice 137
Technology in Nursing Administration 138 Human Resources 138, Medical Records Management 138, Facilities Management 138, Budget and Finance 138, Quality Assurance and Utilization Review 138, Accreditation 138
Technology in Nursing Research 138 Problem Identification 138, Literature Review 139, Research Design 139, Data Collection and Analysis 139, Research Dissemination 139, Research Grants 140
UNIT 3 The Nursing Process 143
Chapter 10 Critical Thinking and Clinical Reasoning 144
Introduction 144
Purpose of Critical Thinking 144
Techniques in Critical Thinking 145
Applying Critical Thinking to Nursing Practice 147
Problem Solving 147
Attitudes That Foster Critical Thinking 148 Independence 148, Fair-Mindedness 148, Insight into Egocentricity 148, Intellectual Humility 148, Intellectual Courage to Challenge the Status Quo and Rituals 148, Integrity 149, Perseverance 149, Confidence 149, Curiosity 149
Components of Clinical Reasoning 149 Setting Priorities 149, Developing Rationales 150, Learning How to Act 150, Clinical Reasoning-in-Transition 150, Responding to Changes in the Client’s Condition 150, Reflection 150
Integration of Critical Thinking and Clinical Reasoning 150
Concept Mapping 151 Concept Mapping and Enhancing Critical Thinking and Clinical Reasoning 151
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Stages of Health Behavior Change 252 Precontemplation Stage 252, Contemplation Stage 252, Preparation Stage 252, Action Stage 252, Maintenance Stage 253, Termination Stage 253
The Nurse’s Role in Health Promotion 253
The Nursing Process and Health Promotion 254
Nursing Management 254
Chapter 17 Health, Wellness, and Illness 262
Introduction 262
Concepts of Health, Wellness, and Well-Being 262
Health 262, Wellness and Well-Being 263
Models of Health and Wellness 264 Clinical Model 264, Role Performance Model 264, Adaptive Model 264, Eudaimonistic Model 264, Agent–Host–Environment Model 264, Health–Illness Continua 265
Variables Influencing Health Status, Beliefs, and Practices 266
Internal Variables 267, External Variables 268
Health Belief Models 268 Health Locus of Control Model 269, Rosenstock and Becker’s Health Belief Models 269
Health Care Adherence 270
Illness and Disease 271 Illness Behaviors 272, Effects of Illness 273
Chapter 18 Culturally Responsive Nursing Care 276
Introduction 276
Cultural Concepts 276
Health Disparities 278
Demographics 279
Immigration 279
Cultural Models of Nursing Care 280 American Association of Colleges of Nursing Competencies 280, Cultural Competence 280, HEALTH Traditions Model 280
Providing Culturally Responsive Care 282
Health Beliefs and Practices 282, Family Patterns 283, Communication Style 283, Space Orientation 286, Time Orientation 286, Nutritional Patterns 286
Nursing Management 287
Chapter 19 Complementary and Alternative Healing Modalities 295
Introduction 295
Basic Concepts 296 Holism 296, Humanism 296, Balance 296, Spirituality 296, Energy 296, Healing Environments 296
Evaluating 210 Relationship of Evaluating to Other Nursing Process Phases 211, Process of Evaluating Client Responses 211, Evaluating the Quality of Nursing Care 214
Chapter 15 Documenting and Reporting 221
Introduction 221
Ethical and Legal Considerations 221 Ensuring Confidentiality of Computer Records 222
Purposes of Client Records 222 Communication 222, Planning Client Care 222, Auditing Health Agencies 222, Research 222, Education 222, Reimbursement 222, Legal Documentation 222, Health Care Analysis 222
Documentation Systems 223 Source-Oriented Record 223, Problem-Oriented Medical Record 224, PIE 226, Focus Charting 226, Charting by Exception 227, Computerized Documentation 227, Case Management 228
Documenting Nursing Activities 229 Admission Nursing Assessment 230, Nursing Care Plans 230, Kardexes 230, Flow Sheets 231, Progress Notes 231, Nursing Discharge/Referral Summaries 231
Long-Term Care Documentation 232
Home Care Documentation 232
General Guidelines for Recording 232 Date and Time 233, Timing 233, Legibility 233, Permanence 233, Accepted Terminology 234, Correct Spelling 235, Signature 235, Accuracy 235, Sequence 235, Appropriateness 236, Completeness 236, Conciseness 236, Legal Prudence 236
Reporting 236 Change-of-Shift Reports 237, Telephone Reports 238, Telephone Orders 238, Care Plan Conference 239, Nursing Rounds 239
UNIT 4 Health Beliefs and Practices 243
Chapter 16 Health Promotion 244
Introduction 244
Individual Health 244 Concept of Individuality 244, Concept of Holism 244, Concept of Homeostasis 245, Assessing the Health of Individuals 246
Applying Theoretical Frameworks 246 Needs Theories 247, Developmental Stage Theories 248
Healthy People 2020 248
Defining Health Promotion 248
Sites for Health Promotion Activities 249
Health Promotion Model 250 Individual Characteristics and Experiences 250, Behavior-Specific Cognitions and Affect 251, Commitment to a Plan of Action 252, Immediate Competing Demands and Preferences 252, Behavioral Outcome 252
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Moral Development 347, Spiritual Development 347, Health Risks 347, Health Assessment and Promotion 348
Chapter 22 Promoting Health in Young and Middle-Aged Adults 353
Introduction 353
Young Adults (20 to 40 Years) 353 Physical Development 354, Psychosocial Development 354, Cognitive Development 355, Moral Development 355, Spiritual Development 355, Health Risks 355, Health Assessment and Promotion 357
Middle-Aged Adults (40 to 65 Years) 357 Physical Development 358, Psychosocial Development 359, Cognitive Development 359, Moral Development 359, Spiritual Development 360, Health Risks 360, Health Assessment and Promotion 360
Chapter 23 Promoting Health in Older Adults 364
Introduction 364
Characteristics of Older Adults in the United States 364
Demographics 364, Socioeconomic 365, Ethnicity 365, Health 365
Attitudes Toward Aging 365 Ageism 365, Myths and Stereotypes 366
Gerontological Nursing 366 Development 366, Roles 367
Care Settings for Older Adults 367 Acute Care Facilities 367, Long-Term Care Facilities 367, Hospice 367, Rehabilitation 367, Community 368
Physiological Aging 369 Integument 369, Neuromuscular 371, Sensory- Perceptual 372, Pulmonary 373, Cardiovascular 373, Gastrointestinal 374, Urinary 374, Genitals 374, Psychosocial Aging 375, Retirement 375, Economic Change 376, Grandparenting 376, Relocation 376, Maintaining Independence and Self-Esteem 377, Facing Death and Grieving 377
Cognitive Abilities and Aging 377 Perception 377, Cognitive Agility 378, Memory 378, Learning 378
Moral Reasoning 378
Spirituality and Aging 378
Health Problems 379 Injuries 379, Chronic Disabling Illness 379, Drug Abuse and Misuse 379, Alcoholism 380, Dementia 380, Mistreatment of Older Adults 380
Health Assessment and Promotion 381
Chapter 24 Promoting Family Health 386
Introduction 386
Family Health 386 Functions of the Family 386, Types of Families in Today’s Society 386
Healing Modalities 297 Systematized Health Care Practices 297, Botanical Healing 298, Nutritional Therapy 300, Manual Healing Methods 300, Mind–Body Therapies 302, Spiritual Therapy 304, Miscellaneous Therapies 305
UNIT 5 Life Span Development 311
Chapter 20 Concepts of Growth and Development 312
Introduction 312
Factors Influencing Growth and Development 312
Genetics 312, Temperament 312, Family 312, Nutrition 313, Environment 313, Health 313, Culture 313
Stages of Growth and Development 313
Growth and Development Theories 313 Biophysical Theory 313, Psychosocial Theories 314, Temperament Theories 318, Attachment Theory 319, Cognitive Theory 319, Behaviorist Theory 319, Social Learning Theories 320, Ecologic Systems Theory 320, Theories of Moral Development 320, Theories of Spiritual Development 323
Applying Growth and Development Concepts to Nursing Practice 323
Chapter 21 Promoting Health from Conception Through Adolescence 328
Introduction 328
Conception and Prenatal Development 328 Health Promotion 329
Neonates and Infants (Birth to 1 Year) 330 Physical Development 330, Psychosocial Development 332, Cognitive Development 333, Moral Development 333, Health Risks 333, Health Assessment and Promotion 334
Toddlers (1 to 3 Years) 335 Physical Development 335, Psychosocial Development 336, Cognitive Development 337, Moral Development 337, Spiritual Development 337, Health Risks 337, Health Assessment and Promotion 338
Preschoolers (4 and 5 Years) 338 Physical Development 338, Psychosocial Development 339, Cognitive Development 340, Moral Development 340, Spiritual Development 341, Health Risks 341, Health Assessment and Promotion 341
School-Age Children (6 to 12 Years) 341 Physical Development 341, Psychosocial Development 342, Cognitive Development 343, Moral Development 343, Spiritual Development 343, Health Risks 343, Health Assessment and Promotion 344
Adolescents (12 to 18 Years) 344 Physical Development 345, Psychosocial Development 345, Cognitive Development 347,
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Learning 439 Learning Domains 440, Learning Theories 440, Factors Affecting Learning 441
The Internet and Health Information 443 Online Health Information 444, Older Adults and Use of the Internet 444, Implications 444
Nurse as Educator 444
Nursing Management 444
Chapter 28 Leading, Managing, and Delegating 462
Introduction 462
The Nurse as Leader and Manager 462
Leadership 462 Leadership Theory 463, Effective Leadership 465
Management 465 Levels of Management 465, Management Functions 466, Principles of Management 466, Skills and Competencies of Nurse Managers 466
The Nurse as Delegator 467
Change 471 Types of Change 471, The Nurse’s Role in Change 471
UNIT 7 Assessing Health 476
Chapter 29 Vital Signs 477
Introduction 477
Body Temperature 478 Regulation of Body Temperature 479, Factors Affecting Body Temperature 479, Alterations in Body Temperature 479, Assessing Body Temperature 481
SKILL 29-1 Assessing Body Temperature 484
Pulse 487 Factors Affecting the Pulse 487, Pulse Sites 487, Assessing the Pulse 488
SKILL 29-2 Assessing a Peripheral Pulse 489
Apical Pulse Assessment 491
SKILL 29-3 Assessing an Apical Pulse 492 SKILL 29-4 Assessing an Apical-Radial Pulse 495
Respirations 496 Mechanics and Regulation of Breathing 496, Assessing Respirations 497, Factors Affecting Respirations 497
SKILL 29-5 Assessing Respirations 498
Blood Pressure 499 Determinants of Blood Pressure 500, Factors Affecting Blood Pressure 500, Hypertension 500, Hypotension 501, Assessing Blood Pressure 501, Common Errors in Assessing Blood Pressure 503
SKILL 29-6 Assessing Blood Pressure 504
Oxygen Saturation 507 Factors Affecting Oxygen Saturation Readings 507
SKILL 29-7 Measuring Oxygen Saturation 508
Applying Theoretical Frameworks to Families 388
Systems Theory 388, Structural–Functional Theory 388
Nursing Management 389
UNIT 6 Integral Aspects of Nursing 397
Chapter 25 Caring 398
Introduction 398
Professionalization of Caring 398 Caring as “Helping the Other Grow” 398
Nursing Theories on Caring 399 Culture Care Diversity and Universality (Leininger) 399, Theory of Bureaucratic Caring (Ray) 399, Caring, the Human Mode of Being (Roach) 399, Nursing as Caring (Boykin and Schoenhofer) 400, Theory of Human Care (Watson) 400, Theory of Caring (Swanson) 401
Types of Knowledge in Nursing 401 Empirical Knowing: The Science of Nursing 401, Personal Knowing: The Therapeutic Use of Self 401, Ethical Knowing: The Moral Component 401, Aesthetic Knowing: The Art of Nursing 401, Developing Ways of Knowing 401
Caring Encounters 402 Knowing the Client 402, Nursing Presence 403, Empowering the Client 403, Compassion 403, Competence 403
Maintaining Caring Practice 404 Caring for Self 404, Reflection on Practice 406
Chapter 26 Communicating 411
Introduction 411
Communicating 411 The Communication Process 412, Modes of Communication 413, Factors Influencing the Communication Process 416, Therapeutic Communication 418, Barriers to Communication 419
The Helping Relationship 419 Phases of the Helping Relationship 423, Developing Helping Relationships 425
Group Communication 425 Group Dynamics 425, Types of Health Care Groups 425
Communication and the Nursing Process 427
Nursing Management 427
Communication Among Health Professionals 431
Disruptive Behaviors 431, Responding to Disruptive Behaviors 432, Nurse and Physician Communication 433
Chapter 27 Teaching 438
Introduction 438
Teaching 438 Teaching Clients and Their Families 438, Teaching in the Community 439, Teaching Health Personnel 439
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SKILL 30-16 Assessing the Musculoskeletal System 578
Neurologic System 580 Mental Status 580, Level of Consciousness 581, Cranial Nerves 581, Reflexes 581, Motor Function 581, Sensory Function 581
SKILL 30-17 Assessing the Neurologic System 582
Female Genitals and Inguinal Area 589 SKILL 30-18 Assessing the Female Genitals and Inguinal Area 591
Male Genitals and Inguinal Area 593 SKILL 30-19 Assessing the Male Genitals and Inguinal Area 594 Anus 596 SKILL 30-20 Assessing the Anus 596
UNIT 8 Integral Components of Client Care 601
Chapter 31 Asepsis 602
Introduction 602
Types of Microorganisms That Cause Infections 603
Types of Infections 603
Nosocomial and Health Care–Associated Infections 604
Chain of Infection 604 Etiologic Agent 605, Reservoir 605, Portal of Exit from Reservoir 606, Method of Transmission 606, Portal of Entry to the Susceptible Host 606, Susceptible Host 606
Body Defenses Against Infection 607 Nonspecific Defenses 607, Specific Defenses 608
Factors Increasing Susceptibility to Infection 608
Nursing Management 609 SKILL 31-1 Performing Hand Hygiene 614 SKILL 31-2 Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear) 621 SKILL 31-3 Establishing and Maintaining a Sterile Field 628 SKILL 31-4 Applying and Removing Sterile Gloves (Open Method) 632 SKILL 31-5 Applying a Sterile Gown and Gloves (Closed Method) 633
Chapter 32 Safety 640
Introduction 640
Factors Affecting Safety 640 Age and Development 640, Lifestyle 640, Mobility and Health Status 640, Sensory-Perceptual Alterations 641, Cognitive Awareness 641, Emotional State 641, Ability to Communicate 641, Safety Awareness 641, Environmental Factors 641
Chapter 30 Health Assessment 513
Introduction 514
Physical Health Assessment 514 Preparing the Client 515, Preparing the Environment 515, Positioning 516, Draping 516, Instrumentation 516, Methods of Examining 516
General Survey 519 Appearance and Mental Status 519
SKILL 30-1 Assessing Appearance and Mental Status 520
Vital Signs 522, Height and Weight 522
Integument 522 Skin 522
SKILL 30-2 Assessing the Skin 525 Hair 528, Nails 528
SKILL 30-3 Assessing the Hair 529 SKILL 30-4 Assessing the Nails 530
Head 531 Skull and Face 531
SKILL 30-5 Assessing the Skull and Face 532
Eyes and Vision 533
SKILL 30-6 Assessing the Eye Structures and Visual Acuity 534
Ears and Hearing 539
SKILL 30-7 Assessing the Ears and Hearing 540
Nose and Sinuses 544
SKILL 30-8 Assessing the Nose and Sinuses 544
Mouth and Oropharynx 545
SKILL 30-9 Assessing the Mouth and Oropharynx 546
Neck 549
Thorax and Lungs 550 Chest Landmarks 550
SKILL 30-10 Assessing the Neck 550 Chest Shape and Size 554, Breath Sounds 555
SKILL 30-11 Assessing the Thorax and Lungs 556
Cardiovascular and Peripheral Vascular Systems 560
Heart 560, Central Vessels 562
SKILL 30-12 Assessing the Heart and Central Vessels 562
Peripheral Vascular System 566
SKILL 30-13 Assessing the Peripheral Vascular System 566 Breasts and Axillae 568 SKILL 30-14 Assessing the Breasts and Axillae 568
Abdomen 571 SKILL 30-15 Assessing the Abdomen 573
Musculoskeletal System 577
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Chapter 34 Diagnostic Testing 718
Introduction 718
Diagnostic Testing Phases 718 Pretest 718, Intratest 719, Post-Test 719, Nursing Diagnoses 719
Blood Tests 719 Complete Blood Count 719, Serum Electrolytes 721, Serum Osmolality 721, Drug Monitoring 721, Arterial Blood Gases 722, Blood Chemistry 723, Metabolic Screening 723, Capillary Blood Glucose 723
SKILL 34-1 Obtaining a Capillary Blood Specimen to Measure Blood Glucose 726
Specimen Collection and Testing 728 Stool Specimens 729, Urine Specimens 731
SKILL 34-2 Collecting a Urine Specimen for Culture and Sensitivity by Clean Catch 732
Sputum Specimens 736, Throat Culture 737
Visualization Procedures 737 Clients with Gastrointestinal Alterations 737, Clients with Urinary Alterations 738, Clients with Cardiopulmonary Alterations 738, Computed Tomography 738, Magnetic Resonance Imaging 739, Nuclear Imaging Studies 739
Aspiration/Biopsy 740 Lumbar Puncture 740, Abdominal Paracentesis 741, Thoracentesis 742, Bone Marrow Biopsy 743, Liver Biopsy 743
Chapter 35 Medications 750
Introduction 751
Drug Standards 751
Legal Aspects of Drug Administration 752
Effects of Drugs 752
Drug Misuse 754
Actions of Drugs on the Body 754 Pharmacodynamics 755, Pharmacokinetics 755
Factors Affecting Medication Action 756 Developmental Factors 756, Gender 757, Cultural, Ethnic, and Genetic Factors 757, Diet 757, Environment 757, Psychological Factors 757, Illness and Disease 757, Time of Administration 757
Routes of Administration 758 Oral 758, Sublingual 758, Buccal 759, Parenteral 759, Topical 759
Medication Orders 759 Types of Medication Orders 760, Essential Parts of a Medication Order 760, Communicating a Medication Order 761
Systems of Measurement 762 Metric System 762, Apothecaries’ System 763, Household System 763, Converting Units of Weight and Measure 763, Methods of Calculating Dosages 764
Administering Medications Safely 767 Medication Administration Errors 768, Medication Reconciliation 769,
Nursing Management 643 SKILL 32-1 Using a Bed or Chair Exit Safety Monitoring Device 652 SKILL 32-2 Implementing Seizure Precautions 654 SKILL 32-3 Applying Restraints 663
Chapter 33 Hygiene 669
Introduction 669
Hygienic Care 669
Skin 670
Nursing Management 670 SKILL 33-1 Bathing an Adult Client 676 SKILL 33-2 Providing Perineal-Genital Care 682
Feet 684 Developmental Variations 684
Nursing Management 684 SKILL 33-3 Providing Foot Care 687
Nails 688
Nursing Management 688
Mouth 689 Developmental Variations 689
Nursing Management 689 SKILL 33-4 Brushing and Flossing the Teeth 692 SKILL 33-5 Providing Special Oral Care for the Unconscious Client 696
Hair 697 Developmental Variations 698
Nursing Management 698 SKILL 33-6 Providing Hair Care 700
Eyes 702
Nursing Management 702
Ears 704 Cleaning the Ears 704, Care of Hearing Aids 704
SKILL 33-7 Removing, Cleaning, and Inserting a Hearing Aid 705
Nose 706
Supporting a Hygienic Environment 706 Environment 707, Hospital Beds 707, Mattresses 707, Side Rails 707, Footboard or Footboot 708, Intravenous Rods 708
Making Beds 708 Unoccupied Bed 708
SKILL 33-8 Changing an Unoccupied Bed 710
Changing an Occupied Bed 713
SKILL 33-9 Changing an Occupied Bed 713
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SKILL 36-2 Irrigating a Wound 849 Supporting and Immobilizing Wounds 851
Bandages 853, Basic Turns for Roller Bandages 853
Circular Turns 854, Spiral Turns 854, Spiral Reverse Turns 854, Recurrent Turns 854, Figure- Eight Turns 855
Binders 855
Arm Sling 855, Straight Abdominal Binder 856
Heat and Cold Applications 856,
Local Effects of Heat 856, Local Effects of Cold 856, Systemic Effects of Heat and Cold 857, Thermal Tolerance 857, Adaptation of Thermal Receptors 857 Rebound Phenomenon 857
Applying Heat and Cold 858
Hot Water Bag 858, Aquathermia Pad 859, Hot and Cold Packs 859, Electric Heating Pads 860, Ice Bags, Ice Gloves, and Ice Collars 860, Compresses 860, Soaks 860, Sitz Baths 860, Cooling Sponge Baths 861
Chapter 37 Perioperative Nursing 865
Introduction 865
Types of Surgery 866 Purpose 866, Degree of Urgency 866, Degree of Risk 866
Preoperative Phase 867 Preoperative Consent 867
Nursing Management 868 SKILL 37-1 Teaching Moving, Leg Exercises, Deep Breathing, and Coughing 871 SKILL 37-2 Applying Antiemboli Stockings 876
Intraoperative Phase 878 Types of Anesthesia 878
Nursing Management 879
Postoperative Phase 881 Immediate Postanesthetic Phase 881, Preparing for Ongoing Care of the Postoperative Client 883
Nursing Management 883 SKILL 37-3 Managing Gastrointestinal Suction 889 SKILL 37-4 Cleaning a Sutured Wound and Changing a Dressing on a Wound with a Drain 892
UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904
Introduction 904
Components of the Sensory Experience 904
Arousal Mechanism 904
Factors Affecting Sensory Function 905 Developmental Stage 905, Culture 905, Stress 905, Medications and Illness 905, Lifestyle and Personality 906
Sensory Alterations 906
Medication Dispensing Systems 770, Process of Administering Medications 771, Developmental Considerations 774
Oral Medications 775 SKILL 35-1 Administering Oral Medications 775
Nasogastric and Gastrostomy Medications 780
Parenteral Medications 780 Equipment 780, Preparing Injectable Medications 784
SKILL 35-2 Preparing Medications from Ampules 787 SKILL 35-3 Preparing Medications from Vials 788 SKILL 35-4 Mixing Medications Using One Syringe 790
Intradermal Injections 791, Subcutaneous Injections 791
SKILL 35-5 Administering an Intradermal Injection for Skin Tests 792 SKILL 35-6 Administering a Subcutaneous Injection 794
Intramuscular Injections 797
SKILL 35-7 Administering an Intramuscular Injection 801
Intravenous Medications 803
SKILL 35-8 Adding Medications to Intravenous Fluid Containers 803 SKILL 35-9 Administering Intravenous Medications Using IV Push 808
Topical Medications 811
SKILL 35-10 Administering Ophthalmic Instillations 813 SKILL 35-11 Administering Otic Instillations 815 SKILL 35-12 Administering Vaginal Instillations 818
Inhaled Medications 820
Irrigations 823
Chapter 36 Skin Integrity and Wound Care 828
Introduction 828
Skin Integrity 828
Types of Wounds 829
Pressure Ulcers 829 Etiology of Pressure Ulcers 829, Risk Factors 830, Stages of Pressure Ulcers 830
Wound Healing 832 Types of Wound Healing 834, Phases of Wound Healing 835, Types of Wound Exudate 836, Complications of Wound Healing 836, Factors Affecting Wound Healing 836
Nursing Management 837 SKILL 36-1 Obtaining a Wound Drainage Specimen for Culture 839
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Spiritual Health and the Nursing Process 959
Nursing Management 960
Spiritual Self-Awareness for the Nurse 965
Chapter 42 Stress and Coping 972
Introduction 972
Concept of Stress 972 Sources of Stress 972, Effects of Stress 972
Models of Stress 972 Stimulus-Based Models 973, Response-Based Models 973, Transaction-Based Models 974
Indicators of Stress 974 Physiological Indicators 975, Psychological Indicators 975, Cognitive Indicators 977
Coping 978
Nursing Management 979
Chapter 43 Loss, Grieving, and Death 989
Introduction 989
Loss and Grief 989 Types and Sources of Loss 989, Grief, Bereavement, and Mourning 990, Stages of Grieving 991, Manifestations of Grief 992, Factors Influencing the Loss and Grief Responses 992
Nursing Management 994
Dying and Death 996 Responses to Dying and Death 996, Definitions and Signs of Death 997, Death-Related Religious and Cultural Practices 997
Nursing Management 998
UNIT 10 Promoting Physiological Health 1009
Chapter 44 Activity and Exercise 1010
Introduction 1010
Normal Movement 1011 Alignment and Posture 1011, Joint Mobility 1012, Balance 1012, Coordinated Movement 1012
Factors Affecting Body Alignment and Activity 1012
Growth and Development 1012, Nutrition 1017, Personal Values and Attitudes 1017, External Factors 1017, Prescribed Limitations 1018
Exercise 1018 Types of Exercise 1018, Benefits of Exercise 1020
Effects of Immobility 1021 Musculoskeletal System 1022, Cardiovascular System 1022, Respiratory System 1023, Metabolic System 1024, Urinary System 1024, Gastrointestinal System 1025, Integumentary System 1025, Psychoneurologic System 1025
Nursing Management 1025
Sensory Deprivation 906, Sensory Overload 906, Sensory Deficits 906
Nursing Management 907
Chapter 39 Self-Concept 922
Introduction 922
Self-Concept 922
Formation of Self-Concept 923
Components of Self-Concept 924 Personal Identity 924, Body Image 924, Role Performance 925, Self-Esteem 925
Factors That Affect Self-Concept 926 Stage of Development 926, Family and Culture 926, Stressors 926, Resources 927, History of Success and Failure 927, Illness 927
Nursing Management 927
Chapter 40 Sexuality 934
Introduction 934
Development of Sexuality 934 Birth to 12 Years 934, Adolescence 934, Young and Middle Adulthood 936, Older Adulthood 936
Sexual Health 938 Components of Sexual Health 938
Varieties of Sexuality 939 Sexual Orientation 939, Gender Identity 939, Erotic Preferences 940
Factors Influencing Sexuality 940 Family 940, Culture 941, Religion 941, Personal Expectations and Ethics 941
Sexual Response Cycle 941
Altered Sexual Function 942 Past and Current Factors 943, Sexual Desire Disorders 943, Sexual Arousal Disorders 943, Orgasmic Disorders 944, Sexual Pain Disorders 944, Problems with Satisfaction 945
Nursing Management 945
Chapter 41 Spirituality 954
Introduction 954
Spirituality and Related Concepts Described 954
Spiritual Care or Spiritual Nursing Care? 955, Spiritual Needs, Spiritual Distress, Spiritual Health, and Religious Coping 955
Spiritual Development 955
Religious Practices That Nurses Should Know 956
Holy Days 956, Sacred Texts 956, Sacred Symbols 957, Prayer and Meditation 957, Beliefs Affecting Diet 958, Beliefs About Illness and Healing 958, Beliefs About Dress and Modesty 958, Beliefs Related to Birth 959, Beliefs Related to Death 959
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Essential Nutrients 1127 Carbohydrates 1128, Proteins 1128, Lipids 1129, Micronutrients 1130
Energy Balance 1130 Energy Intake 1130, Energy Output 1130
Body Weight and Body Mass Standards 1131
Factors Affecting Nutrition 1132 Development 1132, Sex 1132, Ethnicity and Culture 1132, Beliefs About Food 1132, Personal Preferences 1132, Religious Practices 1133, Lifestyle 1133, Economics 1133, Medications and Therapy 1133, Health 1133, Alcohol Consumption 1133, Advertising 1134, Psychological Factors 1134
Nutritional Variations Throughout the Life Cycle 1134
Neonate to 1 Year 1135, Toddler 1135, Preschooler 1135, School-Age Child 1136, Adolescent 1136, Young Adult 1136, Middle-Aged Adult 1137, Older Adults 1137
Standards for a Healthy Diet 1137 Dietary Guidelines for Americans 1139, Recommended Dietary Intake 1140, Vegetarian Diets 1142
Altered Nutrition 1142
Nursing Management 1143 SKILL 47-1 Inserting a Nasogastric Tube 1154 SKILL 47-2 Administering a Tube Feeding 1160 SKILL 47-3 Administering a Gastrostomy or Jejunostomy Feeding 1163 SKILL 47-4 Removing a Nasogastric Tube 1166
Chapter 48 Urinary Elimination 1174
Introduction 1174
Physiology of Urinary Elimination 1174 Kidneys 1174, Ureters 1175, Bladder 1175, Urethra 1176, Pelvic Floor 1176, Urination 1176
Factors Affecting Voiding 1176 Developmental Factors 1176, Psychosocial Factors 1178, Fluid and Food Intake 1178, Medications 1179, Muscle Tone 1179, Pathologic Conditions 1179, Surgical and Diagnostic Procedures 1179
Altered Urine Production 1179 Polyuria 1179, Oliguria and Anuria 1179
Altered Urinary Elimination 1180 Frequency and Nocturia 1180, Urgency 1180, Dysuria 1181, Enuresis 1181, Urinary Incontinence 1181, Urinary Retention 1181
Nursing Management 1181
SKILL 44-1 Moving a Client Up in Bed 1040 SKILL 44-2 Turning a Client to the Lateral or Prone Position in Bed 1041 SKILL 44-3 Logrolling a Client 1042 SKILL 44-4 Assisting a Client to Sit on the Side of the Bed (Dangling) 1043 SKILL 44-5 Transferring Between Bed and Chair 1046 SKILL 44-6 Transferring Between Bed and Stretcher 1048 SKILL 44-7 Assisting a Client to Ambulate 1053
Chapter 45 Sleep 1066
Introduction 1066
Physiology of Sleep 1066 Circadian Rhythms 1066, Types of Sleep 1067, Sleep Cycles 1068
Functions of Sleep 1068
Normal Sleep Patterns and Requirements 1068
Newborns 1068, Infants 1069, Toddlers 1069, Preschoolers 1069, School-Age Children 1069, Adolescents 1069, Adults 1070, Older Adults 1070
Factors Affecting Sleep 1070 Illness 1071, Environment 1071, Lifestyle 1072, Emotional Stress 1072, Stimulants and Alcohol 1072, Diet 1072, Smoking 1072, Motivation 1072, Medications 1072
Common Sleep Disorders 1072 Insomnia 1072, Excessive Daytime Sleepiness 1073, Parasomnias 1075
Nursing Management 1075
Chapter 46 Pain Management 1086
Introduction 1086
The Nature of Pain 1087 Types of Pain 1087, Concepts Associated with Pain 1088
Physiology of Pain 1089 Nociception 1089, Gate Control Theory 1091, Responses to Pain 1092
Factors Affecting the Pain Experience 1092
Ethnic and Cultural Values 1092, Developmental Stage 1093, Environment and Support People 1093, Previous Pain Experiences 1094, Meaning of Pain 1095
Nursing Management 1095 SKILL 46-1 Providing a Back Massage 1116
Chapter 47 Nutrition 1127
Introduction 1127
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Chapter 51 Circulation 1287
Introduction 1287
Physiology of the Cardiovascular System 1287
The Heart 1287, Blood Vessels 1291, Blood 1292
Lifespan Considerations 1293
Factors Affecting Cardiovascular Function 1293
Risk Factors 1294
Alterations in Cardiovascular Function 1296
Decreased Cardiac Output 1297, Impaired Tissue Perfusion 1298, Blood Alterations 1298
Nursing Management 1298 SKILL 51-1 Applying Sequential Compression Devices 1302
Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308
Introduction 1308
Body Fluids and Electrolytes 1309 Distribution of Body Fluids 1309, Composition of Body Fluid 1309, Movement of Body Fluids and Electrolytes 1310, Regulating Body Fluids 1312, Regulating Electrolytes 1313
Acid–Base Balance 1316 Regulation of Acid–Base Balance 1316
Factors Affecting Body Fluid, Electrolytes, and Acid–Base Balance 1317
Age 1317, Sex and Body Size 1318, Environmental Temperature 1318, Lifestyle 1318
Disturbances in Fluid Volume, Electrolyte, and Acid–Base Balances 1318
Fluid Imbalances 1318, Electrolyte Imbalances 1320, Acid–Base Imbalances 1324
Nursing Management 1326 SKILL 52-1 Starting an Intravenous Infusion 1344 SKILL 52-2 Monitoring an Intravenous Infusion 1350 SKILL 52-3 Changing an Intravenous Container and Tubing 1353 SKILL 52-4 Discontinuing an Intravenous Infusion 1354 SKILL 52-5 Changing an Intravenous Catheter to an Intermittent Infusion Lock 1356 SKILL 52-6 Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set 1361
Appendix A Answers to Test Your Knowledge 1370
GLOSSARY 1403
INDEX 1429
SKILL 48-1 Applying an External Urinary Device 1189 SKILL 48-2 Performing Urinary Catheterization 1194 SKILL 48-3 Performing Bladder Irrigation 1200
Chapter 49 Fecal Elimination 1210
Introduction 1210
Physiology of Defecation 1210 Large Intestine 1210, Rectum and Anal Canal 1211, Defecation 1211, Feces 1212
Factors That Affect Defecation 1212 Development 1212, Diet 1213, Fluid Intake and Output 1214, Activity 1214, Psychological Factors 1214, Defecation Habits 1214, Medications 1214, Diagnostic Procedures 1215, Anesthesia and Surgery 1215, Pathologic Conditions 1215, Pain 1215
Fecal Elimination Problems 1215 Constipation 1215, Diarrhea 1216, Bowel Incontinence 1216, Flatulence 1217
Bowel Diversion Ostomies 1218 Permanence 1218, Anatomic Location 1218, Surgical Construction of the Stoma 1218
Nursing Management 1220 SKILL 49-1 Administering an Enema 1227 SKILL 49-2 Changing a Bowel Diversion Ostomy Appliance 1233
Chapter 50 Oxygenation 1241
Introduction 1241
Structure and Processes of the Respiratory System 1242
Structure of the Respiratory System 1242, Pulmonary Ventilation 1243, Alveolar Gas Exchange 1245, Transport of Oxygen and Carbon Dioxide 1245, Systemic Diffusion 1246
Respiratory Regulation 1246
Factors Affecting Respiratory Function 1246
Age 1246, Environment 1246, Lifestyle 1246, Health Status 1247, Medications 1247, Stress 1247
Alterations in Respiratory Function 1247 Conditions Affecting the Airway 1247, Conditions Affecting Movement of Air 1247, Conditions Affecting Diffusion 1247, Conditions Affecting Transport 1248
Nursing Management 1248 SKILL 50-1 Administering Oxygen by Cannula, Face Mask, or Face Tent 1262 SKILL 50-2 Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning 1269 SKILL 50-3 Suctioning a Tracheostomy or Endotracheal Tube 1273 SKILL 50-4 Providing Tracheostomy Care 1276
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UNIT
1 The Nature of Nursing
1 Historical and Contemporary Nursing Practice 2
2 Evidence-Based Practice and Research in Nursing 26
3 Nursing Theories and Conceptual Frameworks 37
4 Legal Aspects of Nursing 47
5 Values, Ethics, and Advocacy 73
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LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Discuss historical factors and nursing leaders, female and
male, who influenced the development of nursing. 2. Discuss the evolution of nursing education and entry into
professional nursing practice. 3. Describe the different types of educational programs for
nurses. 4. Explain the importance of continuing nursing education. 5. Describe how the definition of nursing has evolved since
Florence Nightingale. 6. Identify the four major areas of nursing practice.
INTRODUCTION Nursing today is far different from nursing as it was practiced years ago, and it is expected to continue changing during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one must understand not only past events but also con- temporary nursing practice and the sociologic and historical factors that affect it.
HISTORICAL PERSPECTIVES Nursing has undergone dramatic change in response to societal needs and influences. A look at nursing’s beginnings reveals its con- tinuing struggle for autonomy and professionalization. In recent de- cades, a renewed interest in nursing history has produced a growing amount of related literature. This section highlights only selected aspects of events that have influenced nursing practice. Recurring themes of women’s roles and status, religious (Christian) values, war, societal attitudes, and visionary nursing leadership have influenced nursing practice in the past. Many of these factors still exert their influence today.
Women’s Roles Traditional female roles of wife, mother, daughter, and sister have always included the care and nurturing of other family members. From the beginning of time, women have cared for infants and children; thus, nursing could be said to have its roots in “the home.” Additionally, women, who in general occupied a subservient and de- pendent role, were called on to care for others in the community who were ill. Generally, the care provided was related to physical main- tenance and comfort. Thus, the traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting.
Religion Religion has also played a significant role in the development of nurs- ing. Although many of the world’s religions encourage benevolence, it was the Christian value of “love thy neighbor as thyself ” and Christ’s parable of the Good Samaritan that had a significant impact on the development of Western nursing. During the third and fourth centu- ries, several wealthy matrons of the Roman Empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of
KEY TERMS
Alexian Brothers, 3 caregiver, 15 case manager, 16 change agent, 15 Clara Barton, 6 client, 13 client advocate, 15 communicator, 15 consumer, 13 continuing education (CE), 12 counseling, 15
demography, 20 Dorothea Dix, 4 Fabiola, 2 Florence Nightingale, 6 governance, 17 Harriet Tubman, 3 in-service education, 13 Knights of Saint Lazarus, 3 Lavinia L. Dock, 7 leader, 15 Lillian Wald, 7
Linda Richards, 6 Luther Christman, 8 manager, 15 Margaret Higgins Sanger, 7 Mary Breckinridge, 8 Mary Mahoney, 7 patient, 13 Patient Self-Determination
Act (PSDA), 20 profession, 16 professionalism, 17
professionalization, 17 Sairy Gamp, 5 socialization, 17 Sojourner Truth, 3 Standards of Practice, 15 Standards of Professional
Performance, 15 teacher, 15 telehealth, 20 telenursing, 20
1 Historical and Contemporary Nursing Practice
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7. Identify the purposes of nurse practice acts and standards of professional nursing practice.
8. Describe the roles of nurses. 9. Describe the expanded career roles of nurses and their functions.
10. Discuss the criteria of a profession and the professionaliza- tion of nursing.
11. Discuss Benner’s levels of nursing proficiency. 12. Describe factors influencing contemporary nursing practice. 13. Explain the functions of national and international nurses’
associations.
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soldiers led to a public outcry in Great Britain. The role Florence Night- ingale played in addressing this problem is well known. She was asked by Sir Sidney Herbert of the British War Department to recruit a con- tingent of female nurses to provide care to the sick and injured in the Crimea. Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as hand washing and washing clothing regularly. Nightingale is credited with performing miracles; the mortality rate in the Barrack Hospital in Turkey, for example, was reduced from 42% to 2% in 6 months (Donahue, 2011, p. 118).
During the American Civil War (1861–1865), several nurses emerged who were notable for their contributions to a country torn by internal strife. Harriet Tubman and Sojourner Truth (Figures 1–2 and 1–3 •) provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted
care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of nursing services.
The Crusades saw the formation of several orders of knights, including the Knights of Saint John of Jerusalem (also known as the Knights Hospitalers), the Teutonic Knights, and the Knights of Saint Lazarus (Figure 1–1 •). These brothers in arms provided nurs- ing care to their sick and injured comrades. These orders also built hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. The Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions.
During medieval times, there were many religious orders of men in nursing. For example, the Alexian Brothers organized care for victims of the Black Plague in the 14th century in Germany. In the 19th century, they followed the same traditions as women’s religious nursing orders and established hospitals and provided nursing care.
The deaconess groups, which had their origins in the Roman Empire of the third and fourth centuries, were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836 when Theodor Fliedner reinstituted the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her “training” in nursing at the Kaiserswerth School.
Early religious values, such as self-denial, spiritual calling, and de- votion to duty and hard work, have dominated nursing throughout its history. Nurses’ commitment to these values often resulted in exploita- tion and few monetary rewards. For some time, nurses themselves be- lieved it was inappropriate to expect economic gain from their “calling.”
War Throughout history, wars have accentuated the need for nurses. Dur- ing the Crimean War (1854–1856), the inadequacy of care given to
Figure 1–1 • The Knights of Saint Lazarus (established circa 1200) dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions. From the time of Christ to the mid-13th century, leprosy was viewed as an incurable and terminal disease. Battman/Corbis.
Figure 1–2 • Harriet Tubman (1820–1913) was known as “The Moses of Her People” for her work with the Underground Railroad. During the Civil War she nursed the sick and suffering of her own race. Universal Images Group/Getty Images.
Figure 1–3 • Sojourner Truth (1797–1883), abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, was a nurse for more than 4 years during the Civil War and worked as a nurse and counselor for the Freedmen’s Relief Association after the war. National Portrait Gallery, Smithsonian Institution/Art Resources, NY.
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authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. Another female leader who provided nursing care during the Civil War was Dorothea Dix (Figure 1–4 •). She became the Union’s superintendent of female nurses responsible for recruiting nurses and supervising the nursing care of all women nurses working in the army hospitals.
The arrival of World War I resulted in American, British, and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. A monument entitled “The Spirit of Nursing” stands in Arlington National Cemetery (Figure 1–5 •). It honors the nurses who served in the U.S. armed services in World War I, many of whom are buried in Section 21, which is also called the “Nurses Section” (Arlington National Cemetery, n.d.). Progress in health care occurred during World War I, particularly in the field of surgery. For example, advancements were made in the use of anesthetic agents, infection control, blood typing, and prosthetics.
World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was established in response to a marked shortage of nurses (Figure 1–6 •). Also at that time, auxiliary health care workers became prominent. “Practical” nurses, aides, and tech- nicians provided much of the actual nursing care under the instruc- tion and supervision of better prepared nurses. Medical specialties also arose at that time to meet the needs of hospitalized clients.
During the Vietnam War, approximately 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nurs- ing school, making them the youngest group of medical personnel ever to serve in wartime (Vietnam Women’s Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial (“The Wall”) stands the Vietnam Women’s Memorial (Figure 1–7 •).
Societal Attitudes Society’s attitudes about nurses and nursing have significantly influ- enced professional nursing.
Figure 1–4 • Dorothea Dix (1802–1887) was the Union’s superintendent of female nurses during the Civil War. Bettman/Corbis.
Figure 1–5 • A, Section 21 in Arlington National Cemetery honors the nurses who served in the Armed Services in World War I. B, The “Spirit of Nursing” monument that stands in Section 21. C, Monument plaque. Photo by Sherrilyn Coffman, RN, PhD.
B
C
A
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Before the mid-1800s, nursing was without organization, educa- tion, or social status; the prevailing attitude was that a woman’s place was in the home and that no respectable woman should have a ca- reer. The role for the Victorian middle-class woman was that of wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband and a responsible mother to her children. Nurses in hospitals during this period were poorly educated; some were even incarcerated criminals. Society’s at- titudes about nursing during this period are reflected in the writings of Charles Dickens. In his book Martin Chuzzlewit (1896), Dickens reflected his attitude toward nurses through his character Sairy Gamp (Figure 1–8 •). She “cared” for the sick by neglecting them, stealing from them, and physically abusing them (Donahue, 2011, p. 112). This literary portrayal of nurses greatly influenced the nega- tive image and attitude toward nurses up to contemporary times.
In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florence Nightingale during the Crimean War. After Nightingale brought re- spectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self-sacrificing.
Another image arising in the early 19th century that has affected subsequent generations of nurses and the public and other profes- sionals working with nurses is the image of doctor’s handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic, and when the medical profession portrayed increasing use of scientific knowledge that, at that time, was viewed as a male domain. Since that time, several im- ages of nursing have been portrayed. The heroine portrayal evolved from nurses’ acts of bravery in World War II and their contributions in fighting poliomyelitis—in particular, the work of the Australian nurse Elizabeth Kenney. Other images in the late 1900s include the nurse as sex object, surrogate mother, and tyrannical mother.
During the past few decades, the nursing profession has taken steps to improve the image of the nurse. In the early 1990s, the Tri-Council for Nursing (the American Association of Col- leges of Nursing, the American Nurses Association [ANA], the American Organization of Nurse Executives, and the National
Figure 1–7 • Vietnam Women’s Memorial. Four figures include a nurse tending to the chest wound of a soldier, another woman looking for a helicopter for assistance, and a third woman (behind the other figures) kneeling while staring at an empty helmet in grief. Radius Images/Alamy.
Figure 1–8 • Sairy Gamp, a character in Dickens’ book Martin Chuzzlewit, represented the negative image of nurses in the early 1800s. Stapleton Collection/Corbis.
Figure 1–6 • Recruiting poster for the Cadet Nurse Corps during World War II. Stocktrek Images, Inc./Alamy.
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In 1853 she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses.
When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium of £4,500. She later used this money to develop the Nightingale Training School for Nurses, which opened in 1860. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs.
Despite poor health that left her an invalid, Florence Nightingale worked tirelessly until her death at age 90. As a passionate statistician, she conducted extensive research and analysis (Florence Nightingale International Foundation, 2014). Nightingale is often referred to as the first nurse researcher. For example, her record keeping proved that her interventions dramatically reduced mortality rates among soldiers during the Crimean War.
Nightingale’s vision of nursing changed society’s view of nurs- ing. She believed in personalized and holistic client care. Her vision also included public health and health promotion roles for nurses. It is easy to see how Florence Nightingale still serves as a model for nurses today.
BARTON (1821–1912) Clara Barton (Figure 1–10 •) was a schoolteacher who volunteered as a nurse during the American Civil War. Her responsibility was to organize the nursing services. Barton is noted for her role in establish- ing the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in 1882 to ratify this treaty so that the Red Cross could perform humanitarian efforts in time of peace.
RICHARDS (1841–1930) Linda Richards (Figure 1–11 •) was America’s first trained nurse. She graduated from the New England Hospital for Women and Children in 1873. Richards is known for introducing nurse’s notes and doctor’s orders. She also initiated the practice of nurses wearing uniforms (ANA, 2013b). She is credited for her pioneering work in psychiatric and industrial nursing.
League for Nursing [NLN]) initiated a national effort, titled “Nurses of America,” to improve the image of nursing. Launched in 2002, the Johnson & Johnson corporation continues their “Campaign for Nursing’s Future” to promote nursing as a positive career choice. Through various outreach programs, this campaign increases ex- posure to the nursing profession, raises awareness about its chal- lenges (e.g., nursing shortage), and encourages people of all ages to consider a career in nursing.
Nursing Leaders Florence Nightingale, Clara Barton, Linda Richards, Mary Ma- honey, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable con- tributions both to nursing’s history and to women’s history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory development, are discussed in Chapter 3 .
NIGHTINGALE (1820–1910) The contributions of Florence Nightingale to nursing are well documented. Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title “Lady with the Lamp.” Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse: She was the first nurse to exert political pressure on government. Through her contributions to nursing education— perhaps her greatest achievement—she is also recognized as nursing’s first scientist-theorist for her work Notes on Nursing: What It Is, and What It Is Not (1860/1969).
Nightingale (Figure 1–9 •) was born to a wealthy and intel- lectual family. She believed she was “called by God to help others . . . [and] to improve the well-being of mankind” (Schuyler, 1992, p. 4). She was determined to become a nurse in spite of opposition from her family and the restrictive societal code for affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in 1847, where she received 3 months’ training in nursing.
Figure 1–9 • Considered the founder of modern nursing, Florence Nightingale (1820–1910) was influential in developing nursing education, practice, and administration. Her publication, Notes on Nursing: What It Is, and What It Is Not, first published in England in 1859 and in the United States in 1860, was intended for all women. Classic Clock/Corbis.
Figure 1–10 • Clara Barton (1821–1912) organized the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882. © Bettman/CORBIS.
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in protest movements for women’s rights that resulted in the 1920 passage of the 19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Dock campaigned for legislation to allow nurses rather than physicians to control their pro- fession. In 1893, Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American Society of Super- intendents of Training Schools for Nurses of the United States, a pre- cursor to the current National League for Nursing.
SANGER (1879–1966) Margaret Higgins Sanger (Figure 1–15 •), a public health nurse in New York, has had a lasting impact on women’s health care. Imprisoned for opening the first birth control information clinic in America, she is considered the founder of Planned Parent- hood. Her experience with the large number of unwanted pregnan- cies among the working poor was instrumental in addressing this problem.
MAHONEY (1845–1926) Mary Mahoney (Figure 1–12 •) was the first African American professional nurse. She graduated from the New England Hospital for Women and Children in 1879. She constantly worked for the ac- ceptance of African Americans in nursing and for the promotion of equal opportunities (Donahue, 2011, p. 144). The ANA (2013c) gives a Mary Mahoney Award biennially in recognition of significant con- tributions in interracial relationships.
WALD (1867–1940) Lillian Wald (Figure 1–13 •) is considered the founder of pub- lic health nursing. Wald and Mary Brewster were the first to offer trained nursing services to the poor in the New York slums. Their home among the poor on the upper floor of a tenement, called the Henry Street Settlement and Visiting Nurse Service, provided nurs- ing services, social services, and organized educational and cultural activities. Soon after the founding of the Henry Street Settlement, school nursing was established as an adjunct to visiting nursing.
DOCK (1858–1956) Lavinia L. Dock (Figure 1–14 •) was a feminist, prolific writer, political activist, suffragette, and friend of Wald. She participated
Figure 1–11 • Linda Richards (1841–1930) was America’s first trained nurse. National League for Nursing. National League for Nursing Records. 1894–1952. Located in: Archives and Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, MD; MS C 274.
Figure 1–13 • Lillian Wald (1867–1940) founded the Henry Street Settlement and Visiting Nurse Service (circa 1893), which provided nursing and social services and organized educational and cultural activities. She is considered the founder of public health nursing. National Portrait Gallery, Smithsonian Institution/Art Resources, NY.
Figure 1–14 • Nursing leader and suffragist Lavinia L. Dock (1858–1956) was active in the protest movement for women’s rights that resulted in the constitutional amendment in 1920 that allowed women to vote. Courtesy of The Gottesman Libraries at Teachers College, Columbia University.
Figure 1–12 • Mary Mahoney (1845–1926) was the first African American trained nurse. Schomberg Center for Research in Black Culture/NYPL/Art Resource.
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admission to the Military Nurse Corps during World War II based on gender. It was believed at that time that nursing was women’s work and combat was men’s work. During the 20th century, men were denied admission to most nursing programs. The ANA de- nied membership to male nurses until 1930 and many state nursing associations did not allow men to join until the 1950s (O’Lynn & Tranbarger, 2007, p. 68).
In 1971, a nurse who practiced in Michigan, Steve Miller, formed an organization called Men in Nursing. In 1974, Luther Christman organized a group of male nurses in Chicago. The two groups reor- ganized into the National Male Nurses Association with the primary focus of recruiting more men into nursing. In 1981, the organization was renamed the American Assembly for Men in Nursing (AAMN) (2011). The purpose of the AAMN is to provide a framework for nurses, as a group, to meet to discuss and influence factors that affect men as nurses. In 2009 and 2010, members of the AAMN discussed ways to change the image of men in nursing in both recruitment and retention. They subsequently introduced the theme “Do what you love and you’ll love what you do” (Figure 1–17 •). This idea led to the AAMN initiative “20 × 20 Choose Nursing,” which has the goal of increasing the enrollment of men in nursing programs nationally from the current 10% to 20% by 2020 (Anderson, 2011).
Luther Christman (1915–2011), one of the founders of the AAMN, graduated from the Pennsylvania Hospital School of Nurs- ing for Men in 1939 and did experience discrimination while in nursing school. For example, he was not allowed a maternity clini- cal experience, yet was expected to know the information related
BRECKINRIDGE (1881–1965) After World War I, Mary Breckinridge (Figure 1–16 •), a notable pioneer nurse, established the Frontier Nursing Service (FNS). In 1918, she worked with the American Committee for Devastated France, distributing food, clothing, and supplies to rural villages and taking care of sick children. In 1921, Breckinridge returned to the United States with plans to provide health care to the people of rural America. In 1925, Breckinridge and two other nurses be- gan the FNS in Leslie County, Kentucky. Within this organization, Breckinridge started one of the first midwifery training schools in the United States.
Men in Nursing Men have worked as nurses as far back as before the Crusades. Al- though the history of nursing primarily focuses on the female fig- ures in nursing, schools of nursing for men existed in the United States from the late 1880s until 1969. Male nurses were denied
Figure 1–15 • Nurse activist Margaret Sanger (1879–1966), considered the founder of Planned Parenthood, was imprisoned for opening the first birth control information clinic in Baltimore in 1916. © Bettman/CORBIS.
Figure 1–17 • Poster for American Assembly for Men in Nursing “20 3 20 Choose Nursing Campaign.” Courtesy American Association for Men in Nursing.
Figure 1–16 • Mary Breckinridge (1881–1965), a nurse who practiced midwifery in England, Australia, and New Zealand, founded the Frontier Nursing Service in Kentucky in 1925 to provide family-centered primary health care to rural populations. Newscom.
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programs are eligible to take the licensure examination to become an RN and also may continue into specialty roles such as nurse prac- titioner or nurse educator.
Although educational preparation varies considerably, all RNs in the United States take the same licensure examination, the National Council Licensure Examination (NCLEX-RN). This examination is administered in each state and the successful can- didate becomes licensed in that particular state, even though the examination is of national origin. To practice nursing in another state, the nurse must receive reciprocal licensure by applying to that state’s board of nursing. Some state legislatures have created a regulatory model called mutual recognition that allows for mul- tistate licensure under one license. States that enter into these rec- ognition agreements are referred to as compact states. Nurses who have received their training in other countries may be granted registration after successfully completing the NCLEX. Both licen- sure and registration must be renewed regularly in order to remain valid. For additional information about licensure and registration, see Chapter 4 .
The legal right to practice nursing requires not only passing the licensing examination, but also verification that the candidate has completed a prescribed course of study in nursing. Some states may have additional requirements. All U.S. nursing programs must be approved by their state board of nursing. In addition to state ap- proval, the Accreditation Commission for Education in Nursing (ACEN), formerly called the National League for Nursing Accred- iting Commission (NLNAC), provides accreditation for all levels of nursing programs, and the Commission on Collegiate Nurs- ing Education (CCNE) accredits baccalaureate and higher degree programs. Accreditation is a voluntary, peer review process. Ac- credited programs meet standard requirements that are evaluated periodically through written self-studies and on-site visitation by peer examiners.
Types of Education Programs Education programs available for nurses include practical or voca- tional nursing, registered nursing, graduate nursing, and continu- ing education. All levels of nursing are needed in health care today.
to that clinical experience for the licensing exam. After becoming licensed, he wanted to earn a baccalaureate degree in nursing, but was denied access to two universities because of gender. After re- ceiving his doctorate he accepted the position as dean of nursing at Vanderbilt University. He was the first man to be a dean at a univer- sity school of nursing. He accomplished many firsts: the first man nominated for president of the ANA, the first man elected to the American Academy of Nursing (he was named a “Living Legend” by this organization), and the first man inducted into ANA’s Hall of Fame for his extraordinary contributions to nursing (O’Lynn & Tranbarger, 2007).
Men comprised 9.6% of the nation’s nursing workforce in 2011 (U.S. Census Bureau, 2013). Men do experience barriers to becom- ing nurses. For example, the nursing image is one of femininity, and nursing has been slow to neuter this image. As a result, many people may believe that only homosexual men enter nursing, which is not true. Other barriers and challenges for male nursing students include the lack of male role models in nursing and caring (e.g., differences in caring styles between men and women) and suspicion surrounding intimate touch (MacWilliams, Schmidt, & Bleich, 2013). The nursing profession and nursing education need to address these issues. Im- proved recruitment and retention of men and other minorities into nursing will strengthen the profession.
NURSING EDUCATION The practice of nursing is controlled from within the profession through state boards of nursing and professional nursing organiza- tions. These groups also determine the content and type of educa- tion that is required for different levels or scopes of nursing practice. Originally, the focus of nursing education was to teach the knowl- edge and skills that would enable a nurse to practice in a hospital setting. However, as nursing roles have evolved in response to new scientific knowledge; advances in technology; and cultural, political, and socioeconomic changes in society; nursing education curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles. Nursing programs are increasingly based on a broad knowledge of biologic, social, and physical sciences as well as the liberal arts and humanities. Current nursing curricula emphasize critical thinking and the application of nursing and sup- porting knowledge to health promotion, health maintenance, and health restoration as provided in both community and hospital settings (Figure 1–18 •).
There are two types of entry-level generalist nurses: the reg- istered nurse (RN) and the licensed practical or vocational nurse (LPN or LVN). Responsibilities and licensure requirements differ for these two levels. The majority of new RNs graduate from associ- ate degree or baccalaureate degree nursing programs. In some states, a person can be eligible to take the licensure exam through other qualifications such as completing a diploma nursing program or challenging the exam as a military corps person or LVN after com- pleting specified coursework. There also are “generic” master’s and doctoral programs that lead to eligibility for RN licensure. These latter programs are for students who already have a baccalaureate degree in a discipline other than nursing. On completion of the program, which may be from 1 to 3 years in length, graduates ob- tain their initial professional degree in nursing. Graduates of these
Figure 1–18 • Nursing students learn to care for clients in community settings. Jim West/Alamy.
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ASSOCIATE DEGREE PROGRAMS Associate degree nursing programs, which arose in the early 1950s, were the first and only educational programs for nursing that were systematically developed from planned research and controlled experimentation. Most of these programs take place in community colleges. The graduating student receives an associate degree in nursing (ADN) or an associate of arts (AA), associate of science (AS), or associate in applied science (AAS) degree with a major in nursing. Several trends and events prompted the development of these programs: (a) the Cadet Nurse Corps, (b) the community college movement, (c) earlier nursing studies, and (d) Dr. Mildred Montag’s proposal for an associate degree.
The Cadet Nurse Corps of the United States was legislated and financed during World War II to provide nurses to meet both mili- tary and civilian needs. The corps demonstrated that qualified nurses could be educated in less time than the traditional 3 years of most diploma programs.
After World War II, the number of community colleges in the United States increased rapidly. The low tuition and open-door ad- mission policy of these colleges, as well as their location in towns and cities lacking 4-year colleges and universities, made higher education accessible to more individuals by offering the first 2 years of a 4-year college program as well as vocational programs that addressed com- munity needs.
Studies of nursing education, such as the Goldmark Report in 1923, the Committee on the Grading of Nursing Schools in 1934, and the Brown Report in 1948, also had a significant influence on the development of 2-year nursing programs. The recommenda- tions in all of these reports supported the idea of independent schools of nursing in institutions of higher learning separate from hospitals.
In the United States, associate degree nursing programs were started after Mildred Montag published her doctoral dissertation, “The Education of Nursing Technicians,” in 1951. This study pro- posed a 2-year education program for RNs in community colleges as a solution to the acute shortage of nurses that came about because of World War II. Dr. Montag conceptualized a “nursing technician” or “bedside nurse” able to perform nursing functions broader than those of a practical nurse, but lesser in scope than those of the profes- sional nurse. At the end of the 2 years, the student was to be awarded an ADN and be eligible to take the state board examination for reg- istered nurse licensure. The first ADN program was established at Columbia University Teacher’s College in 1952 under the direction of Dr. Montag. The number of ADN programs has grown steadily. Currently, 45.4% of all new RNs each year are educated in associate degree programs (HRSA, 2010).
Dr. Montag’s original idea that these graduates be nursing tech- nicians and that the degree become a terminal one did not last. In 1978, the ANA proposed that associate degree programs no longer be considered terminal, but part of a career upward-mobility plan. Today many students enter an associate degree program with the in- tention of continuing their education to the baccalaureate or higher level. Many community colleges have articulation agreements with colleges and university bachelor of science in nursing (BSN) pro- grams to facilitate the upward mobility toward the BSN. RN to master of science in nursing (MSN) programs are also available to the associ- ate degree nurse.
Each has a unique scope of practice and by working collaboratively can help meet the often complex needs of clients.
LICENSED PRACTICAL (VOCATIONAL) NURSING PROGRAMS Practical or vocational nursing programs are housed in community colleges, vocational schools, hospitals, or other independent health agencies. These programs generally last 9 to 12 months and include both classroom and clinical experience. At the end of the program, graduates take the NCLEX-PN to obtain licensure as a practical or vocational nurse. Some LPN and LVN programs articulate with as- sociate degree programs. In these ladder programs, the practical/ vocational education component comprises the first year of an associate degree program for registered nursing and, if successful in passing the NCLEX-PN, students can work while continuing their registered nurse education.
Practical nurses work under the supervision of a registered nurse in numerous settings, including hospitals, nursing homes, rehabilita- tion centers, and home health agencies. Although the scope of prac- tice varies by state regulation and agency policy, LPNs usually provide basic direct technical care to clients. Employment of LPNs has shifted away from acute care settings to care of older adults in community- based settings, including long-term care (NLN, 2011).
REGISTERED NURSING PROGRAMS Currently, three major routes lead to eligibility for RN licen- sure: completion of a diploma, associate degree, or baccalaureate program.
DIPLOMA PROGRAMS After Florence Nightingale established the Nightingale Training School of Nurses at St. Thomas Hospital in England in 1860, the concept traveled quickly to North America. Hospital administrators welcomed the idea of training schools as a source of nursing staff for free or inexpensive staffing for the hospital. Nursing education in early years largely took the form of apprenticeship programs. With little formal classroom instruction, students learned by doing—that is, by providing direct care to clients. There was no standardization of curriculum and no accreditation. Programs were designed to meet the service needs of the hospital, not the educational needs of the students.
Three-year diploma programs were the dominant nursing pro- grams and the major source of nursing graduates from the late 1800s until the mid-1960s. Today’s diploma programs are hospital-based educational programs that provide rich clinical experiences for nurs- ing students. These programs often are associated with colleges or universities.
Currently, 20.4% of RNs have obtained their initial nursing edu- cation in diploma programs (Health Resources and Services Admin- istration [HRSA], 2010). The number of diploma nursing programs has declined steadily since a resolution by the ANA in 1965 recom- mended that “education for those who work in nursing should be placed in institutions of learning within the general system of edu- cation,” that “minimal preparation for beginning professional nurs- ing practice at the present time should be the baccalaureate degree education in nursing,” and that “associate degree education in nursing should be the minimum preparation for beginning technical nursing practice” (ANA, 1965, p. 107).
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GRADUATE NURSING PROGRAMS Although graduate schools differ, typical requirements for admission to a graduate program in nursing include the following:
• Licensure as a registered nurse or eligibility for licensure. • A baccalaureate degree in nursing from an approved college or
university. Some graduate programs accept individuals with a diploma or associate degree in nursing and a baccalaureate degree in another field of study. Some accept individuals with an associ- ate degree in nursing as their only postsecondary education.
• Evidence of scholastic ability (usually a minimum grade point average of 3.0 on a 4.0 scale).
• Satisfactory achievement on a standard qualifying examina- tion such as the Graduate Record Examination (GRE) or Miller Analogies Test (MAT).
• Letters of recommendation from supervisors, nursing faculty, or nursing colleagues indicating the applicant’s ability to do graduate study.
MASTER’S DEGREE PROGRAMS The growth of baccalaureate nursing programs encouraged the development of graduate study in nursing. In 1953, the newly established NLN encouraged educators to develop programs for master’s degrees in nursing. Currently, 13.2% of licensed RNs hold a master’s or higher degree (HRSA, 2010). Master’s prepared nurses work in a variety of roles, including clinical nurse specialist (CNS), nurse practitioner (NP and also called advanced practice registered nurse [APRN]), nurse midwife (CNM), and nurse anesthetist (CRNA). The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching (Figure 1–19 •).
An emerging nursing role developed by the AACN is the clini- cal nurse leader (CNL). The CNL is a master’s degree–prepared clinician who oversees the integration of care for a distinct group of clients and may actively provide direct client care in complex situa- tions (AACN, 2012d).
DOCTORAL PROGRAMS Doctoral programs in nursing began in the 1960s in the United States. Before 1960, nurses who pursued doctoral degrees chose related fields such as education, psychology, sociology, and physiology. The two primary doctoral degrees in nursing
BACCALAUREATE DEGREE PROGRAMS The first school of nursing in a university setting was established at the University of Minnesota in 1909. This program’s curriculum, however, differed little from that of a 3-year diploma program. It was not until 1919 that the University of Minnesota established its undergraduate baccalaureate degree in nursing. Most of the early baccalaureate programs were 5 years in length. They consisted of the basic 3-year diploma program plus 2 years of liberal arts education. In the 1960s, the number of students enrolled in baccalaureate programs increased markedly.
Approximately 34% of RNs in the United States are educated in baccalaureate programs (HRSA, 2010). Baccalaureate programs are located in senior colleges and universities and are generally 4 years in length. Programs include courses in the liberal arts, sciences, hu- manities, and nursing. Graduates must complete both the degree requirements of the college or university and the nursing program before being awarded a baccalaureate degree. The usual degree awarded is a BSN. Partially in response to the significant shortage of RNs, some schools have established accelerated BSN programs. These programs may include summer coursework in order to shorten the length of time required to complete the curriculum or may be a modified curriculum designed for students who already have a baccalaureate degree in another field. These “second degree” or “fast track” BSN programs can be completed in as little as 12 to 18 months of study.
Many baccalaureate programs also admit registered nurses who have a diploma or associate degree. These programs typically are re- ferred to as BSN completion, BSN transition, 2 1 2, or RN-BSN pro- grams. Most RN-BSN programs have a special curriculum designed to meet the needs of these students. Many accept transfer credits from other accredited colleges or universities and award academic credit for the nursing coursework completed previously in a diploma or as- sociate degree program. An increasing number of RN-BSN programs are offered online.
Because of changes in the practice environment, the nurse who holds a baccalaureate degree generally experiences more autonomy, responsibility, participation in institutional decision making, and career advancement than the nurse prepared with a diploma or associate degree. Some employers have different salary scales for nurses with a baccalaureate degree, as opposed to an associate de- gree or diploma. In addition, the American Nurses Credentialing Center (ANCC) requires a baccalaureate degree for initial basic certification in most nursing specialties, and certification often is rewarded with a salary increase. The Magnet Recognition Pro- gram®, developed by the ANCC to recognize health care organi- zations that provide nursing excellence, requires that 75% of nurse managers hold at least a baccalaureate degree; 100% compliance was required for magnet facilities as of 2013. Also, the Institute of Medicine’s (IOM’s) recent publication The Future of Nursing (2010) recommended that 80% of RNs be baccalaureate prepared by 2020. All of these points provide an incentive for nurses with diplomas and associate degrees to continue their formal preparation in bac- calaureate completion programs. This is reflected in the increasing enrollment in RN to BSN programs. For example, enrollments in- creased by 15.8% from 2010 to 2011 (AACN, 2012a). Current issues regarding nursing education and entry into practice are discussed in Box 1–1.
Figure 1–19 • A nurse practitioner holds a master’s degree and assumes an advanced practice role. Custom Medical Stock Photo/Alamy.
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and shorter. Participants may receive certificates of completion or specialization.
CE is the responsibility of all practicing nurses. Constant up- dating and growth are essential to keep abreast of scientific and technologic changes and changes within health care and the nursing profession. A variety of educational and health care institutions con- duct CE programs on site, via home study, and online.
CE programs usually are designed to meet one or more of the following needs: (a) to inform nurses of new techniques and knowl- edge; (b) to help nurses attain expertise in a specialized area of prac- tice, such as critical care nursing; and (c) to provide nurses with information essential to nursing practice, such as knowledge about legal and ethical aspects of nursing. Some states require nurses to ob- tain a certain number of CE credits to renew their license. Required contact hours typically range from 15 to 30 hours per 2-year license renewal period. A few states also require a certain number of hours
BOX 1–1 Entry into Practice and Nursing Education: Current Issues
1. In 1985, the ANA endorsed the BSN as the necessary education for entry into professional nursing practice. Only graduates of baccalaureate programs in nursing would be licensed under the legal title “registered nurse.” Associate degree graduates would be considered technical nurses and licensed under the title “associate nurse (AN).” The proposal sparked sharp debates that continue 25 years later. Many students, graduates, and educators, particularly in associate degree programs, perceive that the proposal undervalues associate degree graduates. As a result, the National League for Nursing (NLN) suggested that the title of associate nurse be replaced by “registered associate nurse.” This suggestion has not, however, eliminated the controversy. Many argue that ADN graduates have held the title registered nurse since the inception of associate degree programs and should retain that title.
2. As a professional organization, ANA cannot legislate these changes. It is the right and responsibility of each state to define the legal boundaries of nursing practice and to designate the title to be used by those practitioners who meet the state’s criteria for licensure. For ANA’s proposal to be accepted nationally, each state needs to implement its own changes in its licensure laws.
3. If the ANA proposal were implemented, a grandfather clause would need to be considered for existing associate degree or diploma graduate registered nurses. Under such a clause, these nurses would continue to be licensed as registered nurses, provided their performance meets established standards. However, grandfather clauses would protect only the nurse’s license, not their specific nursing job.
4. Status of diploma nurses and LPNs is not discussed in the proposal.
5. In this proposal, new standardized examinations would be developed in order to test two levels of competence.
6. Some individuals believe that the first step in resolving practice and title issues related to educational preparation should be clarification of the knowledge, skills, and abilities of graduates of each type of nursing program. Because all licensed nurses currently function under the same practice acts and often earn the same salary, the need for differentiated competencies has been debated for years. Differentiated nursing practice is defined by level of education, expected skills, job descriptions, compensation, and participation in decision making. Research
has shown that differentiated practice models foster positive outcomes for job satisfaction, nurse turnover rates, and positive patient outcomes (AACN, 2012a).
7. During the past decade, policy makers, researchers, and nursing practice leaders have recognized that a nurse’s level of education impacts nursing practice. For example, in 2005, the American Organization of Nurse Executives (AONE) released a statement calling for all RNs to be educated in baccalaureate programs because of the increasingly complex and challenging nursing roles (AACN, 2012c). In 2009, Dr. Patricia Benner and her team released a study that recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure (Benner, Sutphen, Leonard, & Day, 2010). In 2010, the Tri-Council for Nursing issued a new consensus policy statement on the educational advancement of registered nurses. The Tri-Council organizations include the AACN, ANA, AONE, and NLN. All of these organizations agreed that “a more highly educated nursing profession is no longer a preferred future; it is a necessary future in order to meet the nursing needs of the nation and to deliver effective and safe care” (Tri-Council for Nursing, 2010). The Tri-Council encourages all nurses, regardless of their entry point into the profession to continue their education (e.g., baccalaureate, masters, and doctoral degrees). Also in 2010, the IOM released its landmark report on the future of nursing, which called for increasing the number of baccalaureate-prepared nurses to 80% and doubling the population of nurses with doctoral degrees by 2020 (IOM, 2010). Currently, only 50% of RNs are prepared at the baccalaureate or graduate degree level (AACN, 2012c). As a final point, a historic landmark agreement occurred in 2012. Five leading organizations in nursing education and community college leadership released a statement on academic progression for nursing students and graduates. This collaborative statement changed the focus from “requirements for initial preparation to how to seed lifelong learning, academic progress, and multiple entry points to professional practice in nursing (NLN, 2012b). It is projected that there will be a need for more than 1.2 million additional RNs by 2020 (NLN, 2012a). The joint statement on academic progression helps facilitate nurses pursuing higher levels of education needed for the current and future nursing workforce.
are the PhD and DNP (doctor of nursing practice). Nurses who earn a PhD in nursing generally assume faculty roles in nursing education programs or work in research programs. The DNP, which has been increasing in popularity, is the highest degree for nurse clinicians. In 2006, the AACN recommended the DNP degree as the entry-level degree for all APRNs by 2015. Currently, however, no NP certification boards require a DNP for the entry-level exam, nor does any state require a DNP as a condition of APRN licensure (Selway, 2012, p. 9). Doctorates in related fields such as education or public health are still highly relevant for nurses depending on their practice role.
CONTINUING EDUCATION The term continuing education (CE) refers to formalized expe- riences designed to enhance the knowledge or skills of practicing professionals. Compared to advanced educational programs, which result in an academic degree, CE courses tend to be more specific
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of practice, either independently or in lieu of study hours, before licensure renewal.
An in-service education program is a specific type of CE program that is offered by an employer. It is designed to upgrade the knowledge or skills of employees, as well as to validate continu- ing competence in selected procedures and areas of practice. For example, an employer might offer an in-service program to inform nurses about a new piece of equipment or a new surgical procedure, new documentation procedures, or methods of implementing a nurse theorist’s conceptual framework for nursing. Some in-service programs are mandatory on a regular basis, such as cardiopulmonary resuscitation and fire or back safety programs.
CONTEMPORARY NURSING PRACTICE An understanding of contemporary nursing practice includes a look at definitions of nursing, recipients of nursing, scope of nursing, set- tings for nursing practice, nurse practice acts, and current standards of clinical nursing practice.
Definitions of Nursing Florence Nightingale defined nursing nearly 150 years ago as “the act of utilizing the environment of the patient to assist him in his recovery” (Nightingale, 1860/1969). Nightingale considered a clean, well-ventilated, and quiet environment essential for recovery. Often considered the first nurse theorist, Nightingale raised the status of nursing through education. Nurses were no longer untrained house- keepers but people educated in the care of the sick.
Virginia Henderson was one of the first modern nurses to de- fine nursing. She wrote, “The unique function of the nurse is to as- sist 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 indepen- dence as rapidly as possible” (Henderson, 1966, p. 3). Like Nightin- gale, Henderson described nursing in relation to the client and the client’s environment. Unlike Nightingale, Henderson saw the nurse as concerned with both healthy and ill individuals, acknowledged that nurses interact with clients even when recovery may not be feasible, and mentioned the teaching and advocacy roles of the nurse.
In the latter half of the 20th century, a number of nurse theorists developed their own theoretical definitions of nursing. Theoretical definitions are important because they go beyond simplistic com- mon definitions. They describe what nursing is and the interrela- tionship among nurses, nursing, the client, the environment, and the intended client outcome: health (see Chapter 3 ).
Certain themes are common to many of these definitions:
• Nursing is caring. • Nursing is an art. • Nursing is a science. • Nursing is client centered. • Nursing is holistic. • Nursing is adaptive. • Nursing is concerned with health promotion, health maintenance,
and health restoration. • Nursing is a helping profession.
Professional nursing associations have also examined nursing and developed their definitions of it. In 1973, the ANA described nursing practice as “direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness” (ANA, 1973, p. 2). In 1980, the ANA changed this defi- nition of nursing to this: “Nursing is the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 1980, p. 9). In 1995, the ANA recognized the influence and contri- bution of the science of caring to nursing philosophy and practice. The current definition of nursing remains unchanged from the 2003 edition of Nursing’s Social Policy Statement: “Nursing is the protection, promotion, and optimization of health and abilities, preventions of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 10).
Research to explore the meaning of caring in nursing has been increasing. Details about caring are discussed in Chapter 25 .
Recipients of Nursing The recipients of nursing are sometimes called consumers, some- times patients, and sometimes clients. A consumer is an individual, a group of people, or a community that uses a service or commod- ity. People who use health care products or services are consumers of health care.
A patient is a person who is waiting for or undergoing medical treatment and care. The word patient comes from a Latin word mean- ing “to suffer” or “to bear.” Traditionally, the person receiving health care has been called a patient. Usually, people become patients when they seek assistance because of illness or for surgery. Some nurses be- lieve that the word patient implies passive acceptance of the decisions and care of health professionals. Additionally, with the emphasis on health promotion and prevention of illness, many recipients of nurs- ing care are not ill. Moreover, nurses interact with family members and significant others to provide support, information, and comfort in addition to caring for the patient.
For these reasons, nurses increasingly refer to recipients of health care as clients. A client is a person who engages the advice or services of another who is qualified to provide this service. The term client presents the receivers of health care as collaborators in the care, that is, as people who are also responsible for their own health. Thus, the health status of a client is the responsibility of the individual in collaboration with health professionals. In this book, client is the preferred term, although consumer and patient are used in some instances.
Scope of Nursing Nurses provide care for three types of clients: individuals, families, and communities. Theoretical frameworks applicable to these client types, as well as assessments of individual, family, and community health, are discussed in Chapters 7 and 24 .
Nursing practice involves four areas: promoting health and well- ness, preventing illness, restoring health, and caring for the dying.
PROMOTING HEALTH AND WELLNESS When health is defined broadly as actualization of human potential, it has been called wellness (Pender, Murdaugh, & Parsons, 2011, p. 20).
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• Teaching clients about recovery activities, such as exercises that will accelerate recovery after a stroke
• Rehabilitating clients to their optimal functional level following physical or mental illness, injury, or chemical addiction.
CARING FOR THE DYING This area of nursing practice involves comforting and caring for people of all ages who are dying. It includes helping clients live as comfortably as possible until death and helping support persons cope with death. Nurses carrying out these activities work in homes, hospitals, and extended care facilities. Some agencies, called hospices, are specifically designed for this purpose.
Settings for Nursing In the past, the acute care hospital was the main practice setting open to most nurses. Today many nurses work in hospitals, but increas- ingly they work in clients’ homes, community agencies, ambulatory clinics, long-term care facilities, health maintenance organizations (HMOs), and nursing practice centers (Figure 1–20 •).
Nurses have different degrees of nursing autonomy and nurs- ing responsibility in the various settings. They may provide direct care, teach clients and support persons, serve as nursing advocates and agents of change, and help determine health policies affecting
Nurses promote wellness in clients who are both healthy and ill. This may involve individual and community activities to enhance healthy lifestyles, such as improving nutrition and physical fit- ness, preventing drug and alcohol misuse, restricting smoking, and preventing accidents and injury in the home and workplace. See Chapter 16 for details.
PREVENTING ILLNESS The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care, and prevention of sexually transmitted infections.
RESTORING HEALTH Restoring health focuses on the ill client, and it extends from early detection of disease through helping the client during the recovery period. Nursing activities include the following:
• Providing direct care to the ill person, such as administering medications, baths, and specific procedures and treatments
• Performing diagnostic and assessment procedures, such as mea- suring blood pressure and examining feces for occult blood
• Consulting with other health care professionals about client problems
Figure 1–20 • Nurses practice in a variety of settings. (Bottom middle) Lisa S./Shutterstock.
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Teacher As a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or main- tain their health. The nurse assesses the client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies, and measures learning. Nurses also teach unlicensed assistive personnel (UAP) to whom they del- egate care, and they share their expertise with other nurses and health professionals. See Chapter 27 for additional details about the teaching–learning process.
Client Advocate A client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health profes- sionals, such as relaying the client’s request for information to the health care provider. They also assist clients in exercising their rights and help them speak up for themselves (see Chapter 5 ).
Counselor Counseling is the process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships, and to promote personal growth. It in- volves providing emotional, intellectual, and psychological support. The nurse counsels primarily healthy individuals with normal ad- justment difficulties and focuses on helping the person develop new attitudes, feelings, and behaviors by encouraging the client to look at alternative behaviors, recognize the choices, and develop a sense of control.
Change Agent The nurse acts as a change agent when assisting clients to make modifications in their behavior. Nurses also often act to make changes in a system, such as clinical care, if it is not helping a client return to health. Nurses are continually dealing with change in the health care system. Technologic change, change in the age of the client population, and changes in medications are just a few of the changes nurses deal with daily. See Chapter 28 for additional information about change.
Leader A leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels: individual client, family, groups of clients, colleagues, or the community. Effec- tive leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others. The leadership role of the nurse is discussed in Chapter 28 .
Manager The nurse manages the nursing care of individuals, families, and communities. The nurse manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. Managing requires knowledge about organiza- tional structure and dynamics, authority and accountability, lead- ership, change theory, advocacy, delegation, and supervision and evaluation. See Chapter 28 for additional details.
consumers in the community and in hospitals. For information about the models for delivery of nursing, see Chapter 6 .
Nurse Practice Acts Nurse practice acts, or legal acts for professional nursing practice, regulate the practice of nursing in the United States with each state having its own act. Although nurse practice acts differ in various jurisdictions, they all have a common purpose: to protect the pub- lic. Nurses are responsible for knowing their state’s nurse practice act as it governs their practice. For additional information, see Chapter 4 .
Standards of Nursing Practice Establishing and implementing standards of practice are major functions of a professional organization. The purpose of the ANA Standards of Practice is to describe the responsibilities for which nurses are accountable. The ANA developed standards of nursing practice that are generic in nature, by using the nursing process as a foundation, and provide for the practice of nursing regardless of area of specialization. Various specialty nursing or- ganizations have further developed specific standards of nursing practice for their area. The ANA Standards of Professional Performance describe behaviors expected in the professional nursing role.
ROLES AND FUNCTIONS OF THE NURSE Nurses assume a number of roles when they provide care to clients. Nurses often carry out these roles concurrently, not exclusively of one another. For example, the nurse may act as a counselor while provid- ing physical care and teaching aspects of that care. The roles required at a specific time depend on the needs of the client and aspects of the particular environment.
Caregiver The caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. The required nursing actions may involve full care for the completely dependent client, partial care for the partially depen- dent client, and supportive-educative care to assist clients in attaining their highest possible level of health and wellness. Caregiving encom- passes the physical, psychosocial, developmental, cultural, and spiri- tual levels. The nursing process provides nurses with a framework for providing care (see Chapters 10 through 14 ). A nurse may pro- vide care directly or delegate it to other caregivers.
Communicator Communication is integral to all nursing roles. Nurses communi- cate with the client, support persons, other health professionals, and people in the community.
In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health care team. The quality of a nurse’s communication is an important factor in nursing care. The nurse must be able to commu- nicate clearly and accurately in order for a client’s health care needs to be met (see Chapters 15 and 26 ).
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of human subjects, (c) participate in the identification of significant researchable problems, and (d) be a discriminating consumer of research findings.
Expanded Career Roles Nurses are fulfilling expanded career roles, such as those of NP, clini- cal nurse specialist, nurse midwife, nurse educator, nurse researcher, and nurse anesthetist, all of which allow greater independence and autonomy (see Box 1–2).
CRITERIA OF A PROFESSION Nursing is gaining recognition as a profession. A profession has been defined as an occupation that requires extensive education or a calling that requires special knowledge, skill, and preparation. A pro- fession is generally distinguished from other kinds of occupations by (a) its requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed; (b) an
Case Manager Nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes. Each agency or unit specifies the role of the nurse case manager. In some institutions, the case manager works with primary or staff nurses to oversee the care of a specific caseload. In other agencies, the case manager is the primary nurse or provides some level of direct care to the client and family. Insurance compa- nies have also developed a number of roles for nurse case managers, and responsibilities may vary from managing acute hospitalizations to managing high-cost clients or case types. Regardless of the setting, case managers help ensure that care is oriented to the client, while controlling costs.
Research Consumer Nurses often use research to improve client care. In a clinical area, nurses need to (a) have some awareness of the process and language of research, (b) be sensitive to issues related to protecting the rights
BOX 1–2 Selected Expanded Career Roles for Nurses
NURSE PRACTITIONER A nurse practitioner (NP) has an advanced education and is a grad- uate of a nurse practitioner program. These nurses are certified by the American Nurses Credentialing Center in areas such as adult- gerontology, family, neonatal, pediatric, women’s health/gender related, or psychiatric-mental health. They are employed in health care agencies or community-based settings. Those choosing the NP role with a pediatric or adult population focus must further select either acute care or primary care. Acute care NPs often function in hospitals managing the care of critically ill patients (Selway, 2012, p. 9). Primary care NPs practice in clinics, home and hospice care, and specialty practices.
CLINICAL NURSE SPECIALIST A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (e.g., gerontology, oncology). The nurse provides direct client care, edu- cates others, consults, conducts research, and manages care. The American Nurses Credentialing Center provides national certification of clinical specialists.
NURSE ANESTHETIST A nurse anesthetist has completed advanced education in an ac- credited program in anesthesiology. The nurse anesthetist carries out preoperative visits and assessments, and administers general anesthetics for surgery under the supervision of a physician pre- pared in anesthesiology. The nurse anesthetist also assesses the postoperative status of clients.
NURSE MIDWIFE A nurse midwife has completed a program in midwifery and is certi- fied by the American College of Nurse Midwives. The nurse midwife gives prenatal and postnatal care and manages deliveries in nor- mal pregnancies. The midwife practices in association with a health care agency and can obtain medical services if complications occur. The nurse midwife may also conduct routine Papanicolaou smears, family planning, and routine breast examinations.
NURSE RESEARCHER Nurse researchers investigate nursing problems to improve nurs- ing care and to refine and expand nursing knowledge. They are
employed in academic institutions, teaching hospitals, and re- search centers such as the National Institute for Nursing Research in Bethesda, Maryland. Nurse researchers usually have advanced education at the doctoral level.
NURSE ADMINISTRATOR The nurse administrator manages client care, including the delivery of nursing services. The administrator may have a middle manage- ment position, such as head nurse or supervisor, or a more senior management position, such as director of nursing services. The functions of nurse administrators include budgeting, staffing, and planning programs. The educational preparation for nurse admin- istrator positions is at least a baccalaureate degree in nursing and frequently a master’s or doctoral degree.
NURSE EDUCATOR Nurse educators are employed in nursing programs, at educational institutions, and in hospital staff education. The nurse educator usu- ally has a baccalaureate degree or more advanced preparation and frequently has expertise in a particular area of practice. The nurse educator is responsible for classroom and, often, clinical teaching. There is now a process to become a certified nurse educator (CNE).
NURSE ENTREPRENEUR A nurse entrepreneur usually has an advanced degree and manages a health-related business. The nurse may be involved in education, consultation, or research, for example.
FORENSIC NURSE The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowl- edge of the legal system and skills in injury identification, evalua- tion, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities. Forensic nurses work in a variety of fields including sexual assault, domestic violence, child abuse and neglect, mistreatment of older adults, death investiga- tion, and corrections. They may be called on in mass disasters or community crisis situations (International Association of Forensic Nurses, n.d.). Nurses complete a certification process to become a forensic nurse.
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orientation of the individual toward service, either to a community or to an organization; (c) ongoing research; (d) a code of ethics; (e) autonomy; and (f) a professional organization.
Two terms related to profession need to be differentiated: pro- fessionalism and professionalization. Professionalism refers to professional character, spirit, or methods. It is a set of attributes, a way of life that implies responsibility and commitment. Nursing professionalism owes much to the influence of Florence Nightingale. Professionalization is the process of becoming professional, that is, of acquiring characteristics considered to be professional.
Specialized Education Specialized education is an important aspect of professional status. In modern times, the trend in education for the professions has shifted toward programs in colleges and universities. Many nursing educators believe that the undergraduate nursing curriculum should include liberal arts education in addition to the biologic and social sciences and the nursing discipline.
In the United States today, there are five means of entry into registered nursing: hospital diploma, associate degree, baccalaureate degree, master’s degree, and doctoral degree. These programs are dis- cussed in Chapter 2 .
Body of Knowledge As a profession, nursing is establishing a well-defined body of knowledge and expertise. A number of nursing conceptual frame- works (discussed in Chapter 3 ) contribute to the knowledge base of nursing and give direction to nursing practice, education, and on- going research.
Service Orientation A service orientation differentiates nursing from an occupation pur- sued primarily for profit. Many consider altruism (selfless concern for others) the hallmark of a profession. Nursing has a tradition of service to others. This service, however, must be guided by certain rules, policies, or codes of ethics. Today, nursing is also an important component of the health care delivery system.
Ongoing Research Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice- related issues. Nursing research as a dimension of the nurse’s role is discussed further in Chapter 2 .
Code of Ethics Nurses have traditionally placed a high value on the worth and dig- nity of others. The nursing profession requires integrity of its mem- bers; that is, a member is expected to do what is considered right regardless of the personal cost.
Ethical codes change as the needs and values of society change. Nursing has developed its own codes of ethics and in most instances
has set up means to monitor the professional behavior of its mem- bers. See Chapter 5 for additional information on ethics.
Autonomy A profession is autonomous if it regulates itself and sets standards for its members. Providing autonomy is one of the purposes of a pro- fessional association. If nursing is to have professional status, it must function autonomously in the formation of policy and in the con- trol of its activity. To be autonomous, a professional group must be granted legal authority to define the scope of its practice, describe its particular functions and roles, and determine its goals and responsi- bilities in delivery of its services.
To practitioners of nursing, autonomy means independence at work, responsibility, and accountability for one’s actions. Autonomy is more easily achieved and maintained from a position of authority. For example, all states have passed legislation granting NPs super- visory, collaborative, or independent authority to practice (Phillips, 2010), and currently, 27 states do not require physician oversight of NPs to practice (Selway, 2012).
Professional Organization Operation under the umbrella of a professional organization differen- tiates a profession from an occupation. Governance is the establish- ment and maintenance of social, political, and economic arrangements by which practitioners control their practice, their self-discipline, their working conditions, and their professional affairs. Nurses, therefore, need to work within their professional organizations.
The ANA is a professional organization that “advances the nurs- ing profession by fostering high standards of nursing practice, pro- moting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regula- tory agencies on health care issues affecting nurses and the public” (ANA, 2013a).
SOCIALIZATION TO NURSING The standards of education and practice for the profession are deter- mined by the members of the profession, rather than by outsiders. The education of the professional involves a complete socializa- tion process, more far reaching in its social and attitudinal aspects and its technical features than is usually required in other kinds of occupations.
Socialization can be defined simply as the process by which people (a) learn to become members of groups and society and (b) learn the social rules defining relationships into which they will enter. Socialization involves learning to behave, feel, and see the world in a manner similar to other persons occupying the same role as oneself (Hardy & Conway, 1988, p. 261). The goal of professional socialization is to instill in individuals the norms, values, attitudes, and behaviors deemed essential for survival of the profession.
Various models of the socialization process have been devel- oped. Benner’s model (2001) describes five levels of proficiency in nursing based on the Dreyfus general model of skill acquisition. The five stages, which have implications for teaching and learning, are novice, advanced beginner, competent, proficient, and expert. Benner writes that experience is essential for the development of pro- fessional expertise (see Box 1–3).
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One of the most powerful mechanisms of professional socializa- tion is interaction with fellow students. Within this student culture, students collectively set the level and direction of their scholastic ef- forts. They develop perspectives about the situation in which they are involved, the goals they are trying to achieve, and the kinds of activi- ties that are expedient and proper, and they establish a set of practices congruent with all of these. Students become bound together by feel- ings of mutual cooperation, support, and solidarity.
The National Student Nurses Association (NSNA) helps link nursing students with nursing leadership groups. This organization exposes student nurses to issues impacting the nursing profession while promoting collegiality and leadership qualities.
Critical Values of Nursing It is within the nursing educational program that the nurse develops, clarifies, and internalizes professional values. Specific professional nursing values are stated in nursing codes of ethics (see Chapter 5 ), in standards of nursing practice (discussed earlier in this chapter), and in the legal system itself (see Chapter 4 ). Additionally, in 2001, the NSNA adopted a code of academic and clinical conduct (see Box 1–4).
FACTORS INFLUENCING CONTEMPORARY NURSING PRACTICE To understand nursing as it is practiced today and as it will be prac- ticed tomorrow requires an understanding of some of the social forces currently influencing this profession. These forces usually affect the
BOX 1–3 Benner’s Stages of Nursing Expertise
STAGE I: NOVICE No experience (e.g., nursing student). Performance is limited, in- flexible, and governed by context-free rules and regulations rather than experience.
STAGE II: ADVANCED BEGINNER Demonstrates marginally acceptable performance. Recognizes the meaningful “aspects” of a real situation. Has experienced enough real situations to make judgments about them.
STAGE III: COMPETENT Has 2 or 3 years of experience. Demonstrates organizational and planning abilities. Differentiates important factors from less impor- tant aspects of care. Coordinates multiple complex care demands.
STAGE IV: PROFICIENT Has 3 to 5 years of experience. Perceives situations as wholes rather than in terms of parts, as in Stage II. Uses maxims as guides for what to consider in a situation. Has holistic understanding of the cli- ent, which improves decision making. Focuses on long-term goals.
STAGE V: EXPERT Performance is fluid, flexible, and highly proficient; no longer re- quires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situations. Is inclined to take a certain action because “it felt right.” From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative Edition, by P. Benner, 2001. Electronically reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.
BOX 1–4 National Student Nurses Association, Inc., Code of Academic and Clinical Conduct
PREAMBLE Students of nursing have a responsibility to society in learning the academic theory and clinical skills needed to provide nursing care. The clinical setting presents unique challenges and respon- sibilities while caring for human beings in a variety of health care environments.
The Code of Academic and Clinical Conduct is based on an un- derstanding that to practice nursing as a student is an agreement to uphold the trust with which society has placed in us. The statements of the Code provide guidance for the nursing student in the personal development of an ethical foundation and need not be limited strictly to the academic or clinical environment but can assist in the holistic development of the person.
A CODE FOR NURSING STUDENTS As students are involved in the clinical and academic environments we believe that ethical principles are a necessary guide to profes- sional development. Therefore within these environments we: 1. Advocate for the rights of all clients. 2. Maintain client confidentiality. 3. Take appropriate action to ensure the safety of clients, self,
and others. 4. Provide care for the client in a timely, compassionate, and
professional manner. 5. Communicate client care in a truthful, timely, and accurate
manner. 6. Actively promote the highest level of moral and ethical
principles and accept responsibility for our actions. 7. Promote excellence in nursing by encouraging lifelong learning
and professional development.
8. Treat others with respect and promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs.
9. Collaborate in every reasonable manner with the academic faculty and clinical staff to ensure the highest quality of client care.
10. Use every opportunity to improve faculty and clinical staff understanding of the learning needs of nursing students.
11. Encourage faculty, clinical staff, and peers to mentor nursing students.
12. Refrain from performing any technique or procedure for which the student has not been adequately trained.
13. Refrain from any deliberate action or omission of care in the academic or clinical setting that creates unnecessary risk of injury to the client, self, or others.
14. Assist the staff nurse or preceptor in ensuring that there is full disclosure and that proper authorizations are obtained from clients regarding any form of treatment or research.
15. Abstain from the use of alcoholic beverages or any substances in the academic and clinical setting that impair judgment.
16. Strive to achieve and maintain an optimal level of personal health.
17. Support access to treatment and rehabilitation for students who are experiencing impairments related to substance abuse and mental or physical health issues.
18. Uphold school policies and regulations related to academic and clinical performance, reserving the right to challenge and critique rules and regulations as per school grievance policy.
Adopted by the NSNA House of Delegates, Nashville, TN, on April 6, 2001. Reprinted with permission.
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entire health care system, and nursing, as a major component of that system, cannot avoid the effects.
Health Care Reform With the passage of the Affordable Care Act (ACA) in 2010, health care reform was on a fast track. Transformation in health care deliv- ery and financing systems accelerated in 2014 when major provisions of the legislation were implemented (Buerhaus et al., 2012, p. 318). Health care delivery’s focus has shifted from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. Also in 2010, an IOM report, The Future of Nursing: Leading Change, Advancing Health, provided rec- ommendations on what nursing needed to do to provide better cli- ent care in the new systems that would be part of health reform. This report identified four key areas: nurses practicing to the fullest extent of their skills and knowledge; nurses achieving higher levels of educa- tion; nurses being full partners with physicians and other health care professionals; and improving data collection and an information in- frastructure (IOM, 2010, p. 4).
Quality and Safety in Health Care Quality and safety are inherent universal values on which health care is based (Sherwood, 2011, p. 227). However, the report To Err is Human, published by the IOM in 2000 revealed a gap between the status of American health care and the quality Americans should re- ceive. Since then, the IOM has published a series of reports confirm- ing that “quality and safety are the leading contemporary issues in health care, contributing to costs and poor outcomes” (Sherwood & Barnsteiner, 2012, p. 3). The 2003 IOM report, Health Professions Ed- ucation: A Bridge to Quality, called for a redesign of the education for health care professions and described six core competencies needed to improve 21st-century health care: patient- centered care, team- work and collaboration, evidence-based practice, quality improve- ment, safety, and informatics. In 2005, the Robert Wood Johnson Foundation funded a project called Quality and Safety Education for Nurses (QSEN). The goal for the QSEN project was to “meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work” (QSEN Institute, n.d.). This project used the IOM six competencies along with the knowledge and experiences of QSEN faculty and a national advisory board to define quality and safety competencies for nursing. The project also proposed KSAs for each competency that could be used as guides for curriculum development in preli- censure nursing programs (see the table at the QSEN website).
Consumer Demands Consumers of nursing services (the public) have become an increas- ingly effective force in changing nursing practice. On the whole, peo- ple are better educated and have more knowledge about health and illness than in the past. Consumers also have become more aware of others’ needs for care. The ethical and moral issues raised by poverty and neglect have made people more vocal about the needs of minor- ity groups and the poor.
The public’s concepts of health and nursing have also changed. Most now believe that health is a right of all people, not just a privilege
of the rich. The media emphasize the message that individuals must assume responsibility for their own health by obtaining a physical examination regularly, checking for the seven danger signals of can- cer, and maintaining their mental well-being by balancing work and recreation. Interest in health and nursing services is therefore greater than ever. Furthermore, many people now want more than freedom from disease—they want energy, vitality, and a feeling of wellness.
Increasingly, the consumer has become an active participant in making decisions about health and nursing care. Planning com- mittees concerned with providing nursing services to a community usually have active consumer membership. Recognizing the legiti- macy of public input, many state nursing associations and regula- tory agencies have consumer representatives on their governing boards.
Family Structure New family structures are influencing the need for and provision of nursing services. More people are living away from the extended family and the nuclear family, and the family breadwinner is no lon- ger necessarily the husband. Today, many single men and women rear children, and in many two-parent families both parents work. It is also common for young parents to live at great distances from their own parents. These young families need support services, such as day care centers. For additional information about the family, see Chapter 24 .
Adolescent mothers also need specialized nursing services, both while they are pregnant and after their babies are born. These young mothers usually have the normal needs of teenagers as well as those of new mothers. Many teenage mothers are raising their children alone with little, if any, assistance from the child’s father. This type of single-parent family is especially vulnerable because motherhood compounds the difficulties of adolescence. Also, because many of these families live in poverty, the children often do not receive pre- ventive immunizations and are at increased risk for nutritional and other health problems.
Science and Technology Advances in science and technology affect nursing practice. For ex- ample, people with acquired immunodeficiency syndrome (AIDS) are receiving new drug therapies to prolong life and delay the on- set of AIDS-associated diseases. Nurses must be knowledgeable about the action of such drugs and the needs of clients receiving them. Biotechnology is affecting health care. For example, nurses are exposed to emerging genetic technology such as the field of can- cer gene therapy (Parsons, 2011). Nurses will need to expand their knowledge base and technical skills as they adapt to meet the new needs of clients.
In some settings, technologic advances have required that nurses be highly specialized. Nurses frequently have to use sophisticated computerized equipment to monitor or treat clients. As technologies change, nursing education changes, and nurses require increasing education to provide effective, safe nursing practice.
The space program has developed advanced technologies for space travel based on the need for long-distance monitoring of astro- nauts and spacecraft, lighter materials, and miniaturization of equip- ment. Health care has benefited as this new technology has been
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oversight of a nurse practitioner’s practice; however 16 states still require NPs to practice under severe restrictions (Selway, 2012, p. 11). As a result, NPs cannot easily move from state to state, which decreases access to care for clients. In 2008, 48 professional organi- zations, including the NCSBN developed a Consensus Model that provides guidance for states to adopt uniformity in the regulation of advanced practice registered nurses. Many states have adopted portions of the model elements, but variations remain from state to state (NCSBN, 2013).
Demography Demography is the study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease). From demographic data, the needs of the population for nursing services can be assessed. For example:
• The total population in North America is increasing. The propor- tion of older adults has also increased, creating an increased need for nursing services for this group.
• The population is shifting from rural to urban settings. This shift signals an increased need for nursing related to problems caused by pollution and by the effects on the environment of concentra- tions of people. Thus, most nursing services are now provided in urban settings.
• Mortality and morbidity studies reveal the presence of risk factors. Many of these risk factors (e.g., smoking) are major causes of death and disease that can be prevented through changes in lifestyle. The nurse’s role in assessing risk factors and helping clients make healthy lifestyle changes is discussed in Chapter 16 .
The Current Nursing Shortage Registered nurses are the largest segment of the health care workforce. According to the Bureau of Labor Statistics (2013), the number of em- ployed RNs will grow from 2.7 million in 2012 to 3.2 million in 2022; this number increases by an additional 1.2 million when including replacements for nurses who leave or retire from the profession. Contrast that information with an AACN statement (2012b) that the United States is projected to have a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Factors for this prediction include the concurrent nursing faculty shortage, the increasing average age of RNs, and the increasing num- ber of aging older adults along with their increasing health care needs.
Whereas there is a projected shortage of nurses by 2022, whether or not there is a current nursing shortage depends on where the nurses live and where they are willing to work. The supply and demand of nurses is not uniform. For example, the RN shortage is projected to be the most intense in the South and the West (AACN, 2012b). Currently, new graduates are having difficulty finding that first job as a consequence of the declining U.S. economy. Because of economic pressures and job losses in all industries, many nurses increased their hours and/or deferred retirement. Combined with lower hospital census, employers hiring new graduates with bacca- laureate degrees, many open RN positions requiring at least 2 years of experience, and the reputation of new graduates having a high turnover rate, many hospitals have stopped interviewing new gradu- ates (Stokowski, 2011). The health care setting is another factor. The growth of RN positions will occur in community-based settings
adapted in such health care aids as Viewstar (an aid for people with visual impairments), the insulin infusion pump, the voice-controlled wheelchair, magnetic resonance imaging, laser surgery, filtering de- vices for intravenous fluid control devices, and monitoring systems for intensive care.
Information, Telehealth, and Telenursing The Internet has already affected health care, with more and more clients becoming well informed about their health concerns. As a result, nurses may need to interpret Internet sources of information for clients and their families. Because not all of the Internet-based in- formation is accurate, nurses need to become information brokers so they can help people to access high-quality, valid websites; interpret the information; and then help clients evaluate the information and determine if it is useful to them.
The prefix tele means “distance,” and is used to describe the many health care services provided via technology. Telehealth is the “use of medical information exchanged from one site to another via elec- tronic communications to improve the patient’s health status.” The words telemedicine and telehealth are often used interchangeably. Telemedicine is often associated with direct client clinical services, whereas telehealth has a broader definition of remote health care services (IOM, 2012, p. 134). Telenursing is the use of telecommu- nications and information technology to provide nursing practice at a distance (Kumar & Snooks, 2011, p. 1). The delivery of telehealth care, however, is not limited to physicians and nurses; it includes other health disciplines such as radiology, pathology, and pharma- cology. These disciplines also deliver care using electronic infor- mation and telecommunications technologies and are accordingly called teleradiology, telepathology, and telepharmacy. Nurses engaged in telenursing practice continue to use the nursing process to provide care to clients, but they do so using technologies such as the Internet, computers, telephones, videoteleconferencing, and telemonitoring equipment. Telenursing continues to grow, especially in home health care and in rural communities.
Telehealth recognizes no state boundaries and, subsequently, licensure issues have been raised. For example, if a nurse licensed in one state provides health information to a client in another state, does the nurse need to maintain licensure in both states? The National Council of State Boards of Nursing (NCSBN) endorses a change from single-state licensure to a mutual recognition model. Many state leg- islatures have adopted mutual recognition language into statutes and are currently implementing it (see Chapter 4 ).
Legislation Legislation about nursing practice and health matters affects both the public and nursing. Legislation related to nursing is discussed in Chapter 4 . Changes in legislation relating to health also affect nurs- ing. For example, the Patient Self-Determination Act (PSDA) requires that every competent adult be informed in writing on admis- sion to a health care institution about his or her rights to accept or re- fuse medical care and to use advance directives. See Chapter 4 for more information about the PSDA and advance directives.
Health care reform and the shortage of physicians calls for an increase in advance practice registered nurses such as NPs. Cur- rently, there are wide variations in state regulation of nurse prac- titioner practice. For example, 27 states do not require physician
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BOX 1–5 Preparing for a Competitive Job Market
The following tips can help prepare you to be successful in obtain- ing your first nursing position: • Attend the NSNA Career Planning Conference and annual
convention before and after you graduate. • Continue your education: If you have a diploma or associate
degree, explore RN to BSN programs; if you have a BSN, explore MSN programs.
• Attend meetings of your alumni association. • Include a cover letter when you submit your resume and
application. • Practice interviewing skills. • Network with the nurses at the health care agencies where
you are completing your clinical practicum. • Take the NCLEX-RN as soon as possible after graduation. • When you get an interview, smile and show you are excited
about this opportunity. • Join a professional nursing organization. • Be open and flexible. Find an entry-level position that will give
you work and professional-growth experiences. • Look outside of acute care settings for entry-level positions. • Take a residency or internship even if it is not in your interest
area. • Stay current through continuing education and consider
completing certification opportunities. • Make sure that your resume truly reflects your education,
skills, and experience. From Realities of the Current Job Market, National League for Nursing and National Student Nurses Association, n.d. Retrieved from http://www.nsna.org/Portals/0/Skins/NSNA/pdf/ RealitiesOfTheCurrentJobMarket.pdf.
rather than acute care hospitals as an increasing proportion of the U.S. population has health care coverage through the Affordable Care Act (Sullivan, Fries, & Relf, 2012). Stokowski (2011) pointed out that many new graduates have unrealistic expectations (e.g., seeking only the day shift or working minimal weekends or only being available part-time). These types of demands will limit the graduate from getting a job, making flexibility for hours, shift, and unit key advantages. Together, the National League for Nursing and the National Student Nurse Association (n.d.) have published a bro- chure with helpful information and tips for the new graduate who is looking for a job (see Box 1–5).
As the economy improves, opportunities for new graduates should open up. One current solution to assist new graduates to transi- tion into practice is nurse residency programs. Some of these residency
programs are partnerships between the acute care setting and a school of nursing, and others are programs within the acute care institution. Evidence shows that substantive orientation plans for mentoring, residency, and other formal transition-to-practice programs result in higher retention rates of the new graduate (Sullivan et al., 2012).
Collective Bargaining More nurses are using collective bargaining to deal with their con- cerns. The ANA participates in collective bargaining on behalf of nurses through its economic and general welfare programs. Today, some nurses are joining other labor organizations that represent them at the bargaining table. Nurses have gone on strike over eco- nomic concerns and over issues about safe care for clients and safety for themselves.
Nursing Associations Professional nursing associations have provided leadership that affects many areas of nursing. Voluntary accreditation of nursing education programs by the Accreditation Commission for Education in Nursing (ACEN) and Commission on Collegiate Nursing Educa- tion (CCNE) has also influenced nursing. Many nursing programs have steadily improved to meet the standards for accreditation over the years. As a result, nurse graduates are better prepared to meet the demands of society.
To influence policy making for health care, a group of profes- sional nurses organized formally to promote political action in the nursing and health care arenas. Nurses for Political Action (NPA) formed in 1971 and became an arm of the ANA in 1974, when its name changed to Nurses’ Coalition for Action in Politics (N-CAP). In 1986, the name was changed to American Nurses Association— Political Action Committee (ANA-PAC). Through this group, nurses have lobbied actively for legislation affecting health care. A number of nursing leaders hold positions of authority in government. Attain- ing such positions is essential if nurses hope to exert ongoing political influence.
NURSING ORGANIZATIONS As nursing has developed, an increasing number of nursing organiza- tions have formed. These organizations are at the local, state, national, and international levels. The organizations that involve most North American nurses are the ANA, the National League for Nursing, the
The purpose of Bratt and Felzer’s (2011) repeated measures design study was to examine new graduates’ perceptions of their profes- sional practice competence and work environment throughout a yearlong nurse residency program. High stress levels and inexperi- ence make new graduates prone to error and turnover. The nurs- ing literature recommends that actions take place to ensure that new nurse graduates receive better transition experiences, such as nurse residency programs. The total sample consisted of 468 newly licensed registered nurses who were predominantly White females with associate’s degrees and worked primarily on medical–surgical units in urban hospitals. Data were collected at 3 months after hire, 6 months later, and at the conclusion of the residency program. The new graduates’ perceptions of their professional practice competency
were measured with two instruments, and their perceptions of work environment measured with three instruments. The number of nurses who completed surveys at all three measurements points was 227. On completion of the residency program, participants had higher means of job satisfaction, clinical decision-making ability, quality of nursing performance and organizational commitment, and lower means of stress compared with baseline or 6-month measures.
IMPLICATIONS Even though a limitation of the study was its nonexperimental de- sign, this study adds to the growing body of evidence showing the effectiveness of nurse residency programs. Continued research is needed to determine best practices for nurse residency programs.
Evidence-Based Practice Does a Nurse Residency Program Make a Difference for the New Graduate? EVIDENCE-BASED PRACTICE
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International Council of Nurses The International Council of Nurses (ICN) was established in 1899. Nurses from Great Britain, the United States, and Canada were among the founding members. The council is a federation of national nurses’ associations, such as the ANA and CNA.
The ICN provides an organization through which member national associations can work together for the mission of repre- senting nursing worldwide, advancing the profession, and influ- encing health policy. The five core values of the ICN are visionary leadership, inclusiveness, innovativeness, partnership, and trans- parency (ICN, 2012). The official journal of the ICN is Interna- tional Nursing Review.
National Student Nurses Association The NSNA is the official preprofessional organization for nursing students. Formed in 1953 and incorporated in 1959, the NSNA originally functioned under the aegis of the ANA and NLN; how- ever, in 1968 the NSNA became an autonomous body, although it communicates with the NLN and the ANA. To qualify for member- ship in the NSNA, a student must be enrolled in a state-approved nursing education program. The official journal of the NSNA is Imprint magazine.
International Honor Society: Sigma Theta Tau Sigma Theta Tau, the international honor society in nursing, was founded in 1922 and is headquartered in Indianapolis, Indiana. The Greek letters stand for the Greek words storga, tharos, and tima, meaning “love,” “courage,” and “honor.” The society is a member of the Association of College Honor Societies. The society’s purpose is pro- fessional rather than social. Membership is attained through academic achievement. Students in baccalaureate programs in nursing and nurses in master’s, doctoral, and postdoctoral programs are eligible to be selected for membership. Potential members, who hold a minimum of a bachelor’s degree and have demonstrated achievement in nursing, can apply for membership as a nurse leader in the community.
The official journal of Sigma Theta Tau, the Journal of Nursing Scholarship, is published quarterly. The journal publishes scholarly articles of interest to nurses. The society also publishes Reflections, a quarterly newsletter that provides information about the organiza- tion and its various chapters.
International Council of Nurses, and the National Student Nurses Association. The number of nursing specialty organizations is also increasing, for example, the Academy of Medical Surgical Nursing, the American Association of Nurse Anesthetists, the National Black Nurses Association, and the National Association of Pediatric Nurse Practitioners. Participation in the activities of nursing associations enhances the growth of involved individuals and helps nurses collec- tively influence policies affecting nursing practice.
American Nurses Association The ANA is the national professional organization for nursing in the United States. It was founded in 1896 as the Nurses Associated Alumnae of the United States. In 1911 the name was changed to the American Nurses Association. It was a charter member of the Inter- national Council of Nurses, along with organizations in Great Britain and Germany, in 1899. The purposes of the ANA are to foster high standards of nursing practice and to promote the educational and professional advancement of nurses so that all people may have bet- ter nursing care.
In 1982, the organization became a federation of state nurses’ as- sociations. Individuals participate in the ANA by joining their state nurses’ associations. The official journal of the ANA is American Nurse Today, and The American Nurse is the official newspaper.
National League for Nursing The NLN, formed in 1952, is an organization of both individuals and agencies. Its objective is to foster the development and improvement of all nursing services and nursing education. People who are not nurses but have an interest in nursing services, for example, hospi- tal administrators, can be members of the league. This feature of the NLN—involving nonnurse members, consumers, and nurses from all levels of practice—is unique.
The NLN presents continuing education workshops and semi- nars for its members. For schools of nursing, the NLN offers testing services including preadmission testing for potential students and achievement testing throughout the program. The NLN also con- ducts yearly surveys of nursing schools, newly registered nurses, and post-basic graduates. These surveys serve as a primary source of re- search data about nursing education in the United States. The ACEN, an independent body within the NLN, provides voluntary accredita- tion for educational programs in nursing. The official journal of the NLN is Nursing and Health Care Perspectives.
• Historical perspectives of nursing practice reveal recurring themes or influencing factors. For example, women have traditionally cared for others, but often in subservient roles. Religious orders left an imprint on nursing by instilling such values as compassion,
devotion to duty, and hard work. Wars created an increased need for nurses and medical specialties. Societal attitudes have influ- enced nursing’s image. Visionary leaders have made notable con- tributions to improve the status of nursing.
CHAPTER HIGHLIGHTS
Chapter 1 Review
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• With advanced education and experience, nurses can fulfill ad- vanced practice roles such as clinical nurse specialist, NP, nurse midwife, nurse anesthetist, educator, administrator, and researcher.
• A desired goal of nursing is professionalism, which necessitates specialized education; a unique body of knowledge, including spe- cific skills and abilities; a service orientation; ongoing research; a code of ethics; autonomy; and a professional organization.
• Socialization is the process by which people learn to become members of groups and society, and learn social rules defining relationships into which they will enter. Socialization to professional nursing practice is the process whereby the values and norms of the nursing profession are internalized into the nurse’s own behav- ior and self-concept. The nurse acquires the knowledge, skill, and attitudes characteristic of the profession.
• Although several models of the socialization process have been developed, Benner’s five stages of novice, advanced beginner, competent, proficient, and expert may serve as guidelines to es- tablish the phase and extent of an individual’s socialization.
• Contemporary nursing practice is influenced by health care re- form; quality and safety in health care; consumer demands; fam- ily structure; science and technology; information, telehealth, and telenursing; legislation; demographic and social changes; the nursing shortage; collective bargaining; and the work of nursing associations.
• Participation in the activities of nursing associations enhances the growth of involved individuals and helps nurses collectively influ- ence policies that affect nursing practice.
• Nursing education curricula are continually undergoing revisions in response to new scientific knowledge and technologic, cultural, political, and socioeconomic changes in society.
• Originally, the focus of nursing education was to teach the knowl- edge and skills that would enable a nurse to practice in a hospi- tal setting. Today, curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles.
• Some professional organizations have changed the focus from requirements for initial preparation to academic progression and multiple entry points to professional practice in nursing.
• Continuing education is the responsibility of each practicing nurse to keep abreast of scientific and technologic change and changes within the nursing profession.
• The scope of nursing practice includes promoting wellness, pre- venting illness, restoring health, and caring for the dying.
• Although traditionally the majority of nurses were employed in hos- pital settings, today the numbers of nurses working in home health care, ambulatory care, and community health settings are increasing.
• Nurse practice acts vary among states, and nurses are responsible for knowing the act that governs their practice.
• Standards of nursing practice provide criteria against which the effectiveness of nursing care and professional performance behav- iors can be evaluated.
• Every nurse may function in a variety of roles that are not exclusive of one another; in reality, they often occur together and serve to clarify the nurse’s activities. These roles include caregiver, commu- nicator, teacher, client advocate, counselor, change agent, leader, manager, case manager, and research consumer.
1. Which women made significant contributions to the nursing care of soldiers during the Civil War? Select all that apply. 1. Harriet Tubman 2. Florence Nightingale 3. Fabiola 4. Dorothea Dix 5. Sojourner Truth
2. Curricula for nursing education are strongly influenced by which of the following? Select all that apply. 1. Physician groups 2. Professional nursing organizations 3. Individual state boards of nursing 4. Hospital administrators 5. The National Council of State Boards of Nursing
3. Which is an example of continuing education for nurses? 1. Attending the hospital’s orientation program 2. Completing a workshop on ethical aspects of nursing 3. Obtaining information about the facility’s new computer
charting system 4. Talking with a company representative about a new piece
of equipment 4. Health promotion is best represented by which activity?
1. Administering immunizations 2. Giving a bath 3. Preventing accidents in the home 4. Performing diagnostic procedures
5. Who were America’s first two trained nurses? 1. Barton and Wald 2. Dock and Sanger 3. Richards and Mahoney 4. Henderson and Breckinridge
6. A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner’s stages of nursing expertise? 1. Advanced beginner 2. Competent 3. Proficient 4. Expert
7. Which professional organization developed a code for nursing students? 1. ANA 2. NLN 3. AACN 4. NSNA
8. Which social force is most likely to significantly impact the future supply and demand for nurses? 1. Aging 2. Economics 3. Science/technology 4. Telecommunications
TEST YOUR KNOWLEDGE
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Suggested Readings Coleman, C. L. (2013). Man up! A practical guide for men in
nursing. Indianapolis, IN: Sigma Theta Tau International. The author and contributors to this book are all successful male nursing leaders. They provide expert advice, practical information, tools for success in the nursing profession, and a male student’s survival guide for nursing school. All nurses should read this book.
Heikkila, K. (2011). Sisterhood of war. Minnesota women in Vietnam. St. Paul, MN: Minnesota Historical Society. The author focuses on the experiences of 15 nurses from Minnesota who went to war in Vietnam. The story “rises to heights of excitement as they embarked on their gen- eration’s defining adventure, falls to depths of despair as they experienced the carnage of war, ascends again as they eagerly left the war zone and returned home, only to descend once more as they encountered public hostility, institutional indifference, and psychological stress in the aftermath of war” (p. 5).
References American Assembly for Men in Nursing. (2011). About us:
AAMN history. Retrieved from http://aamn.org/history.shtml American Association of Colleges of Nursing. (2012a). Degree
completion programs for registered nurses: RN to master’s degree and RN to baccalaureate programs. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/ degree-completion-programs
American Association of Colleges of Nursing. (2012b). Fact sheet. Nursing shortage. Retrieved from http://www.aacn .nche.edu/media-relations/fact-sheets/nursing-shortage
American Association of Colleges of Nursing. (2012c). Fact sheet. The impact of education on nursing practice. Retrieved from http://www.aacn.nche.edu/media-relations/ fact-sheets/impact-of-education
American Association of Colleges of Nursing. (2012d). Frequently asked questions. Retrieved from http://www .aacn.nche.edu/cnl/frequently-asked-questions
American Nurses Association. (1965). ANA’s first position on education for nursing. American Journal of Nursing, 65(12), 106–111.
American Nurses Association. (1973). Standards of nursing practice. Kansas City, MO: Author.
American Nurses Association. (1980). Nursing: A social policy statement. Kansas City, MO: Author.
American Nurses Association. (2010). Nursing’s social policy statement. Washington, DC: American Nurses Publishing.
American Nurses Association. (2013a). About ANA. Retrieved from http://www.nursingworld.org/FunctionalMenuCategories/ AboutANA/default.aspx
American Nurses Association. (2013b). Linda Anne Judson Richards. Retrieved from http://www.nursingworld.org/ LindaAnneJudsonRichards
American Nurses Association. (2013c). Mary Eliza Mahoney. Retrieved from http://www.nursingworld.org/ MaryElizaMahoney
Anderson, D. (2011). Man enough: The 20 3 20 choose nursing campaign. Retrieved from http:// www.minoritynurse.com/nursing-associations/ man-enough-20-x-20-choose-nursing-campaign
Arlington National Cemetery. (n.d.). Nurses memorial. Retrieved from http://www.arlingtoncemetery.mil/ VisitorInformation/MonumentMemorials/NursesMemorial .aspx
Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice (Commemorative ed.). Upper Saddle River, NJ: Prentice Hall Health.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses. A call for radical transformation. Stanford, CA: Carnegie Foundation for the Advancement of Teaching.
Bratt, M. M., & Felzer, H. M. (2011). Perceptions of professional practice and work environment of new graduates in a nurse residency program.The Journal of Continuing Education in Nursing, 42(12), 559–568. doi:10.3928/00220124-20110516-03
Buerhaus, P. I., DesRoches, C., Applebaum, S., Hess, R., Norman, L. D., & Donelan, K. (2012). Are nurses ready for health care reform? A decade of survey research. Nursing Economics, 30(6), 318–329, quiz 330.
Bureau of Labor Statistics. (2013). The 30 occupations with the largest projected employment growth, 2010–2020. Retrieved from http://www.bls.gov/news.release/ecopro .t06.htm
Donahue, M. P. (2011). Nursing: The finest art. An illustrated history (3rd ed.). St. Louis, MO: Mosby.
Florence Nightingale International Foundation. (2014). The Florence Nightingale legacy. Retrieved from http://www .fnif.org/nightingale.htm
Hardy, M. E., & Conway, M. E. (1988). Role theory: Perspec- tives for healthy professionals (2nd ed.). Norwalk, CT: Appleton & Lange.
Health Resources and Services Administration (HRSA). (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Retrieved from htpp://bhpr.hrsa.gov/healthworkforce/rnsurveys/ rnsurveyfinal.pdf
Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York, NY: Macmillan.
Institute of Medicine (IOM). (2010, October 5). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
Institute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary. Washington, DC: National Academies Press.
International Association of Forensic Nurses. (n.d.). Welcome to IAFN. Retrieved from http://www.forensicnurse.org
International Council of Nurses. (2012). Our mission. Retrieved from http://www.icn.ch/about-icn/icns-mission
Kumar, S., & Snooks, H. (Eds.). (2011). Telenursing, health informatics. London, United Kingdom: Springer-Verlag.
MacWilliams, B. R., Schmidt, B., & Bleich, M. R. (2013). Men in nursing. American Journal of Nursing, 113(1), 38–44. doi:10.1097/01.NAJ.0000425746.83731.16
National Council of State Boards of Nursing. (2013). The consensus model for APRN regulation, licensure, accreditation, certification and education. Retrieved from https://www.ncsbn.org/4213.htm
National League for Nursing. (2011). Recognizing the vital contributions of the licensed practical/vocational nurse. Retrieved from http://www.nln.org/aboutnln/reflection_ dialogue/refl_dial_8.htm
National League for Nursing. (2012a). Joint statement on academic progression for nursing students and graduates. Retrieved from http://www.nln.org/aboutnln/ academicprogression.htm
National League for Nursing. (2012b). National league for nurs- ing applauds landmark joint statement on academic pro- gression for nursing students and graduates. Retrieved from http://www.nln.org/newsreleases/academicprogression.htm
National League for Nursing and National Student Nurses Association. (n.d.). Realities of the current job market. Re- trieved from http://www.nsna.org/Portals/0/Skins/NSNA/ pdf/RealitiesOfTheCurrentJobMarket.pdf
National Student Nurses Association House of Delegates. (2001). Code of academic and clinical conduct. Retrieved from http://www.nsna.org/ProgramActivities/ BylawsPolicies/Ethics.aspx
Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover. (Original work published 1860.)
O’Lynn, C. E., & Tranbarger, R. E. (Eds.). (2007). Men in nursing: History, challenges, and opportunities. New York, NY: Springer.
Parsons, M. (2011). Li-Fraumeni syndrome and the role of the pediatric nurse practitioner. Clinical Journal of Oncology Nursing, 15, 79–87. doi:10.1188/11.CJON.79-87
Pender, N., Murdaugh, C., & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson.
Phillips, S. J. (2010). 22nd annual legislative update: Regulatory and legislative successes for APNs. The Nurse Practitioner, 35, 24–27. doi:10.1097/ 01.NPR.0000366130.98728.34
QSEN Institute. (n.d.). Pre-licensure KSAs. Retrieved from http://qsen.org/competencies/pre-licensure-ksas
Schuyler, C. B. (1992). Florence Nightingale. In F. Nightingale, Notes on nursing: What it is, and what it is not (Commemo- rative ed., pp. 3–17). Philadelphia, PA: Lippincott.
Selway, J. (2012). Nurse practitioners: A vital force in healthcare delivery. American Nurse Today, 7(9), 8–11.
Sherwood, G. (2011). Integrating quality and safety science in nursing education and practice. Journal of Research in Nursing, 16, 226–240. doi:10.1177/1744987111400960
Sherwood G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. West Sussex, United Kingdom: John Wiley & Sons.
Stokowski, L. A. (2011). Looking out for our new nurse grads. Retrieved from http://www.medscape.com/ viewarticle/744221
Stokowski, L. A. (2012). Just call us nurses: Men in nursing. Retrieved from http://www.medscape.com/ viewarticle/768914
Sullivan, D. T., Fries, K. S., & Relf, M. V. (2012). Exploring the changing landscape of jobs for new graduates: Practice, education, and new graduate imperatives.Creative Nursing, 18(1), 17–24.
Tri-Council for Nursing. (2010). Educational advancement of registered nurses: A consensus position. Retrieved from http://www.aacn.nche.edu/Education/pdf/ TricouncilEdStatement.pdf
U.S. Census Bureau. (2013). Men in nursing occupations. American community survey highlight report. Retrieved from http://www.census.gov/people/io/files/Men_in_ Nursing_Occupations.pdf
Vietnam Women’s Memorial Foundation (n.d.). During the Vietnam era. . . . Retrieved from http://www .vietnamwomensmemorial.org/vwmf.php
Selected Bibliography Aiken, L. H. (2011). Nurses for the future. New England
Journal of Medicine, 364(3), 196–198. doi:10.1056/ NEJMp1011639
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O., (2012). The future nursing workforce: The authors reply. Health Affairs, 31, 652. doi:10.1377/hlthaff.2012.0120
Biletchi, J. (2013). Men work here too: How men can thrive in maternal–newborn nursing. Nursing, 43(3), 50–53. doi:10.1097/01.NURSING.0000425862.64948.1b
Cipriano, P. F. (2011). The future of nursing and health IT: The quality elixir. Nursing Economics, 29(5), 286–289.
Fairman, J. A., & Okoye, S. M. (2011). Nursing for the future, from the past: Two reports on nursing from the institute of medicine. Journal of Nursing Education, 50(6), 305–311. doi:10.3928/01484834-20110519-02
Hassmiller, S. B. (2011). The future of nursing institute of medicine report: One year later. (2011). Journal of Continuing Education in Nursing, 42(11), 479–480. doi:10.3928/00220124-20111024-01
READINGS AND REFERENCES
9. A registered nurse is interested in functioning as a health care advocate for individuals whose lives are affected by violence. This nurse will be investigating which expanded career role? 1. Clinical nurse specialist 2. Forensic nurse 3. Nurse practitioner 4. Nurse educator
10. Fill in the blank: Instead of debating academic requirements for RN preparation, nursing is now focusing on academic __________ for nursing students and graduates.
See Answers to Test Your Knowledge in Appendix A.
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Hinds, L. E. (2013). Patient-centered care: A nursing priority. Journal of Continuing Education in Nursing, 44(1), 10–11. doi:10.3928/00220124-20121227-70
Holland, C., & Moddeman, G. R. (2012). Transforming the journey for newly licensed registered nurses. Journal of Continuing Education in Nursing, 43(7), 330–336. doi:10.3928/00220124-20120402-16
Ierardi, J., Fitzgerald, D. A., & Holland, D. T. (2010). Exploring male students’ educational experi- ences in an associate degree nursing program. Journal of Nursing Education, 49, 215–218. doi:10.3928/01484834-20091217-04
Kelly, L., McHugh, M., & Aiken, L.H. (2011). Nurse out- comes in Magnet and non-Magnet hospitals. Journal of Nursing Administration, 41(10), 428–433. doi:10.1097/ NNA.0b013e31822eddbc
Kramer, M., Maguire, P., Halfer, D., Brewer, B., & Schmalenberg, C. (2011). Impact of residency programs on professional socialization of newly licensed registered
nurses. Western Journal of Nursing Research, 35(4), 459–496. doi:10.1177/0193945911415555
McEwen, M., White, M. J., Pullis, B. R., & Krawtz, S. (2012). National survey of RN-to-BSN programs. Journal of Nursing Education, 51(7), 373–380. doi:10.3928/01484834-20120509-02
Millan, A. (2012). Nurse shortage in the United States: A Hispanic perspective. Hispanic Health Care International, 10(2), 59–60. doi:10.1891/1540-4153.10.2.59
Moore, P., & Carolyn, S. C. (2012). The lived experience of new nurses: Importance of the clinical preceptor. Journal of Continuing Education in Nursing, 43(12), 555–565. doi:10.3928/00220124-20120904-29
Munkvold, J., Tanner, C. A., & Herinckx, H. (2012). Factors affecting the academic progression of associate degree graduates. Journal of Nursing Education, 51(4), 232–235. doi:10.3928/01484834-20120224-04
Pfeifer, G. M. (2013). The top nursing news story of 2012: Health care reform goes hand in hand with expanded
nursing roles. American Journal of Nursing, 113(1), 15. doi:10.1097/01.NAJ.0000425737.68484.17
Potempa, K. (2012). A future nursing shortage? Health Affairs, 31(3), 652. doi:10.1377/hlthaff.2012.0119
Stokowski, L. A. (2011). What happened to the cap? The dawn of the cap. Retrieved from http://www.medscape .com/viewarticle/741581_print
Stokowski, L. A. (2011). The demise of the nurse’s cap. Retrieved from http://www.medscape.com/ viewarticle/747498_print
Varner, K. D., & Leeds, R. A. (2012). Transition within a graduate nurse residency program. The Journal of Continuing Education in Nursing, 43(11), 491–499. doi:10.3928/00220124-20121001-28
Williams, T., & Heavey, E. (2014). How to meet the challenges of correctional nursing. Nursing, 44(1), 51–54. doi:10.1097/01.NURSE.0000438716.50840.04
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LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Explain the relationship between research and evidence-
based nursing practice. 2. Apply the steps of change used in implementing evidence-
based practice. 3. Describe limitations in relying on research as the primary
source of evidence for practice.
INTRODUCTION Current standards of professional performance for nurses include using evidence and research findings in practice. At the minimum, all nurses are expected to use evidence and research to determine proper nursing actions, to engage in research activities as appro- priate to their abilities, and to share knowledge with other nurses ( American Nurses Association, 2010). Additionally, nurses today are actively involved in generating and publishing evidence in order to improve client care and expand nursing’s knowledge base. These activities support the current emphasis on practice that is based on evidence and on all nurses needing to be able to locate, understand, and evaluate both research findings and nonresearch evidence. All nurses need a basic understanding of the research process and its re- lationship to evidence-based practice.
EVIDENCE-BASED PRACTICE Evidence-based practice (EBP), or evidence-based nurs- ing, occurs when the nurse can “integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care” (Cronenwett et al., 2007). See Figure 2–1 •. Thus, as evidence changes, so must practice. One model for changing practice as a result of evidence (Melnyk,
Fineout-Overholt, Stillwell, & Williamson, 2010) uses the follow- ing steps:
• Cultivate a spirit of inquiry. Nurses need to be curious and willing to investigate how various practices compare and which might be best for a specific client.
• Ask clinical questions. For consistency and efficiency, nurses should state the question in a standard format such as PICOT (see page 30).
• Search for the best evidence. In the previous step, key terms are identified that facilitate identifying relevant evidence in the literature.
• Critically appraise the evidence. Several toolkits or schema are available to assist the nurse in determining the most valid, reli- able, and applicable evidence. In some cases, relevant studies may already have been synthesized (see Box 2–1).
• Integrate the evidence with clinical expertise and client/family preferences and values. Evidence must not be automatically ap- plied to the care of individual clients. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established.
• Implement and evaluate the outcomes of the intervention. The nurse gathers all relevant data that may indicate whether or not
KEY TERMS
comparative analysis, 31 confidentiality, 34 content analysis, 31 cost–benefit analysis, 31 critique, 32 dependent variable, 30 descriptive statistics, 31 ethnography, 29 evidence-based practice
(EBP), 26
extraneous variables, 28 grounded theory, 29 hypothesis, 30 independent variable, 30 inferential statistics, 31 logical positivism, 28 measures of central
tendency, 31 measures of variability, 31 methodology, 30
naturalism, 29 phenomenology, 29 pilot study, 30 protocols, 30 qualitative research, 29 quantitative research, 28 reliability, 30 research, 27 research design, 30 research process, 29
sample, 30 scientific validation, 31 statistically significant, 31 target population, 30 validity, 30
2 Evidence-Based Practice and Research in Nursing
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4. Differentiate the quantitative approach from the qualitative approach in nursing research.
5. Outline the steps of the research process. 6. Describe research-related roles and responsibilities for nurses. 7. Describe the nurse’s role in protecting the rights of human
participants in research.
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4. Not all published research is robust and flawless. 5. EBP should promote cost-effective care, but cost is often not in-
cluded in traditional research studies.
NURSING RESEARCH Using research findings to guide decisions about client care is noth- ing new. As early as 1854, Florence Nightingale demonstrated how research findings could be used to improve nursing care. When Nightingale arrived in the Crimea in 1854, she found the military hospital barracks overcrowded, filthy, infested with fleas and rats, and lacking in food, drugs, and essential medical supplies. By systemati- cally collecting, organizing, and reporting data, Nightingale was able to institute sanitary reforms and significantly reduce mortality rates from contagious diseases and infection. Although the Nightingale tradition influenced the establishment of American nursing schools, her ideas about the importance of research did not take hold in nurs- ing until early in the 20th century.
Currently, accrediting organizations require all baccalaure- ate and higher degree programs to include coursework in research and evidence-based practice. Many associate degree and diploma programs also include content in these important areas. Research- related role expectations for nurses with different levels of educa- tional preparation were reaffirmed by the American Association of Colleges of Nursing (AACN) in 2006 and are presented in Table 2–1. All nurses, however, have a responsibility to identify nursing issues that require research and to participate in research studies to the extent they are able.
The journal Nursing Research was first published in 1952 to serve as a vehicle for communicating nurses’ research findings. The publication of many other nursing research journals followed, some dedicated to research and others combining clinical and research ar- ticles. The breadth and diversity of nursing research is reflected in the examples of recent nursing studies shown in Box 2–2.
In 1985, after intense lobbying by the American Nurses Associa- tion (ANA), the U.S. Congress passed a bill creating the National Cen- ter for Nursing Research as a part of the National Institutes of Health. The center was elevated to institute status in 1993 and became the National Institute of Nursing Research (NINR). The establishment of NINR puts nursing research on an equal footing with research by other health-related professions by supporting research training and research related to client care. The budget of the NINR reflects a steady increase in federal funding for nursing research. Current pri- ority areas for research funding by NINR are health promotion and disease prevention, symptom management, innovation, developing nurse scientists, and palliative/end-of-life care (NINR, 2011). Many nursing specialty organizations also regularly identify priority areas for research funding.
Approaches to Nursing Research Nurse researchers use two major approaches to investigating clients’ responses to health alterations and nursing interventions. These ap- proaches, quantitative and qualitative research, originate from differ- ent philosophical perspectives and generate different types of data. Both approaches make valuable contributions to evidence-based practice.
Figure 2–1 • Components of evidence-based practice.
Clinical Expertise
EBP
Best Evidence
Patient Values &
Preferences
BOX 2–1
Cochrane Collaborative Database of Abstracts of Reviews of Effects (DARE) Evidence Based Nursing Journal Health Information Resource Database Johanna Briggs Institute National Guidelines Clearinghouse Essential Evidence Plus/Patient-Oriented Evidence That Matters
(POEMS) Worldviews on Evidence-Based Nursing
Sources of Synthesized Knowledge
the intervention was successful. If the outcomes varied from those reported in the evidence, this evaluation can help determine the reasons for the variable responses and will contribute to improv- ing the evidence available for future situations.
Some scholars contend that, while evidence includes theories, opinions of recognized experts, clinical expertise, clinical experi- ences, and findings from client assessments, findings from research studies are often given the most weight in the decision-making process. This emphasis is because research entails using formal and systematic processes to address problems and answer questions. The disciplined thinking and the careful planning and execution that characterize research means that the resulting findings should be accurate, dependable, and free from bias.
Other scholars and practitioners express concerns about the cur- rent prominence and conception of EBP as primarily using research as the source of evidence. Some believe that the best evidence for EBP is theory rather than research (Fawcett, 2012). Reasons for concerns about reliance solely on research for EBP include the following:
1. Research is often done under very controlled circumstances, which is very different from the real world of health care delivery.
2. Research evidence suggests that there is one best solution to a problem for all clients and this limited perspective stifles creativity.
3. Research may ignore the significance of life events to the indi- vidual. Nursing care should consider feasibility, appropriateness, meaningfulness, and effectiveness (FAME) of interventions and plans (Pearson, Jordan, & Munn, 2012).
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TABLE 2–1 Research-Related Role Expectations for Nurses with Different Levels of Educational Preparation
Educational Preparation Identified Expectations
Baccalaureate degree Basic understanding of the research process. Able to understand and apply research findings from nursing and other disciplines in clinical practice. Understand the basic elements of evidence-based practice. Work with others to identify potential research problems. Collaborate on research teams.
Master’s degree Evaluate research findings. Implement evidence-based practice guidelines. Form and lead research teams in work settings and professional groups. Identify practice and systems problems that require study. Work with scientists to initiate research.
Practice-focused doctoral (DNP) degree
Focus on the evaluation and use of research rather than the conduct of research. Translate scientific knowledge into complex clinical interventions tailored to meet individual, family, and community health and illness needs. Use leadership skills to evaluate the translation of research into practice. Collaborate with scientists on new health policy research opportunities that evolve from the translation and evaluation processes.
Research-focused doctoral (PhD) degree
Conduct independent research. Seek needed support for the initial phases of a research program. Involve others in research projects.
Postdoctoral preparation Establish and pursue a focused research agenda. From AACN Position Statement on Nursing Research, by American Association of Colleges of Nursing, 2006, Washington, DC: Author.
BOX 2–2
• The feeding method of neonates and babies and, especially, the issue of breast-feeding is one of the most important for public health. The Greek study by Daglas and Anoniou (2012) reviewed studies about cultural practices and beliefs for breast-feeding. The research question focused on how cultural and social standards influence breast-feeding in a society. They discovered that breast-feeding is often not determined by biologic factors, but is mainly based on the habits, standards, and behaviors existing in each society. Public health policies worldwide must take into account and study the cultural status of a society in order to create favorable conditions for the initiation and duration of breast-feeding.
• Howie and Dutton (2012), a nurse anesthetist–physician team, conducted a prospective, case-controlled observational study to determine whether an evidence-based checklist for removing clients from a ventilator (extubation) following surgical anesthesia would increase providers’ documentation of extubation criteria and reduce the occurrence of preventable extubation failures in the early postoperative period. More than 600 adult and pediatric clients were studied. Following use of the extubation checklist, documentation of clients’ readiness for extubation increased and extubation failures decreased.
• The purpose of a study by Massey (2012) was to provide evidence from a randomized clinical trial regarding the return of bowel sounds as an indicator of the end of intestinal immobility (ileus) after abdominal surgery. The number of days until return of bowel sounds after abdominal surgery was compared to the days until first postoperative flatus, an indicator of the end of ileus. There was no correlation between return of bowel sounds and time to first flatus. Thus, the results of this study support that the traditional nursing practice of listening to bowel sounds as an indicator of the end of ileus is not evidence based.
• Because no published randomized controlled trials existed concerning methods to guide practice in ongoing placement verification of temporary feeding tubes, Stepter (2012) conducted a systematic review of the literature. Only six studies specific to ongoing bedside verification methods of tube placement after initial radiologic confirmation were found between 2005 and 2010. A critical appraisal of current evidence and best practice recommendations regarding temporary feeding tubes is provided.
Additional examples of research are found in the more than 50 Evidence-Based Practice boxes featured throughout this textbook.
Examples of Current Nursing Research Studies
QUANTITATIVE RESEARCH Quantitative research entails the systematic collection, statistical analysis, and interpretation of numerical data. Quantitative research is characterized by planned and fixed study processes, careful attention to extraneous variables (any variables that could influence the results of the study other than the specific variable[s] being studied for their influence) or contaminating factors in the study environment, and an objective and distanced relationship between the researcher and what is being studied. Reports of quantitative research are characterized
by statistical information, tables, and graphs, which can make them intimidating to read. The quantitative approach to research is linked to the philosophical perspective of logical positivism, which main- tains that “truth” is absolute and can be discovered by careful measure- ment. This perspective proposes that phenomena are best understood by examining their component parts; this is referred to as a reduction- istic perspective. Positivism is the philosophical perspective of natural sciences such as biology and chemistry. It focuses on the who, what, where, when, why, and how questions (Cannon, 2014).
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In addition, compared to quantitative research, there are few publi- cations that summarize the findings and implications from groups of qualitative studies on related topics. However, the nurse must still be able to evaluate qualitative research in order to determine its rel- evance to the questions and problems central to nursing.
Table 2–2 compares the quantitative and qualitative approaches to research.
Overview of the Research Process The research process is a process in which decisions are made that result in a detailed plan or proposal for a study, as well as the actual implementation of the plan. Nurses who are reading research reports to inform their practice need a basic understanding of the research process in order to judge the credibility of a study’s findings and their usefulness for EBP. Nurses who are assisting with a study as a member of a research team need to understand the research process in order to provide meaningful input into a study and help ensure that it results in credible and useful information. Although the research process unfolds somewhat differently for quantitative and qualitative studies, the same general steps are involved: formulating the research prob- lem and purpose, determining study methods, collecting research data, analyzing research data, communicating research findings, and using research findings in practice.
FORMULATING THE RESEARCH PROBLEM AND PURPOSE The researcher’s first task is to narrow a broad area of interest into a more specific problem that indicates the issue of concern behind the study. Ideas for research problems may arise from recurrent problems encountered in practice, questions that are difficult to resolve because of contradictions in the literature, or areas in which minimal or no re- search has been done. Because conducting a study requires resources and the time and effort of study participants, a research problem should be significant to nursing and offer the potential to improve client care. The problem must also be feasible to study in light of the resources (including time and skill) that are available to conduct the study. Taking shortcuts because of insufficient resources can com- promise the quality of study findings. A research problem also must be something that can be answered by scientific investigation. Ques- tions that deal with moral or ethical issues such as “Should assisted
A quantitative approach to research is useful for research ques- tions such as these:
• What causes ___________? • Which treatment for a condition is more effective? • What factors are associated with a specific condition or outcome? • If I know X, to what extent can I predict the occurrence of Y?
QUALITATIVE RESEARCH Qualitative research is the systematic collection and thematic analysis of narrative data. In other words, the research collects and analyzes words, rather than numbers. The qualitative approach to research is rooted in the philosophical perspective of naturalism (sometimes referred to as constructivism), which maintains that real- ity is relative or contextual and constructed by individuals who are experiencing a phenomenon. This philosophical perspective is re- flected in the human sciences such as anthropology, sociology, and existential psychology.
A qualitative approach to research is characterized by flexible and evolving study processes and by minimized “distancing” between the researcher and study informant. In contrast to a quantitative study, where objectivity is sought and valued, in a qualitative study, the researcher’s subjectivity and values are seen as inevitable and even desirable. Qualitative research has a holistic perspective and results in a report that may read like a story. Nurse researchers tend to use one of three distinct qualitative traditions: phenomenology, ethnography, or grounded theory. Phenomenology focuses on lived experiences, ethnography focuses on cultural patterns of thoughts and behav- iors, and grounded theory focuses on social processes. Additional qualitative types include historical and case study research.
A qualitative approach to research is useful for research ques- tions such as these:
• What is the experience of receiving diagnosis X or undergoing treatment Y? (phenomenology)
• What are typical behaviors of certain groups of clients (who may be defined by a diagnosis or membership in a cultural or ethnic group)? (ethnography)
• How do individuals cope with X? (grounded theory)
Individual qualitative research studies are not designed with the intent to change nursing practice directly (Finfgeld-Connett, 2010).
TABLE 2–2 Comparison of Quantitative and Qualitative Research Approaches
Characteristic Quantitative Research Qualitative Research
Reality Stable Personal, contextual Data Numbers, “hard” data Words, “soft” data Perspective Outsider Insider Approach to knowing Reductionistic Contextual, holistic Research approach Objective, structured, rational, empirical Subjective, artistic, intuitive Research conditions Controlled, laboratory Naturalistic, fieldwork Goal Verification, test theory Discovery, generate theory Methods Measurement Thick description Data analyses Deductive, statistics Inductive, intuitive, themes Outcome Facts Meaning, understanding Findings/results Replicable, reliable, generalizable Valid, credible, transferable From Research Essentials: Foundations for Evidence-Based Practice (p. 55) by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health. Reprinted with permission.
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study findings are more reliable and accurate. There are two major types of research designs. With an experimental design, the researcher controls the independent variable by administering an experimen- tal treatment to some participants while withholding it from others. Experimental designs are used to determine cause-and-effect rela- tionships. With a nonexperimental design, there is no manipulation of the independent variable; in fact, there may be no identifiable in- dependent and dependent variables in the study. Nonexperimental designs are used for descriptive research studies.
Another key methodological decision is determining who (or what) will provide the data for the study. The sample or sources of in- formation for a study may be humans, events, behaviors, documents, or biologic specimens. Samples are carefully selected so that they are as accurate a representation as possible of the target population, or the universe of elements to which the researcher wishes to be able to apply the study’s findings. The sample is a carefully chosen segment of the target population. Sampling decisions are also a key factor in the usefulness of a study’s findings for evidence-based practice, since findings are more likely to be replicated in practice settings when there is a close match between the characteristics of the study sample and the characteristics of the client population to which the study findings will be applied.
Nurse researchers use a wide variety of data collection strategies, including questionnaires, interviews, observation, record reviews, and biophysical measures. Data collection decisions spell out how any intervention that is going to be administered to study partici- pants will be implemented. Data collection decisions interface closely with sampling decisions. For example, if a researcher is going to dis- tribute a questionnaire to collect data, study participants must be able to read it!
One quality control strategy in research is to conduct a pilot study. A pilot study is a “dress rehearsal” before the actual study begins. Pilot studies are helpful for detecting problems such as in- structions or questionnaire items that can be misunderstood and for providing a chance to correct these problems before formal data collection procedures get under way.
COLLECTING RESEARCH DATA During the actual data collection phase of a research study, all of the methodological decisions that have been made are implemented. Re- searchers expend great effort to ensure that data collection occurs in a consistent manner throughout the course of the study. Detailed data collection protocols or instructions and careful training of research assistants are strategies that can be used to ensure the consistency and integrity of data collection procedures. Various procedures are available for establishing the reliability and validity of research data. Reliability refers to the consistency of measures. Validity refers to the completeness and conceptual accuracy of measures. The way in which reliability and validity are established depends on the data col- lection procedure being used and the nature of the data being col- lected. Conducting a pilot test allows a researcher to do a preliminary estimate of reliability and validity.
ANALYZING RESEARCH DATA During the data analysis stage of the research process, the collected data are organized and analyzed to answer the research question(s) or test the study’s hypothesis. If a study has used a quantitative ap- proach, data analysis involves the application of a variety of statistical
suicide be allowed in this hospital?” are timely and relevant, but can- not be answered through research. Finally, because conducting a study requires a lot of time and energy, a research problem should be of interest to the researcher because the researcher’s enthusiasm and commitment to the problem can be a factor in the successful comple- tion of the study.
In addition to determining the specific problem that will be the focus of the study, the researcher must also decide on the purpose of the study or on the nature of information that it will provide. A study’s purpose statement is characterized by an action verb that indicates whether the study will provide descriptive information, explanatory information, cause-and-effect information, or information that will allow prediction and control. A study’s purpose statement has impor- tant implications for how the study will be conducted and how the data collected will be analyzed.
One strategy for stating the problem you wish to explore is to use the PICO format:
P – Patient, population, or problem of interest I – Intervention or therapy to consider for the subject of interest C – Comparison of interventions, such as no treatment O – Outcome of the intervention.
In some cases, additional components are added to make PICO into PICOD by adding study Design, PICOS by adding Setting or PICOC adding Context, and PICOT by adding Timeframe. Several other frameworks are available and are not limited to asking nursing ques- tions (Davies, 2011).
Formulating the research problem and purpose is facilitated by conducting a review of the relevant literature. This literature re- view helps the researcher become familiar with the current state of knowledge in regard to the problem area and build on that knowl- edge when designing the current study. Reviewing the literature can also help the researcher identify strategies that have been used suc- cessfully (and unsuccessfully) in the past to investigate the problem and to measure the variables of interest. A dependent variable is a behavior, characteristic, or outcome that the researcher wishes to explain or predict. An independent variable is the presumed cause of or influence on the dependent variable. In some studies, the re- searcher may develop a hypothesis or a predictive statement about the relationship between two or more variables.
DETERMINING STUDY METHODS A study’s methodology can be thought of as its logistics or mechan- ics. The methodological elements of the research process deal with how the study is organized, who or what will be the sources of in- formation for the study, and data collection details such as what data will be collected, how data will be collected, and the timing of data collection. The first methodological decision made by a researcher is whether the study will use a quantitative or qualitative research ap- proach. This decision has implications for subsequent methodologi- cal decisions about research design, sampling, and data collection, as well as data analysis.
Research design refers to the overall structure or blueprint or general layout of a study. The research design indicates how many times data will be collected in a study, the timing of data collection relative to other study events, the types of relationships between vari- ables that are being examined, the number of groups being compared in the study, and how extraneous variables will be controlled so that
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findings are statistically significant. It is important to keep in mind that just because results are statistically significant does not automati- cally mean that they are clinically significant.
If a research study uses a qualitative approach, data analy- sis involves searching for themes and patterns. This procedure is sometimes referred to as content analysis because the content of narrative materials is being analyzed. Qualitative researchers may synthesize their findings to develop a theory or conceptual frame- work of the phenomenon being studied.
COMMUNICATING RESEARCH FINDINGS Research findings must be made public if they are to become acces- sible and used to guide practice decisions. Research findings can be communicated through publication in journals or at conferences. Even small-scale research projects that are carried out in a clinical setting should be communicated. Newsletter articles and research posters are ideally suited for this purpose.
USING RESEARCH FINDINGS IN PRACTICE As described earlier, EBP entails using research findings and other sources of evidence to guide decisions about client care. Before a study’s findings are used to guide practice, they should undergo three types of evaluation: scientific validation, comparative analysis, and cost–benefit appraisal.
Scientific validation is a thorough critique of a study for its conceptual and methodological integrity. This means scrutiniz- ing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its find- ings. Comparative analysis involves assessing study findings for their implementation potential. Three factors are considered: (1) how the study’s findings compare to findings from other studies about the problem; (2) how the study’s findings will transfer from the research conditions to the clinical practice conditions in which they will be used; and (3) practical or feasibility considerations that need to be addressed when applying the findings in practice. The closer the fit between the characteristics of the setting and sample of the study and the conditions and clients with which the findings will be used, the more likely it is that the desired outcomes will be achieved. Cost–benefit analysis involves consideration of the potential risks and benefits of both implementing a change based on a study’s findings and not implementing a change. Both imme- diate and delayed potential costs and benefits to clients, nursing staff, and the organization as a whole should be considered. With the evaluation of an EBP innovation, the research process begins again. See Figure 2–2 •.
Research-Related Roles and Responsibilities for Nurses In today’s EBP environment, all nurses, regardless of their educational preparation, need to be able to assume two research-related roles: that of research consumer and research team member.
RESEARCH CONSUMER Being a research consumer means routinely searching and reading the current research literature in order to stay current with new in- sights in client experiences and nursing and medical interventions. Two skills are fundamental to this role: locating relevant literature and critiquing research reports.
Descriptive Statistics: Measures of Central Tendency and VariabilityBOX 2–3
MEASURES OF CENTRAL TENDENCY Mean—the arithmetic average for a set of scores. The mean is
calculated by summing all scores and dividing by the number of scores.
Median—the middle value in a distribution of scores or the value above and below which 50% of the scores lie.
Mode—the most common or frequently occurring value in a data set.
MEASURES OF VARIABILITY Range—the difference or span between the lowest and highest
value for a variable. Standard deviation—the average amount by which a single score
in a distribution deviates or differs from the mean score.
procedures. Descriptive statistics are procedures that organize and summarize large volumes of data including measures of cen- tral tendency and measures of variability. Measures of central tendency provide a single numerical value that denotes the “average” value for a variable. Measures of variability describe how values for a variable are dispersed or spread out. Specific measures of central tendency and variability are defined in Box 2–3.
The use of inferential statistics allows researchers to test hypotheses about relationships between variables or differences between groups. Inferential statistics are particularly useful when a researcher wants to establish the effectiveness of an intervention. Commonly used inferential statistics are defined in Box 2–4.
After inferential statistics have been computed, the results are inspected for statistical significance. If results are statistically significant, it means that they are not likely to have occurred only by chance. The notion of statistical significance is linked to probabil- ity. By convention, probability (a p value) of less than .05 is consid- ered to indicate statistical significance. A p value of .05 means that the observed statistical results are likely to occur solely by chance only 5% of the time. Another measure of the significance of findings is the confidence interval (CI). The CI indicates the range within which the true value lies, with a specific level of confidence. For example, if a study indicates that something occurs, on average, 2.5 times more often in one group than in another, with a 95% CI of 1.9–3.2, this means that there is a 95% likelihood that it occurs between 1.9 and 3.2 times more often. As long as zero does not fall within the CI, the
BOX 2–4
Independent t-test—used to compare the mean performance of two independent groups (such as men and women).
Dependent (or paired) t-tests—used to compare the mean performance of two dependent or related groups (such as a before and after test given to the same individuals).
Analysis of variance (ANOVA)—used to compare the mean performance of three or more groups.
Pearson’s product-moment correlation coefficient (Pearson’s r)— used to describe and test the relationship between two continuous variables (such as age and weight).
Chi-squared—used to compare the distribution of a condition across two or more groups.
Commonly Used Inferential Statistics
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Figure 2–2 • The research process. When the effects of using research findings to guide practice are evaluated, the research process begins all over again.
Evaluate evidence-based practice
Communicate research findings
Determine study methods
Use research findings in practice
Formulate research problem
Collect research data
Analyze research data
LOCATING RESEARCH LITERATURE Increasingly, policies and procedures used in hospitals and other health care settings are evidence based, meaning that nurses who develop such documents must be familiar with the current evidence as it is presented in a variety of information sources. Searching the current information on a specific topic can be overwhelming. Because most literature searches are conducted by using key terms to locate information sources that are available through an electronic database, careful planning is important so that the sources identified stand the best chance of being relevant.
Once key terms have been identified, this information can be entered into one of the many health-related electronic databases that are available. The most comprehensive electronic database for nurses is CINAHL (Cumulative Index of Nursing and Allied Health Literature). CINAHL and other useful databases and the type of in- formation they include are listed in Box 2–5. Although many of these databases are fee based, authors and publishers are moving toward open-access (free full-text) scholarly journals. Tips for conducting a literature review are shared in Box 2–6.
CRITIQUING RESEARCH REPORTS In addition to locating research literature about current clinical topics and identified clinical problems, nurses must be able to critique or critically read and evaluate research articles. A research critique enables the nurse, as a research consumer, to determine whether the findings of a study are of sufficient quality to be used to influence practice decisions. A research critique involves dissecting a study to determine its strengths and weaknesses, statistical and clinical significance, and the generalizability and applicability of its results. Conducting an effective critique of a research study entails reading it several times. First, scan the article from start to finish getting a general sense of how the study was conducted. Next, focus on the results and discussion sections of the article. A key question that guides the research critique process is “Do the study findings and the researcher’s interpretation of these findings make sense in view of how the study was conducted?” This is true for both quantitative and qualitative research studies. Characteristics of an “ideal” research study are listed in Table 2–3. Features of a published study can be compared to these characteristics to guide a research critique.
BOX 2–5
Academic Search Premier: Academic multidisciplinary database provides abstracts and other information for more than 13,600 publications, including full-text access for over 4,700 scholarly publications.
CINAHL (Cumulative Index of Nursing and Allied Health Literature): Indexes current nursing and allied health journals and publications dating back to 1937.
ERIC: Citations and abstracts from more than 1,180 educational and education-related journals.
Health Source: Scholarly full-text journals focusing on medicine. Health Source—Consumer Edition: Consumer-oriented health
topics including the medical sciences, food sciences and nutrition, child care, sports medicine, and general health.
MEDLINE®: The U.S. National Library of Medicine’s bibliographic database consists of more than 11 million articles from over 4,800 indexed titles.
ProQuest: An interdisciplinary index of magazines, newspapers, and scholarly journals.
PsychInfo: Published by the American Psychological Association. Contains more than 2 million citations and summaries of journal articles, book chapters, books, and dissertations, all in the field of psychology, dating as far back as 1840.
PubMed: Access to Medline and additional biomedical information resources.
Social Services Abstracts: This database abstracts and indexes more than 1,300 journals, dissertations, and citations in social work, human services, social welfare, social policy, and community development.
Useful Electronic Databases
BOX 2–6
1. Be a detective. 2. Be organized. 3. Identify keywords you will use to guide your search. Some
articles and online search engines identify keywords associated with particular articles. It may be useful to use these to guide your own search.
4. If possible, start with a manual search by going to the library. If you prefer to begin with an online search, keep track of references you locate so you can find them again when you need them.
5. Consult the reference lists in useful articles. 6. Be flexible and creative. 7. Consider conducting separate searches for key variables. 8. Ask for help from a librarian!
From “Study Backgrounds and Literature Reviews,” by C. E. Fitzgerald. In S. Norwood, Research Essentials: Foundations for Evidence-Based Practice (p. 147), 2010, Upper Saddle River, NJ: Prentice-Hall Health.
Tips for Conducting a Literature Review
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TABLE 2–3 Characteristics of an Ideal Study
Study Element Quality Standard
Research problem Significant, not trivial. Addresses an issue that is important to nursing. Addresses a researchable problem. Is feasible to address in study setting.
Research purpose Is clearly stated. Will generate and refine knowledge. Consistent with current knowledge about problem.
Research subproblems
Clear, flow logically from purpose.
Review of literature Relevant, thorough, current, authoritative. Study framework Appropriate, clearly informs and enhances
study. Research approach Appropriate for problem and purpose.
Consistent with nature of subproblems. Study design Appropriate for study purpose.
Incorporates appropriate control strategies.
Sample Representative of target population or able to represent phenomenon of interest. Sufficient size. Ethical recruitment strategies.
Data collection Appropriate for variables and sample. Yields appropriate level of measure. Reliable and valid. Safe and humane.
Ethical considerations
Protection of human rights. Ethical standards of beneficence, respect for human dignity, and fair treatment upheld. Approved by Institutional Review Board (IRB).
Data analysis Appropriate for data and research questions.
Findings and interpretation
Consistent with study results, address research questions, supported with evidence, logical and reasonable.
From Research Essentials: Foundations for Evidence-Based Practice (p. 268), by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health.
RESEARCH TEAM MEMBER In addition to being well-informed research consumers, in today’s evidence-based practice environment, nurses need to be able to function as a member of a research team. This role is particularly important in hospitals that are seeking or wishing to maintain mag- net recognition status. Nurses in hospitals with this designation are expected to be involved in research and EBP activities on an ongoing basis. Research priorities were established by the Magnet National Research Agenda Study and include items in the catego- ries of clinical outcomes, client and nurse satisfaction, practice en- vironment, human resources, and financial and material resources (American Nurses Credentialing Center, 2013). Depending on their individual experience with research, nurses who are working
directly with clients can make particularly valuable contributions to research projects, including:
• Identifying clinically relevant problems that need to be studied • Reviewing the literature to provide background information for
a study • Recruiting study participants • Securing clients’ consent to participate in a study • Designing data collection instruments • Pilot-testing data collection procedures • Collecting research data • Monitoring for adverse effects of study participation • Implementing research interventions • Assisting with interpretation of study findings.
A chief responsibility in all of these activities is serving as a client ad- vocate and protecting the rights of clients who are involved in a re- search study. Unfortunately, there are many historical instances of our failure to advocate for ethical treatment of clients in the conduct of research. Examples of these include the 40-year-long study of Black men in Alabama in the mid-1900s who were allowed to go untreated for syphilis in order to investigate the progression of the disease— commonly referred to as the Tuskegee study, the 1992 Kennedy Krieger Institute study in which young children were knowingly exposed to lead in their homes (Schildmann, Sandow, Rauprich, & Vollmann, 2012), and the Havasupai Arizona Indian tribe study where blood drawn to study diabetes was used for additional research regarding genetic tendencies in the population without their permis- sion (Langford & Young, 2013). The nurse’s responsibility to protect clients’ rights is discussed in more depth in the following section.
PROTECTING THE RIGHTS OF STUDY PARTICIPANTS Because nursing research usually involves humans, a major nursing responsibility is to be aware of and to advocate on behalf of clients’ rights. Before any research on humans can be started, the researcher must obtain approval from the relevant committee designated to protect human subjects’ rights. This includes research that does not require direct involvement of the person, only access to data about the client. This committee is often called the Institutional Review Board (IRB). The IRB ensures that all clients are informed of and understand the consequences of consenting to serve as research participants (Figure 2–3 •). The specific elements that comprise informed consent are listed in Box 2–7.
The client needs to have enough information to be able to assess whether an appropriate balance exists between the risks and inconvenience of participating in a study and the potential benefits, either to the client or to the development of knowledge that may benefit others.
For many years, adults have been the focus of much health care research conducted on human subjects. The American Academy of Pediatrics has identified the need to conduct pediatric research so that children can benefit from advances in medical science. At the same time, because children are so vulnerable, extra precautions must be taken to ensure their rights are upheld and they are not harmed. It is critical to have pediatric expertise on panels that review prospec- tive research studies and in research development. All nurses who practice in settings where research is being conducted with human subjects or who participate in such research play an important role in safeguarding the rights discussed next.
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RIGHT NOT TO BE HARMED The risk of harm to a research subject is exposure to the possibility of injury going beyond everyday situations. The risk can be immediate or delayed and can be physical, emotional, legal, financial, or social in nature. For instance, withhold- ing standard care from a client in labor for the purpose of studying the course of natural childbirth clearly poses a potential physical dan- ger. Risks can also involve psychological factors such as exposure to stress or anxiety, or social factors, such as loss of confidentiality or loss of privacy. Potential risks of participating in a study need to be detailed in informed consent documents.
RIGHT TO FULL DISCLOSURE Even though it may be possible to collect research data about a client as part of everyday care without the client’s particular knowledge or consent, to do so is considered unethical. Full disclosure, the act of making clear the client’s role in a research situation, is a basic right. This means that deception, by ei- ther withholding information about a client’s participation in a study or giving the client false or misleading information about what par- ticipating in the study will involve, must not occur.
RIGHT TO SELF-DETERMINATION Many clients feel pressured to participate in studies. They believe that they must please the phy- sicians and nurses who are responsible for their treatment and care. The right to self-determination means that participants should feel free from constraints, coercion, or any undue influence to participate in a study. Hidden inducements—for instance, suggesting to poten- tial participants that by taking part in the study they might become famous, make an important contribution to science, or receive spe- cial attention—must be strictly avoided.
RIGHT TO PRIVACY Privacy enables a client to participate with- out worrying about later embarrassment. The anonymity of a study participant must be ensured even if the investigator cannot link a specific person to the information reported. Confidentiality means that any information a participant relates will not be made public or available to others without the participant’s consent. Investiga- tors must inform research participants about the laws (such as the Privacy and Security Rules of the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) and measures that provide for these rights. Such measures may include the use of pseudonyms or code numbers or reporting only aggregate or group data in pub- lished research.
Figure 2–3 • It is important for clients to be fully informed before they participate in a research study. Ron Sutherland/Photo Researchers, Inc.
BOX 2–7
Subject status (“You are being asked to participate in a research study.”)
Study purpose Sponsorship (“This study is being paid for by [name of
pharmaceutical company, research grant, hospital].”) Subject selection (“You are being asked to take part in this
study because [identify relevant subject characteristics or eligibility requirements].”)
Study procedures, type of data to be collected Nature of commitment (“Taking part in this study should
take no longer than [period of time].”) Potential risks and costs associated with participation Potential benefits associated with participation Protection of privacy Voluntary consent (“By signing this form, you are indicating
that you are freely agreeing to take part in this study and are indicating that no one is forcing you to take part.”)
Alternatives (If the individual is being asked to take part in a study about an experimental treatment, information must be provided about other ways in which his or her condition could be treated.)
Right to decline to participate or to withdraw from the study; nonprejudicial treatment (“You can refuse to take part in this study and will not be punished or treated dif- ferently in any way. If you agree to take part in this study, you can stop taking part at any time or refuse to answer any questions. If you do this, you will not be punished or treated differently in any way.”)
Comprehension of information (“By signing this form you indicate that you have read and understand the information on the form. You also are indicating that you have had a chance to ask questions.”)
Contact information: whom to contact with questions about the study or complaints about treatment during the course of the study
Adapted from Research Essentials: Foundations for Evidence-Based Practice (p. 82), by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health.
Elements of Informed Consent
Critical Thinking Checkpoint
Imagine that you have read a research report that found a new type of mattress overlay reduced the incidence of skin breakdown by 25%. Before you recommend that your agency purchase these overlays: 1. What other aspects of the research study should be carefully
examined? 2. How would other aspects of EBP be brought into this situation? 3. What additional aspects would you take into consideration?
See Critical Thinking Possibilities on student resource website.
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• Evidence-based practice, or evidence-based nursing, involves clinical decision making using a variety of sources of evidence modified for use in specific settings and for individual clients.
• Change in practice requires assessing the need for change; locating and analyzing the best evidence; designing, implementing, and evalu- ating the practice change; and integrating and maintaining the change.
• Some nurses believe that research should not be the sole or pri- mary source of evidence for practice because it may differ greatly from the real world of practice, limits creativity, does not adequately consider meaning and significance to clients, and has not been demonstrated to be cost effective.
• Nursing research began in North America in the early 1900s. Since that time, the concept of research has been introduced into
nursing education programs, research journals in nursing have been developed, and the National Institute for Nursing Research has been established.
• Nurses use both quantitative and qualitative approaches to ad- dress issues of concern for client care. Quantitative studies are reported using descriptive and analytical statistics, and qualitative studies are reported in narrative format.
• In today’s evidence-based practice environment, all nurses need to be well-informed consumers of research and able to serve as effective research team members.
• A key responsibility for nurses who are assisting on a research team is to protect the rights of clients who are participating in the study.
CHAPTER HIGHLIGHTS
1. Which of the following is the lowest level of “best evidence” for evidence-based practice? 1. Clinical experiences 2. Opinions of experts 3. Client values and preferences 4. Trial and error
2. A quantitative research approach is most appropriate for which study? 1. A study measuring the effects of sleep deprivation on wound
healing 2. A study examining the bereavement process in spouses of
clients with terminal cancer 3. A study exploring factors influencing weight control behavior 4. A study examining a client’s feelings before and after a bone
marrow aspiration 3. A qualitative research approach is most appropriate for which
study? 1. A study measuring nutrition and weight loss or gain in clients
with cancer 2. A study examining oxygen levels after endotracheal suctioning 3. A study examining client reactions to stress after open heart
surgery 4. A study measuring differences in blood pressure before,
during, and after a procedure 4. A key function of a study’s methodology is to
1. Determine the hypotheses that will be tested in the study. 2. Exercise control over contaminating factors in the study
environment. 3. Identify grants and other funding sources for conducting the
study. 4. Protect the rights of the study’s participants.
5. In the PICO format for phrasing research questions and identifying key terms for a literature search, what does the “P” stand for? 1. Patterns 2. Population 3. Probability 4. Purpose
6. Which of the following is a nursing responsibility when reading published nursing research? 1. Assume that the research was properly conducted since it
has been published.
2. Evaluate whether the findings are applicable to the nurse’s specific clients.
3. Implement the research findings if at least two studies have shown the same results.
4. Request the raw data from the researchers so that the nurse can analyze the statistics again.
7. A research critique can best be defined as a/an 1. Appraisal of a study’s strengths and weaknesses. 2. Conclusion about the utilization potential of a study’s findings. 3. Criticism of a study’s flaws. 4. Summary of a study’s key points.
8. An 85-year-old client in a nursing home tells a nurse, “Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me.” Which client right is being violated? 1. Right not to be harmed 2. Right to full disclosure 3. Right to privacy and confidentiality 4. Right to self-determination
9. Place each of the following steps of evidence-based practice change in their usual sequence. 1. _____ Locate the best evidence. 2. _____ Ask the clinical question. 3. _____ Assess the need for change. 4. _____ Integrate the change with client preferences. 5. _____ Analyze the evidence. 6. _____ Implement and evaluate the change.
10. A nurse proposes that the hospital apply the findings from a re- cent research study that shows that clients appreciate classical orchestra music and playing it frequently lowers clients’ blood pressure. Which aspect of research suggests that it may not be appropriate to implement this as evidence-based practice? 1. All research is flawed. 2. The research would not have taken into consideration the
cost of acquiring and playing the music in a hospital. 3. One study would not be sufficient to show that all clients
would find orchestral music pleasing. 4. Research cannot demonstrate clients’ appreciation of music
since research is only appropriate for physiological problems. See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
35
Chapter 2 Review
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Suggested Reading McCleland, A. (2011). Culturally safe nursing research: Explor-
ing the use of an indigenous research methodology from an indigenous researcher’s perspective. Journal of Transcultural Nursing, 22, 362–367. doi:10.1177/1043659611414141 This article defines cultural safety and the concern that indig- enous students put aside their culture when they commit to study within a Western perspective. It outlines the use of a methodology and method in a project that enabled partici- pants and the researcher to develop a culturally safe process.
Related Research Breimaier, H., Halfens, R., & Lohrmann, C. (2011). Nurses’
wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing, 20, 1744–1756. doi:10.1111/j.1365-2702.2010.03491.x
Majid, S., Foo, S., Luyt, B., Xue, Z., Yin-Leng, T., Yun-Ke, C., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99, 229–236. doi:10.3163/1536-5050.99.3.010
Solomons, N., & Spross, J. (2011). Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: An integrative review. Journal of Nursing Management, 19, 109–120. doi:10.1111/j.1365-2834.2010.01144.x
References American Association of Colleges of Nursing. (2006). AACN posi-
tion statement on nursing research. Washington, DC: Author. American Nurses Association. (2010). Nursing: Scope and
standards of practice (2nd ed.). Silver Spring, MD: Author. American Nurses Credentialing Center. (2013). National
Magnet Research Agenda. Retrieved from http://www .nursecredentialing.org/Magnet/ResourceCenters/ MagnetResearch/NationalMagnetResearchAgenda.html
Cannon, S. (2014). Quantitative research design. In C. Boswell and S. Cannon (Eds.), Introduction to nursing research: Incorporating evidence-based practice (pp. 203–225). Burlington, MA: Jones & Bartlett.
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006
Daglas, M., & Antoniou, E. (2012). Cultural views and practices related to breastfeeding. Health Science Journal, 6, 353–361.
Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75–80.
Fawcett, J. (2012). Thoughts about evidence-based nurs- ing practice. Nursing Science Quarterly, 25, 199–200. doi:10.1177/0894318412437967
Finfgeld-Connett, D. (2010). Generalizability and trans- ferability of meta-synthesis research findings. Journal of Advanced Nursing, 66, 246–254. doi:10.1111/j.1365-2648.2009.05250.x
Fitzgerald, C. E. (2010). Study backgrounds and literature reviews. In S. Norwood, Research essentials: Foundations for evidence-based practice (pp. 125–162). Upper Saddle River, NJ: Prentice-Hall Health.
Howie, W. O., & Dutton, R. P. (2012). Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: A pilot study. AANA Journal, 80, 179–184.
Langford, R., & Young, A. (2013). Making a difference with nursing research. Upper Saddle River, NJ: Pearson.
Massey, R. L. (2012). Return of bowel sounds indicating an end of postoperative ileus: Is it time to cease this long-standing nursing tradition? MEDSURG Nursing, 21, 146–150.
Melnyk , B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51–53. doi:10.1097/01.NAJ.0000366056.06605.d2
National Institute of Nursing Research, National Institutes of Health. (2011). Bringing science to life: NINR strategic plan (NIH Publication No. 11-7783). Retrieved from https:// www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr- strategic-plan-2011.pdf
Norwood, S. (2010). Research essentials: Foundations for evidence-based practice. Upper Saddle River, NJ: Prentice-Hall Health.
Pearson A., Jordan, Z., & Munn, Z. (2012). Translational science and evidence-based healthcare: A clarification and reconceptualization of how knowledge is generated and used in healthcare. Nursing Research and Practice, 2012, Article 792519. doi:10.1155/2012/792519
Schildmann, J., Sandow, V., Rauprich, O., & Vollmann, J. (2012). Human medical research: Ethical, legal and socio-cultural aspects. Basel, Switzerland: Springer.
Stepter, C. R. (2012). Maintaining placement of temporary enteral feeding tubes in adults: A critical appraisal of the evidence. MEDSURG Nursing, 21(2), 61–102.
Selected Bibliography Brown, S. J. (2012). Evidence-based nursing: The research-
practice connection (2nd ed.). Sudbury, MA: Jones & Bartlett. Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing
evidence based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
Fineout-Overholt, E., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Evaluating and disseminating the impact of an evidence-based intervention: Show and tell. American Journal of Nursing, 111(7), 56–59. doi:10.1097/01 .NAJ.0000399317.21279.47
Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part I. American Journal of Nursing, 110(7), 47–52. doi:10.1097/01 .NAJ.0000383935.22721.9c
Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step
by step: Critical appraisal of the evidence: Part II: Digging deeper—Examining the “keeper” studies. American Journal of Nursing, 110(9), 41–48. doi:10.1097/01.NAJ.0000388264.49427.f9
Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part III. American Journal of Nursing, 110(11), 43–51. doi:10.1097/01.NAJ.0000390523.99066.b5
Fineout-Overholt, E., Williamson, K. M., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Following the evidence: Planning for sustainable change. American Journal of Nursing, 111(1), 54–60. doi:10.1097/01.NAJ.0000393062.83761.c0
Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Rolling out the rapid response team. American Journal of Nursing, 111(5), 42–47. doi:10.1097/01 .NAJ.0000398050.30793.0f
Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Implementing an evidence-based practice change. American Journal of Nursing, 111(3), 54–60. doi:10.1097/10.1097/01.NAJ.0000395243.14347.7e
Melnyk, B. M., & Fineout-Overholt, B. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Sustaining evidence-based practice through organizational policies and an innovative model. American Journal of Nursing, 111(9), 57–60. doi:10.1097/01.NAJ.0000405063.97774.0e
Rebar, C. R., Gersch, C. J., Macnee, C. L., & McCable, S. (2011). Understanding nursing research: Using research in evidence-based practice (3rd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Wiliams & Wilkins.
Schmidt, N. A., & Brown, J. M. (2012). Evidence-based practice for nurses: Appraisal and application of research (2nd ed.). Sudbury, MA: Jones & Bartlett.
Sherwood, G., & Barnsteiner, J. (Eds.). (2012). Quality and safety in nursing: A competency approach to improving outcomes. Ames, IA: John Wiley & Sons.
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Searching for the evidence. American Journal of Nursing, 110(5), 41–47. doi:10.1097/ 01.NAJ.0000372071.24134.7e
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Asking the clinical question: A key step in evidence- based practice. American Journal of Nursing, 110(3), 58–61. doi:10.1097/01.NAJ.0000368959.11129.79
Titler, M. G. (2011). Nursing science and evidence-based prac- tice. Western Journal of Nursing Research, 33(3), 291–295. doi:10.1177/0193945910388984
READINGS AND REFERENCES
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LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Differentiate the terms theory, concept, conceptual framework,
paradigm, and metaparadigm for nursing. 2. Describe the major purpose of theory in the sciences and
practice disciplines. 3. Identify the components of the metaparadigm for nursing.
INTRODUCTION As a profession, nursing is involved in identifying its own unique body of knowledge essential to nursing practice—nursing science. To identify this knowledge base, nurses must develop and recognize concepts and theories specific to nursing. Because theories in some other disciplines were developed and used much before nursing theories, it is helpful to explore briefly how theory has been used by those disciplines before considering theory in nursing.
INTRODUCTION TO THEORIES A theory may be defined as a system of ideas that is presumed to explain a given phenomenon. For now, think of a theory as a major, very well-articulated idea about something important. Theories are used to describe, predict, and control phenomena.
Four influential theories from the 20th century were Marx’s the- ory of alienation, Freud’s theory of the unconscious, Darwin’s theory of evolution, and Einstein’s theory of relativity. Most undergraduate students are introduced to the major theories in their disciplines. Psy- chology majors study Freud and Jung’s theories of the unconscious, Sullivan and Piaget’s theories of development, and Skinner’s theory of behaviorism. Sociology majors study Marx’s theory of alienation and Weber’s theories of modern work. Biology majors are introduced to Darwin’s theory of evolution, but also to Stephen Jay Gould’s critique and modification of evolutionary theory. Physics majors are intro- duced to a historical progression of theorists including Copernicus, Newton, Einstein, and newer theorists in quantum mechanics.
The extent to which theories build on or modify previous theo- ries varies with the discipline, as does the importance of theory in the discipline. Students in nursing, teaching, and management often take some courses in theory, but these students generally focus on learn- ing their practice. Management students study management theories,
but the relationship between the theory of management and the prac- tice of management is not nearly as strong as the relationship between the theory of physics and the practice of physics. This is because the practice of physics is theory and research, whereas the practice of management, teaching, nursing, art, music, law, clinical psychol- ogy, and pastoral care is something else entirely. The term practice discipline is used for fields of study in which the central focus is per- formance of a professional role (e.g., nursing, teaching, management, music). Practice disciplines are differentiated from the disciplines that have research and theory development as their central focus, for example, the natural sciences. In the practice disciplines, the main function of theory (and research) is to provide new possibilities for understanding the discipline’s practice.
Context for Theory Development in American Universities In the 19th century, Florence Nightingale thought that the people of Great Britain needed to know more about how to maintain healthy homes and how to care for sick family members. Nightingale’s Notes on Nursing: What It Is, and What It Is Not (1860/1969) was our first textbook on home care and community health. However, the audi- ence for that text was the public at large, not a separate discipline or profession. To Nightingale, the knowledge needed to provide good nursing was neither unique nor specialized. Rather, Nightingale viewed nursing as a central human activity grounded in observation, reason, and commonsense health practices. Nightingale’s theory is further described on page 40.
In the 20th century, nursing education in the United States took a different path from nursing education in Great Britain and Europe. The drive to establish nursing departments in colleges and universi- ties exposed American nursing to the dominant ideas and pressures
KEY TERMS
clients, 38 conceptual framework, 38 critical theory, 39 environment, 38
grand theories, 38 health, 38 metaparadigm, 38
midlevel (or middle range) theories, 39
nursing, 38 paradigm, 38
philosophy, 40 practice discipline, 37 theory, 37
3 Nursing Theories and Conceptual Frameworks
4. Identify the role of nursing theory in nursing education, research, and clinical practice.
5. Identify one positive and one negative effect of using theory to understand clinical practice.
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in American higher education at the time. During the latter half of the 20th century, disciplines seeking to establish themselves in univer- sities had to demonstrate something that Nightingale had not envi- sioned for nursing: a unique body of theoretical knowledge.
The natural and technologic sciences were often seen as role mod- els in this regard. Theories in the natural sciences provided a founda- tion and direction for research. Research in these disciplines often produced tangible results: knowledge that could be used in our efforts to control nature, disease, and foreign threats. Scientifically produced knowledge resulted in a stronger national security and economy.
The term practice discipline was not in common use until the very end of the 20th century. Disciplines without a strong theory and research base were referred to as “soft,” a negative comparison with the “hard” natural sciences. Many of the soft disciplines attempted to emulate the sciences, so theory and scientific research became a more important part of academic life, both in the practice disciplines and in the humanities.
In practice disciplines, theories work like lenses through which we are invited to interpret things like market forces, industrial effi- ciency, the human mind, pain, and suffering. Their usefulness comes from helping us interpret phenomena from unique perspectives, building new understandings, relationships, and possibilities.
Defining Terms Concepts are often called the building blocks of theories. Concepts are hard to define because the definition has to include everything from the speed of light to the unconscious. Concepts are easier to un- derstand by example. Einstein’s theory of relativity consists of a beau- tiful mathematical relationship between three concepts in physics: mass, energy, and the speed of light. However, theories are not always built like houses out of block-like concepts. Freud’s theory of the un- conscious not only required some new concepts, it required a com- pletely new model. Freud needed a model for the mind that could bring a host of human experiences together under one mental roof: dreams, wishes, decisions, behaviors, feelings, anxieties, and sexual- ity. Freud’s theory of the mind included three new concepts: the ego, the id, and the superego. It would not be right to say that Freud’s the- ory of the unconscious evolved out of these concepts. Rather, these new concepts helped him create a model in which his larger idea, the unconscious, might be understood.
A conceptual framework is a group of related ideas, state- ments, or concepts. Freud’s structure of the mind (id, ego, superego) could be considered a conceptual framework. The term conceptual model is often used interchangeably with conceptual framework, and sometimes with grand theories, those that articulate a broad range of the significant relationships among the concepts of a discipline (Peterson & Bredow, 2013).
No scientific theory is purely objective, because each is devel- oped in cultures and expressed in language. Theories offer ways of looking at or conceptualizing the central interests of a discipline. In the natural sciences, theories are often expressed in mathematical formulas, but Darwin’s Origin of Species theory requires a short book. In the social and behavioral sciences, theories attempt to explain re- lationships among concepts. The conceptualization is often complex. Other authors build on, explain, and critique the original work.
Broadly speaking, a paradigm refers to a pattern of shared un- derstandings and assumptions about reality and the world. Paradigms
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include our notions of reality that are largely unconscious or taken for granted. However, the term paradigm is used in a variety of ways by different authors, and its everyday usage varies considerably.
We become aware of paradigms when realities clash. The para- digm of 16th-century Europe, informed largely by established reli- gious doctrines and practices, clashed with the emerging discoveries in astronomy. The Industrial Revolution clashed with the long- standing feudal order, disrupting social and class relationships. In the 20th century, the ideals of socialism clashed with the ideals of capi- talism, and religious fundamentalism clashed with evolution. The next paradigm clash is likely to be between commonsense notions of space and time and the emerging field of quantum mechanics.
THE METAPARADIGM FOR NURSING In the late 20th century, much of the theoretical work in nursing fo- cused on articulating relationships among four major concepts: per- son, environment, health, and nursing. Because these four concepts can be superimposed on almost any work in nursing, they are collec- tively referred to as the metaparadigm for nursing. The term origi- nates from two Greek words: meta, meaning “with,” and paradigm, meaning “pattern.” Many consider the following four concepts to be central to nursing:
1. The individuals or clients are the recipients of nursing care (in- cludes individuals, families, groups, and communities).
2. The environment is the internal and external surroundings that affect the client. This includes people in the physical environ- ment, such as families, friends, and significant others.
3. Health is the degree of wellness or well-being that the client experiences.
4. Nursing is the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client.
The work of American nurse theorists reflects a wide range of ideas about people, the world, health, and nursing. Each nurse theorist’s definitions of these four major concepts vary with scientific and philosophical orientation, experience in nursing, and the effects of that experience on the theorist’s view of nursing.
Nursing theorists have built on the metaparadigm and on the work of Nightingale, whether or not they were conscious of doing so. In addition, other theories foundational to many nursing theories in- clude interactive, systems, and developmental theories (Figure 3–1 •).
ROLE OF NURSING THEORY Direct links exist among theory, education, research, and clinical practice. In many cases, nursing theory guides knowledge develop- ment and directs education, research, and practice although each influences the others. The interface between nursing experts in each area helps to ensure that work in the other areas remains relevant, cur- rent, useful, and ultimately influences health. Im and Chang (2012) reviewed the nursing literature from 2001 to 2010 and identified more than 2,000 articles that included key terms related to nursing theory. Of those, almost two thirds used grounded theory, while the remainder involved concept analysis, grand theory, midrange theory, or situation-specific theory. Although the focus of theory develop- ment has changed during the past 70 years, it is apparent that theory remains an important focus of nurses’ work.
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midlevel (or middle range) theories that focus on the explora- tion of concepts such as pain, self-esteem, learning, and hardiness. In qualitative research, theory can be used to help select the phenom- enon, frame the philosophical underpinnings of the study, and guide data analysis and interpretation. Qualitative research in nursing and the social sciences can also be grounded in theories from philosophy or the social sciences. For example, the term critical theory is used in academia to describe theories that help elucidate how social struc- tures affect a wide variety of human experiences from art to social practices. In nursing, critical theory research helps explain how these structures such as race, gender, sexual orientation, and economic class affect client experiences and health outcomes.
Bond et al. (2011) reviewed 2,184 research reports in seven lead- ing nursing journals over 5 years and found that 38% used theory, al- though only slightly more than half of those studied nursing theories. In comparison to previous studies, these percentages have not increased.
In Clinical Practice Where nursing theory has been employed in a clinical setting, its pri- mary contribution has been the facilitation of reflecting, questioning, and thinking about what nurses do. For example, one publication described how practicing school nurses could use Orem’s self-care deficit theory to work with children with special health care needs (Green, 2012).
As described in Chapter 2 , evidence-based practice involves the recognition of which knowledge is appropriate for application
In Education Because nursing theory was used primarily to establish the profes- sion’s place in the university, it is not surprising that nursing theory became more firmly established in academia than in clinical practice. In the 1970s and 1980s, many nursing programs identified the ma- jor concepts in one or two nursing models, organized these concepts into a conceptual framework, and built the entire curriculum around that framework. The unique language in these models was typi- cally introduced into program objectives, course objectives, course descriptions, and clinical performance criteria. The purpose was to elucidate the central meanings of the profession and to improve the status of the profession. Although all nursing programs are organized around concepts, many nursing programs have abandoned theory- driven conceptual frameworks.
In Research Nursing research identifies the philosophical assumptions or con- ceptual frameworks from which it proceeds because all thinking, writing, and speaking is based on previous assumptions about peo- ple and the world. New theoretical perspectives provide an essential service by identifying gaps in the way we approach specific fields of study such as symptom management or quality of life. Different con- ceptual perspectives also help generate new ideas, research questions, and interpretations.
Because of their breadth, grand theories only occasionally di- rect nursing research. Nursing research is more often informed by
Figure 3–1 • The living tree of nursing theories. From “The Living Tree of Nursing Theories,” by C. Tourville & K. Ingalls, 2003, Nursing Forum, 38(3), p. 23. Copyright © 2003 Blackwell Publishers. Reprinted with permission.
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to client care. Practice theories, those that describe the relationships among variables as applied to specific clinical situations (e.g., theory of postpartum depression), are important contributors to effective evidence-based practice. The Magnet Recognition Program (American Nurses Credentialing Center, 2011), which recognizes organizations that demonstrate excellence in nursing practice, requires that the orga- nization use a professional practice model. Although this model could be a nursing theory, it could also be a model from another discipline.
An increasing body of theoretical scholarship in nursing practice has been outside the framework of the formal theories presented in the next section. Philosophy is used to explore both clinical and theoreti- cal issues in the journal Nursing Philosophy. Family theorists and criti- cal theorists have encouraged the profession to move the focus from individuals to families and social structures. In addition, as nurses work increasingly in interprofessional teams, they will need theories that are applicable not only to nurses, but to the other health care pro- fessionals with whom they work (Bond et al., 2011). Debates about the role of theory in nursing practice provide evidence that nursing is maturing, both as an academic discipline and as a clinical profession.
OVERVIEW OF SELECTED NURSING THEORIES The nursing theories discussed in this chapter vary considerably in their (a) level of abstraction; (b) conceptualization of the client, health/illness, environment, and nursing; and (c) ability to describe, explain, or predict phenomena. Some theories are broad in scope; others are limited. The works presented may be classified as philoso- phies, nursing models, or nursing theories using the categorizations of Alligood and Tomey (2010). A philosophy is a belief system, of- ten an early effort to define nursing phenomena, and serves as the basis for later theoretical formulations. Examples of philosophies are those of Nightingale, Henderson, and Watson. Nursing models include those of Neuman, Orem, Rogers, Roy, and King, whereas nursing theories are those of Peplau, Leininger, and Parse. Only brief summaries of the authors’ central themes and basic assumptions are included here (and presented in chronologic order).
Nightingale’s Environmental Theory Florence Nightingale, often considered the first nurse theorist, de- scribed nursing 150 years ago as establishing an environment that allows persons to recover from illness (Nightingale, 1860/1969). She linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness.
These environmental factors attain significance when one con- siders that sanitation conditions in the hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client’s diet in terms of assessing intake, timeliness of the food, and its effect on the person.
Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today.
Peplau’s Interpersonal Relations Model Hildegard Peplau, a psychiatric nurse, introduced her interpersonal concepts in 1952. Central to Peplau’s theory is the existence of a ther- apeutic relationship between the nurse and the client. Nurses enter into a personal relationship with an individual when a need is pres- ent. The nurse–client relationship evolves in four phases:
1. Orientation. The client seeks help and the nurse assists the client to understand the problem and the extent of the need for help.
2. Identification. The client assumes a posture of dependence, interdependence, or independence in relation to the nurse (re- latedness). The nurse’s focus is on ensuring the individual that the nurse understands the interpersonal meaning of the client’s situation.
3. Exploitation. The client derives full value from what the nurse offers through the relationship. The client uses available services based on self-interest and needs. Power shifts from the nurse to the client.
4. Resolution. In the final phase, old needs and goals are put aside and new ones adopted. Once older needs are resolved, newer and more mature ones emerge.
To help clients fulfill their needs, nurses assume many roles: stranger, teacher, resource person, surrogate, leader, and counselor. Peplau’s model continues to be used by clinicians when working with individuals who have psychological problems (see, for example, Draucker, Cook, Martsolf, & Stephenson, 2012).
Henderson’s Definition of Nursing In 1966, Virginia Henderson’s definition of the unique function of nursing was a major stepping stone in the emergence of nursing as a discipline separate from medicine. Like Nightingale, Henderson de- scribes nursing in relation to the client and the client’s environment. Unlike Nightingale, Henderson sees the nurse as concerned with both healthy and ill individuals, acknowledges that nurses interact with clients even when recovery may not be feasible, and mentions the teaching and advocacy roles of the nurse. Henderson’s emphasis on the importance of nursing’s independence from, and interdepen- dence with, other health care disciplines is well recognized.
Henderson (1966) conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fun- damental needs:
1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining a desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range by adjusting
clothing and modifying the environment 8. Keeping the body clean and well groomed to protect the
integument 9. Avoiding dangers in the environment and avoiding injuring others
10. Communicating with others in expressing emotions, needs, fears, or opinions
11. Worshipping according to one’s faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing or participating in various forms of recreation
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hazards to life and well-being; and promoting normal human functioning.
2. Developmental requisites result from maturation or are associ- ated with conditions or events, such as adjusting to a change in body image or to the loss of a spouse.
3. Health deviation requisites result from illness, injury, or disease or its treatment. They include actions such as seeking health care assistance, carrying out prescribed therapies, and learning to live with the effects of illness or treatment.
Therapeutic self-care demand refers to all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health and well-being.
Self-care deficit results when self-care agency is not adequate to meet the known self-care demand. Orem’s self-care deficit theory ex- plains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and providing an environment that promotes the individual’s abilities to meet current and future demands.
Orem identifies three types of nursing systems. The five meth- ods of helping discussed for self-care deficit can be used in each of the three nursing systems:
1. Wholly compensatory systems are required for individuals who are unable to control and monitor their environment and pro- cess information.
2. Partly compensatory systems are designed for individuals who are unable to perform some, but not all, self-care activities.
3. Supportive-educative (developmental) systems are designed for persons who need to learn to perform self-care measures and need assistance to do so.
Self-Care, Dependent Care & Nursing is the official journal of the International Orem Society. The society holds an international con- ference approximately every 4 years. Many research and theoretical articles are published every year using Orem’s theory (see, for example, Sürücü & Kizilci, 2012).
King’s Goal Attainment Theory Imogene King’s theory of goal attainment (1981) was derived from her conceptual framework (Figure 3–2 •). King’s framework shows
14. Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities.
Rogers’ Science of Unitary Human Beings Martha Rogers first presented her theory of unitary human beings in 1970. It contains complex conceptualizations related to multiple sci- entific disciplines (e.g., Einstein’s theory of relativity, von Bertalanffy’s general systems theory, and many other disciplines, such as anthro- pology, psychology, sociology, astronomy, religion, philosophy, his- tory, biology, and literature).
Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts. She states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. The “human field image” perspective surpasses that of the physical body. Both human and environmental fields are characterized by pattern, a universe of open systems, and four dimensionality. According to Rogers, unitary man:
• Is an irreducible, four-dimensional energy field identified by pattern. • Manifests characteristics different from the sum of the parts. • Interacts continuously and creatively with the environment. • Behaves as a totality. • As a sentient being, participates creatively in change.
Nurses applying Rogers’ theory in practice (a) focus on the person’s wholeness, (b) seek to promote symphonic interaction be- tween the two energy fields (human and environment) to strengthen the coherence and integrity of the person, (c) coordinate the human field with the rhythmicities of the environmental field, and (d) direct and redirect patterns of interaction between the two energy fields to promote maximum health potential.
Nurses’ use of noncontact therapeutic touch is based on the concept of human energy fields. The qualities of the field vary from person to person and are affected by pain and illness. Nurses trained in noncontact therapeutic touch claim they can assess and feel the en- ergy field and manipulate it to enhance the healing process of people who are ill or injured.
Orem’s General Theory of Nursing Dorothea Orem’s theory, first published in 1971, includes three related concepts: self-care, self-care deficit, and nursing systems. Self-care the- ory is based on four concepts: self-care, self-care agency, self-care requi- sites, and therapeutic self-care demand. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. Self-care agency is the individual’s ability to perform self-care activities. It consists of two agents: a self-care agent (an individual who performs self-care independently) and a dependent care agent (a person other than the individual who provides the care). Most adults care for themselves, whereas infants and people weakened by illness or disability require assistance with self-care activities.
Self-care requisites, also called self-care needs, are measures or actions taken to provide self-care. There are three categories of self- care requisites:
1. Universal requisites are common to all people. They include maintaining intake and elimination of air, water, and food; balancing rest, solitude, and social interaction; preventing
Figure 3–2 • King’s conceptual framework for nursing: dynamic interacting systems. From A Theory for Nursing: Systems, Concepts, Process (p. 11), by I. M. King, 1981, Albany, NY: Delmar. Copyright Imogene M. King. Reprinted with permission.
Social Systems (Society)
Interpersonal Systems (Groups)
Personal Systems (Individual)
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depicted as a solid line, represents the person’s state of equilibrium or the state of adaptation developed and maintained over time and con- sidered normal for that person. The flexible line of defense, depicted as a broken line, is dynamic and can be rapidly altered over a short period of time. It is a protective buffer that prevents stressors from penetrating the normal line of defense. Certain variables (e.g., sleep deprivation) can create rapid changes in the flexible line of defense.
Neuman categorizes stressors as intrapersonal stressors, those that occur within the individual (e.g., an infection); interpersonal stressors, those that occur among individuals (e.g., unrealistic role expectations); and extrapersonal stressors, those that occur outside the person (e.g., financial concerns). The individual’s reaction to stressors depends on the strength of the lines of defense. When the lines of defense fail, the resulting reaction depends on the strength of the lines of resistance. As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution. Nursing interventions focus on retaining or maintaining system stability. These interventions are carried out on three preventive levels: primary, secondary, and tertiary.
1. Primary prevention focuses on protecting the normal line of de- fense and strengthening the flexible line of defense.
2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and increasing resistance factors.
3. Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to wellness following treatment.
Betty Neuman’s model of nursing is applicable to a variety of nursing practice settings involving individuals, families, groups, and communities. The model is used in many countries and to direct nursing administration and research programs. It is also used in a variety of nursing education programs at the associate degree and higher levels (Beckman, Boxley-Harges, & Kaskel, 2012).
Roy’s Adaptation Model Sister Callista Roy (2009) defines adaptation as “the process and out- come whereby the thinking and feeling person uses conscious aware- ness and choice to create human and environmental integration” (p. 26). Roy’s work focuses on the increasing complexity of person and environment self-organization, and on the relationship between and among persons, universe, and what can be considered a supreme being or God.
the relationship of personal systems (individuals), interpersonal sys- tems (groups such as nurse–client), and social systems (such as edu- cational system, health care system). She selected 15 concepts from the nursing literature (self, role, perception, communication, inter- action, transaction, growth and development, stress, time, personal space, organization, status, power, authority, and decision making) as essential knowledge for use by nurses.
Ten of the concepts in the framework were selected (self, role, perception, communication, interaction, transaction, growth and de- velopment, stress, time, and personal space) as essential knowledge for use by nurses in concrete nursing situations. Within this theory, a transaction process model was designed (Figure 3–3 •). This process describes the nature of and standard for nurse–client interactions that lead to goal attainment—that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment repre- sents outcomes. When this information is recorded in the client record, nurses have data that represent evidence-based nursing practice.
King’s theory offers insight into nurses’ interactions with individ- uals and groups within the environment. It highlights the importance of a client’s participation in decisions that influence care and focuses on both the process of nurse–client interaction and the outcomes of care. King believes that her theory, used in evidence theory-based practice, blends the art and the science of nursing. In India, one re- search study used King’s work as the theoretical framework for a study of perceptions of nursing practice (Andrade, George, & Roach, 2013).
Neuman’s Systems Model Betty Neuman (Neuman & Fawcett, 2002), a community health nurse and clinical psychologist, developed a model based on the in- dividual’s relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. Reconstitution is the state of adap- tation to stressors.
Neuman views the client as an open system consisting of a basic structure or central core of energy resources (physiologic, psychologic, sociocultural, developmental, and spiritual) surrounded by two concentric boundaries or rings referred to as lines of resistance (Figure 3–4 •). The lines of resistance represent internal factors that help the client defend against a stressor; one example is an increase in the body’s leukocyte count to combat an infection. Outside the lines of resistance are two lines of defense. The inner or normal line of defense,
Figure 3–3 • King’s model of transactions. From A Theory for Nursing: Systems, Concepts, Process (p. 145), by I. M. King, 1981, Albany, NY: Delmar. Copyright Imogene M. King. Reprinted with permission.
Nurse
Client
Judgment
Feedback
Judgment
Perception
Feedback
Perception
TransactionInteraction
Action
Action
Reaction
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Leininger’s Cultural Care Diversity and Universality Theory Madeleine Leininger, a nurse anthropologist, put her views on transcultural nursing in print in the 1970s, established the Journal of Transcultural Nursing in 1986, and then in 1991 published her book Culture Care Diversity and Universality: A Theory of Nursing. Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing. She emphasizes that hu- man caring, although a universal phenomenon, varies among cul- tures in its expressions, processes, and patterns; it is largely culturally derived. Leininger produced the Sunrise model to depict her theory of cultural care diversity and universality. This model emphasizes that health and care are influenced by elements of the social struc- ture, such as technology, religious and philosophical factors, kinship and social systems, cultural values, political and legal factors, eco- nomic factors, and educational factors. These social factors are ad- dressed within environmental contexts, language expressions, and ethnohistory. Each of these systems is part of the social structure of any society; health care expressions, patterns, and practices are also integral parts of these aspects of social structure. In order for nurses to assist people of diverse cultures, Leininger presents three inter- vention modes:
• Culture care preservation and maintenance • Culture care accommodation, negotiation, or both • Culture care restructuring and repatterning.
Leininger states that her theory is the only one focused unequivocally on culture care, examining what is universal among cultures and what varies (Leininger & McFarland, 2010).
Roy focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of input (stimuli), throughput (control processes), and output (behaviors or adaptive responses). Both the individual and the environment are sources of stimuli that require modification to promote adaptation, an ongoing purposive response. Adaptive responses contribute to health, which she defines as the process of being and becoming integrated; ineffective or mal- adaptive responses do not contribute to health. Each person’s adapta- tion level is unique and constantly changing.
The goal of Roy’s model is to enhance life processes through adaptation in four adaptive modes. Individuals respond to needs (stimuli) in one of the four modes:
1. The physiological mode involves the body’s basic physiological needs and ways of adapting with regard to fluids and electrolytes, activity and rest, circulation and oxygen, nutrition and elimination, protection, the senses, and neurologic and endocrine function.
2. The self-concept mode includes two components: the physical self, which involves sensation and body image, and the personal self, which involves self-ideal, self-consistency, and the moral- ethical self.
3. The role function mode is determined by the need for social in- tegrity and refers to the performance of duties based on given positions within society.
4. The interdependence mode involves one’s relations with signifi- cant others and support systems that provide help, affection, and attention.
In evolving her work since the early 1980s, Roy has expanded the model for application with families and clients in relationships.
Figure 3–4 • Neuman’s client system. From The Neuman Systems Model, 4th ed. (p. 15), by B. Neuman and J. Fawcett, 2002, Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
Basic structure energy
resources
Note: Physiologic, psychologic, sociological, developmental, and spiritual variables occur and are considered simultaneously in each client concentric circle.
Flexible l ine of defense
Norm al line of defense
Lines of resistance
Basic structure
Basic factors common to all organisms, e.g.,
• Normal temperature range • Genetic structure • Response pattern • Organ strength or weakness • Ego structure • Knowns or commonalities
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• Rhythmicity is the movement toward greater diversity. • Cotranscendence is the process of reaching out beyond the self.
Parse’s model of humanbecoming emphasizes how individu- als choose and bear responsibility for patterns of personal health. Parse contends that the client, not the nurse, is the authority figure and decision maker. The nurse’s role involves helping individuals and families in choosing the possibilities for changing the health process. Specifically, the nurse’s role consists of using “true presence” in illumi- nating meaning (uncovering what was and what will be), synchroniz- ing rhythms (leading through discussion to recognize harmony), and mobilizing transcendence (dreaming of possibilities and planning to reach them). The goal of nursing from the humanbecoming perspec- tive is quality of life (Parse, 2010).
CRITIQUE OF NURSING THEORY There are several arguments opposing the use of nursing models. Five discussed by McCrae (2011) are:
1. There is not a single global, commonly accepted definition of nursing and, thus, how can there be a theory of nursing?
2. The existing theories and models are too vague or too complex to clearly guide practice.
3. Because many theories are untested, they cannot be considered to provide evidence-based practice.
4. Interprofessional teamwork and overlapping of health care pro- fessional roles suggest that a theory guiding nursing practice cannot be unique to nursing.
5. Science and the world in general have changed so much that historically fundamental theories or models do not fit with 21st-century nursing practice.
Most things in the world have both positive and negative impli- cations. Theory can be used to broaden our perspectives in nursing and facilitate the altruistic and humanistic values of the profession. At the same time, rational and predictive theory can produce language and social practices that are superimposed onto the lives of vulner- able clients and do violence to the fragility of human dignity. As a lens, theory can either illuminate or obscure. As a tool, theory can either liberate or enslave. Work is still needed—even to reach agree- ment on the meaning of the terminology used in the discussion of theory (Webber, 2010).
Watson’s Human Caring Theory Jean Watson believes the practice of caring is central to nursing; it is the unifying focus for practice. Nursing interventions related to human care originally referred to as carative factors have now been translated into 10 clinical caritas processes (Watson, 2013):
1. Embrace altruistic values and practice loving kindness with self and others.
2. Instill faith and hope and honor others. 3. Be sensitive to self and others by nurturing individual beliefs and
practices. 4. Develop helping–trusting, human caring relationships. 5. Promote and accept positive and negative feelings as you authen-
tically listen to another’s story. 6. Use creative scientific problem-solving methods for caring deci-
sion making. 7. Share teaching and learning that addresses the individual needs
and comprehension styles. 8. Create a healing environment for the physical and spiritual self
which respects human dignity. 9. Assist with basic physical, emotional, and spiritual human needs.
10. Open to mystery and allow miracles to enter.
A survey has been created and tested that measures these processes used by nurses in caring for clients (DiNapoli, Nelson, Turkel, & Watson, 2010).
Parse’s Humanbecoming Theory Parse (2010) proposes three assumptions about humanbecoming:
1. Humanbecoming is freely choosing personal meaning in situ- ations in the intersubjective process of relating value priorities.
2. Humanbecoming is cocreating rhythmic patterns or relating in mutual process with the universe.
3. Humanbecoming is cotranscending multidimensionally with the emerging possibles.
These three assumptions focus on meaning, rhythmicity, and cotranscendence:
• Meaning arises from a person’s interrelationship with the world and refers to happenings to which the person attaches varying degrees of significance.
Preterm infants face unique challenges due to immaturities in many major organ systems. Because neonatal nurses play an essential role in supporting preterm infants and their families through their criti- cal postnatal transition, theoretical frameworks to guide planning and delivery of holistic neonatal nursing care need refinement and testing. The purpose of the study by Mefford and Alligood (2011) was to per- form an exploratory test of a middle range theory of health promotion for preterm infants based on Levine’s conservation model of nursing.
More than 130 babies who met the criteria were included in the study. Analysis of the data supported the applicability of the theory to this population, which, in turn, supports the assumption that the role of the nurse is essential in facilitating infant survival. One of the
most central findings indicated that consistency of the nurse was an essential component in infant improvement.
IMPLICATIONS Mathematical models such as those used in the analysis of the data in this study can be useful in determining the interrelationships between the variables of preterm infant characteristics, nursing roles and ac- tions, and infant health outcomes. The study demonstrates the value of nursing, which may have previously only been known intuitively to nurses and their clients. Using a theoretical model or framework such as that of Levine’s conservation model of nursing anchors the study and the knowledge it provides in a broader context.
Evidence-Based Practice How Well Does a Levine-Based Theory Apply to the Care of Preterm Infants? EVIDENCE-BASED PRACTICE
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Critical Thinking Checkpoint
Tony is a 32-year-old man with HIV. His first AIDS-defining illness caused his weight to drop from 175 to 116 pounds due to intrac- table diarrhea. The physician thought caloric intake was of primary importance and urged Tony to eat whatever he wanted. The physi- cian also prescribed tincture of opium for the diarrhea, but Tony hated the tincture of opium because it made him feel out of con- trol. Because Tony was getting worse, his nurse argued that he needed intravenous nutrition and should eat only bananas, rice, applesauce, and weak tea until the diarrhea stopped. The nurse suggested adding other foods one at a time and only as toler- ated. Tony’s family and friends offered to take control of Tony’s food preparation.
The physician compared AIDS to advanced cancer and argued he would not prescribe intravenous nutrition for advanced cancer.
The nurse argued that this was Tony’s first AIDS infection and that his prognosis was better than someone with advanced cancer. The nurse’s primary focus was on stopping the diarrhea, and supplement- ing nutrition with IVs. Tony’s friends preferred the nurse’s approach, but Tony was not as easily convinced. 1. What concepts are present in this case? 2. What appear to be the perspectives or views represented by the
physician and the nurse (how might you say they are defining the metaparadigm)?
3. How might Florence Nightingale analyze this situation? 4. Which of the nursing models in this chapter best supports the
nurse’s plan of care? See Critical Thinking Possibilities on student resource website.
• In the natural sciences, the main function of theory is to guide re- search. In the practice disciplines, the main function of theory (and research) is to provide new possibilities for understanding the dis- cipline’s focus (music, art, management, nursing).
• To Florence Nightingale, the knowledge required to provide good nursing was neither unique nor specialized. Rather, Nightingale viewed nursing as a central human activity grounded in observa- tion, reason, and commonsense health practices.
• During the latter half of the 20th century, disciplines seeking to establish themselves in universities had to demonstrate something that Nightingale had not envisioned for nursing—a unique body of theoretical knowledge.
• Theories articulate significant relationships between concepts in order to point to something larger, such as gravity, the uncon- scious, or the experience of pain.
• Paradigms include our notions of reality that are largely uncon- scious or taken for granted. Most theories reflect the dominant
paradigm of a culture, although some may grow out of a develop- ing rival paradigm.
• In the late 20th century, much of the theoretical work in nursing focused on articulating relationships between four major concepts: person, environment, health, and nursing. Because these four concepts can be superimposed on almost any work in nursing, they are sometimes collectively referred to as a metaparadigm for nursing.
• Nursing theories vary considerably in their (a) level of abstraction; (b) conceptualization of the client, health/illness, environment, and nursing; and (c) ability to describe, explain, or predict phenomena. Some theories are broad in scope; others are limited.
• Debates about the role of theory in nursing practice provide evi- dence that nursing is maturing, as both an academic discipline and a clinical profession.
CHAPTER HIGHLIGHTS
1. “A supposition or system of ideas that is proposed to explain a given phenomenon” best defines which of the following? 1. A concept 2. A conceptual framework 3. A theory 4. A paradigm
2. “A group of related ideas or statements” best defines which of the following? 1. A philosophy 2. A conceptual framework 3. A theory 4. A paradigm
3. “A set of shared understandings and assumptions about reality and the world” is a definition for which of the following? 1. A concept 2. A conceptual framework 3. A practice discipline 4. A paradigm
4. Which provides the best explanation for describing nursing as a practice discipline? 1. Nursing focuses on performing the professional role. 2. It takes time and experience to become a competent nurse. 3. Research and theory development is a central focus. 4. Nurses function as members of a team who form a practice
group.
TEST YOUR KNOWLEDGE
Chapter 3 Review
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7. The purpose of theory in science is to 1. Build a rationale for programs of research. 2. Explain why scientists do what they do. 3. Help scientists interpret phenomena. 4. Distinguish science from art.
See Answers to Test Your Knowledge in Appendix A.
5. Person, environment, health, and nursing constitute the metaparadigm for nursing because they do which of the following? 1. Provide a framework for implementing the nursing process. 2. Can be utilized in any setting when caring for a client. 3. Can be utilized to determine applicability of a research study. 4. Focus on the needs of a group of clients.
6. Which is an accurate statement about the role of nursing theory? 1. Practice theories assist nurses to reflect on the effectiveness
of what they do. 2. Midlevel theories, describing the interrelationships among
a broad range of concepts within nursing, have been well tested through nursing research.
3. All schools of nursing in the United States are organized around one of the conceptual models described in this chapter.
4. Nursing theory guides the direction of research but not that of education or practice.
Suggested Reading Burdette, L. (2012). Relationship between self-care agency,
self-care practices and obesity among rural midlife women. Self-Care, Dependent Care & Nursing, 19(1), 5–14. This article provides an example of applying the Orem self- care deficit theory to 224 overweight women in rural South Dakota. Facilitators, barriers, and practices were identified.
Related Research Alligood, M. (2011). Theory-based practice in a major medical
centre. Journal of Nursing Management, 19(8), 981–988. doi:10.1111/j.1365-2834.2011.01327.x
Häggström, M., Asplund, K., & Kristiansen, L. (2012). How can nurses facilitate patient’s transitions from intensive care?: A grounded theory of nursing. Intensive & Critical Care Nursing, 28(4), 224–233. doi:10.1016/J.ICCN.2012.01.002
References Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and
their work (7th ed.). St. Louis, MO: Mosby. American Nurses Credentialing Center. (2011). Magnet model
components and sources of evidence (2nd ed.). Silver Spring, MD: Author.
Andrade, M., George, A., & Roach, E. J. (2013). Perceptions of health care consumers, deliverers and nurse educa- tors on nursing practice. Nitte University Journal of Health Science, 3(1), 11–16.
Beckman, S. J., Boxley-Harges, S. L., & Kaskel, B. L. (2012). Experience informs: Spanning three decades with the Neuman systems model. Nursing Science Quarterly, 25, 341–346. doi:10.1177/0894318412457053
Bond, A. E., Eshah, N. F., Bani-Khaled, M., Hamad, A. O., Habashneh, S., Kataua, H., . . . Maabreh, R. (2011). Who uses nursing theory? A univariate descriptive analysis of five years of research articles. Scandi- navian Journal of Caring Science, 25, 404–409. doi:10.1111/j.1471-6712.2010.00835.x
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.
Draucker, C. B., Cook, C. B., Martsolf, D. S., & Stephenson, P. S. (2012). Adolescent dating violence and Peplau’s dimensions of the self. Journal of the American Psychiatric Nurses Association, 18, 175–188. doi:10.1177/1078390312442743
Green, R. (2012). Application of the self care deficit nursing theory to the care of children with special health care
needs in the school setting. Self-Care & Dependent-Care & Nursing, 19(1), 35–40.
Henderson, V. A. (1966). The nature of nursing: A definition and its implications for practice, research, and education. Riverside, NJ: Macmillan.
Im, E.-O., & Chang, S. J. (2012). Current trends in nursing theories. Journal of Nursing Scholarship, 44, 156–164. doi:10.1111/j.1547-5069.2012.01440.x
King, I. M. (1981). A theory for nursing: Systems, concepts, process. Albany, NY: Delmar.
Leininger, M. M. (Ed.). (1991). Culture care diversity and univer- sality: A theory of nursing. New York, NY: National League for Nursing Press.
Leininger, M., & McFarland, M. R. (2010). Madeleine Leininger’s theory of culture care diversity and universality. In M. E. Parker & M. C. Smith (Eds.), Nursing theories & nursing practice (3rd ed., pp. 317–336). Philadelphia, PA: F.A. Davis.
McCrae, N. (2011). Whither nursing models? The value of nurs- ing theory in the context of evidence-based practice and multidisciplinary health care. Journal of Advanced Nursing, 68(1), 222–229. doi:10.1111/j.1365-2648.2011.05821.x
Mefford, L. C., & Alligood, M. (2011). Testing a theory of health promotion for preterm infants based on Levine’s conserva- tion model of nursing. Journal of Theory Construction and Testing, 15(2), 41–47.
Neuman, B., & Fawcett, J. (2002). The Neuman systems model (4th ed.). Upper Saddle River, NJ: Prentice Hall.
Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover. (Original work published 1860)
Orem, D. E. (1971). Nursing: Concepts of practice. Hightstown, NJ: McGraw-Hill.
Parse, R. R. (2010). Rosemarie Rizzo Parse’s humanbecoming school of thought. In M. E. Parker & M. C. Smith (Eds.), Nursing theories and nursing practice (3rd ed., pp. 277–289). Philadelphia, PA: F.A. Davis.
Peplau, H. E. (1952). Interpersonal relations in nursing. New York, NY: Putnam.
Peterson, S. J., & Bredow, T. S. (2013). Middle range theories (3rd ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.
Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA: F.A. Davis.
Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
Sürücü, H., & Kizilci, S. (2012). Use of Orem’s self- care deficit nursing theory in the self-management
education of patients with type 2: A case study. Self-Care & Dependent-Care Nursing, 19(1), 53–59.
Tourville, C., & Ingalls, K. (2003). The living tree of nurs- ing theories. Nursing Forum, 38(3), 21–30, 36. doi:10.1111/j.0029-6473.2003.t01-1-00021.x
Watson, J. (2013). Ten caritas processes. Retrieved from http://watsoncaringscience.org/about-us/ caring-science-definitions-processes-theory/#
Webber, P. (2010). Language consistency: A missing link in the- ory, research, and reasoning? Journal of Advanced Nursing, 66, 218–227. doi:10.1111/j.1365-2648.2009.05176.x
Selected Bibliography Chinn, P. L., & Kramer, M. K. (2010). Integrated theory and
knowledge development in nursing (8th ed.). St. Louis, MO: Mosby Elsevier.
Fawcett, J., & DeSanto-Madeya, S. (2012). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia, PA: F.A. Davis.
George, J. B. (Ed.). (2011). Nursing theories: The base for professional nursing practice (6th ed.). Upper Saddle River, NJ: Pearson.
Hanna, D. R. (2013). Roy’s specific life values and the philosophical assumption of humanism. Nursing Science Quarterly, 26, 53–58. doi:10.1177/0894318412467070
Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years. New York, NY: National League for Nursing Press.
Malinski, V. (2010). Celebrating nursing theory. Nursing Sci- ence Quarterly, 23, 5–6. doi:10.1177/0894318409353798
Meleis, A. I. (2011). Theoretical nursing: Development and progress (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Orem, D. E., Taylor, S. G., & Renpenning, K. M. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.
Riegel, B., Jaarsma, T., & Strömberg, A. (2012). A middle- range theory of self-care of chronic illness. Advances in Nursing Science, 35, 194 –204.
Rogers, M. E. (1994). The science of unitary human beings: Current perspectives. Nursing Science Quarterly, 7, 33–35. doi:10.1177/089431849400700111
Watson, J. (2008). Nursing: The philosophy and science of caring. Norman, OK: University of Oklahoma Press.
READINGS AND REFERENCES
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LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. List sources of law and types of laws. 2. Describe ways nurse practice acts, credentialing, standards
of care, and agency policies and procedures affect the scope of nursing practice.
3. Compare and contrast the state-based licensure model and the mutual recognition model for multistate licensure.
4. Describe the purpose and essential elements of informed consent.
5. Describe the purpose of the Americans with Disabilities Act. 6. Discuss the impaired nurse and available diversion or peer
assistance programs. 7. Recognize the nurse’s legal responsibilities with selected
aspects of nursing practice.
INTRODUCTION Nursing practice is governed by many legal concepts. It is important for nurses to know the basics of legal concepts, because nurses are ac- countable for their professional judgments and actions. Accountabil- ity is an essential concept of professional nursing practice and the law. Knowledge of laws that regulate and affect nursing practice is needed for two reasons:
1. To ensure that the nurse’s decisions and actions are consistent with current legal principles.
2. To protect the nurse from liability.
GENERAL LEGAL CONCEPTS Law can be defined as “the sum total of rules and regulations by which a society is governed. As such, law is created by people and exists to regulate all persons” (Guido, 2014, p. 2).
Functions of the Law in Nursing The law serves a number of functions in nursing:
• It provides a framework for establishing which nursing actions in the care of clients are legal.
KEY TERMS
advance health care directives, 59
answer, 49 assault, 64 autopsy, 59 battery, 64 breach of duty, 62 burden of proof, 49 causation, 62 civil actions, 48 civil law, 48 common law, 48 complaint, 49 contract, 52 contract law, 48 contractual obligations, 52 contractual relationships, 52 coroner, 61 credentialing, 49 crime, 62
criminal actions, 48 criminal law, 48 damages, 62 decision, 49 defamation, 65 defendants, 49 delegation, 56 discovery, 49 do not resuscitate (DNR), 59 duty, 62 euthanasia, 61 expert witness, 49 express consent, 54 false imprisonment, 64 felony, 62 foreseeability, 62 gross negligence, 62 harm, 62 health care proxy, 59 impaired nurse, 57
implied consent, 54 implied contract, 52 informed consent, 53 injury, 62 inquest, 61 interstate compact, 51 invasion of privacy, 64 law, 47 liability, 52 libel, 65 license, 49 litigation, 49 living will, 59 malpractice, 62 mandated reporters, 57 manslaughter, 62 medical examiner, 61 misdemeanor, 62 mutual recognition model, 51 negligence, 62
plaintiff, 49 postmortem examination, 59 private law, 48 public law, 48 res ipsa loquitur, 62 respondeat superior, 52 responsibility, 53 right, 53 slander, 65 standards of care, 51 statutory laws, 48 strike, 53 tort, 62 tort law, 48 trial, 49 unprofessional conduct, 67 verdict, 49
4 Legal Aspects of Nursing
8. Discriminate between negligence and professional negligence/ malpractice.
9. Delineate the elements of professional negligence. 10. Compare and contrast intentional torts (assault/battery, false
imprisonment, invasion of privacy, defamation) and uninten- tional torts (professional negligence).
11. Describe the four specific areas of the Health Insurance Por- tability and Accountability Act and their impact on nursing practice.
12. Describe the laws and strategies that protect the nurse from litigation.
13. Discuss the legal responsibilities of nursing students.
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• It differentiates the nurse’s responsibilities from those of other health professionals.
• It helps establish the boundaries of independent nursing action. • It assists in maintaining a standard of nursing practice by making
nurses accountable under the law.
Sources of Law The legal system in the United States has its origin in the English common law system. Figure 4–1 • provides an overview of the pri- mary sources of law (i.e., how laws are created): constitutions, statutes, administrative agencies, and decisions of courts (common law).
CONSTITUTIONAL LAW The Constitution of the United States is the supreme law of the coun- try. It establishes the general organization of the federal government, grants certain powers to the government, and places limits on what federal and state governments may do. A constitution creates legal rights and responsibilities and is the foundation for a system of jus- tice. For example, the U.S. Constitution ensures each U.S. citizen the right to due process of law.
LEGISLATION (STATUTORY LAW) Laws enacted by any legislative body are called statutory laws. When federal and state laws conflict, federal law supersedes. Like- wise, state laws supersede local laws.
The regulation of nursing is a function of state law. State legisla- tures pass statutes that define and regulate nursing, that is, nurse prac- tice acts. These acts, however, must be consistent with constitutional and federal provisions.
CLINICAL ALERT!
It is important for nurses to keep their legislators informed about nurs- ing because it is the legislature that passes laws that affect nursing practice.
ADMINISTRATIVE LAW When a state legislature passes a statute, an administrative agency is given the authority to create rules and regulations to enforce the statutory laws. For example, state boards of nursing write rules and regulations to implement and enforce a nurse practice act, which was created through statutory law.
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Figure 4–1 • Overview of sources of law.
Administrative Law
Legislation (Statutes)
Nurse Practice Acts
Constitution Common Law
Sources of Law
COMMON LAW Laws evolving from court decisions are referred to as common law. In addition to interpreting and applying constitutional or statutory law, courts also are asked to resolve disputes between two parties. Common law is continually being adapted and expanded. In decid- ing specific controversies, courts generally adhere to the doctrine of stare decisis— “to stand by things decided”—usually referred to as “ following precedent.” In other words, to arrive at a ruling in a par- ticular case, the court applies the same rules and principles applied in previous, similar cases.
Types of Laws Laws can be further classified into different types. The two main types are public law and private or civil law.
Public law refers to the body of law that deals with relation- ships between individuals and the government and governmen- tal agencies. An important segment of public law is criminal law, which deals with actions against the safety and welfare of the pub- lic. Examples are homicide, manslaughter, and theft. Crimes can be classified as either felonies or misdemeanors, which are described in more detail later in this chapter.
Private law, or civil law, is the body of law that deals with relationships among private individuals. It can be categorized into a variety of legal specialties such as contract law and tort law. Contract law involves the enforcement of agreements among private individu- als or the payment of compensation for failure to fulfill agreements. Tort law defines and enforces duties and rights among private indi- viduals that are not based on contractual agreements. Some examples of tort laws applicable to nurses are professional negligence, invasion of privacy, and assault and battery, which are discussed in more de- tail later in this chapter. See Table 4–1 for selected categories of law affecting nurses.
Kinds of Legal Actions There are two kinds of legal actions: civil or private actions and crimi- nal actions. Civil actions deal with the relationships among indi- viduals in society; for example, a man may file a suit against a person who he believes cheated him. Civil actions that are of concern to nurses include the torts and contracts listed in Table 4–1. Criminal actions deal with disputes between an individual and society as a whole; for example, if a man shoots a person, society brings him to
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called the burden of proof. See Figure 4–2 • for a diagram of the judicial process.
Nurses as Witnesses A nurse may be called to testify in a legal action. It is advisable that any nurse who is asked to testify in such a situation seek the advice of an attorney before providing testimony. In most cases, the attorney for the nurse’s employer will provide support and counsel during the legal case. If the nurse is the defendant, however, the nurse should retain his or her own attorney to protect the nurse’s interests.
A nurse may also be asked to provide testimony as an expert witness. An expert witness has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within his or her area of expertise. The nurse’s creden- tials and expertise help a judge or jury understand the appropriate standard of care. The nurse expert, thus, has the ability to analyze the facts or evidence and draw inferences. For example, the nurse expert may offer an opinion on whether or not a particular standard of care was met.
REGULATION OF NURSING PRACTICE Protection of the public is the legal purpose for defining the scope of nursing practice, licensing requirements, and standards of care. Nurses who know and follow their nurse practice act and standards of care provide safe, competent nursing care.
Nurse Practice Acts Each state has a nurse practice act, which protects the public by le- gally defining and describing the scope of nursing practice. State nurse practice acts also legally control nursing practice through licensing requirements. For advanced nursing practice, many states require a different license or have an additional clause that pertains to ac- tions that may be performed only by nurses with advanced educa- tion. For example, an additional license may be required to practice as a nurse midwife, nurse anesthetist, or nurse practitioner. The advanced practice nurse also requires a license to prescribe medi- cation or order treatments from physical therapists or other health professionals.
Nurse practice acts, although similar, do differ from state to state. For example, they may differ in their scope of practice definition and in licensing and license renewal requirements. It is the nurse’s respon- sibility to know the nurse practice act of the state in which he or she practices nursing. A state’s nurse practice act is easily accessed at the specific state board of nursing’s website.
Credentialing Credentialing is the process of determining and maintaining com- petence in nursing practice. The credentialing process is one way in which the nursing profession maintains standards of practice and ac- countability for the educational preparation of its members. Creden- tialing includes licensure, certification, and accreditation.
LICENSURE A license is a legal permit that a government agency grants to indi- viduals to engage in the practice of a profession and to use a particular title. Nursing licensure is mandatory in all states. For a profession or
trial. The major difference between civil and criminal law is the po- tential outcome for the defendant. If found guilty in a civil action, such as professional negligence, the defendant will have to pay a sum of money. If found guilty in a criminal action, the defendant may lose money, be jailed, or be executed and, if a nurse, could lose his or her license. The action of a lawsuit is called litigation, and lawyers who participate in lawsuits may be referred to as litigators.
The Civil Judicial Process The judicial process primarily functions to settle disputes peacefully and in accordance with the law. A lawsuit has strict procedural rules. There are generally five steps:
1. A document, called a complaint, is filed by a person referred to as the plaintiff, who claims that his or her legal rights have been infringed on by one or more other persons or entities, referred to as defendants.
2. A written response, called an answer, is made by the defendants. 3. Both parties engage in pretrial activities, referred to as discovery,
in an effort to obtain all the facts of the situation. 4. In the trial of the case, all relevant facts are presented to a judge
or to a jury. 5. The judge renders a decision, or the jury renders a verdict. If
the outcome is not acceptable to one of the parties, an appeal can be made for another trial.
During a trial, a plaintiff must offer evidence of the defendant’s wrongdoing. This duty to prove an assertion of wrongdoing is
Category Examples
Constitutional Due process Equal protection
Statutory (legislative) Nurse practice acts Good Samaritan acts Child and adult abuse laws Living wills Sexual harassment laws Americans with Disabilities Act
Criminal (public) Homicide, manslaughter Theft Arson Active euthanasia Sexual assault Illegal possession of controlled drugs
Contracts (private/civil) Nurse and client Nurse and employer Nurse and insurance Client and agency
Torts (private/civil) Professional negligence/malpractice Libel and slander Invasion of privacy Assault and battery False imprisonment Abandonment
Selected Categories of Laws Affecting NursesTABLE 4–1
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Figure 4–2 • Anatomy of a lawsuit. Adapted from Legal and Ethical Issues in Nursing, 6th ed. (pp. 15–29), by G. W. Guido, 2014, Upper Saddle River, NJ: Pearson Education, Inc.
Anatomy of a Lawsuit
Initiation and Pleadings [written statements of facts as perceived by both parties]
Discovery of Evidence [Each side gathers information about the other]
complaint filed by plaintiff
served on defendant
answer or response filed by defendant
health care provider contacts employer and/or insurance provider
Methods of pretrial questioning
May result in a settlement. This is not considered an admission
of liability but allows party to settle upon a dollar figure and
not have to go to trial.
Trial
Interrogatories - questions served on opposing parties,
requiring written responses
Depositions - Oral questions are asked of witnesses, under oath, by attorney from opposing side. Information is recorded by court reporter and admissible as evidence.
Request to produce documents - Each side can request and receive
documents (e.g., medical record, x-ray films, consultation reports).
Jury selection
Opening statements as to what each side intends to show by the evidence
Plaintiffs case presented with cross-examination by defendant
Defendant's case presented with cross-examination by plaintiff
Closing statements
Jury deliberates to reach a verdict
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occupation to obtain the right to license its members, three criteria must generally be met:
1. There is a need to protect the public’s safety or welfare. 2. The occupation is clearly delineated as a separate, distinct area
of work. 3. A proper authority has been established to assume the obliga-
tions of the licensing process, for example, in nursing, state boards of nursing.
The government agency issuing the RN license views the hold- ing of that license to be a privilege, not a right. Nurse attorney Brous (2012) states that “nurses don’t have the right to practice nursing or to hold themselves out as nurses unless their nursing licenses are in good standing” (p. 59). Each state has a mechanism by which licenses can be revoked for just cause (e.g., incompetent nursing practice, pro- fessional misconduct, or conviction of a crime such as using illegal drugs or selling drugs illegally). In each situation, a committee at a hearing reviews all the facts. Nurses are entitled to be represented by legal counsel at such a hearing. If a nurse’s license is revoked as a result of the hearing, either the nurse can appeal the decision to a court of law or, in some states, an agency is designated to review the decision before any court action is initiated.
MUTUAL RECOGNITION MODEL Historically, licensure for nurses has been state based; that is, the state’s board of nursing has licensed all nurses practicing in the state. Changes, however, in health care delivery and telecommunication technology advances (e.g., telehealth) have raised questions about the state-based model. Telehealth is the “use of medical information exchanged from one site to another via electronic communications to improve the patient’s health status” (Institute of Medicine, 2012, p. 134). Thus, according to the state-based model, a nurse who electronically interacts with a client in another state to provide health information or intervention is practicing across state lines without a license in the other state.
In response, the National Council of State Boards of Nursing (NCSBN) developed a new regulatory model named the mutual recognition model, which allows for multistate licensure. With mutual recognition, a nurse who is not under any disciplinary action can practice in person or electronically across state lines under one license. For example, a nurse who lives on the border of a state can practice in both states under one license if the adjoining states have an interstate compact. A nurse who practices nursing in a state other than his or her primary state of residence must still contact the other state’s board of nursing and provide proof of licensure.
An interstate compact called the Nurse Licensure Compact (NLC) (an agreement between two or more states) is the mechanism used to create mutual recognition among states. Each state’s legislature initiates and decides on the establishment of an interstate compact or NLC. As of 2014, 24 states had implemented the Nurse Licensure Compact for RNs and LVN/LPNs (National Licensure Compact Administrators [NLCA], 2010, 2011; NCSBN, 2014b). Only those states who have adopted the RN and LPN/LVN Nurse Licensure Compact may implement a compact for advanced practice registered nurses (APRNs). Utah, Iowa, and Texas have passed laws authorizing APRN compacts. Since 2010, these states have been discussing the implementation of the APRN compact and the anticipated date of implementation is 2016 (NLCA, 2010, 2012). The NCSBN website
provides current information about the number of states that have passed NLC legislation. See Box 4–1 for additional information about the mutual recognition model.
CERTIFICATION Certification is the voluntary practice of validating that an individual nurse has met minimum standards of nursing competence in spe- cialty areas such as maternal–child health, pediatrics, mental health, gerontology, and school nursing. National certification may be re- quired to become licensed as an advanced practice nurse. Certifica- tion programs are conducted by the American Nurses Association (ANA) and by specialty nursing organizations.
ACCREDITATION/APPROVAL OF BASIC NURSING EDUCATION PROGRAMS One of the functions of a state board of nursing is to ensure that schools preparing nurses maintain minimum standards of education. Depending on the state, a state board of nursing must either approve or accredit a nursing program. This is a legal requirement.
Nursing programs can also choose to seek voluntary accredi- tation from a private organization such as the Accreditation Com- mission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE). Maintaining voluntary accreditation is a means of informing the public and prospective stu- dents that the nursing program has met certain criteria.
All states require approval/accreditation by the state board of nursing. Some states require that nursing programs be both state approved/accredited and accredited by a national accrediting agency such as ACEN or CCNE.
Standards of Care The purpose of standards of care is to protect the public. Standards of care are the skills and learning commonly possessed by members
BOX 4–1 Mutual Recognition Model
• Each state has to enter into an interstate compact, called the Nurse Licensure Compact (NLC), that allows nurses to practice in more than one state.
• Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.
• A nurse must have a license in his or her primary state of legal residency, if it is an NLC state.
• The states continue to have authority in determining licensure requirements and disciplinary actions.
• The nurse is held accountable for knowing and practicing the nursing practice laws and regulations in the state where the client is located at the time of care.
• Enactment does not change a state’s nurse practice act. • Complaints and/or violations would be addressed by the
home state (place of residence) and the remote (practice) state.
• RNs and LPNs/LVNs are included in the interstate compact or NLC. There is now a separate APRN compact. A state must be a member of the NLC for RNs and LPNs before entering into the APRN compact. A state must adopt both compacts to cover LPNs/RNs and APRNs for mutual recognition.
From “Nurse Licensure Compact Frequently Asked Questions” by National Council State Boards of Nursing, 2014a. Retrieved from https://www.ncsbn.org/2002.htm.
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of a profession (Guido, 2014). These standards are used to evaluate the quality of care nurses provide and, therefore, become legal guide- lines for nursing practice.
Nursing standards of care can be classified into two categories: internal and external standards. Internal standards of care include “the nurse’s job description, education, and expertise as well as indi- vidual institutional policies and procedures” (Guido, 2014, p. 55).
External standards consist of the following:
• Nurse practice acts • Professional organizations (e.g., ANA) • Nursing specialty-practice organizations (e.g., Emergency Nurses
Association, Oncology Nursing Society) • Federal organizations and federal guidelines (e.g., The Joint
Commission and Medicare).
It is important, therefore, for nurses to know their institution’s poli- cies and procedures and nurse practice act. They also need to remain competent through reading professional journals and attending con- tinuing education and in-service programs. Again, the purpose of knowing and practicing nursing’s standards of care is to protect the client/consumer.
CONTRACTUAL ARRANGEMENTS IN NURSING A contract is the basis of the relationship between a nurse and an employer—for example, a nurse and a hospital or a nurse and a pri- mary care provider. A contract is an agreement between two or more competent persons, on sufficient consideration (remunera- tion), to do or not to do some lawful act. A contract may be written or oral. An oral contract is as equally binding as a written contract. The terms of the oral contract, however, may be more difficult to prove in a court of law. A written contract cannot be changed le- gally by an oral agreement. If two people wish to change some aspect of a written contract, the change must be written into the contract, because one party cannot hold the other to an oral agreement that differs from the written one.
A contract is considered to be expressed when the two parties discuss and agree, orally or in writing, to terms and conditions dur- ing the creation of the contract. For example, a nurse will work at a hospital for a stated length of time and under stated conditions. An implied contract is one that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist. For ex- ample, the nurse is expected to be competent and to follow hospital policies and procedures even though these expectations were not written or discussed. Likewise, the hospital is expected to provide the necessary supplies and equipment needed to provide competent nursing care.
A lawful contract requires the following four features (Guido, 2014):
1. Promise or agreement between two or more persons for the per- formance of an action or restraint from certain actions
2. Mutual understanding of the terms and meaning of the contract by all
3. A lawful purpose (i.e., the activity must be legal) 4. Compensation in the form of something of value—in most
cases, compensation is monetary.
Legal Roles of Nurses Nurses have three separate, interdependent legal roles, each with rights and associated responsibilities: provider of service, employee or contractor for service, and citizen.
PROVIDER OF SERVICE The nurse is expected to provide safe and competent care. Implicit in this role are several legal concepts: liability, standards of care, and contractual obligations.
Liability is the quality or state of being legally responsible for one’s obligations and actions and for making financial restitution for wrongful acts. A nurse, for example, has an obligation to prac- tice and direct the practice of others under the nurse’s supervision so that harm or injury to the client is prevented and standards of care are maintained. Even when a nurse carries out treatments ordered by the primary care provider, the responsibility for the nursing activity belongs to the nurse. When a nurse is asked to carry out an activity that the nurse believes will be injurious to the client, the nurse’s re- sponsibility is to refuse to carry out the order and report this to the nurse’s supervisor.
The standards of care by which a nurse acts or fails to act are legally defined by nurse practice acts and by the rule of reasonable and prudent action—what a reasonable and prudent professional with similar preparation and experience would do in similar cir- cumstances. Contractual obligations refer to the nurse’s duty of care, that is, duty to render care, established by the presence of an expressed or implied contract.
EMPLOYEE OR CONTRACTOR FOR SERVICE A nurse who is employed by an agency works as a representative of the agency, and the nurse’s contract with clients is an implied one. However, a nurse who is employed directly by a client, for example, a private nurse, may have a written contract with that client in which the nurse agrees to provide professional services for a certain fee. A nurse might be prevented from carrying out the terms of the contract because of illness or death. However, personal inconvenience and personal problems, such as the nurse’s car failure, are not legitimate reasons for failing to fulfill a contract.
Contractual relationships vary among practice settings. An independent nurse practitioner is a contractor for service whose con- tractual relationship with the client is an independent one. The nurse employed by a hospital functions within an employer–employee re- lationship in which the nurse represents and acts for the hospital and therefore must function within the policies of the employing agency. This type of legal relationship creates the ancient legal doctrine known as respondeat superior (“let the master answer”). In other words, the master (employer) assumes responsibility for the conduct of the servant (employee) and can also be held responsible for pro- fessional negligence by the employee. By virtue of the employee role, therefore, the nurse’s conduct is the hospital’s responsibility.
This doctrine does not imply that the nurse cannot be held liable as an individual. Nor does it imply that the doctrine will prevail if the employee’s actions are extraordinarily inappropriate, that is, beyond those expected or foreseen by the employer. For example, if the nurse hits a client, the employer could disclaim responsibility because this behavior is beyond the bounds of expected behavior. Criminal acts, such as assisting with criminal abortions or taking tranquilizers from
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of employment, including work hours, working environment, and fringe benefits of employment (e.g., vacation time, sick leave, and personal leave). Through a written agreement, both management and employees legally commit themselves to observe the terms and conditions of employment.
The collective bargaining process involves the recognition of a certified bargaining agent for the employees. This agent can be a union, a trade association, or a professional organization. The agent represents the employees in negotiating a contract with management. The ANA, through its state constituent associations (e.g., MSNA— Michigan State Nurses Association), has represented the interests of nurses within individual states.
When collective bargaining breaks down because an agreement cannot be reached, the employees usually call a strike. A strike is an organized work stoppage by a group of employees to express a griev- ance, enforce a demand for changes in conditions of employment, or solve a dispute with management.
Because nursing practice is a service to people who are often ill or vulnerable, striking presents a moral dilemma to many nurses. Actions taken by nurses can affect the safety of people. When faced with a strike, each nurse must make an individual decision to cross or not to cross a picket line. Nursing students may also be faced with decisions about crossing picket lines in the event of a strike at a clini- cal agency used for learning experiences. The ANA supports striking as a means of achieving economic and general welfare.
SELECTED LEGAL ASPECTS OF NURSING PRACTICE Nurses need to know and apply legal aspects in their many different roles. For example, as client advocates, nurses ensure the client’s right to informed consent or refusal, and they identify and report violent behavior and neglect of vulnerable clients. Legal aspects also include the duty to report the nurse suspected of chemical impairment.
Informed Consent Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete informa- tion, including the benefits and risks of treatment, alternatives to
a client’s supply for personal use, would also be considered extraordi- narily inappropriate behavior. Nurses can be held liable for failure to act as well. For example, a nurse who sees another nurse consistently performing in an incompetent manner and fails to do anything to protect the client may be considered negligent.
The nurse in the role of employee or contractor for service has obligations to the employer, the client, and other personnel. The nurs- ing care provided must be within the limitations and terms specified. The nurse has an obligation to contract only for those responsibilities that the nurse is competent to discharge. For example, the nurse must practice according to the state’s nurse practice act and the policies and procedures of the facility or organization.
The nurse is expected to respect the rights and responsibilities of other health care participants. For example, although the nurse has a responsibility to explain nursing activities to a client, the nurse does not have the right to comment on medical practice in a way that dis- turbs the client or denounces the primary care provider. At the same time, the nurse has the right to expect reasonable and prudent con- duct from other health professionals.
CITIZEN The rights and responsibilities of the nurse in the role of citizen are the same as those of any individual under the legal system. Rights of citi- zenship protect clients from harm and ensure consideration for their personal property rights, rights to privacy, confidentiality, and other rights discussed later in this chapter. These same rights apply to nurses.
Nurses move in and out of these roles when carrying out profes- sional and personal responsibilities. An understanding of these roles and the rights and responsibilities associated with them promotes legally responsible conduct and practice by nurses. A right is a privi- lege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily; a responsibility is the obligation associated with a right. See Table 4–2 for examples of the responsibilities and rights associated with each role.
Collective Bargaining Collective bargaining is the formalized decision-making process between representatives of management (employer) and repre- sentatives of labor (employee) to negotiate wages and conditions
TABLE 4–2 Legal Roles, Responsibilities, and Rights
Role Responsibilities Rights Provider of service
To provide safe and competent care commensurate with the nurse’s preparation, experience, and circumstances To inform clients of the consequences of various alternatives and outcomes of care To provide adequate supervision and evaluation of others for whom the nurse is responsible To remain competent
Right to adequate and qualified assistance as necessary Right to reasonable and prudent conduct from clients (e.g., provision of accurate information as required)
Employee or contractor for service
To fulfill the obligations of contracted service with the employer To respect the employer To respect the rights and responsibilities of other health care providers
Right to adequate working conditions (e.g., safe equipment and facilities) Right to compensation for services rendered Right to reasonable and prudent conduct by other health care providers
Citizen To protect the rights of the recipients of care Right to respect by others of the nurse’s own rights and responsibilities Right to physical safety
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Cultural perspective also needs to be considered when clients are asked to make decisions about a procedure or treatment. For ex- ample, informed consent in the United States is based on the prin- ciple of autonomy. That is, each person has the right to decide what can or cannot be done to his or her person. The competent adult cli- ent is expected to have the autonomy to make his or her own health care decisions. In contrast to this individual perspective, people from other cultures (e.g., Southeast Asia, Native American) may apply a group perspective to decision making. They may believe that another member of their family or group or tribe should make the decision. The nurse can provide culturally responsive care by asking clients if there is someone they would like to be present when information or discussion of their health care treatment occurs.
It is also important for the client to understand the written mate- rial. Illiteracy in the United States continues to present a challenge as it pertains to recognizing and understanding words commonly used in consent forms. According to Koh et al. (2012), only 12% of U.S. adults are proficient enough to understand and use health informa- tion effectively, and more than 33% of adults have low literacy, which means they do not understand important warnings on the label of an over-the-counter medication. Additionally, 24 million Americans are not proficient in English (p. 435). Technical words and language bar- riers inhibit understanding and may encourage a signature without discussion of its actual meaning when the client has a lower literacy level. A person with low or limited literacy skills is not illiterate. See Box 4–2 for literacy definitions.
CLINICAL ALERT!
Consent forms often consist of language that exceeds the average reading level of clients. As a result, many clients do not read the form before signing it.
There is a link between literacy, health, and client safety. For example, adverse and even potentially life-threatening errors can occur if a client cannot read a pill bottle label or an educational brochure. Communication is critical for client safety and qual- ity nursing care. The increasing diversity of the client population means that nurses are treating individuals with limited English pro- ficiency (LEP) because of language, literacy, and/or cultural barri- ers. Recent federal policy initiatives, including the Affordable Care Act of 2010, the U.S. Department of Health and Human Services’
the treatment, and prognosis if not treated by a health care provider. Richardson (2013) reminds us that the goal of informed consent is “mutual decision making between both professional and patient over the treatment option that the patient wishes to receive or not to re- ceive” (p. 27). However, little research has been conducted to deter- mine if clients realize this purpose of consent. A review of literature by Leclercq, Keulers, Scheltinga, Spauwen, and Van der Will (2010) found that neither health care providers nor clients are well prepared for the informed consent process. Usually the client signs a form pro- vided by the agency. The form is a record of the informed consent, not the informed consent itself.
There are two types of consent: express and implied. Express consent may take the form of either an oral or written agreement. Usually, the more invasive a procedure or the greater the potential for risk to the client, the greater the need for written permission. Implied consent exists when the individual’s nonverbal behavior indicates agreement. For example, clients who position their bodies for an injec- tion or cooperate with the taking of vital signs infer implied consent. Consent is also implied in a medical emergency when an individual cannot provide express consent because of physical condition.
Obtaining informed consent for specific medical and surgical treatments is the responsibility of the person who is going to perform the procedure. Generally this person is the primary care provider; however, it could also be a nurse practitioner, nurse anesthetist, nurse midwife, clinical nurse specialist, or physician assistant who is per- forming procedures in their advanced practices.
Informed consent also applies to nurses who are not indepen- dent practitioners and are performing direct nursing care for such procedures as nasogastric tube insertion or medication administra- tion. The nurse relies on orally expressed consent or implied consent for most nursing interventions. It is imperative to remember the im- portance of communicating with the client by explaining nursing pro- cedures, ensuring the client understands, and obtaining permission.
The law says that a “reasonable amount” of information required for the client to make an informed decision is what any other reason- able health care practitioner would disclose under similar circum- stances. General guidelines include the following:
• The diagnosis or condition that requires treatment • The purposes of the treatment • What the client can expect to feel or experience • The intended benefits of the treatment • Possible risks or negative outcomes of the treatment • Advantages and disadvantages of possible alternatives to the
treatment (including no treatment).
Informed consent has three major elements:
1. The consent must be given voluntarily. 2. The consent must be given by a client or individual with the
capacity and competence to understand. 3. The client or individual must be given enough information to be
the ultimate decision maker.
To give informed consent voluntarily, the client must not feel coerced. Sometimes fear of disapproval by a health professional can be the motivation for giving consent; such consent is not voluntarily given. Coercion invalidates the consent. It is important, therefore, for the person obtaining the consent to invite and answer client questions.
BOX 4–2
• Literacy: an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential
• Low literacy: a limited ability to do what is defined above • Illiteracy: being unable to read or write • Health literacy: the degree to which individuals have the
capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
From “Plain Language: A Promising Strategy for Clearly Communicating Health Information and Improving Health Literacy,” by U.S. Department of Health and Human Services. Retrieved from http://www.health.gov/communication/literacy/plainlanguage/PlainLanguage .htm#top.
Literacy Definitions
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National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010 have made health literacy a priority in im- proving health care and health for all Americans (Koh et al., 2012). Health organizations need to address the communication needs of clients who have language and cultural barriers. For example, if a client cannot read, the consent form must be read to the client and the client must state understanding before the form is signed. If the client does not speak the same language as the health professional who is providing the information, an interpreter must be present. However, even with an interpreter, it is important to remember that potential interpretation errors can occur (see the Culturally Responsive Care features).
CLINICAL ALERT!
You cannot tell someone’s literacy level by looking at the person. In addition, some people may read at a lower level than their educational level. Many clients are embarrassed about their reading level and will conceal that they cannot read. Instead, they may say things like “I forgot my glasses,” “The form is too long,” “I want my family to read it first,” or “There are too many medical and legal terms.”
If given sufficient information, a competent adult can make decisions regarding health. A competent adult is a person over 18 years of age who is conscious and oriented. A client who is confused, disoriented, or sedated is not considered functionally
competent. A legal guardian or representative can provide or refuse consent for the incompetent adult.
Informed consent regulations were originally written with acute care settings in mind. Nonetheless, ensuring informed consent is equally important in providing nursing care in the home. Because the provision of home care often occurs over an extended period of time, the nurse has multiple opportunities to ensure that the client agrees to the plan of treatment. A challenge to informed consent in the home, however, is that the plan may affect other members of the family and, if so, they need to be consulted.
EXCEPTIONS Three groups of people cannot provide consent. The first is minors. In most areas, a parent or guardian must give consent before minors can obtain treatment. The same is true of an adult who has the men- tal capacity of a child and who has an appointed guardian. In some states, however, minors are allowed to give consent for such proce- dures as blood donations, treatment for substance abuse, treatment for mental health problems, and treatment for reproductive health concerns such as sexually transmitted infections or pregnancy. In ad- dition, certain groups of minors are often legally permitted to provide their own consent. These include those who are married, pregnant, parents, members of the military, or emancipated (living on their own). These statutes may vary by state.
The second group is individuals who are unconscious or injured in such a way that they are unable to give consent. In these situations, consent is usually obtained from the closest adult relative if existing statutes permit. In a life-threatening emergency, if consent cannot be obtained from the client or a relative, then the law generally agrees that consent is implied to provide necessary care for the client’s emer- gency condition.
The third group is people with mental illnesses who have been judged by professionals to be incompetent. State mental health acts or similar statutes generally provide definitions of mental illness and specify the rights of those who have mental illnesses under the law as well as the rights of the staff caring for such clients.
NURSE’S ROLE Nurses are often asked to obtain a signed consent form. The nurse is not responsible for explaining the procedure but for witnessing the client’s signature on the form (Figure 4–3 •). The nurse’s signature confirms three things:
• The client gave consent voluntarily. • The signature is authentic. • The client appears competent to give consent.
The nurse advocates for the client by verifying that the client received enough information to give consent. Therefore, it is impor- tant for the nurse to assess the client’s understanding and identify any misconceptions. If a client is just asked if she or he understands, most will answer “yes” (Richardson, 2013, p. 28). To prevent this, the nurse can ask clients to explain in their own words what the person who is going to perform the procedure explained to them. If the client has questions or if the nurse has doubts about the client’s understanding, the nurse must notify the health care provider. Again, the nurse is not responsible for explaining the medical or surgical procedure. In fact, the nurse could be liable for giving incorrect or incomplete informa- tion or interfering with the client–provider relationship.
Providing Culturally and Linguistically Appropriate Services
Health institutions have a legal and ethical responsibility to pro- vide language access services to clients who have limited ability to speak, read, write, or understand the English language (limited English proficiency). Appropriate communication between provider and client is essential for ensuring quality and safety in health care. The Office of Minority Health has developed 14 national standards for culturally and linguistically appropriate services (CLAS) orga- nized by three themes: culturally competent care, language access services, and organizational supports for cultural competence. Fol- lowing are the mandated language access services: Standard 4: Health care organizations must offer and provide
language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.
Standard 5: Health care organizations must provide to patients/ consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.
Standard 6: Health care organizations must assure the com- petence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).
Standard 7: Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups or groups represented in the service area.
From “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” by U.S. Department of Health & Human Services, Office of Minority Health, 2007. Retrieved from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.
PATIENT-CENTERED CARECulturally Responsive Care
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Figure 4–3 • Obtaining informed consent is the responsibility of the individual performing the procedure. The nurse may be asked to witness the client’s signature on the consent form.
The right of consent also involves the right of refusal (Guido, 2014). Remind clients that they can change their minds and cancel the procedure at any time because the right to refuse continues even after signing the consent. Similar to informed consent, it is important to verify that the client is aware of the pros and cons of refusal and is mak- ing an informed decision. The nurse needs to notify the health care provider of the client’s refusal and document the refusal in the chart.
Documentation is an important aspect of informed consent. A cli- ent’s concerns or questions must be documented along with the noti- fication of the health care provider. Equally important is documenting when the client states understanding. Record any teaching as a result of nursing-related questions by the client. Any special circumstances, such as use of an interpreter, should be documented. When document- ing the use of an interpreter, include the interpreter’s full name and title.
Delegation In 2005, the ANA and the NCSBN both defined delegation as “the process for a nurse to direct another person to perform nursing tasks and activities” (NCSBN, n.d.). Competent unlicensed assistive personnel (UAP) can be of assistance to the nurse, which allows the nurse to perform those functions appropriate to the nurse’s scope of practice. From a legal perspective, however, the nurse’s authority to delegate is based on laws and regulations. Therefore, nurses must be familiar with their nurse practice act (NPA).
Nurses must know not only their own scope of practice but also the scope of practice of the UAP, which may vary depending on a facil- ity’s policies and procedures. Thus, the nurse must know the employer’s
Working with a Health Care Interpreter
The interpreter’s primary task is the transformation of a message ex- pressed in a source language into its equivalent in a target language, so that the interpreted message has the potential to elicit the same response in the listener as the original message. This encounter is a highly interactive process in which the nurse uses language that can be understood and provides teaching. The interpreter serves as a cultural broker and engages both the health care provider and the client effectively and efficiently in accessing the nuances and hid- den sociocultural assumptions embedded in each other’s language (International Medical Interpreters Association, 2013). The following are helpful guidelines (Minnesota Department of Health Refugee Health Program, 2010): • Use qualified interpreters. Have access to an experienced
and qualified interpreter who knows his or her role, limitations, and responsibilities. Refrain from using children, relatives, and friends of clients, because they are not qualified for health- related interpretation and may compromise the client’s health outcomes and right to confidentiality.
• Have a brief pre-interview meeting with the interpreter to explain the situation and determine the best place for the interpreter to be seated.
• Plan sufficient time for the interpreted session. Interpretation is time consuming, because every statement must be repeated.
• Talk to the client directly, not the interpreter. • State only what you want interpreted; expect that everything
you utter will be interpreted. • Use words, not gestures, to convey your meaning. This makes
it easier for the interpreter. • Speak in a normal voice, clearly, and not too fast. There is
no need to speak louder, or very slowly; it is easier for the
interpreter to interpret speech at normal speed, with normal rhythms.
• Avoid jargon and technical terms, particularly idiomatic expressions (such as “I’m pulling your leg”) or cultural expres- sions (“for all the tea in China”) that either the interpreter might not understand or may have difficulty translating.
• Keep your sentences short, pausing to permit time for interpre- tation. After a long sentence, or three or four short sentences, you should pause at a natural place. Avoid taxing your inter- preter’s memory, particularly for complex explanations. Do not pause in the middle of the sentence, because the interpreter may need to hear the whole sentence before being able to translate. Remember that grammatical structure of sentences varies across languages.
• Ask only one question at a time. • Expect the interpreter to interrupt when necessary for
clarification. • Expect the interpreter to take notes if things get complicated.
This will help the interpreter remember the concepts during the interpretation.
• Be prepared to repeat yourself in different words if your message is not understood.
• Have a brief post-interview meeting with the interpreter to address any questions or concerns about the process of communication.
• Document in the client’s chart that the client gave consent to use an interpreter, the process used, the client’s verbal and nonverbal responses, the full name and title of the profes- sional medical language interpreter, the translation service, and the names of all those present during the interaction. If a professional interpreter is not available, document if the interpreter is a family member or a nonprofessional.
PATIENT-CENTERED CARE Culturally Responsive Care
SAFETY ALERT!
Ask clients to state in their own words what they have been told about the procedure or treatment.
SAFETY
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criteria for ADA eligibility. The ADA also enables individuals of nor- mal intelligence who have a physical or learning disability to pursue a nursing curriculum through alternative learning methods.
Court cases have challenged the definition of a qualified indi- vidual with a disability. For example, early challenges to the ADA concerned individuals with an HIV infection. A landmark 1998 Su- preme Court decision, Bragdon v. Abbott, ruled that an asymptomatic HIV-positive individual is considered to have a disability and is pro- tected by the ADA (Guido, 2014). In contrast, courts have also held that a variety of conditions do not constitute a disability under ADA. Examples include a lifting disability, depression and anxiety, inability to handle the stress of a specific job, migraine headaches, nonlatex allergies, and pregnancy (Guido, 2014).
It is the employer’s responsibility to provide reasonable accom- modations that would allow the person with a disability to perform the job satisfactorily. The employer, however, can claim undue hardship if the accommodation is extremely expensive or difficult to implement.
Controlled Substances U.S. laws regulate the distribution and use of controlled substances such as narcotics, depressants, stimulants, and hallucinogens. Misuse of con- trolled substances leads to criminal penalties (see Chapter 35 ).
The Impaired Nurse The term impaired nurse refers to a nurse’s inability to perform es- sential job functions because of chemical dependency on drugs or alcohol or mental illness. Darbro and Malliarakis (2012) report that the top four risk factors that make nurses susceptible to substance use disorders in the workplace are access, stress, lack of education, and attitude (p. 45). Nurses administer medications for all purposes (e.g., to relieve pain, prevent infections, decrease anxiety and depression). The ready availability of drugs is an occupational hazard, especially if the administration of controlled substances in the health care agency is poorly managed. Stress can be caused by increased workloads, de- creased staffing, fatigue, and isolation. Substance abuse may be a way of coping with the stress. An overlooked risk factor is the lack of edu- cation on the addictive process and its signs and symptoms. Finally, there are five attitudes that can increase nurses’ chances of having a problem with substance abuse: (1) viewing substance abuse as an acceptable means of coping with problems; (2) developing a faith in drugs as a means of promoting healing; (3) having a sense of entitle- ment that it is important to keep working along with the view that it is okay to use drugs to keep working; (4) feeling invulnerable to the illnesses of their clients (e.g., it won’t happen to them); and (5) hav- ing the attitude that their knowledge about addictive substances serves as a barrier against becoming addicted themselves (Darbro & Malliarakis, 2012, p. 46).
policies and procedures for delegation, the UAP’s job description, and the UAP’s skill level. Is the UAP competent to perform the delegated task? The NCSBN has provided “five rights of delegation” to help nurses make delegation decisions (see Chapter 28 ). It is important to remember that the nurse may delegate a task to a UAP; however, the responsibility for action or inaction on the part of the nurse or UAP remains with the nurse.
Violence, Abuse, and Neglect Violent behavior can include domestic violence, child abuse, abuse of older adults, and sexual abuse. Neglect is the absence of care necessary to maintain the health and safety of a vulnerable individual such as a child or older adult. Nurses, in their many roles (e.g., home health nurse, pediatric nurse, emergency department nurse), can often identify and assess cases of violence against others. As a result, they are often considered mandated reporters, meaning that they are required, by law, to report suspected abuse, neglect, or exploitation. Mandated reporting is designed to detect cases of abuse and neglect at an early stage, protect children, and facilitate the provision of ser- vices to children and families. Health care providers are protected when they, in good faith, report suspected abuse even if subsequent investigation shows the report to be groundless (Guido, 2014). See Chapter 21 for additional information about child abuse and Chapter 23 for information about abuse of older adults.
The Americans with Disabilities Act The Americans with Disabilities Act (ADA), passed by the U.S. Con- gress in 1990 and fully implemented in 1994, prohibits discrimina- tion on the basis of disability in employment, public services, and public accommodations. The purposes of the act are as follows:
• To provide a clear and comprehensive national mandate for elimi- nating discrimination against individuals with disabilities.
• To provide clear, strong, consistent, enforceable standards address- ing discrimination against individuals with disabilities.
• To ensure that the federal government plays a central role in enforcing standards established under the act.
The ADA is about productivity, economic independence, and the ability to move about freely in society. The nurse plays a key part in helping individuals with disabilities comprehend the opportuni- ties provided by the law. For example, nurses working in a variety of settings may be involved in educating clients with disabilities about accessing and using public transportation, communicating through telecommunications devices for individuals with speech and hearing impairments, and patronizing public accommodations such as gro- cery stores, restaurants, and theaters. Furthermore, an employer may not refuse to hire a nurse with disabilities if the nurse is qualified and able to fulfill the essential functions of the work role. Box 4–3 lists the
BOX 4–3
The employee or applicant for employment must show: • A physical or mental impairment that substantially limits one
or more major life activities of such individual; • A record of such an impairment; or • Being regarded as having such an impairment. From Legal and Ethical Issues in Nursing, 6th ed. (p. 276), by G. W. Guido, 2014, Upper Saddle River, NJ: Pearson Education, Inc. Reprinted with permission.
Meeting ADA Eligibility SELF-CARE ALERT
Nurses have a high level of compassion and empathy for their clients. Giving of yourself, however, all day at work along with caring for your family may result in compassion fatigue. It is important for nurses to be as compassionate, understanding, and forgiving of themselves as they are of their clients and loved ones.
The prevalence of alcohol and drug abuse in the nursing pop- ulation is approximately 10%, which is comparable to that of the
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problems. Reporting a nurse may save the nurse’s license and possibly his or her life. The only wrong thing to do about a fellow nurse who is impaired is to do nothing (Servodidio, 2011, p. 144). The Practice Guidelines on page 69 can be used to report the nurse suspected of chemical impairment.
CLINICAL ALERT!
It is important for student nurses and nurses to become knowledge- able about the risk factors of chemical abuse and its early identifica- tion and interventions.
A variety of programs have been developed to assist impaired nurses to recover. The Intervention Project for Nurses (IPN), an affiliate of the Florida Nurses Association, is the oldest and most comprehensive program. It provides swift interventions and close monitoring and advocacy for impaired nurses (IPN, 2013). In many states, impaired nurses who voluntarily enter a diversion program (sometimes called a peer assistance program) do not have their nursing license revoked if they follow treatment requirements. Their practice, however, is closely supervised within specific guide- lines (e.g., working on a general nursing unit versus critical care area, no overtime, work only day shift, not allowed to administer or have access to narcotics). The programs require counseling and ongoing participation in support groups with periodic progress reports that may include random drug screening. The nurse may petition the state board of nursing for reinstatement of full licensure after a specified amount of time and evidence of recovery as deter- mined by the state board. Diversion programs allow for rehabilita- tion of the nurse while still being able to work in the profession. They also allow the state board to protect the public while comply- ing with the ADA.
Sexual Harassment Sexual harassment is a violation of an individual’s rights and a form of discrimination. In 1987, the law prohibiting sexual discrimination was clarified to apply to all educational and employing institutions re- ceiving federal funding. The Equal Employment Opportunity Com- mission (EEOC) defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” occurring in the following circumstances (EEOC, 2000, section 1604.11):
• When submission to such conduct is considered, either explicitly or implicitly, a condition of an individual’s employment
• When submission to or rejection of such conduct is used as the basis for employment decisions affecting the individual
• When such conduct interferes with an individual’s work perfor- mance or creates an “intimidating, hostile, or offensive working environment.”
The victim or the harasser may be male or female. The victim does not have to be of the opposite sex. Nurses must develop skills of assertiveness to deter sexual harassment in the workplace. In ad- dition, nurses must be familiar with the sexual harassment policies and procedures that must be in place in every institution. These will include information regarding the reporting procedure, to whom in- cidents should be reported, the investigative process, and how confi- dentiality will be protected to the extent possible.
general population (Darbro & Malliarakis, 2012; Servodidio, 2011). As a result, professional organizations have passed resolutions to ensure that nurses and student nurses with chemical dependencies receive treatment and support, not discipline and derision.
Employers must have sound policies and procedures for iden- tifying and intervening in situations involving a possibly impaired nurse. The primary concern is for the protection of clients, but it is also critically important that the nurse’s problem be identified quickly so that appropriate treatment may be instituted. Box 4–4 lists behav- iors that may be seen in the impaired nurse.
Nurses usually avoid dealing with impaired colleagues. Nurses work as a team and the friendships that develop can be barriers to reporting problems. Another reason is that the nurse who observes suspicious behavior may fear retribution in the work environment or being called a whistle-blower. Although the reporting of unsafe or suspicious behavior may be difficult, it is important to remem- ber that nurses are client advocates. The ANA (2010) Code of Ethics for Nurses states that the “nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” Additionally, nurses need to advocate for their colleagues who have substance
BOX 4–4
NURSE WITH ALCOHOLISM • Irritability, mood swings • Elaborate excuses for behavior; unkempt appearance • Blackouts (periods of temporary amnesia) • Impaired motor coordination, slurred speech, flushed face,
bloodshot eyes • Numerous injuries, burns, bruises, etc., with vague
explanations • Smell of alcohol on breath, or excessive use of mouthwash,
mints, etc. • Increased isolation from others
NURSE WITH A SUBSTANCE ABUSE PROBLEM • Rapid mood and/or performance changes • Frequent absence from unit; frequent use of restroom • May work a lot of overtime, usually arriving early and staying
late • Increased somatic complaints necessitating prescriptions of
pain medications • Consistently signs out more or larger amounts of controlled
drugs than anyone else; excessive wasting of drugs • Often medicates others’ clients; may wear long sleeves all of
the time • Increased isolation from others • Client complaints that pain medication is not effective or that
they did not receive medication • Excessive discrepancies in signing and documentation
procedures of controlled substances
NURSE WHO IS MENTALLY ILL • Depressed, lethargic, unable to focus or concentrate,
apathetic • Makes many mistakes at work • Erratic behavior or mood swings • Inappropriate or bizarre behavior or speech • May also exhibit some of the same or similar characteristics
as chemically dependent nurses Note: It is most important to look for patterns or changes in behavior. Not all characteristics need to be present to indicate that a problem exists. From “Texas Peer Assistance Program for Nurses. Warning Signs: Clues to Nurses with Problems,” 2013, by Texas Nurses Association. Retrieved from http://www.texasnurses.org/ displaycommon.cfm?an=1&subarticlenbr=103. Reprinted with permission.
Warning Signs of Impairment
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need to incorporate teaching in this area and continue to be support- ive of clients’ decisions.
The two types of advance health care directives are the living will and the health care proxy or surrogate. The living will provides spe- cific instructions about what medical treatment the client chooses to omit or refuse (e.g., ventilatory support) in the event that the client is unable to make those decisions.
The health care proxy, also referred to as a durable power of at- torney for health care, is a notarized or witnessed statement appointing someone else (e.g., a relative or trusted friend) to manage health care treatment decisions when the client is unable to do so. Figure 4–4 • shows an example of an advance health care directive that combines a living will declaration and a durable power of attorney for health care. A form specific to the state in which you live can be obtained from the National Hospice and Palliative Care Organization.
Nurses should learn the law regarding client self-determination for the state in which they practice, as well as the policies and pro- cedures for implementation in the institution where they work. The legally binding nature and specific requirements of advance medi- cal directives are determined by individual state legislation. In most states, advance directives must be witnessed by two people but do not require review by an attorney. Some states do not permit relatives, heirs, or primary care providers to witness advance directives. As a client advocate, it is important for the nurse to facilitate family discus- sion about end-of-life concerns and decisions.
AUTOPSY An autopsy or postmortem examination is an examination of the body after death. It is performed only in certain cases. The law de- scribes under what circumstances an autopsy must be performed, for example, when death is sudden or occurs within 48 hours of admis- sion to a hospital. The organs and tissues of the body are examined to establish the exact cause of death, to learn more about a disease, and to assist in the accumulation of statistical data.
The primary care provider or, in some instances, a designated individual in the hospital is responsible for obtaining consent for an autopsy. Consent must be given by the decedent (before death) or by the next of kin. Laws in many states and provinces prioritize the fam- ily members who can provide consent as follows: surviving spouse, adult children, parents, and siblings. After an autopsy, hospitals can- not retain any tissues or organs without the permission of the indi- vidual who consented to the autopsy.
CERTIFICATION OF DEATH The formal determination of death, or pronouncement, must be per- formed by a primary care provider, a coroner, or a nurse. The grant- ing of the authority to nurses to pronounce death is regulated by the state. It may be limited to nurses in long-term care, home health, and hospice agencies or to advanced practice nurses. By law, a death cer- tificate must be made out when an individual dies. It is usually signed by the attending primary care provider and filed with a local health or other government office. The family is usually given a copy to use for legal matters, such as insurance claims.
DO-NOT-RESUSCITATE ORDERS Primary care providers may order “no code” or “do not resuscitate” (DNR) for clients who are in a stage of terminal, irreversible illness or expected death. A DNR order is generally written when the cli- ent or proxy has expressed the wish for no resuscitation in the event
Abortions Abortion laws provide specific guidelines for nurses about what is legally permissible. In 1973, when the Roe v. Wade and Doe v. Bolton cases were decided, the Supreme Court of the United States held that the constitutional rights of privacy give a woman the right to control her own body to the extent that she can abort her fetus in the early stages of pregnancy.
In 1989, the Supreme Court’s decision in Webster v. Reproductive Health Services upheld a Missouri law banning the use of public funds or facilities for performing or assisting with abortions. In 1992, Presi- dent Clinton rescinded the 1991 Rust v. Sullivan decision, dubbed the “gag rule,” that prevented health care providers from discussing abor- tion services with clients in nonprofit agencies. The Supreme Court and state legislatures continue to struggle with the issue of abortion.
Many statutes also include conscience clauses, upheld by the Su- preme Court, designed to protect nurses and hospitals. These clauses give hospitals the right to deny admission to abortion clients and give health care personnel, including nurses, the right to refuse to partici- pate in abortions. When these rights are exercised, the statutes also protect the agency and employee from discrimination or retaliation.
Death and Related Issues The nurse’s role in legal issues related to death is prescribed by the laws of the region and the policies of the health care institution. For example, in some states, a feeding tube cannot be removed from a person in a persistent vegetative state without a prior directive from the client, but in other states the removal is allowed at the family’s re- quest or a primary care provider’s order. Some facilities permit do- not-resuscitate orders or protocols that specify the extent of invasive life-sustaining measures. Caring for dying clients who have agreed to organ donation can also be complex in terms of determining which medications, treatments, or equipment must be continued until the time for harvesting the organs has arrived. Many of these legal issues stimulate strong ethical concerns. It is important for the nurse to have support from other team members in understanding and providing appropriate care to clients facing death.
ADVANCE HEALTH CARE DIRECTIVES Advance health care directives include a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences. The Patient Self-Determination Act implemented in 1991 requires all health care facilities receiving Medicare and Medic- aid reimbursement to (a) recognize advance directives, (b) ask clients whether they have advance directives, and (c) provide educational materials advising clients of their rights to declare their personal wishes regarding treatment decisions, including the right to refuse medical treatment. Clients and families often have difficulty making advance treatment decisions for end-of-life matters. They need to be reassured that even if they make a decision and have an advance di- rective, they will always have the option to change their decision. For example, clients who are terminally ill may have decided not to have ventilator support, but if and when the actual situation occurs, they have the right to change their mind or take more time to make the decision.
Nurses need to assess if clients and families have an accurate understanding of life-sustaining measures. They may misunderstand what actually sustains life and base their decisions on that. Nurses
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Figure 4–4 • Sample advance health care directive.
POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me: ________________________________________ __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a healthcare decision for me, I designate as my first alternate agent: __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as first alternate agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent: __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as second alternate agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)
(2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other forms of health care to keep me alive, except as I state here:
(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box. If I mark this box [ ], my agent's authority to make health care decisions for me takes effect immediately.
(4) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give below, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
(5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or elsewhere in this form:
INSTRUCTIONS FOR HEALTH CARE Strike any wording you do not want.
(6) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: (Initial only one box) [ ] (a) Choice NOT to Prolong Life I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR [ ] (b) Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
(7) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort should be provided at all times even if it hastens my death: DONATION OF ORGANS AT DEATH (8) Upon my death: (mark applicable box) [ ] (a) I give any needed organs, tissues, or parts, OR [ ] (b) I give the following organs, tissues, or parts only: ___________________________________________________________________________ [ ] (c) My gift is for the following purposes: (strike any of the following you do not want) (1) Transplant (2) Therapy (3) Research (4) Education (9) EFFECT OF COPY: A copy of this form has the same effect as the original.
(10) SIGNATURE: Sign and date the form here: ______________________________________________________ _______________________________________________________ (date) (sign your name) ______________________________________________________ _______________________________________________________ (address) (print your name) ______________________________________________________ _______________________________________________________ (city) (state)
(11) WITNESSES: This advance health care directive will not be valid for making health care decisions unless it is either: (1) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (2) acknowledged before a notary public.
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of a respiratory or cardiac arrest. Many primary care providers are reluctant to write such an order if there is any conflict between the client and family members or among family members. A DNR or- der is written to indicate that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are not in- dicated. If it is contrary to the nurse’s personal beliefs to carry out a DNR order, the nurse should consult the nurse manager for a change in assignment. Family members may think that DNR means giving permission to terminate an individual’s life. The term allow natural death (AND) is clear, more descriptive, and perhaps less threatening (ANA, 2012, p. 8).
The ANA (2012) makes the following recommendations for clinical nurses:
• Clinical nurses actively participate in timely and frequent discus- sions on changing goals of care and initiate DNR/AND discus- sions with patients and their families and significant others.
• Clinical nurses ensure that DNR orders are clearly documented, reviewed, and updated periodically to reflect changes in the pa- tient’s condition.
• All nurses ensure that, whenever possible, the DNR decision is a subject of explicit discussion between the health care team, patient, and family (or designated surrogate), and that actions taken are in accordance with the patient’s wishes.
• All nurses facilitate and participate in interdisciplinary mecha- nisms for the resolution of disputes among patients, families, and clinicians’ DNR orders.
• All nurses actively participate in developing DNR policies within the institutions where they work (pp. 9–10).
Many states (but not all) permit clients living at home to arrange special orders so that emergency technicians called to the home in the event of a cardiopulmonary arrest will respect the client’s wish not to be resuscitated. Some emergency medical services have writ- ten policies specifying that staff may withhold CPR if the client has a signed order or approved form or wears a medical alert DNR medal- lion. Nurses should be familiar with the federal and state laws and the policies of their agency concerning withholding life-sustaining measures.
EUTHANASIA Euthanasia is the act of painlessly putting to death people suffer- ing from incurable or distressing disease. It is sometimes referred to as “mercy killing.” Regardless of compassion and good intentions or moral convictions, euthanasia is legally wrong in the United States and can lead to criminal charges of homicide or to a civil lawsuit for withholding treatment or providing an unacceptable standard of care. Because advanced technology has enabled the medical profes- sion to sustain life almost indefinitely, people are increasingly consid- ering the meaning of quality of life. For some people, the withholding of artificial life-support measures or even the withdrawal of life sup- port is a desired and acceptable practice for clients who are terminally ill or who are incurably disabled and believed unable to live their lives with some happiness and meaning.
Voluntary euthanasia refers to situations in which the dying individual desires some control over the time and manner of death. All forms of euthanasia are illegal except in states where right-to-die statutes and living wills exist. In 1994, the state of Oregon approved
the first U.S. physician-assisted suicide law, the Death with Dignity Act (DWDA), which permits primary care providers to prescribe le- thal doses of medications. Since the law was passed in 1997, and as of January 2013, a total of 1,050 people have had DWDA prescrip- tions written, and 673 clients have died from ingesting medications prescribed under the DWDA (Oregon Public Health Division, 2012, p. 2). Since Oregon’s action, a number of states have proposed right- to-die laws. Right-to-die statutes legally recognize the client’s right to refuse treatment.
INQUEST An inquest is a legal inquiry into the cause or manner of a death. When a death is the result of an accident, for example, an inquest is held into the circumstances of the accident to determine any blame. The inquest is conducted under the jurisdiction of a coroner or medical examiner. A coroner is a public official, not necessarily a physician, appointed or elected to inquire into the causes of death, when appropriate. A medical examiner is a physician and usually has advanced education in pathology or forensic medicine. Agency policy dictates who is responsible for reporting deaths to the coroner or medical examiner.
ORGAN DONATION Under the Uniform Anatomical Gift Act and the National Organ Transplant Act in the United States, people 18 years or older and of sound mind may make a gift of all or any part of their own bodies for the following purposes: for medical or dental education, research, advancement of medical or dental science, therapy, or transplanta- tion. The donation can be made by a provision in a will or by signing a card-like form. This card is usually carried at all times by the person who signed it. In some states, the driver’s license will indicate if the in- dividual is an organ donor. In most states, the person can revoke the gift, either by destroying the card or by revoking the gift orally in the presence of two witnesses. Nurses may serve as witnesses for people consenting to donate organs.
In early 2004, the Organ Donation and Recovery Improvement Act was signed by the U.S. Congress, authorizing funds through 2009 for projects and activities to increase public awareness of and will- ingness to participate in organ donation. In almost every case, there is a greater need for transplantation than there are available organs. Thus, in many states, if there is no valid donor document, health care workers are required to discuss with survivors of a potential organ donor the option to make an anatomic gift. Survivors are obliged to grant or withhold donation in accordance with their knowledge of the donor’s views on anatomic gifts. The details regarding this process of requesting donation from family members and other legal aspects of organ donation vary by state. The nurse needs to be familiar with the appropriate legislation.
AREAS OF POTENTIAL LIABILITY IN NURSING Nursing liability is usually involved with tort law. It is important for the nurse to know the differences between professional negligence (an unintentional tort) and intentional torts. Nurses must also rec- ognize those nursing situations in which negligent actions are most likely to occur, and take measures to prevent them.
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The standard can come from documents published by national or professional organizations, boards of nursing, institutional poli- cies and procedures, or textbooks or journals, or it may be stated by expert witnesses.
• Foreseeability. A link must exist between the nurse’s act and the injury suffered.
• Causation. It must be proved that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and that the nurse could have (or should have) known that failure to follow the standard of care could result in such harm.
• Harm or injury. The client or plaintiff must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client. The plaintiff will be asked to document physical injury, medical costs, loss of wages, “pain and suffering,” and any other damages.
• Damages. If professional negligence caused the injury, the nurse is held liable for damages that may be compensated. The goal of awarding damages is to assist the injured party to his or her origi- nal position as far as financially possible (Guido, 2014).
CLINICAL ALERT!
The best defense against a professional negligence claim is to know your nursing responsibilities and the scope of practice of members of your health team (e.g., LPN/LVN, UAP).
Several legal doctrines or principles are related to negligence. One such doctrine is respondeat superior. A lawsuit for a negligent act performed by a nurse will also name the nurse’s employer. In addi- tion, employers may be held liable for negligence if they fail to pro- vide adequate human and material resources for nursing care, fail to properly educate nurses on the use of new equipment or procedures, or fail to orient nurses to the facility. Another doctrine or principle is res ipsa loquitur (“the thing speaks for itself ”). In some cases, the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act. An example is harm that results when surgical instruments or bandages are accidentally left in a client during surgery.
To defend against a professional negligence lawsuit, the nurse must prove that one or more of the six required elements is not met. There is also a limit to the amount of time that can pass between recognition of harm and the bringing of a suit. This is referred to as the statute of limitations. The exact time limitation varies by type of suit and state.
To avoid charges of professional negligence, nurses must rec- ognize those nursing situations in which negligent actions are most likely to occur, and take measures to prevent them (Box 4–5). The most common situation is the medication error. Because of the large number of medications on the market today and the variety of meth- ods of administration, these errors may be on the increase. Nursing errors include failing to read the medication label, misreading or in- correctly calculating the dosage, failing to correctly identify the client, preparing the wrong concentration, or administering a medication by the wrong route (e.g., intravenously instead of intramuscularly). Some medication errors are very serious and can result in death. For example, administering dicumarol, an anticoagulant, to a client re- cently returned from surgery could cause the client to hemorrhage.
Crimes and Torts A crime is an act committed in violation of public (criminal) law and punishable by a fine or imprisonment. A crime does not have to be intentional in order to be a crime. For example, a nurse may acciden- tally give a client an additional and lethal dose of a narcotic to relieve discomfort.
Crimes are classified as either felonies or misdemeanors. A felony is a crime of a serious nature, such as murder, punishable by a term in prison. In some areas, second-degree murder is called manslaughter. A nurse who accidentally gives an additional and lethal dose of a narcotic can be accused of manslaughter.
Crimes are punished through criminal action by the state against an individual. A misdemeanor is an offense of a less serious nature and is usually punishable by a fine or short-term jail sentence, or both.
A tort is a civil wrong committed against a person or a person’s property. Torts are usually litigated in court by civil action between individuals. In other words, the person or persons claimed to be responsible for the tort are sued for damages. Tort liability almost always is based on fault, which is something that was done incorrectly (an unreasonable act of commission) or something that should have been done but was not (an act of omission).
Torts are classified as unintentional or intentional.
UNINTENTIONAL TORTS Negligence and professional negligence are examples of uninten- tional torts that may occur in the health care setting. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places an- other person at risk for harm. Both nonmedical and professional individuals can be liable for negligent acts. Gross negligence in- volves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Malpractice is “professional negligence,” that is, negligence that oc- curred while the person was performing as a professional. Malprac- tice applies to primary care providers, dentists, lawyers, and generally includes nurses. In some states nurses cannot be sued for malpractice, only professional negligence. The terms malpractice and professional negligence are often used interchangeably. Six elements must be pres- ent for a case of nursing professional negligence to be proven:
• Duty. The nurse must have (or should have had) a relationship with the client that involves providing care and following an ac- ceptable standard of care. Such duty, for example, is evident when the nurse has been assigned to care for a client in the home or hos- pital. A nurse also has a general duty of care, even if not specifi- cally assigned to a client, if the client needs help.
CLINICAL ALERT!
It is a nurse’s duty to respond to all clients’ call lights, not just those of assigned clients.
• Breach of duty. There must be a standard of care that is expected in the specific situation but that the nurse did not observe. For ex- ample, something was done that should not have been done or nothing was done when it should have been done. This is the fail- ure to act as a reasonable, prudent nurse under the circumstances.
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appendix ruptures and death occurs. By failing to take the blood pres- sure and pulse and to check the dressing of a client who has just had abdominal surgery, a nurse omits important assessments. If the cli- ent hemorrhages and dies, the nurse may be held responsible for the death as a result of this professional negligence.
CLINICAL ALERT!
Monitor both the physical and psychosocial status of the client. Document observations and interventions.
Incorrectly identifying clients is a problem, particularly in busy hospital units. Unfortunate occurrences, such as removal of a healthy gallbladder from the wrong person, have resulted from nurses preparing the wrong client for surgery. Cases of mistaken identity are costly to the client and render the nurse liable for profes- sional negligence.
The number of nurses being named in professional negligence suits is increasing. The most common causes of nursing profes- sional negligence include failure to monitor, failure to perform as- sessment and notify health care provider, and failure to document and report a deteriorating condition (Painter & Dudjak, 2010, p. 534). See Practice Guidelines later in this chapter for steps to help nurses reduce potential liability.
INTENTIONAL TORTS Several differences distinguish unintentional torts from intentional torts. Unintentional torts (e.g., professional negligence) do not re- quire intent but do require the element of harm. In contrast, with intentional torts, the defendant executed the act on purpose or with intent. No harm need be caused by intentional torts for liability to exist. Also, since no standard is involved, no expert witnesses are
Nurses always must check medications very carefully. Even after checking, the nurse is wise to recheck the medication order and the medication before administering it if the client states, for example, “I did not have a green pill before.”
CLINICAL ALERT!
To be a client advocate, you must know about the medications be- ing administered. Know why the client is receiving the medication, the dosage range, possible adverse effects, toxicity levels, and contraindications.
Clients often fall accidentally, sometimes with resultant injury. Some falls can be prevented by elevating the side rails on the cribs, beds, and stretchers of babies and small children and, when neces- sary, of adults. If a nurse leaves the rails down or leaves a baby unat- tended on a bath table, that nurse is guilty of professional negligence if the client falls and is injured as a direct result. Most hospitals and nursing homes have policies regarding the use of safety devices. The nurse needs to be familiar with these policies and to take indicated precautions to prevent injuries (see Chapter 32 ).
BOX 4–5
Failure to follow standards of care, including failure to: • Perform a complete admission assessment or design a plan of
care. • Institute a fall protocol. • Adhere to standardized protocols or institutional policies and
procedures (e.g., using an improper injection site). • Follow a primary care provider’s verbal or written orders. Failure to use equipment in a responsible manner, including failure to: • Follow the manufacturer’s recommendations for operating the
equipment. • Check equipment for safety prior to use. • Place equipment properly during treatment. • Learn how equipment functions. Failure to communicate, including failure to: • Notify a primary care provider in a timely manner when
conditions warrant it. • Listen to a client’s complaints and act on them. • Communicate effectively with a client (e.g., inadequate or
ineffective communication of discharge instructions). • Communicate important assessment findings to the nurse for
the oncoming shift. • Seek higher medical authorization for a treatment.
Failure to document, including failure to follow the facility’s documentation policies and procedures and/or failure to note in the client’s medical record: • A client’s progress and response to treatment. • A client’s injuries. • Pertinent nursing assessment information (e.g., drug allergies). • A primary care provider’s medical orders. • Information on telephone conversations with primary care
providers, including time, content of communication between nurse and primary care provider, and actions taken.
Failure to assess and monitor, including failure to: • Complete a shift assessment. • Implement a plan of care. • Observe a client’s ongoing progress. • Interpret a client’s signs and symptoms. • Recognize significant changes in a client’s condition and
communicate them promptly. Failure to act as a client advocate, including failure to: • Question discharge orders when a client’s condition warrants it. • Question incomplete or illegible medical orders. • Provide a safe environment. From “Make Your Nursing Care Malpractice-Proof,” by D. L. Reising, 2012, American Nurse Today, 7(1), pp. 24–28; “How to Avoid the Top Seven Nursing Errors,” by A. Delamont, 2013, Nursing Made Incredibly Easy!, 11(2), pp. 8–10.
Categories of Negligence That Result in Professional Negligence Lawsuits
SAFETY ALERT!
Assess clients for fall potential. Document all nursing measures taken to protect the client (e.g., “Instructed client how to use the call light”).
SAFETY
In some instances, ignoring a client’s complaints can consti- tute professional negligence. This type of professional negligence is termed failure to observe and take appropriate action. The nurse who does not report a client’s complaint of acute abdominal pain is neg- ligent and may be found guilty of professional negligence if ensuing
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False imprisonment is the “unjustifiable detention of a per- son without legal warrant to confine the person” (Guido, 2014, p. 88). False imprisonment accompanied by forceful restraint or threat of restraint is battery.
Although nurses may suggest under certain circumstances that a client remain in the hospital room or in bed, the client must not be detained against the client’s will. The client has a right to insist on leaving even though it may be detrimental to health. In this instance, the client can leave by signing an AWA (absence without authority) or AMA (against medical advice) form. As with assault or battery, cli- ent competency is a factor in determining whether there is a case of false imprisonment or a situation of protecting a client from injury. To guide nurses in such dilemmas, agencies usually have clear poli- cies regarding the application of restraints (see Chapter 32 ).
Invasion of privacy is a direct wrong of a personal nature. It injures the feelings of the person and does not take into account the effect of revealed information on the reputation of the person in the community. The right to privacy is the right of individuals to with- hold themselves and their lives from public scrutiny. It can also be described as the right to be left alone. Liability can result if the nurse breaches confidentiality by passing along confidential client informa- tion to others or intrudes into the client’s private domain.
In this context, a delicate balance must be maintained between the need of a number of people to contribute to the diagnosis and treatment of a client and the client’s right to confidentiality. In most situations, necessary discussion about a client’s medical condition is considered appropriate, but unnecessary discussions and gossip are considered breaches of confidentiality. Necessary discussion involves only those people engaged in the client’s care.
CLINICAL ALERT!
Never discuss client situations in the elevator, cafeteria, or other public areas.
needed. Four intentional torts related to nursing are discussed here: assault/battery, false imprisonment, invasion of privacy, and defa- mation (libel/ slander). Figure 4–5 • provides an overview of the types of law in nursing.
The terms assault and battery are often heard together, but each has its own meaning. Assault can be described as an attempt or threat to touch another person unjustifiably. Assault precedes bat- tery; it is the act that causes the person to believe a battery is about to occur. For example, the person who threatens someone by making a menacing gesture with a club or a closed fist is guilty of assault. A nurse who threatens a client with an injection after the client refuses to take the medication orally would be committing assault.
Battery is the willful touching of a person (or the person’s clothes or even something the person is carrying) that may or may not cause harm. To be actionable at law, however, the touching must be wrong in some way; for example, touching done without permission, that is em- barrassing, or that causes injury. In the previous example, if the nurse followed through on the threat and gave the injection without the cli- ent’s consent, the nurse would be committing battery. Liability applies even though the primary care provider ordered the medication or the activity and even if the client benefits from the nurse’s action.
Consent is required before procedures are performed. Battery exists when there is no consent, even if the plaintiff was not asked for consent. Unless there is implied consent, such as in life-threatening emergencies, a procedure performed on an unconscious client with- out informed consent is battery. Another requirement for consent is that the client be competent to give consent. It can be very difficult to determine if clients who are older, who have specific mental dis- orders, or who take particular medications are competent to agree to treatments. If the nurse is uncertain whether a client refusing a treat- ment is competent, the supervisor and primary care provider should be consulted so that ethical treatment that does not constitute battery can be provided. Determination of competency is not a medical deci- sion; it is one made through court hearings.
Analysis of professional negligence claims can contribute to cor- recting deficiencies that contribute to practice errors. Little research has investigated the relationships among the nursing characteris- tics, actions, or behaviors of nurses whose actions contributed to professional negligence suits providing monetary compensation. Painter and Dudjak (2010) conducted a retrospective chart review of claims from a professional liability insurance program managed internally by a large health care system. The claims were limited to adult clients receiving care in acute care hospitals located in a single state. These cases were then further limited to those that involved nursing care during medication administration, IV therapy, and/or monitoring of physiological changes because these events were considered preventable. As a result the authors reviewed 16 professional negligence claims that involved 19 RNs. Data were col- lected on client, environment, and nurse. There were 8 men and 8 women clients with an average age of 55. The environment of the events included a postoperative surgical unit, general medicine unit, intensive care unit, and the emergency department. The actions of the nurses that contributed to the events included failure to respond or set audible monitor alarms (15.7%), failure to follow the five rights of medication administration (15.7%), failure to escalate commu- nication with a nonresponsive clinical provider (10.5%), and failure to perform timely assessment and intervention in a clinical situation
with the majority of these cases related to opioid administration and monitoring (42%). Fifty-three percent of the nursing behaviors were related to failure to follow the policies and procedures of the facility, and 47% were associated with nurses not performing their duty. The nurse characteristics included an average age of 41 years with the majority of nurses involved being non-BSN prepared. The probabil- ity of client death was substantially greater for nurses with less than 48 months of nursing experience. One third of the nurses involved in the events were not working in their regularly assigned unit, and 50% of the deaths involved nurses from this subgroup.
IMPLICATIONS Although this study is small, it is important and worthy of attention. That 89% of the nurses had less than a BSN supports previous research of the direct relationship between nurse education and fa- vorable client outcomes. The finding that 50% of the client deaths involved nurses who were reassigned to a unit other than their usual nursing unit raises concerns about this staffing practice. There is a need for nurse leaders to provide processes that promote a safe work environment for nurses and clients. As the authors stated, “Nurse leaders should encourage active involvement of direct-care nurses in quality forums not only within the unit, but across all levels of the organization” (p. 538).
Evidence-Based Practice What Are the Actions, Behaviors, and Characteristics of RNs Involved in Professional Negligence Claims? EVIDENCE-BASED PRACTICE
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Figure 4–5 • An overview of the types of law in nursing practice.
Negligence/ Malpractice
Failure to meet
standard of care
Duty Breach of duty Foreseeability
Causation Harm/Injury
Damage
Assault/battery
False imprisonment
Invasion of privacy
Private/Civil
Contract Law Torts
Unintentional
Public
Criminal Law
Felony Misdemeanor
Types of Law
Intentional
Willful action
Causation
Intended to bring about
consequence
Defamation
Libel Slander
Must be present
Common elements
Most jurisdictions of the country have a variety of statutes that impose a duty to report certain confidential client information. Four major categories are (a) vital statistics, such as births and deaths; (b) infections and communicable diseases, such as diphtheria, syphi- lis, and typhoid fever; (c) child or abuse of older adults; and (d) vio- lent incidents, such as gunshot wounds and knife wounds.
The client must be protected from four types of invasion:
• Use of the client’s name or likeness for profit, without consent. This refers to use of identifiable photographs or names such as ad- vertising for the health care agency or provider without the client’s permission.
• Unreasonable intrusion. This involves observation of client care (such as by nursing students) or taking of photographs for any purpose without the client’s consent.
• Public disclosure of private facts. This occurs when private in- formation is given to others who have no legitimate need for that information.
• Putting a person in a false light. This type of invasion involves publishing information that is normally considered offensive but which is not true.
Defamation is communication that is false, or made with a careless disregard for the truth, and results in injury to the reputation of a person. Both libel and slander are wrongful actions that come un- der the heading of defamation. Libel is defamation by means of print, writing, or pictures. Writing in the nurse’s notes that a primary care provider is incompetent because he did not respond immediately to a call is an example of libel. Slander is defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a
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reputation is damaged. An example of slander would be for the nurse to tell a client that another nurse is incompetent.
Only the person defamed may bring the lawsuit. The defama- tory material must be communicated to a third party such that the person’s reputation may be harmed. For example, a comment made in private criticizing that person’s competence is not defamation since a third party did not hear it.
Nurses have a qualified privilege to make statements that could be considered defamatory, but only as a part of nursing practice and only to a primary care provider or another health team member car- ing directly for the client. The communication must be made in good faith with the intent to protect the quality of client care—for example, when a nurse manager provides a prospective employer with infor- mation about a nurse’s professional practice.
Privacy of Clients’ Health Information Protecting clients’ confidentiality has always been an important re- sponsibility of nursing. Recent changes in the laws regarding privacy have implications for health care providers and organizations. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the first nationwide legislation to protect privacy for health infor- mation. It is important to be aware of identifying information that is protected under HIPAA but may not be initially perceived as health information. Examples include Social Security number, name, ad- dress, phone number, e-mail address, and fingerprints. Age should also be a consideration because age can become an identifier in the population older than age 89.
HIPAA includes four specific areas:
1. Electronic transfer of information among organizations. Instead of each health provider using its own electronic format to transact claims, etc., HIPAA implements a national uniform standard to simplify such transactions.
2. Standardized numbers for identifying providers, employers, and health plans. Instead of each health care organization us- ing different formats for identification, HIPAA published stan- dard identifiers. For example, an employer’s tax ID number or employer identification number is the standard for electronic transactions.
3. The security rule provides for a uniform level of protection of all health information. This rule requires health care organizations and providers to ensure the confidentiality, integrity, and avail- ability of all electronic protected health information (ePHI).
4. The privacy rule sets standards defining appropriate disclosure of protected health information. This rule also gives clients new rights to understand and control how their health information is used (i.e., how to access their medical records, restrict access by others, request changes, and learn how they have been accessed).
See Box 4–6 for examples of how HIPAA compliance affects nursing practice.
Social Media The use of social media and other types of electronic communication is rapidly growing. Social media is a valuable tool when used wisely. Nurses and nursing students must understand the benefits and con- sequences of participating in social networking of all types. Inappro- priate use of social networking by nurses has resulted in nurses losing
Examples of HIPAA Compliance and Nursing PracticeBOX 4–6
• Store charts in a secure, nonpublic location to prevent the public from viewing or accessing confidential health information.
• Place clipboards face down. • Do not leave printed copies of protected health information
unattended at a printer or fax machine. • Verify the number dialed before faxing personal health
information. • Encrypt personal health information when transmitting by
e-mail. • Limit access to protected health information to those
authorized to obtain the information. • Require health care providers to have passwords to access
a client’s electronic chart. • Post or provide a notice informing clients of their rights to
privacy regarding their health information. • Lower voice levels to minimize disclosure of information
when, for example, discussing a client’s condition over the telephone, giving a report, or reading information aloud from a computer screen or chart.
• Ensure that health care providers stay current with HIPAA regulations.
their jobs and being disciplined by the board of nursing. Both the NCSBN and ANA have published social media guidelines for nurses.
Health care organizations have policies about the use of elec- tronic and social media in the workplace. Therefore, it is usually the nurse’s use of social media outside of the workplace where the nurse may face serious consequences for inappropriate use of social media. Here are guidelines from the ANA (2011) and NCSBN (2011) for avoiding the inappropriate use of social media:
• Remember that the standards of professionalism (e.g., an ethical and legal obligation to maintain client privacy and confidentiality at all times) are the same online as in any other circumstance.
• Do not take photos or videos of clients on personal devices, in- cluding cell phones.
• Maintain professional boundaries when using electronic media. • Do not transmit or place online individually identifiable client
information. • Report any identified breach of confidentiality or privacy.
Loss of Client Property Loss of client property, such as jewelry, money, eyeglasses, and den- tures, is a constant concern to hospital personnel. Today, agencies are taking less responsibility for property and are generally requesting clients to sign a waiver on admission relieving the hospital and its employees of any responsibility for property. Situations arise, how- ever, in which the client cannot sign a waiver and the nursing staff must follow prescribed policies for safeguarding the client’s property. Nurses are expected to take reasonable precautions to safeguard a cli- ent’s property, and they can be held liable for its loss or damage if they do not exercise reasonable care.
Unprofessional Conduct According to most nurse practice acts, unprofessional conduct is considered one of the grounds for action against a nurse’s license.
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The same reasoning applies to nurses, who are among the people best prepared to help at the scene of an accident. If the level of care a nurse provides is of the caliber that would have been provided by any other nurse, then the nurse will not be held liable.
Guidelines for nurses who choose to render emergency care are as follows:
• Limit actions to those normally considered first aid, if possible. • Do not perform actions that you do not know how to do. • Offer assistance, but do not insist. • Have someone call or go for additional help. • Do not leave the scene until the injured person leaves or another
qualified person takes over. • Do not accept any compensation.
Professional Liability Insurance Because of the increase in the number of professional negligence lawsuits against health professionals, nurses are advised to carry their own liability insurance. Most hospitals have liability insurance that covers all employees, including all nurses. However, some smaller facilities, such as walk-in clinics, may not. Thus, the nurse should al- ways check with the employer at the time of hiring to see what cover- age the facility provides. A primary care provider or a hospital can be sued because of the negligent conduct of a nurse, and the nurse can also be sued and held liable for professional negligence. Because hospitals have been known to countersue nurses when they have been found negligent and the hospital was required to pay, nurses are advised to provide their own insurance coverage and not rely on hospital-provided insurance.
Additionally, nurses often provide nursing services outside of employment-related activities, such as being available for first aid at children’s sport or social activities or providing health screening and education at health fairs. Neighbors or friends may seek advice about illnesses or treatment for themselves or family members. In the lat- ter situation, the nurse may be tempted to give advice; however, it is always advisable for the nurse to refer the friend or neighbor to their family primary care provider. The nurse may be protected from li- ability under Good Samaritan acts when nursing service is volun- teered; however, if the nurse receives any compensation or if there is a written or verbal agreement outlining the nurse’s responsibility to the group, the nurse needs liability coverage for legal expenses in the event that the nurse is sued.
Liability insurance coverage usually defrays all costs of defend- ing a nurse, including the costs of retaining an attorney. The insur- ance also covers all costs incurred by the nurse up to the face value of the policy, including a settlement made out of court. In return, the insurance company may have the right to make the decisions about the claim and the settlement.
Nursing faculty and nursing students are also vulnerable to law- suits. Students and teachers of nursing employed by community col- leges and universities are not likely to be covered by the insurance carried by hospitals and health agencies. It is advisable for nursing students to check with their school about the coverage that applies to them. Increasingly, faculty carry their own professional liability insurance. Liability insurance can be obtained through the ANA or private insurance companies. Nursing students can also obtain in- surance through the National Student Nurses Association. In some states, hospitals do not allow nursing students to provide nursing
Unprofessional conduct includes incompetence or gross negli- gence, conviction for practicing without a license, falsification of cli- ent records, and illegally obtaining, using, or possessing controlled substances. Having a personal relationship with a client, especially a vulnerable client, may be considered unprofessional conduct be- cause the Code of Ethics for Nurses states that nurses are responsible for maintaining their professional boundaries (ANA, 2010, p.151). Certain acts may constitute a tort or crime in addition to being un- professional conduct.
Unethical conduct may also be addressed in nurse practice acts. Unethical conduct includes violation of professional ethical codes, breach of confidentiality, fraud, or refusing to care for clients of spe- cific socioeconomic or cultural origins (see Chapter 5 ).
Nurses at all levels of nursing practice, can be reported to na- tional data banks. The Healthcare Integrity and Protection Data Bank (HIPDB) was created for the reporting of civil judgments or criminal convictions related to health care and licensure or certifica- tion actions. Another data bank, the National Practitioner Data Bank (NPDB), was established to identify incompetent and unprofessional health care practitioners. The information in these two data banks is not accessible by the public. It can be accessed, however, by state licensing boards, HMOs, hospitals, and professional organizations. The data banks are examples of a nationwide effort to protect the public and to identify and track professionals found liable of profes- sional negligence or actions taken against their license. NPDB annual reports of group data are available at their website.
LEGAL PROTECTIONS IN NURSING PRACTICE Laws and strategies are in place to protect the nurse against litigation. Good Samaritan acts are an example of laws designed to help protect nurses when assisting at the scene of an emergency. Providing safe, competent practice by following the nurse practice act and standards of practice is a major legal safeguard for nurses. Accurate and com- plete documentation is also a critical component of legal protection for the nurse.
Good Samaritan Acts Good Samaritan acts are laws designed to protect health care pro- viders who provide assistance at the scene of an emergency against claims of professional negligence unless it can be shown that there was a gross departure from the normal standard of care or willful wrongdoing on their part. Gross negligence usually involves further injury or harm to the person. For example, an automobile may strike an injured child left on the side of the road when the nurse leaves to obtain help.
Most state statutes do not require citizens to render aid to people in distress. Such assistance is considered more of an ethical than a le- gal duty. To encourage citizens to be Good Samaritans, most states have now enacted legislation releasing a Good Samaritan from legal liability for injuries caused under such circumstances, even if the in- juries resulted from negligence of the person offering emergency aid. It is important, however, to check your state’s statute since some states (e.g., Vermont) require people to stop and aid persons in danger.
It is generally believed that a person who renders help in an emergency, at a level that would be provided by any reasonably prudent person under similar circumstances, cannot be held liable.
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Application of the nursing process is another essential aspect of providing safe and effective client care. Clients need to be as- sessed and monitored appropriately and involved in care decisions. All assessments and care must be documented accurately. Effec- tive communication can also protect the nurse from negligence claims. Nurses need to approach every client with sincere concern and include the client in conversations. In addition, nurses should always acknowledge when they do not know the answer to a client’s questions, telling the client they will find out the answer and then follow through.
Methods of legal protection are summarized in the accompany- ing Practice Guidelines.
Documentation The client’s medical chart is a legal document and can be produced in court as evidence. Often, the chart is used to remind a witness of events surrounding a lawsuit, because several months or years usu- ally elapse before a suit goes to trial. The effectiveness of a witness’s testimony can depend on the accuracy of the nurse’s documentation of nursing care. Nurses, therefore, need to provide accurate and com- plete documentation of the nursing care provided to clients. Failure to properly document can constitute negligence and be the basis for tort liability. Insufficient or inaccurate assessments and documenta- tion can hinder proper diagnosis and treatment and result in injury to the client (Figure 4–6 •). See Chapter 15 for types of records and facts about recording.
The Incident Report An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contrib- ute to statistical data about accidents or incidents, and to help health personnel prevent future incidents or accidents. All accidents are usually reported on incident forms. Some agencies also report other incidents, such as the occurrence of client infection or the loss of per- sonal effects.
care without liability insurance or a signed disclaimer placing the responsibility of the student’s actions while in the clinical setting on the student.
Carrying Out a Physician’s Orders Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse’s responsibil- ity to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unaccept- able and regarded as a departure from competent nursing practice.
If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. For example, if the order is for oxygen to be administered at 4 liters per minute, the nurse must ad- minister oxygen at that rate, and not at 2 or 6 liters per minute. If the orders state that the client is not to have solid food after a bowel resec- tion, the nurse must ensure that no solid food is given to the client.
There are several categories of orders that nurses must question to protect themselves legally:
• Question any order a client questions. For example, if a client who has been receiving an intramuscular injection tells the nurse that the health care provider changed the order from an injectable to an oral medication, the nurse must recheck the order before giv- ing the medication.
• Question any order if the client’s condition has changed. The nurse is considered responsible for notifying the primary care provider of any significant changes in the client’s condition, whether the pri- mary care provider requests notification or not. For example, if a client who is receiving an intravenous infusion suddenly develops a rapid pulse, chest pain, and a cough, the nurse must notify the primary care provider immediately and question continuance of the ordered rate of infusion. If a client who is receiving morphine for pain develops severely depressed respirations, the nurse must withhold the medication and notify the primary care provider.
• Question and record verbal orders to avoid miscommunications. In addition to recording the time, the date, the primary care provider’s name, and the orders, the nurse documents the circumstances that occasioned the call to the primary care provider, reads the orders back to the primary care provider, and documents that the primary care provider confirmed the orders as the nurse read them back.
• Question any order that is illegible, unclear, or incomplete. Mis- interpretations in the name of a drug or in dose, for example, can easily occur with handwritten orders. The nurse is responsible for ensuring that the order is interpreted the way it was intended and that it is a safe and appropriate order.
Providing Competent Nursing Care Competent practice is a major legal safeguard for nurses. Nurses need to provide care that is within the legal boundaries of their practice and within the boundaries of agency policies and procedures. Nurses therefore must be familiar with their various job descriptions, which may differ from agency to agency. Every nurse is responsible for en- suring that his or her education and experience are adequate to meet the responsibilities delineated in the job description.
Competency also involves care that protects clients from harm. Nurses need to anticipate sources of client injury, educate clients about hazards, and implement measures to prevent injury.
Figure 4–6 • Clear and accurate documentation is the nurse’s best defense against potential liability. Ryan McVay/Getty Images.
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PRACTICE GUIDELINES
Legal Protection for Nurses
• Function within the scope of your education, job description, and nurse practice act.
• Follow the policies and procedures of the employing agency. • Build and maintain good rapport with clients. • Always check the identity of a client to make sure it is the
right client. • Observe and monitor the client accurately. Communicate
and record significant changes in the client’s condition to the primary care provider.
• Promptly and accurately document all assessments and care given.
• Be alert when implementing nursing interventions, and give each task your full attention and skill.
• Perform procedures correctly and appropriately. • Make sure the correct medications are given in the correct dose,
by the right route, at the scheduled time, and to the right client.
• When delegating nursing responsibilities, make sure that the person who is delegated a task understands what to do and that the person has the required knowledge and skill.
• Protect clients from injury. • Report all incidents involving clients. • Always check any order that a client questions. • Know your own strengths and weaknesses. Ask for assistance
and supervision in situations for which you feel inadequately prepared.
• Maintain your clinical competence. For students, this demands study and practice before caring for clients. For graduate nurses, it means continued study to maintain and update clinical knowledge and skills.
The nurse completes the following tasks when completing an incident report:
• Identify the client by name, initials, and hospital or identification number.
• Give the date, time, and place of the incident. • Describe the facts of the incident. Avoid any conclusions or blame.
Describe the incident as you saw it even if your impressions differ from those of others.
• Incorporate the client’s account of the incident. State the client’s comments by using direct quotes.
• Identify all witnesses to the incident. • Identify any equipment by number and any medication by name
and dosage.
The report should be completed as soon as possible and filed according to agency policy. Because incident reports are not part of the client’s medical record, the facts of the incident should also be noted in the medical record. Do not record in the client record that an incident report has been completed because the facts are already documented in the chart. The purpose of the report form is to alert the risk manager to the event.
The person who identifies that the incident occurred should complete the incident report. This may not be the same person actu- ally involved with the incident. For example, the nurse who discovers that an incorrect medication has been administered completes the form even if it was another nurse who administered the medication. In addition, all witnesses to an incident, such as a client fall, are listed on the incident form even if they were not directly involved.
Incident reports are often reviewed by an agency risk manage- ment committee, which decides whether to investigate the incident further. Nurses may be required to answer such questions as what they believe precipitated the accident, how it could have been pre- vented, and whether any equipment should be adjusted.
When an accident occurs, the nurse should first assess the client and intervene to prevent injury. If a client is injured, nurses must take steps to protect the client, themselves, and their employer. Most agen- cies have policies regarding accidents. It is important to follow these policies and not to assume one is negligent. Although negligence may
be involved, accidents can and do happen even when every precau- tion has been taken to prevent them.
REPORTING CRIMES, TORTS, AND UNSAFE PRACTICES Nurses may need to report nursing colleagues or other health profes- sionals for practices that endanger the health and safety of clients. For instance, alcohol and drug use, theft from a client or agency, and un- safe nursing practice should be reported. Reporting a colleague is not easy. The person reporting may feel disloyal, incur the disapproval of others, or perceive that chances for promotion are endangered. When reporting an incident or series of incidents, the nurse must be care- ful to describe observed behavior only and not make inferences as to what might be happening. The accompanying Practice Guidelines can be used for reporting a crime, tort, or unsafe practice.
Reporting these events is referred to as whistle-blowing. Many states have laws that prevent wrongful termination of whistle-blowers by employers. In some states, it is mandatory for a nurse with knowledge of unprofessional conduct to report that behavior to the state board of nursing. In addition, reporting illegal, unethical, or incompetent performance is an expectation found in the ANA Code of Ethics.
PRACTICE GUIDELINES
Reporting a Crime, Tort, or Unsafe Practice
• Write a clear description of the situation you believe you should report.
• Make sure that your statements are factual and complete. • Make sure you are credible. • Obtain support from at least one trustworthy person before
filing the report. • Report the matter starting at the lowest possible level in the
agency hierarchy. • Assume responsibility for reporting the individual by being
open about it. Sign your name to the letter. • See the problem through once you have reported it.
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LEGAL RESPONSIBILITIES OF STUDENTS Nursing students are responsible for their own actions and liable for their own acts of negligence committed during the course of clinical ex- periences. When they perform duties that are within the scope of profes- sional nursing, such as administering an injection, they are legally held to the same standard of skill and competence as a registered professional nurse. Lower standards are not applied to the actions of nursing students.
CLINICAL ALERT!
Each nurse and nursing student is responsible and accountable for providing safe client care.
Nursing students are not considered employees of the agencies in which they receive clinical experience because these nursing programs contract with agencies to provide clinical experiences for students. In cases of negligence involving such students, the hospital or agency (e.g., public health agency) and the educational institution will be held po- tentially liable for negligent actions by students. Some nursing schools require students to carry individual professional liability insurance.
Nursing students need to be aware that most state boards of nursing require a reporting of prior criminal history when applying for licensure. A person with past felony and some misdemeanor of- fenses may be denied licensure even though that individual gradu- ated from an approved nursing program. Nursing students who are unsure of their personal situation are advised to contact their state board of nursing for more information. Many nursing schools
currently require a background check of students before they can at- tend their clinical practicum. The purpose of this requirement is to protect the public.
Students in clinical situations must be assigned learning experi- ences within their capabilities and be given reasonable guidance and supervision. Nursing instructors are responsible for assigning students to the care of clients and for providing reasonable supervision. Failure to provide reasonable supervision or the assignment of a client to a student who is not prepared and competent can be a basis for liability.
To fulfill responsibilities to clients and to minimize chances for liability, nursing students need to:
• Make sure they are prepared to carry out the necessary care for assigned clients.
• Ask for additional help or supervision in situations for which they feel inadequately prepared.
• Comply with the policies of the agency in which they obtain their clinical experience.
• Comply with the policies and definitions of responsibility sup- plied by the school of nursing.
Students who work as part-time or temporary nursing assistants or aides must also remember that legally they can perform only those tasks that appear in the job description of a nurse’s aide or assistant. Even though a student may have received instruction and acquired competence in administering injections or suctioning a tracheostomy tube, the student cannot legally perform these tasks while employed as an aide or assistant. While acting as a paid employee, the student is covered for negligent acts by the employer, not the school of nursing.
Critical Thinking Checkpoint
A female adult client who has been blind since birth is admitted to the surgical unit. She is to have surgery the next morning. The primary care provider has written an order for the client to sign the surgical consent form. The husband is in the client’s room when the nurse ap- proaches the client to sign the consent form. The husband says that he will sign for his wife. 1. What question(s) should the nurse ask before addressing the
signing of the form?
2. Can someone who is blind give consent? 3. How can the nurse ensure that the client is aware of what she is
signing? 4. What else should the nurse consider when obtaining a
signature? 5. What would the nurse include in the documentation?
See Critical Thinking Possibilities on student resource website.
• Accountability is an essential concept of professional nursing prac- tice under the law.
• Nurses need to understand laws that regulate and affect nursing practice to ensure that nurses’ actions are consistent with current legal principles and to protect themselves from liability.
• Nurse practice acts legally define and describe the scope of nurs- ing practice that the law seeks to regulate.
• Competence in nursing practice is determined and maintained by various credentialing methods, such as licensure, certification, and accreditation, that protect the public’s welfare and safety.
• Standards of practice published by national and state nursing as- sociations, agency policies and procedures, and job descriptions further delineate the scope of a nurse’s practice.
• The nurse has specific legal obligations and responsibilities to cli- ents and employers. As a citizen, the nurse has the rights and responsibilities shared by all individuals in the society.
• Collective bargaining is one way nurses can improve their working conditions and economic welfare.
• Informed consent implies that (a) the consent was given voluntarily, (b) the client was of age and had the capacity and competency to
CHAPTER HIGHLIGHTS
Chapter 4 Review
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• Nurses can be held liable for intentional torts, such as assault and battery, false imprisonment, invasion of privacy, and defamation.
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was the first nationwide legislation to protect the privacy of health information. HIPAA includes four specific areas: a uniform standard for electronic transfer of information among organiza- tions; standardized numbers for identifying providers, employers, and health plans; a security rule; and a privacy rule.
• Good Samaritan acts protect health professionals from claims of professional negligence when they offer assistance at the scene of an emergency, provided that there is no willful wrongdoing or gross departure from normal standards of care.
• Nursing students and practicing nurses can obtain professional liability insurance through professional nursing associations.
• When a client is accidentally injured or involved in an unusual situ- ation, the nurse’s first responsibility is to take steps to protect the client and then to notify appropriate agency personnel.
• Nursing students are held to the same standard as licensed nurses and, therefore, need to make certain that they are prepared to pro- vide the necessary care to assigned clients. It is important that students ask for help or supervision in situations for which they feel inadequately prepared.
understand, and (c) the client was given enough information on which to make an informed decision.
• The Americans with Disabilities Act of 1990 prohibits discrimi- nation on the basis of disability in employment, public services, and public accommodations. Nurses need to know how the ADA affects nursing practice.
• Chemical dependence in health care workers is a problem, in part, because of the high levels of stress involved in many health care settings and the easy access to addictive drugs. Chemical impairment includes abuse of alcohol and addictive drugs. The nurse needs to know the proper reporting procedures for nursing colleagues whose practice is chemically impaired.
• Nurses must be knowledgeable of their responsibilities about legal issues surrounding death: advance directives, autopsies, certification of death, DNR orders, euthanasia, inquests, and or- gan donation.
• Nurse professional negligence, an unintentional tort, can be estab- lished when the following criteria are met: (a) the nurse (defendant) owed a duty to the client, (b) the nurse failed to carry out that duty according to standards, (c) there was foreseeability of harm, (d) the client’s injury was caused by the nurse’s failure to follow the stan- dard, and (e) the client (plaintiff) was injured. The nurse is liable for damages that may be compensated.
1. A primary care provider’s orders indicate that a surgical consent form needs to be signed. Because the nurse was not present when the primary care provider discussed the surgical proce- dure, which statement best illustrates the nurse fulfilling the client advocate role? 1. “The doctor has asked that you sign this consent form.” 2. “Do you have any questions about the procedure?” 3. “What were you told about the procedure you are going to
have?” 4. “Remember that you can change your mind and cancel the
procedure.” 2. Although the client refused the procedure, the nurse insisted and
inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? 1. An unintentional tort 2. Assault 3. Invasion of privacy 4. Battery
3. A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action? 1. Administer the medication. 2. Notify the prescriber. 3. Call the pharmacist. 4. Refuse to administer the medication.
4. A primary care provider prescribes one tablet, but the nurse accidently administers two. After notifying the primary care pro- vider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for professional negligence? 1. No, the client was not harmed. 2. No, the nurse notified the primary care provider. 3. Yes, a breach of duty exists. 4. Yes, foreseeability is present.
5. A nursing student is employed and working as an unlicensed as- sistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be gradu- ating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in the nursing program. When the UAP says “Yes,” the nurse asks him to help her out by doing a urinary catheterization on a postsurgical client. What is the best response by the UAP? 1. “Let me get permission from the client first.” 2. “Sure. Which client is it?” 3. “I can’t do it unless you supervise me.” 4. “I can’t do it. Is there something else I can help you with?”
6. The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? 1. The client may no longer make decisions regarding his or her
own health care. 2. The client and family know that the client will most likely die
within the next 48 hours. 3. The nurses will continue to implement all treatments focused
on comfort and symptom management. 4. A DNR order from a previous admission is valid for the
current admission. 7. The nurse’s partner/spouse undergoes exploratory surgery at
the hospital where the nurse is employed. Which practice is most appropriate? 1. Because the nurse is an employee, access to the chart is
allowed. 2. The relationship with the client provides the nurse special
access to the chart. 3. Access to the chart requires a signed release form. 4. The nurse can ask the surgeon to discuss the outcome of
the surgery.
TEST YOUR KNOWLEDGE
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3. “Forgets” to sign out for administration of controlled substances.
4. Offers to administer prn opioids for other nurses’ clients. 5. Is able to say “no” to requests to work more shifts.
10. Which nursing actions could result in professional negligence? Select all that apply. 1. Learns about a new piece of equipment. 2. Forgets to complete the assessment of a client. 3. Does not follow up on client’s complaints. 4. Charts client’s drug allergies. 5. Questions primary care provider about an illegible order.
See Answers to Test Your Knowledge in Appendix A.
8. Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions is/are most appropriate? Select all that apply. 1. The nurse needs to know the Good Samaritan Act for the state. 2. The nurse is not held liable unless there is gross negligence. 3. After assessing the situation, the nurse can leave to obtain help. 4. The nurse can expect compensation for helping. 5. The nurse offers to help but cannot insist on helping.
9. The nurse notices that a colleague’s behaviors have changed during the past month. Which behaviors could indicate signs of impairment? Select all that apply. 1. Is increasingly absent from the nursing unit during the shift. 2. Interacts well with others.
Suggested Readings Brous, E. A. (2012). Common misconceptions about profes-
sional licensure. American Journal of Nursing,112(10), 55–59. doi:10.1097/01.NAJ.0000421027.92789.95
Brous, E. A. (2012). Professional licensure: Investigation and disciplinary action. American Journal of Nursing,112(11), 53–60. doi:10.1097/01.NAJ.0000422256.95706.9b
Brous, E. A. (2012). Professional licensure protection strategies. American Journal of Nursing,112(12), 43–47. doi:10.1097/01.NAJ.0000423512.68887.8d The author of this three-part series is a nurse attorney. Part 1 discusses misconceptions nurses commonly have about licensure; Part 2 discusses common reasons boards of nursing conduct investigations and take disciplinary action; and Part 3 reviews strategies for protecting the nursing license.
Koh, H. K., Berwick, D. M., Clancy, C. M., Baur, C., Brach, C., Harris, L. M., & Zerhusen, E. G. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “crisis care.” Health Affairs, 31(2), 434–443. doi:10.1377/hlthaff.2011.1169 The authors provide a comprehensive review of the current status of health literacy among U.S. adults and the needed priority for improving health literacy to promote better health and health care for the nation.
Related Research Cole, C. A. (2012). Implied consent and nursing practice:
Ethical or convenient? Nursing Ethics, 19, 550–557. doi:10.1177/0969733011436028
Tschurtz, B. A., Koss, R. G., Kupka, N. J., & Williams, S. C. (2011). Language services in hospitals: Discordance in availability and staff use. Journal of Healthcare Manage- ment, 56(6), 403–418.
References American Nurses Association. (2010). Guide to the code of
ethics for nurses interpretation and application. Silver Spring, MD: Author.
American Nurses Association. (2011). Principles for social networking and the nurse. Silver Spring, MD: Author.
American Nurses Association. (2012). Nursing care and do not resuscitate (DNR) and allow natural death (AND) deci- sions. Revised position statement. Retrieved from http:// nursingworld.org/dnrposition
Brous, E. (2012). Common misconceptions about professional licensure. American Journal of Nursing, 112(10), 55–59. doi:10.1097/01.NAJ.0000421027.92789.95
Darbro, N., & Malliarakis, K. D. (2012). Substance abuse: Risk factors and protective factors. Journal of Nursing Regulation, 3(1), 44–48.
Delamont, A. (2013). How to avoid the top seven nursing errors. Nursing Made Incredibly Easy!, 11(2), 8–10. doi:10.1097/01.NME.0000426302.88109.4e
Equal Employment Opportunity Commission. (2000). Guidelines on discrimination because of sex (Section
1604.11, Sexual harassment. Code of Federal Regula- tions, Title 29, Vol. 4). Retrieved from http://www.ecfr.gov/ cgi-bin/text-idx?c=ecfr&SID=08e7cb0e14fbc6fa1607e54 c8b77db5b&rgn=div8&view=text&node=29:4.1.4.1.5.0.2 1.11&idno=29
Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Pearson.
Institute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary. Washington, DC: National Academies Press.
International Medical Interpreters Association. (2013). Standards of practice. Retrieved from http://www.imiaweb .org/standards/standards.asp
Intervention Project for Nurses. (2013). Intervention project for nurses. Retrieved from http://www.ipnfl.org
Leclercq, W. K., Keulers, B. J., Scheltinga, M. R., Spauwen, P. H., & Van der Will, G. J. (2010). A review of surgical informed consent: Past, present, and future. A quest to help patients make better decisions. World Journal of Surgery, 34, 1406–1415. doi:10.1007/s00268-010-0542-0
Minnesota Department of Health Refugee Health Program. (2010). Minnesota refugee health provider guide— Chapter 11—Working with medical interpreters. Retrieved from http://www.health.state.mn.us/divs/idepc/refugee/ guide/11interpreters.html
National Council of State Boards of Nursing. (n.d.). Joint state- ment on delegation. Retrieved from https://www.ncsbn .org/Delegation_joint_statement_NCSBN-ANA.pdf
National Council of State Boards of Nursing. (2011). White paper: A nurse’s guide to the use of social media. Chicago, IL: Author.
National Council of State Boards of Nursing. (2014a). Nurse Licensure Compact frequently asked questions. Retrieved from https://www.ncsbn.org/2002.htm
National Council of State Boards of Nursing. (2014b). Nurse licen- sure compact. Retrieved from https://www.ncsbn.org/nlc.htm
National Licensure Compact Administrators. (2010). NLCA annual report: Oct. 1, 2009–Sept. 30, 2010. Retrieved from https://www.ncsbn.org/NLCA_AnnualReport_2010.pdf
National Licensure Compact Administrators. (2011). NLCA 2011 annual report. Retrieved from https://www.ncsbn .org/NLCA_AnnualReport_2011_web.pdf
National Licensure Compact Administrators. (2012). APRN (advanced practice nurse) licensure compact. Retrieved from https://www.ncsbn.org/APRN_Compact_hx_ timeline_April_2012_(2).pdf
Oregon Public Health Division. (2012). Oregon’s death with dignity act—2012. Retrieved from http://public.health .oregon.gov/ProviderPartnerResources/EvaluationResearch/ DeathwithDignityAct/Documents/year15.pdf
Painter, L. M., & Dudjak, L. A. (2010). Actions, behaviors, and characteristics of RNs involved in compensable injury. Jour- nal of Nursing Administration, 40, 534–539. doi:10.1097/ NNA.0b013e3181fc19eb
Reising, D. L. (2012). Make your nursing care malpractice- proof. American Nurse Today, 7(1), 24–28.
Richardson, V. (2013). Patient comprehension of informed consent. Journal of Perioperative Practice, 23(1), 26–30.
Servodidio, C. A. (2011). Alcohol abuse in the workplace and patient safety. Clinical Journal of Oncology Nursing, 15(2), 143–145. doi:10.1188/11.CJON.143-145
Texas Nurses Association. (2013). Warning sign: Clues to nurses with problems. Retrieved from http://www .texasnurses.org/displaycommon.cfm?an= 1&subarticlenbr=103
U.S. Department of Health and Human Services. (n.d.). Plain language: A promising strategy for clearly communicating health information and improving health literacy. Retrieved from http://www.health.gov/communication/literacy/ plainlanguage/PlainLanguage.htm#top
U.S. Department of Health and Human Services, Office of Minority Health. (2007). National standards on culturally and linguistically appropriate services (CLAS). Retrieved from http://minorityhealth.hhs.gov/templates/browse .aspx?lvl=2&lvlID=15
Selected Bibliography Arizona State Board of Nursing Regulatory Journal. (2010).
Nurse licensure compact—Sharing the realities. Retrieved from https://ncsbn.org/AZBN_Journal_NLC_ edition_12_1_10.pdf
Buppert, C. (2012). When does a nurse need a lawyer? Medscape. Retrieved from http://www.medscape.com/ viewarticle/760437
Buppert, C. (2012). When is gossip a HIPAA violation? Medscape. Retrieved from http://www.medscape.com/ viewarticle/766976
Cook, L. (2013). Can nurses trust nurses in recovery reentering the workplace? Nursing, 43(3), 21–24. doi:10.1097/01 .NURSE.0000427092.87990.86
Cummings, S. (2012). How to tell whether patients can make decisions about their care. Emergency Nurse, 20(5), 22–26.
Hicks, D. (2012). Cultural competence and the Hispanic population. Medsurg Nursing, 21, 314–315.
Mitchell, M. (2011). An analysis of common arguments against advance directives. Nursing Ethics, 19(2), 245–251. doi:10.1177/0969733011416398
Monroe, T., & Kenaga, H. (2010). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20, 504–509. doi:10.1111/j.1365-2702.2010.03518.x
Orozco, E. (2012). Understanding the culturally and linguisti- cally appropriate services (CLAS) standards. Migrant Health, 29(1), 1–2.
Ward-Smith, P. (2012). Health literacy. Urologic Nursing, 32(3), 168–170.
READINGS AND REFERENCES
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LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Explain how values, moral frameworks, and codes of ethics
affect moral decisions. 2. Explain how nurses use knowledge of values to make ethical
decisions and to assist clients in clarifying their values. 3. When presented with an ethical situation, identify the moral
issues and principles involved.
INTRODUCTION In their daily work, nurses deal with intimate and fundamental human events such as birth, death, and suffering. They must decide the moral- ity of their own actions when they face the many ethical issues that surround such sensitive areas. Because of the special nurse– client rela- tionship, nurses are the ones who are there to support and advocate for clients and families who are facing difficult choices, and for those who are living the results of choices that others make for and about them.
The present environment of cost containment and the nursing shortage tends to emphasize business values. This creates new moral problems and intensifies old ones, making it more critical than ever for nurses to make sound moral decisions. Therefore, nurses need to (a) develop sensitivity to the ethical dimensions of nursing prac- tice, (b) examine their own and clients’ values, (c) understand how values influence their decisions, and (d) think ahead about the kinds of moral problems they are likely to face. This chapter explores the influences of values and moral frameworks on the ethical dimensions of nursing practice and on the nurse’s role as a client advocate.
VALUES Values are enduring beliefs or attitudes about the worth of a person, object, idea, or action. Values are important because they influence decisions and actions, including nurses’ ethical decision making. Even though they may be unspoken and perhaps even unconsciously held, questions of value underlie all moral dilemmas. Of course, not all values are moral values. For example, people hold values about work, family, religion, politics, money, and relationships. Values are often taken for granted. In the same way that people are not aware
of their breathing, they usually do not think about their values; they simply accept them and act on them.
People organize their values internally along a continuum from most important to least important, forming a value system. Value systems are basic to a way of life, give direction to life, and form the basis of behavior—especially behavior that is based on decisions or choices.
Beliefs and attitudes are related, but not identical, to values. Peo- ple have many different beliefs and attitudes, but a smaller number of values. Beliefs (or opinions) are interpretations or conclusions that people accept as true. They are based more on faith than fact. Beliefs do not necessarily involve values. For example, the statement “If I study hard I will get a good grade” expresses a belief that does not involve a value. By contrast, the statement “Good grades are really important to me. I must study hard to obtain good grades” involves both a value and a belief.
Attitudes are mental positions or feelings toward a person, ob- ject, or idea (e.g., acceptance, compassion, openness). Typically, an at- titude lasts over time, whereas a belief may last only briefly. Attitudes are often judged as bad or good, positive or negative, whereas beliefs are judged as correct or incorrect. Attitudes have thinking and behav- ioral aspects. Attitudes vary greatly among individuals. For example, some clients may feel strongly about their need for privacy, whereas others may dismiss it as unimportant.
Values Transmission Values are learned through observation and experience. As a result, they are heavily influenced by a person’s sociocultural environment— that is, by societal traditions; by cultural, ethnic, and religious groups; and by family and peer groups. For example, if a parent consistently
KEY TERMS
accountability, 77 active euthanasia, 82 advocate, 83 assisted suicide, 82 attitudes, 73 autonomy, 76 beliefs, 73 beneficence, 76 bioethics, 75
code of ethics, 78 consequence-based
(teleological) theories, 76
ethics, 75 fidelity, 77 justice, 77 moral development, 76 moral distress, 79
moral rules, 76 morality, 75 nonmaleficence, 76 nursing ethics, 75 passive euthanasia, 82 personal values, 74 principles-based
(deontological) theories, 76 professional values, 74
relationships-based (caring) theories, 76
responsibility, 77 utilitarianism, 76 utility, 76 value system, 73 values, 73 values clarification, 74 veracity, 77
5 Values, Ethics, and Advocacy
4. Discuss common ethical issues currently facing health care professionals.
5. Discuss the advocacy role of the nurse.
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One widely used theory of values clarification was developed by Raths, Harmin, and Simon (1978). They described a “valuing pro- cess” of thinking, feeling, and behavior that they termed “choosing,” “prizing,” and “acting” (Box 5–2). In some cases, a values clarification exercise can be useful in helping individuals or groups to become more aware of their values and how they may influence their actions. For example, asking a client to agree or disagree with a list of state- ments or to rank in order of importance a list of beliefs can assist the nurse and client to make the client’s values more open so they can be considered in planning the client’s care.
CLARIFYING THE NURSE’S VALUES Nurses and nursing students need to reflect on the values they hold about life, death, health, and illness. Nurses hold both per- sonal and professional values. One strategy for gaining awareness of personal values is to consider attitudes about specific issues such as abortion or euthanasia, asking: “Can I accept this, or live with this?” “What would I do or want done in this situation?” As is true with all people, nurses’ values are influenced by culture, education, and age. However, research shows that fundamental professional nursing values of human dignity, equality, and pre- vention of suffering have not varied over time or across groups (Snellman & Gedda, 2012).
CLARIFYING CLIENT VALUES To plan effective client-centered care, nurses need to identify clients’ values as they influence and relate to a particular health problem. For example, a client with failing eyesight will probably place a high value on the ability to see, and a client with chronic pain will value comfort. Normally, people take such things for granted. For informa- tion about health beliefs and practices, see Chapter 17 . The nurse should never assume that the client has any particular values. Rather,
demonstrates honesty in dealing with others, the child will probably begin to value honesty. Historically, American values reflected the influence of original settlers, who originated from a limited number of countries. In a classic essay, members of the Washington Interna- tional Center identified 13 U.S. values that differed significantly from the traditional values of residents from other countries (Kohls, 1984). For example, Americans place less value on the past than on the fu- ture, whereas in other countries, the past and present are the most important perspectives.
Nurses should keep in mind the influence of values on health (see Chapter 17 ). For example, some cultures value treatment by a folk healer over that by a physician. For additional information about cultural values related to health and illness, see Chapter 18 .
PERSONAL VALUES Although people derive values from society and their individual subgroups, they internalize some or all of these values as personal values. People need societal values to feel accepted, and they need personal values to have a sense of individuality.
PROFESSIONAL VALUES Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. The American Association of Colleges of Nursing (2008) iden- tified five values essential for the professional nurse: altruism, auton- omy, human dignity, integrity, and social justice (Box 5–1).
Values Clarification Values clarification is a process by which people identify, examine, and develop their own individual values. A principle of values clarifi- cation is that no one set of values is right for everyone. When people can identify their values, they can retain or change them and thus act based on freely chosen, rather than unconscious, values. Values clari- fication promotes personal growth by fostering awareness, empathy, and insight. Therefore, it is an important step for nurses to take in dealing with ethical problems.
BOX 5–1
Altruism is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse’s concern for the welfare of patients, other nurses, and other health care providers.
Autonomy is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients’ rights to make decisions about their health care.
Human dignity is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues.
Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is re- flected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession.
Social justice is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.
From The Essentials of Baccalaureate Education for Professional Nursing Practice (pp. 27–28), American Association of Colleges of Nursing, 2008, Washington, DC: Author. Reprinted with permission.
Essential Nursing Values BOX 5–2
Choosing (Cognitive) Beliefs are chosen • Freely, without outside pressure • From among alternatives • After reflecting and considering
consequences. Example: A person learns about energy resources, production, and consumption; the greenhouse effect; and other environmental issues, including ways to minimize use of and to recycle limited resources.
Prizing (Affective) Chosen beliefs are prized and cherished.
Example: The person is proud of the belief that he or she has an obligation to participate in some way in reducing environmental waste.
Acting (Behavioral) Chosen beliefs are • Affirmed to others • Incorporated into one’s behavior • Repeated consistently in one’s life.
Example: The person participates in the city recycling program for household waste, uses public transportation rather than driving a personal car when possible, helps organize recycling in the work- place, and is active in legislative and political activities related to environmental issues. From Values and Teaching: Working with Values in the Classroom, 2E, by L. Raths, J. Harmin, and S. Simon. Published by C. E. Merrill Publishing Company, 1978. Used by permission of James Raths.
Values Clarification
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TABLE 5–1 Behaviors That May Indicate Unclear Values
Behavior Example
Ignoring a health professional’s advice A client with heart disease who values hard work ignores advice to exercise regularly.
Inconsistent communication or behavior A pregnant woman says she wants a healthy baby, but continues to drink alcohol and smoke tobacco.
Numerous admissions to a health agency for the same problem
A middle-aged obese woman repeatedly seeks help for back pain but does not lose weight.
Confusion or uncertainty about which course of action to take
A woman wants to obtain a job to meet financial obligations, but also wants to stay at home to care for an ailing husband.
the nurse explores client values through discussion. As described in the QSEN competencies, the client’s values, and thus their prefer- ences, are assessed and used in each step of nursing care, including the communication of these values to other members of the health care team (Cronenwett et al., 2007). When it seems as if clients hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as an intervention. Examples of behaviors that may indicate the need for clarification of health values are listed in Table 5–1.
The following process may help clients clarify their values:
1. List alternatives. Make sure that the client is aware of all alterna- tive actions. Ask “Are you considering other courses of action?” “Tell me about them.”
2. Examine possible consequences of choices. Make sure the client has thought about possible results of each action. Ask “What do you think you will gain from doing that?” “What benefits do you foresee from doing that?”
3. Choose freely. To determine whether the client chose freely, ask “Did you have any say in that decision?” “Do you have a choice?”
4. Feeling about the choice. Some clients may not feel satisfied with their decision. A sensitive question may be “Some people feel good after a decision is made; others feel bad. How do you feel?”
5. Affirm the choice. Ask “How will you discuss this with others (family, friends)?”
6. Act with a pattern. To determine whether the client consistently behaves in a certain way, ask “How many times have you done that before?” or “Would you act that way again?”
When implementing these steps to clarify values, the nurse assists the client to think each question through, but does not impose personal values. The nurse rarely, if ever, offers an opinion when the client asks for it—and then only with great care or when the nurse is an expert in the content area. Because each situation is different, what the nurse would choose in his or her own life may not be relevant to the client’s circumstances. Thus, if the client asks the nurse “What would you have done in my situation?” it is best to redirect the question back to the client rather than answering from the nurse’s personal view.
ETHICS AND MORALITY The term ethics has several meanings in common use. It refers to (a) a method of inquiry that helps people to understand the morality of human behavior (i.e., it is the study of morality), (b) the practices or beliefs of a certain group (e.g., medical ethics, nursing ethics), and (c) the expected standards of moral behavior of a particular group as described in the group’s formal code of professional ethics. Nurses
have been viewed as the most honest and ethical professionals in U.S. Gallup polls every year since 1999 except when firefighters ranked first shortly after the September 11, 2001, terrorist attacks (Newport, 2012). Bioethics is ethics as applied to human life or health (e.g., to deci- sions about abortion or euthanasia). Nursing ethics refers to ethical issues that occur in nursing practice. The American Nurses Associa- tion (ANA) has updated its Nursing: Scope and Standards of Practice (2010) publication, which holds nurses accountable for their ethical conduct. Professional Performance Standard 7 relates to ethics. The current edition of this standard was significantly expanded to include greater emphasis on nurse advocacy and professional responsibility.
Morality (or morals) is similar to ethics, and many people use the terms interchangeably. Morality usually refers to private, per- sonal standards of what is right and wrong in conduct, character, and attitude. Sometimes the first clue to the moral nature of a situation is an active conscience or an awareness of feelings such as guilt, hope, or shame. Another indicator is the tendency to respond to the situation with words such as ought, should, right, wrong, good, and bad. Moral issues are concerned with important social values and norms; they are not about trivial things.
Nurses should distinguish between morality and law. Laws re- flect the moral values of a society, and they offer guidance in deter- mining what is moral. However, an action can be legal but not moral. For example, an order for full resuscitation of a dying client is legal, but one could still question whether the act is moral. On the other hand, an action can be moral but illegal. For example, if a child at home stops breathing, it is moral but not legal to exceed the speed limit when driving to the hospital. Legal aspects of nursing practice are covered in Chapter 4 .
Nurses should also distinguish between morality and religion as they relate to health practices, although the two concepts are related. For example, according to some religious beliefs, women should un- dergo procedures such as female circumcision that may cause physi- cal mutilation. Other religions or groups may consider this practice to be an ethical violation of the human right to self-determination. Additional common instances of differences in moral perspectives on health involving religious beliefs include blood transfusions, abortion, sterilization, and contraceptive and safer sex counseling.
CLINICAL ALERT!
Many Chinese people are members of either the Confucian or the Buddhist religion. Confucian religious beliefs do not consider a fetus a human being. However, Buddhists believe the fetus is a form of human life. As a result, Chinese people may vary in their views on abortion, depending on their religious affiliation.
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even feel guilty later.” Using principles-based reasoning, Nurse B thinks, “This violates the principle of autonomy. This man has a right to decide what happens to his body.” Using caring-based reasoning, Nurse C thinks, “My relationship to this client commits me to protect- ing him and meeting his needs, and I feel such compassion for him. I must try to help the family understand that he needs their support.” Each of these perspectives is based on the nurse’s moral framework.
Moral Principles Moral principles are statements about broad, general, philosophical concepts such as autonomy and justice. They provide the foundation for moral rules, which are specific prescriptions for actions. For ex- ample, the rule “Do not lie” is based on the moral principle of respect for persons (autonomy). Principles are useful in ethical discussions because even if people disagree about which action is right in a situ- ation, they may be able to agree on the principles that apply. Such an agreement can serve as the basis for a solution that is acceptable to all parties. For example, most people would agree to the principle that nurses are obligated to respect their clients, even if they disagree as to whether the nurse should deceive a particular client about his or her prognosis.
Autonomy refers to the right to make one’s own decisions. Nurses who follow this principle recognize that each client is unique, has the right to be who that individual is, and has the right to choose personal goals. People have “inward autonomy” if they have the abil- ity to make choices; they have “outward autonomy” if their choices are not limited or imposed by others.
Honoring the principle of autonomy means that the nurse re- spects a client’s right to make decisions even when those choices seem to the nurse not to be in the client’s best interest. It also means treat- ing others with consideration. In a health care setting, this principle is violated, for example, when a nurse disregards clients’ subjective ac- counts of their symptoms (e.g., pain). Finally, respect for autonomy means that people should not be treated as impersonal sources of knowledge or training. This principle comes into play, for example, in the requirement that clients provide informed consent before tests, procedures, or participation in a research project can be carried out. See the discussion of informed consent in Chapter 4 .
Nonmaleficence is the duty to “do no harm.” Although this would seem to be a simple principle to follow, in reality it is complex. Harm can mean intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. In nursing, intentional harm is never acceptable. However, placing a person at risk of harm has many facets. A client may be at risk of harm as a known conse- quence of a nursing intervention that is intended to be helpful. For example, a client may react adversely to a medication. Unintentional harm occurs when the risk could not have been anticipated. For ex- ample, while catching a client who is falling, the nurse grips the client tightly enough to cause bruises to the client’s arm. Caregivers do not always agree on the degree of risk that is morally permissible in order to attempt the beneficial result.
Beneficence means “doing good.” Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons. However, doing good can also pose a risk of doing harm. For example, a nurse may advise a client about a strenuous ex- ercise program to improve general health, but should not do so if the client is at risk of a heart attack.
Moral Development Ethical decisions require persons to think and reason. Reason- ing is a cognitive function and is, therefore, developmental. Moral development is the process of learning to tell the difference be- tween right and wrong and of learning what ought and ought not to be done. It is a complex process that begins in childhood and con- tinues throughout life.
Theories of moral development attempt to answer questions such as these: How does a person become moral? What factors influ- ence the way a person behaves in a moral situation? Two well-known theorists of moral development are Lawrence Kohlberg (1969) and Carol Gilligan (1982). Kohlberg’s theory emphasizes rights and for- mal reasoning; Gilligan’s theory emphasizes care and responsibility, although it points out that people use the concepts of both theorists in their moral reasoning. For a full discussion of these two theories, see Chapter 20 .
Moral Frameworks Moral theories provide different frameworks through which nurses can view and clarify disturbing client care situations. Nurses can use moral theories in developing explanations for their ethical decisions and actions and in discussing problem situations with others. Three types of moral theories are widely used, and they can be differentiated by their emphasis on (a) consequences, (b) principles and duties, or (c) relationships.
Consequence-based (teleological) theories look to the outcomes (consequences) of an action in judging whether that ac- tion is right or wrong. Utilitarianism, one form of consequentialist theory, views a good act as one that is the most useful—that is, one that brings the most good and the least harm to the greatest number of people. This is called the principle of utility. This approach is often used in making decisions about the funding and delivery of health care. Teleological theories focus on issues of fairness.
Principles-based (deontological) theories involve logical and formal processes and emphasize individual rights, duties, and obligations. The morality of an action is determined not by its conse- quences but by whether it is done according to an impartial, objective principle. For example, following the rule “Do not lie,” a nurse might believe he or she should tell the truth to a dying client, even though the physician has given instructions not to do so. There are many deontological theories; each justifies the rules of acceptable behavior differently.
Relationships-based (caring) theories stress courage, gen- erosity, commitment, and the need to nurture and maintain relation- ships. Unlike the two preceding theories, which frame problems in terms of justice (fairness) and formal reasoning, caring theories (see Chapter 25 ) judge actions according to a perspective of caring and responsibility. Principles-based theories stress individual rights, but caring theories promote the common good or the welfare of the group.
A moral framework guides moral decisions, but it does not de- termine the outcome. Imagine a situation in which a frail, older adult client has made it clear that he does not want further surgery, but the family and surgeon insist. Three nurses have each decided that they will not help with preparations for surgery and that they will work through proper channels to try to prevent it. Using consequence- based reasoning, Nurse A thinks, “Surgery will cause him more suf- fering; he probably will not survive it anyway, and the family may
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accountability means “answerable to oneself and others for one’s own actions” (p. 157), whereas responsibility refers to “the specific accountability or liability associated with the performance of duties of a particular role” (p. 157). Thus, the ethical nurse is able to explain the rationale behind every action and recognize the standards to which he or she will be held.
NURSING ETHICS In the past, nurses looked on ethical decision making as the physi- cian’s responsibility. However, no one profession is responsible for ethical decisions, nor does expertise in one discipline such as medi- cine or nursing necessarily make a person an expert in ethics. As situations become more complex, input from all caregivers becomes increasingly important.
Ethical standards of The Joint Commission (2013) mandate that health care institutions provide ethics committees or a similar structure to write guidelines and policies and to provide education, counseling, and support on ethical issues. These multidisciplinary committees include nurses and can be asked to review a case and provide guidance to a competent client, an incompetent client’s fam- ily, or health care providers. They ensure that the relevant facts of a case are brought out, provide a forum in which diverse views can be
Justice is frequently referred to as fairness. Nurses often face de- cisions in which a sense of justice should prevail. For example, a nurse making home visits finds one client tearful and depressed, and knows she could help by staying for 30 more minutes to talk. However, that would take time from her next client, who has diabetes and needs a great deal of teaching and observation. The nurse will need to weigh the facts carefully in order to divide her time justly among her clients.
Fidelity means to be faithful to agreements and promises. By virtue of their standing as professional caregivers, nurses have re- sponsibilities to clients, employers, government, and society, as well as to themselves. Nurses often make promises such as “I’ll be right back with your pain medication” or “I’ll find out for you.” Clients take such promises seriously, and so should nurses.
Veracity refers to telling the truth. Although this seems straight- forward, in practice, choices are not always clear. Should a nurse tell the truth when it is known that it will cause harm? Does a nurse tell a lie when it is known that the lie will relieve anxiety and fear? Lying to sick or dying people is rarely justified. The loss of trust in the nurse and the anxiety caused by not knowing the truth, for example, usually outweigh any benefits derived from lying.
Nurses must also have professional accountability and respon- sibility. According to the Code of Ethics for Nurses (Fowler, 2010),
Decision support involves helping the client choose among two or more health care options. In this study, Llewellyn-Thomas and Crump (2013) identified the roles that values clarification and prefer- ence elicitation play in the process of clients’ decision support, em- phasizing the importance of effective communication between client and care provider. The authors describe various approaches to val- ues clarification, including direct and indirect, interactive and passive strategies. Decision aids are tools that assist in the clarification and preferences processes. These aids may vary in effectiveness based on the particular kind of decision and on the skill of the health care provider using the aid.
IMPLICATIONS It is the nurse’s responsibility to assist the client in making informed decisions about health care that are consistent with the clients’ values and preferences. Even the most motivated nurse, however, may not have the skills needed to elicit these opinions from the cli- ent. This study presents the breadth of tools available to guide the nurse and also emphasizes the usefulness of such tools in ensur- ing that the result is the client, and not the health care provider’s, decision.
Evidence-Based Practice What Is the Best Way to Determine Clients’ Values and Preferences When Assisting in Health Care Decision Making? EVIDENCE-BASED PRACTICE
Moral Principles
Moral principles are commonly accepted as universal. However, the principles that guide bioethics are rooted in a secular Western European perspective. Thus, there is often conflict in creating a fit between these principles and the guiding moral principles of vari- ous cultural groups. Religious groups (such as Catholics, Jehovah’s
Principle Examples of Ethnic/Cultural Variations
Autonomy The client/family may expect the healthcare provider to respect their right to refuse a treatment. Primary responsibility for decision making may rest with others, such as the family, elders, or religious community. The family and community are viewed as affected by the client’s condition and decisions as much as the individual is affected.
Veracity Clients may not value truth-telling for life-threatening conditions, because this may eliminate hope and, therefore, hasten death. Family members may request that the client not be told of his or her diagnosis.
Nonmaleficence Discussion of advance directives and issues such as cardiopulmonary resuscitation may be viewed as physically and emotionally harmful to the client. Withdrawal of life support or withdrawal of futile or damaging treatments may be seen as decreasing length of life or hastening death.
Beneficence The client/family may expect health care providers to promote client well-being and hope, and provide treatment that will help prolong life.
PATIENT-CENTERED CARECulturally Responsive Care
Witnesses, and Muslims) and ethnic groups (such as African, Asian, and Latin American) may hold different views from those of health care providers. Nurses must be familiar with each of these principles as it relates to ethical decision making, in addition to gaining an understanding of the client’s moral principles.
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expressed, provide support for caregivers, and can reduce the insti- tution’s legal risks. In some settings, ethics rounds are held. In these meetings, ethical dilemmas from real or simulated cases are presented from a theoretical perspective, introducing those present to the issues and processes used in analyzing such dilemmas (Figure 5–1 •).
Nursing Codes of Ethics A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Nurses are responsible for being familiar with the code that governs their practice.
International, national, and state nursing associations have es- tablished codes of ethics. The International Council of Nurses (ICN) first adopted a code of ethics in 1953, and the most recent revi- sion (2012) is shown in Box 5–3. The ANA first adopted a Code for
Figure 5–1 • An ethics committee contemplates all aspects of the case being considered. Ghislain & Marie David de Lossy/Alamy.
BOX 5–3 International Council of Nurses Code of Ethics
PREAMBLE Nurses have four fundamental responsibilities: to promote health,
to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal.
Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status.
Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.
THE ICN CODE The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct.
ELEMENTS OF THE CODE 1. Nurses and People
The nurse’s primary professional responsibility is to people requiring nursing care.
In providing care, the nurse promotes an environment in which the human rights, values, customs and spiri- tual beliefs of the individual, family and community are respected.
The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information.
The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.
The nurse advocates for equity and social justice in resource allocation, access to health care, and other social and economic services.
The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness, and integrity.
2. Nurses and Practice The nurse carries personal responsibility and accountability
for nursing practice, and for maintaining competence by continual learning.
The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
The nurse uses judgement regarding individual competence when accepting and delegating responsibility.
The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.
The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.
The nurse strives to foster and maintain a practice culture promoting ethical behaviour and open dialogue.
3. Nurses and the Profession The nurse assumes the major role in determining and
implementing acceptable standards of clinical nursing practice, management, research and education.
The nurse is active in developing a core of research-based professional knowledge.
The nurse is active in developing and sustaining a core of professional values.
The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.
The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.
The nurse contributes to an ethical organisational environment and challenges unethical practices and settings.
4. Nurses and Co-workers The nurse sustains a co-operative relationship with coworkers
in nursing and other fields. The nurse takes appropriate action to safeguard individuals,
families and communities when their health is endangered by a coworker or any other person.
The nurse takes appropriate action to support and guide coworkers to advance ethical conduct.
From The ICN Code of Ethics for Nurses, International Council of Nurses, 2012, Geneva, Switzerland: Imprimerie Fornara. Reprinted with permission.
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ensure clients receive care and are not abandoned, and feeling loyalty to the hospital employer.
Making Ethical Decisions Many nursing problems are not moral problems at all, but simply questions of good nursing practice. An important first step in ethical decision making is to determine whether a moral situation exists. The following criteria may be used:
• A difficult choice exists between actions that conflict with the needs of one or more persons.
• Moral principles or frameworks exist that can be used to provide some justification for the action.
• The choice is guided by a process of weighing reasons. • The decision must be freely and consciously chosen. • The choice is affected by personal feelings and by the particular
context of the situation.
Responsible ethical reasoning is rational and systematic. It should be based on ethical principles and codes rather than on emo- tions, intuition, fixed policies, or precedent (that is, an earlier similar occurrence). A variety of decision-making models are available that are compatible with the nursing process. Each institution adopts its own set of steps for making formal ethical decisions, but each nurse also benefits from having an organizing framework for analyzing ethical issues.
A good decision is one that is in the client’s best interest and at the same time preserves the integrity of all involved. Nurses have ethical obligations to their clients, to the agency that employs them, and to primary care providers. Therefore, nurses must weigh competing factors when making ethical decisions. See Box 5–4 for examples.
Although ethical reasoning is principle based and has the client’s well-being at center, being involved in ethical problems and dilemmas is stressful for the nurse. The nurse may feel torn between obligations to the client, the family, and the employer. What is in the client’s best interest may be contrary to the nurse’s personal belief system. This conflict is referred to as moral distress and is considered a serious issue in the workplace. Wocial and Weaver (2012) created an easy- to-use instrument that measures hospital nurses’ level of moral dis- tress. Another method to assist nurses in coping with moral distress is using the four steps of The 4A’s to Rise Above Moral Distress: ask, af- firm, assess, act (American Association of Critical-Care Nurses, n.d.). Using this model, the nurse asks whether signs of moral distress are present, affirms a commitment to addressing the distress, assesses the sources and severity of the distress plus readiness to act, and acts to
Nurses in 1950. The current version reflects several major changes in the code (now called the Code of Ethics for Nurses). A statement on compassion has been added, and the duty to protect clients has been broadened to include all client rights.
Nursing codes of ethics have the following purposes:
1. Inform the public about the minimum standards of the profes- sion and help them understand professional nursing conduct.
2. Provide a sign of the profession’s commitment to the public it serves.
3. Outline the major ethical considerations of the profession. 4. Provide ethical standards for professional behavior. 5. Guide the profession in self-regulation. 6. Remind nurses of the special responsibility they assume when
caring for the sick.
Origins of Ethical Problems in Nursing Nurses’ growing awareness of ethical problems has occurred largely because of (a) social and technologic changes and (b) nurses’ conflict- ing loyalties and obligations.
SOCIAL AND TECHNOLOGIC CHANGES Social changes, such as the women’s movement and a growing con- sumerism, also expose problems. The large number of people with- out health insurance, the high cost of health care, and workplace redesign under managed care all raise issues of fairness and allocation of resources.
Technology creates new issues that did not exist in earlier times. Before monitors, respirators, and parenteral feedings, there was no question about whether to “allow” an 800-gram premature infant to die. Before organ transplantation, death did not require a legal defi- nition that permits viable tissues to be removed and given to other living persons. Advances in the ability to decode and control the growth of tissues through gene manipulation present new poten- tial ethical dilemmas related to cloning organisms and altering the course of hereditary diseases and biologic characteristics. Today, with treatments that can prolong and enhance biologic life, these questions arise: Should we do what we know we can? Who should be treated—everyone, only those who can pay, only those who have a chance to improve?
CONFLICTING LOYALTIES AND OBLIGATIONS Because of their unique position in the health care system, nurses experience conflicts among their loyalties and obligations to clients, families, primary care providers, employing institutions, and licens- ing bodies. Client needs may conflict with institutional policies, pri- mary care provider preferences, needs of the client’s family, or even laws of the state. According to the nursing code of ethics, the nurse’s first loyalty is to the client. However, it is not always easy to deter- mine which action best serves the client’s needs. For instance, the nurse may be aware that marijuana has been shown to be effective for a condition a client has that has not responded to mainstream therapies. Although legal issues are involved, the nurse must deter- mine if, ethically, the client should be made aware of a potentially effective alternative. Another example is individual nurses’ decisions regarding honoring picket lines during employee strikes. The nurse may experience conflict among feeling the need to support cowork- ers in their efforts to improve working conditions, feeling the need to
Examples of Nurses’ Obligations in Ethical Decision MakingBOX 5–4
• Maximize the client’s well-being. • Balance the client’s need for autonomy with family members’
responsibilities for the client’s well-being. • Support each family member and enhance the family support
system. • Carry out hospital policies. • Protect other clients’ well-being. • Protect the nurse’s own standards of care.
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Strategies to Enhance Ethical Decisions and Practice Several strategies help nurses overcome possible organizational and social constraints that may hinder the ethical practice of nursing and create moral distress for nurses. You as a nurse should do the following:
• Become aware of your own values and the ethical aspects of nursing.
• Be familiar with nursing codes of ethics. • Seek continuing education opportunities to stay knowledgeable
about ethical issues in nursing. • Respect the values, opinions, and responsibilities of other health
care professionals that may be different from your own. • Participate in or establish ethics rounds. Ethics rounds use hypo-
thetical or real cases that focus on the ethical dimensions of client care rather than the client’s clinical diagnosis and treatment.
• Serve on institutional ethics committees. • Strive for collaborative practice in which nurses function effec-
tively in cooperation with other health care professionals.
SPECIFIC ETHICAL ISSUES Some of the ethical problems nurses encounter most frequently are issues in the care of clients with HIV/AIDS, abortion, organ or tis- sue transplantation, end-of-life decisions, cost-containment issues that jeopardize client welfare and access to health care (resource al- location), and breaches of client confidentiality (e.g., computerized information management).
Acquired Immunodeficiency Syndrome (AIDS) Because of its association with sexual behavior, illicit drug use, and physical decline and death, AIDS bears a social stigma. According to an ANA position statement, the moral obligation to care for a client with HIV infection cannot be set aside unless the risk exceeds the re- sponsibility (ANA, 2006).
Other ethical issues center on testing for HIV status and for the presence of AIDS in health professionals and clients. Questions arise as to whether testing of all providers and clients should be mandatory or voluntary and whether test results should be released to insurance companies, sexual partners, or caregivers. As with all ethical dilem- mas, each possibility has both positive and negative implications for specific individuals.
Abortion Abortion is a highly publicized issue about which many people feel very strongly. Debate continues, pitting the principle of sanctity of life against the principle of autonomy and a woman’s right to control her own body. This is an especially volatile issue because no public con- sensus has yet been reached.
Most state laws have provisions known as conscience clauses that permit individual primary care providers and nurses, as well as institutions, to refuse to assist with an abortion if doing so vio- lates their religious or moral principles. However, nurses have no right to impose their values on a client. Nursing codes of ethics support clients’ rights to information and counseling in making decisions.
implement a plan to reduce the distress. In settings in which ethical issues arise frequently, nurses should establish support systems such as team conferences and use of counseling professionals to allow ex- pression of their feelings.
One structure that may be useful to nurses in ethical decision making is the Four Topic or Four Box method (Jonsen, Siegler, & Winslade, 2010). This structure provides questions that guide the nurse in gathering all relevant information in the four topics/boxes: medical indications, patient preferences, quality of life, and contex- tual features. Once the data have been collected, ethical principles such as autonomy, nonmaleficence, beneficence, and justice are re- viewed against the data to reach a decision or resolution (Butts & Rich, 2013).
Although the nurse’s input is important, in reality several people are usually involved in making an ethical decision. The client, family, spiritual support persons, and other members of the health care team work together in reaching ethical decisions (Figure 5–2 •). There- fore, collaboration, communication, and compromise are important skills for health professionals. When nurses do not have the auton- omy to act on their moral or ethical choices, compromise becomes essential.
CLINICAL ALERT!
Ethical behavior is contextual—what is an ethical action or decision in one situation may not be ethical in a different situation.
Box 5–5 presents an example of an approach to ethical decision making for a specific clinical case.
Addressing moral distress is consistent with the Quality and Safety Education for Nurses patient-centered care attitude competencies: “Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. Appre- ciate shared decision making with empowered patients and families, even when conflicts occur” (Cronenwett et al., 2007, p. 124).
Figure 5–2 • When there is a need for ethical decisions or client advocacy, many different individuals contribute to the final outcome. Photo Network/Alamy.
SAFETY ALERT! SAFETY
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BOX 5–5
SITUATION Mrs. L., a 67-year-old woman, is hospitalized with multiple fractures and lacerations caused by an automobile collision. Her husband, who was killed in the collision, was taken to the same hospital. Mrs. L., who had been driving the automobile, constantly questions her nurse about her husband. The surgeon has told the nurse not to
tell Mrs. L. about the death of her husband; however, the surgeon does not give the nurse any reason for these instructions. The nurse expresses concern to the charge nurse, who says the surgeon’s orders must be followed—that the surgeon will decide when Mrs. L. should be told. However, the nurse is not comfortable with this and wonders what should be done.
Application of a Bioethical Decision-Making Model
Nursing Actions Considerations
1. Identify the moral aspects. See the criteria provided on page 79 to determine whether a moral situation exists.
Alternative actions are to tell the truth or withhold it. The moral principles involved are honesty and loyalty. These principles conflict because the nurse wants to be honest with Mrs. L. without being disloyal to the surgeon and the charge nurse. The nurse weighs reasons in making a freely and consciously chosen choice. The choice will be affected by feelings of concern for Mrs. L. and a context that includes the surgeon’s incomplete communication with the client and the nurse.
2. Gather relevant facts that relate to the issue.
Data should include information about the client’s health problems. Determine who is involved, the nature of their involvement, and their motives for acting. In this case, the people involved are the client (who is concerned about her husband), the husband (who is deceased), the surgeon, the charge nurse, and the primary nurse. Motives are not known. Perhaps the nurse wishes to protect the therapeutic relationship with Mrs. L.; possibly the surgeon believes this action protects Mrs. L. from psychological trauma and consequent physical deterioration.
3. Determine ownership of the decision. For example, for whom is the decision being made? Who should decide and why?
In this case, the decision is being made for Mrs. L. The surgeon obviously believes that a physician should be the one to decide, and the charge nurse agrees. It would be helpful if caregivers agreed on criteria for deciding who the decision maker should be.
4. Clarify and apply personal values. We can infer from this situation that Mrs. L. values her husband’s welfare, that the charge nurse values policy and procedure, and that the nurse seems to value a client’s right to have information. The nurse needs to clarify his or her own and the surgeon’s values, as well as confirm the values of Mrs. L. and the charge nurse.
5. Identify ethical theories and principles.
For example, failing to tell Mrs. L. the truth can negate her autonomy. The nurse would uphold the principle of honesty by telling Mrs. L. The principles of beneficence and nonmaleficence are also involved because of the possible effects of the alternative actions on Mrs. L.’s physical and psychological well-being.
6. Identify applicable laws or agency policies.
Because the surgeon simply “gave instructions” rather than an actual order, agency policies might not require the nurse to follow the instructions. The nurse should clarify this with the charge nurse and be familiar with the nurse practice act in that state.
7. Use competent interdisciplinary resources.
In this case, the nurse might consult the literature to find out whether clients are harmed by receiving bad news when they are injured and might also consult with the chaplain.
8. Develop alternative actions and project their outcomes on the client and family. Possibly because of the limited time available for ethical deliberations in the clinical setting, nurses tend to identify two opposing, either–or alternatives (e.g., to tell or not to tell) instead of generating multiple options. This creates a dilemma even when none exists.
Two alternative actions, with possible outcomes, follow (others may also be appropriate): 1. Follow the charge nurse’s advice and do as the surgeon says. Possible outcomes:
(a) Mrs. L. might become anxious and angry when she finds out that information has been withheld from her; or (b) by waiting until Mrs. L. is stronger to give her the bad news, the health care team may avoid harming Mrs. L.’s health.
2. Discuss the situation further with the charge nurse and surgeon, pointing out Mrs. L.’s right to autonomy and information. Possible outcomes: (a) The surgeon acknowledges Mrs. L.’s right to be informed, or (b) the surgeon states that Mrs. L.’s health is at risk and insists that she not be informed until a later time. Regardless of whether the action is congruent with the nurse’s personal value system, Mrs. L.’s best interests take precedence.
9. Apply nursing codes of ethics to help guide actions. (Codes of nursing usually support autonomy and nursing advocacy.)
If the nurse believes strongly that Mrs. L. should hear the truth, then as a client advocate, the nurse should choose to confer again with the charge nurse and surgeon.
10. For each alternative action, iden- tify the risk and seriousness of consequences for the nurse. (Some employers may not support nursing autonomy and advocacy in ethical situations.)
If the nurse tells Mrs. L. the truth without the agreement of the charge nurse and surgeon, the nurse risks the surgeon’s anger and a reprimand from the charge nurse. If the nurse follows the charge nurse’s advice, the nurse will receive approval from the charge nurse and surgeon; however, the nurse risks being seen as unassertive, and the nurse violates a personal value of truthfulness. If the nurse requests a conference, the nurse may gain respect for assertiveness and professionalism, but the nurse risks the surgeon’s annoyance at having the instructions questioned.
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BOX 5–5 Application of a Bioethical Decision-Making Model—continued
Nursing Actions Considerations
11. Participate actively in resolving the issue. Recommend actions that can be ethically supported, recognizing that all actions have positive and negative aspects.
The appropriate degree of nursing input varies with the situation. Sometimes nurses participate in choosing what will be done; sometimes they merely support a client who is making the decision. In this situation, if an action cannot be agreed on, the nurse must decide whether this issue is important enough to merit the personal risks involved.
12. Implement the action. The nurse will carry out one of the actions developed in step 8.
13. Evaluate the action taken. Involve the client, family, and other healthcare members in the evaluation, if possible.
The nurse can begin by asking, “Did I do the right thing?” Would the nurse make the same decisions again if the situation were repeated? If the nurse is not satisfied, the nurse can review other alternatives and work through the process again.
Organ and Tissue Transplantation Organs or tissue for transplantation may come from living donors or from donors who have just died. Many living people choose to be- come donors by giving consent under the Uniform Anatomical Gift Act (see Chapter 43 ). Ethical issues related to organ transplanta- tion include allocation of organs, selling of body parts, involvement of children as potential donors, consent, clear definition of death, and conflicts of interest between potential donors and recipients. In some situations, a person’s religious belief may also present conflict. For ex- ample, certain religions forbid the mutilation of the body, even for the benefit of another person.
Individuals’ spiritual beliefs and views on when human life be- gins have an impact on their opinions about stem cell research. The ANA (2007) supports the ethical use of stem cells for research and therapeutic purposes that impact health. This position is slightly different from a previous position statement regarding cloning (ex- act duplication of cells or organisms). Stem cell research is the foun- dation for cell-based therapies in which stem cells are induced to differentiate into the specific cell type required to repair damaged or destroyed cells or tissues. Both embryonic and adult cells are used in this research. Embryonic cells are derived from a 5-day pre- implantation embryo. Adult cells are undifferentiated cells found in differentiated tissue.
End-of-Life Issues The increase in technologic advances and the growing number of older adults have expanded ethical dilemmas. Providing infor- mation and professional assistance, as well as the highest qual- ity of care and caring, is of the utmost importance during the end-of-life period. Some of the most frequent disturbing ethical problems for nurses involve issues that arise around death and dying. These include euthanasia, assisted suicide, termination of life-sustaining treatment, and withdrawing or withholding of food and fluids.
ADVANCE DIRECTIVES Many moral problems surrounding the end of life can be resolved if clients complete advance directives. Presently, all 50 of the United States have enacted advance directive legislation. Advance directives direct caregivers as to the client’s wishes about treatments, providing an ongoing voice for clients when they have lost the capacity to make or communicate their decisions. See Chapter 43 for a full discus- sion of advance directives.
EUTHANASIA AND ASSISTED SUICIDE Euthanasia, a Greek word meaning “good death,” is popularly known as “mercy killing.” Active euthanasia involves actions to bring about the client’s death directly, with or without client consent. An example of this would be the administration of a lethal medication to end the client’s suffering. Regardless of the caregiver’s intent, active euthanasia is forbidden by law and can result in criminal charges of murder.
A variation of active euthanasia is assisted suicide, or giving cli- ents the means to kill themselves if they request it (e.g., providing lethal doses of pills). Some countries or states have laws permitting assisted suicide for clients who are severely ill, who are near death, and who wish to commit suicide. Although some people may disagree with the con- cept, assisted suicide is currently legal in the states of Montana, Oregon, Vermont, and Washington and several countries. In any case, the nurse should recall that legality and morality are not the same thing. Deter- mining whether an action is legal is only one aspect of deciding whether it is ethical. The questions of suicide and assisted suicide are still con- troversial in Western society. The ANA’s position statement on assisted suicide and active euthanasia (2013) states that both active euthanasia and assisted suicide are in violation of the Code of Ethics for Nurses.
Passive euthanasia, more commonly referred to now as with- drawing or withholding life-sustaining therapy (WWLST), involves the withdrawal of extraordinary means of life support, such as re- moving a ventilator or withholding special attempts to revive a client (e.g., giving the client “no code” status) and allowing the client to die of the underlying medical condition. WWLST may be both legally and ethically more acceptable to most people than assisted suicide.
TERMINATION OF LIFE-SUSTAINING TREATMENT Antibiotics, organ transplants, and technologic advances (e.g., ventila- tors) help to prolong life, but not necessarily to restore health. Clients may specify that they wish to have life-sustaining measures withdrawn, they may have advance directives on this matter, or they may appoint a surrogate decision maker. However, it is usually more troubling for health care professionals to withdraw a treatment than to decide ini- tially not to begin it. Nurses must understand that a decision to with- draw treatment is not a decision to withdraw care. Nurses must ensure that sensitive care and comfort measures are given as the client’s illness progresses. When the client is at home, nurses often provide this type of education and support through hospice services (see Chapter 43 for more information regarding hospice and end-of-life care).
It is difficult for families to withdraw treatment, which makes it very important that they fully understand the treatment. They often
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ADVOCACY When people are ill, they are frequently unable to assert their rights as they would if they were healthy. An advocate is one who expresses and defends the cause of another. The health care system is complex, and many clients are too ill to deal with it. If they are to keep from “falling through the cracks,” clients need an advocate to cut through the layers of bureaucracy and help them get what they require. Values basic to client advocacy are shown in Box 5–6. Clients may also advocate for themselves. Today, clients are seeking more self- determination and control over their own bodies.
If a client lacks decision-making capacity, is legally incompe- tent, or is a minor, these rights can be exercised on the client’s behalf by a designated surrogate or proxy decision maker. It is important, however, for the nurse to remember that client control over health decisions is a Western view. In other societies, such decisions may normally be made by the head of the family or another member of the community. The nurse must ascertain the client’s and family’s views and honor their traditions regarding the locus of decision making.
To help make clients’ rights more explicit to both the client and the health care provider, several versions of a patient’s bill of rights have been published by consumer organizations. The most com- monly used was last revised in 2003 by the American Hospital Association into the Patient Care Partnership: Understanding Expec- tations, Rights, and Responsibilities.
The Advocate’s Role The overall goal of the client advocate is to protect clients’ rights. An advocate informs clients about their rights and provides them with the information they need to make informed decisions.
An advocate supports clients in their decisions, giving them full or at least mutual responsibility in decision making when they are capable of it. The advocate must be careful to remain objective and not convey approval or disapproval of the client’s choices. Advocacy requires accepting and respecting the client’s right to decide, even if the nurse believes the decision to be wrong.
In mediating, the advocate directly intervenes on the client’s be- half, often by influencing others. An example of acting on behalf of a client is asking a primary care provider to review with the client the reasons for and the expected duration of therapy because the client says he always forgets to ask the primary care provider.
ADVOCACY IN HOME CARE Although the goals of advocacy remain the same, home care poses unique concerns for the nurse advocate. For example, while in the hospital, people may operate from the values of the nurses and pri- mary care providers. When they are at home, they tend to operate
have misunderstandings about which treatments are life sustaining. Keeping clients and families well informed is an ongoing process, al- lowing them time to ask questions and discuss the situation. It is also essential that they understand that they can reevaluate and change their decision if they wish.
WITHDRAWING OR WITHHOLDING FOOD AND FLUIDS It is generally accepted that providing food and fluids is part of ordi- nary nursing practice and, therefore, a moral duty. However, when food and fluids are administered by tube to a dying client, or are given over a long period to an unconscious client who is not expected to improve, then some consider it to be an extraordinary, or heroic, measure. A nurse is morally obligated to withhold food and fluids (or any treatment) if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent and informed clients’ refusal of food and fluids. The ANA Code of Ethics for Nurses (2010) supports this position through the nurse’s role as a client advocate and through the moral principle of autonomy. However, the debate on ethical, legal, personal, and religious grounds continues—especially as it relates to the care of children who are un- able to speak for themselves. In addition, client views on the accept- ability of these actions vary according to culture (Preedy, 2011).
Allocation of Scarce Health Resources Allocation of limited supplies of health care goods and services, including organ transplants, artificial joints, and the services of specialists, has become an especially urgent issue as medical costs continue to rise and more stringent cost-containment measures are implemented. The moral principle of autonomy cannot be applied if it is not possible to give each client what he or she chooses. In this situation, health care providers may use the principle of justice— attempting to choose what is most fair to all.
Nursing care is also a health resource. Most institutions have been implementing “workplace redesign” to cut costs. Some nurses are concerned that staffing in their institutions is not adequate to give the level of care they value. California is the first state to enact legisla- tion mandating specific nurse-to-client ratios in hospitals and other health care settings. With a nationwide shortage of nurses, an ethical dilemma arises when, in order to provide adequate staffing, facilities must turn away needy clients. Nurses must continue to look for ways to balance economics and caring in the allocation of health resources.
Management of Personal Health Information In keeping with the principle of autonomy, nurses are obligated to re- spect clients’ privacy and confidentiality. Privacy is both a legal and ethical mandate. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes standards protecting the confidential- ity, integrity, and availability of data, and standards defining appro- priate disclosures of identifiable health information and client rights protection. Clients must be able to trust that nurses will reveal details of their situations only as appropriate and will communicate only the information necessary to provide for their health care. Computerized client records make sensitive data accessible to more people and ac- cent issues of confidentiality. Nurses should help develop and follow security measures and policies to ensure appropriate use of client data.
BOX 5–6
• The client is a holistic, autonomous being who has the right to make choices and decisions.
• Clients have the right to expect a nurse–client relationship that is based on shared respect, trust, collaboration in solving problems related to health and health care needs, and consideration of their thoughts and feelings.
• It is the nurse’s responsibility to ensure the client has access to health care services that meet health needs.
Values Basic to Client Advocacy
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arena, the nurse needs an understanding of the ethical issues in nursing and health care, as well as knowledge of the laws and regulations that affect nursing practice and the health of society (see Chapter 4 ).
Being an effective client advocate involves the following:
• Being assertive • Recognizing that the rights and values of clients and families must
take precedence when they conflict with those of health care providers
• Being aware that conflicts may arise over issues that require consul- tation, confrontation, or negotiation between the nurse and admin- istrative personnel or between the nurse and a primary care provider
• Working with community agencies and lay practitioners • Knowing that advocacy may require political action—
communicating a client’s health care needs to government and other officials who have the authority to do something about these needs.
from their own personal values and may revert to old habits and ways of doing things that may not be beneficial to their health. The nurse may see this as noncompliance; nevertheless, client autonomy must be respected.
In home care, limited resources and a lack of client care ser- vices may shift the focus from client welfare to concerns about re- source allocation. Financial considerations can limit the availability of services and materials, making it difficult to ensure that client needs are met.
PROFESSIONAL AND PUBLIC ADVOCACY Advocacy is needed for the nursing profession as well as for the pub- lic. Gains that nursing makes in developing and improving health policy at the institutional and government levels help to achieve bet- ter health care for the public.
Nurses who function responsibly as professional and public ad- vocates are in a position to effect change. To act as an advocate in this
Critical Thinking Checkpoint
A 79-year-old man with severe peripheral vascular disease has been told that a nonhealing lesion on his foot must be treated with either vascular bypass surgery or amputation of the foot. Although the sur- geon believes the foot can be saved with bypass, the man elects to have the amputation. His main reason is that the site will heal more quickly and allow him to resume normal activities sooner. He asks for the nurse’s opinion. 1. What values and beliefs does the client seem to embrace?
2. What additional information might the nurse need to gather from the client or the surgeon?
3. What is the nurse’s ethical/moral responsibility in this instance? 4. What conflicting loyalties and obligations does the nurse face? 5. Of what value is the Code of Ethics for Nurses to the nurse in
solving this dilemma? See Critical Thinking Possibilities on student resource website.
• Values are enduring beliefs that give direction and meaning to life and guide a person’s behavior.
• Values clarification is a process in which people identify, examine, and develop their own values.
• Nursing ethics refers to the ethical problems that occur in nursing practice and to ethical decisions that nurses make.
• Morality refers to private, personal standards of what is right and wrong in conduct, character, and attitude.
• Moral issues are those that arouse the conscience or awareness of feelings such as guilt, hope, or shame; are concerned with im- portant social values and norms; and evoke words such as good, bad, right, wrong, should, and ought.
• Three common moral frameworks (approaches) are consequence- based (teleological), principles-based (deontological), and relationships-based (caring-based) theories.
• Moral principles (e.g., autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity) are broad, general philosophical con- cepts that can be used to make and explain moral choices.
• A professional code of ethics is a formal statement of a group’s ideals and values that serves as a standard and guideline for
the group’s professional actions and informs the public of its commitment.
• Ethical problems are created as a result of changes in society, ad- vances in technology, conflicts within nursing itself, and nurses’ conflicting loyalties and obligations (e.g., to clients, families, em- ployers, primary care providers, and other nurses).
• The goal of ethical reasoning, in the context of nursing, is to reach a mutual, peaceful agreement that is in the best interests of the client; reaching the agreement may require compromise.
• Nurses are responsible for determining their own actions and for supporting clients who are making moral decisions or for whom decisions are being made by others.
• Nurses can enhance their ethical practice and client advocacy by clarifying their own values, understanding the values of other health care professionals, becoming familiar with nursing codes of ethics, and participating in ethics committees and rounds.
• Client advocacy involves concern for and actions on behalf of another person or organization in order to bring about change.
• The functions of the advocacy role are to inform, support, and mediate.
CHAPTER HIGHLIGHTS
Chapter 5 Review
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1. When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is which of the following? 1. Be able to defend the morality of one’s own actions. 2. Remain neutral and detached when making ethical
decisions. 3. Ensure that a team is responsible for deciding ethical
questions. 4. Follow the client and family’s wishes exactly.
2. Which of the following situations is most clearly a violation of the underlying principles associated with professional nursing ethics? 1. A hospital’s policy permits use of internal fetal monitoring
during labor. However, there is literature to both support and refute the value of this practice.
2. When asked about the purpose of a medication, a nurse colleague responds, “Oh, I never look them up. I just give what is prescribed.”
3. The nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by fellow nurses at another facility.
4. A client reports that he didn’t quite tell the doctor the truth when asked if he was following his therapeutic diet at home.
3. Following a motor vehicle crash, the parents of a child with no apparent brain function refuse to permit withdrawal of life support from the child. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse’s actions? 1. Respect for autonomy 2. Nonmaleficence 3. Beneficence 4. Justice
4. Which of the following statements would be most helpful when a nurse is assisting clients in clarifying their values? 1. “That was not a good decision. Why did you think it
would work?” 2. “The most important thing is to follow the plan of care. Did
you follow all your doctor’s orders?” 3. “Some people might have made a different decision. What
led you to make your decision?” 4. “If you had asked me, I would have given you my opinion
about what to do. Now, how do you feel about your choice?”
5. After recovering from her hip replacement, an older adult client wants to go home. The family wants the client to go to a nursing home. If the nurse were acting as a client advocate, the nurse would perform which of the following actions? 1. Inform the family that the client has a right to decide on
her own. 2. Ask the primary care provider to discharge the client
to home. 3. Suggest the client hire a lawyer to protect her rights. 4. Help the client and family communicate their views to
each other. 6. Values, moral frameworks, and codes of ethics influence
the professional nurse’s moral decisions in which of the following ways? 1. The nurse will provide direct client care that is consistent
with the nurse’s personal values. 2. The nurse will seek to ensure that the client’s values and the
nurse’s are the same. 3. The choice of moral framework determines what the client
outcome will be. 4. The nurse is bound to act according to the nurses’ code of
ethics even if the nurse’s values are different. See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
Suggested Reading Huffman, D., & Rittenmeyer, L. (2012). How professional
nurses working in hospital environments experience moral distress: A systematic review. Critical Care Nursing Clinics of North America, 24(1), 91–100. A systematic review is a formal survey of the literature and research about one particular topic. The overall objective of this systematic review was to appraise and synthesize the best available evidence published between 1995 and 2008 on how professional nurses working in hospital environ- ments experience ethical/moral distress. The context was professional nurses experiencing ethical/moral distress as a result of their client care responsibilities. The 101 articles revealed four themes: “1. Human Reactivity: Nurses who experience moral distress respond with a myriad of biologi- cal, psychological, and stress reactions. 2. Institutional Culpability: Moral distress is experienced when nurses feel the need to advocate for clients’ well-being while coping with institutional constraints. 3. Client Pain and Suffering: The perception of client pain and suffering as a result of medical decisions, of which the nurse has little power to influence, contribute to the experience. 4. Unequal Power Hierarchies: Unequal power structures, prevalent in institu- tions, exacerbate the problem” (p. 96).
Related Research Davis, S., Schrader, V., & Belcheir, M. (2012). Influencers
of ethical beliefs and the impact on moral distress and conscientious objection. Nursing Ethics, 19(6), 738–749. doi:10.1177/0969733011423409
Dekeyser Ganz, F., & Berkovitz, K. (2012). Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing, 68(7), 1516–1525. doi:10.1111/J.1365-2648.2011.05897.x
References American Association of Colleges of Nursing. (2008). The
essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.
American Association of Critical-Care Nurses. (n.d.). The 4 A’s to Rise Above Moral Distress. Aliso Viejo, CA: Author. Retrieved from http://www.aacn.org/WD/Practice/ Docs/4As_to_Rise_Above_Moral_Distress.pdf
American Hospital Association. (2003). The patient care partnership: Understanding expectations, rights and responsibilities. Washington, DC: Author. Retrieved from http://www.aha.org/aha/issues/Communicating- With-Patients/pt-care-partnership.html
American Nurses Association (ANA). (2006). Position statement: Risk and responsibility in providing nursing care. Retrieved from http://nursingworld.org/ MainMenuCategories/Policy-Advocacy/Positions-and- Resolutions/ANAPositionStatements/Position-Statements- Alphabetically/RiskandResponsibility.pdf
American Nurses Association (ANA). (2007). Position statement on stem cell research. Retrieved from http://nursingworld.org/MainMenuCategories/ Policy-Advocacy/Positions-and-Resolutions/ ANAPositionStatements/Position-Statements-Alphabetically/ StemCellResearch.txt
American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
American Nurses Association (ANA). (2013). Position statement: Euthanasia, assisted suicide, and aid in dying. Retrieved from http://www.nursingworld.org/ euthanasiaanddying
Butts, J. B., & Rich, K. L. (2013). Nursing ethics: Across the curriculum and into practice (3rd ed.). Burlington, MA: Jones & Bartlett.
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006
Fowler, M. D. M. (Ed.). (2010). Guide to the code of ethics for nurses: Interpretation and application. Silver Spring, MD: American Nurses Association.
Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press.
International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva, Switzerland: Imprimerie Fornara.
The Joint Commission. (2013). Joint Commission International accreditation standards for hospitals (4th ed.). Oakbrook Terrace, IL: Author.
Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York, NY: McGraw-Hill.
Kohlberg, L. (1969). Stage and sequence: The cognitive- developmental approach to socialization. In D. A. Goslin (Ed.), Handbook of socialization theory and research (pp. 347–480). Chicago, IL: Rand McNally.
READINGS AND REFERENCES
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Kohls, L. R. (1984). The values Americans live by. Washington, DC: Meridian House International.
Llewellyn-Thomas, H. A., & Crump, R. T. (2013). Decision support for patients: Values clarification and preference elicitation. Medical Care Research Review, 70, 50s –79s. doi:10.1177/1077558712461182
Newport, F. (2012). Congress retains low honesty rating: Nurses have highest honesty rating; car salespeople, lowest. Retrieved from http://www.gallup.com/ poll/159035/congress-retains-low-honesty-rating.aspx
Preedy, V. R. (Ed.). (2011). Diet and nutrition in palliative care. Boca Raton, FL: Taylor & Francis.
Raths, L., Harmin, M., & Simon, S. (1978). Values and teaching: Working with values in the classroom (2nd ed.). Columbus, OH: Merrill.
Snellman, I., & Gedda, K. M. (2012). The value ground of nursing. Nursing Ethics, 19, 714 –726. doi:10.1177/0969733011420195.
Wocial, L. D., & Weaver, M. T. (2012). Development and psychometric testing of a new tool for detecting moral distress: The Moral Distress Thermom- eter. Journal of Advanced Nursing, 69(1), 167–174. doi:10.1111/j.1365-2648.2012.06036.x
Selected Bibliography Beauchamp, T., & Childress, J. (1979). Principles of biomedical
ethics. New York, NY: Oxford University Press.
Burkhardt, M. A., & Nathaniel, A. K. (2013). Ethics and issues in contemporary nursing (4th ed.). Albany, NY: Delmar.
Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., … Zask, A. (2011). Evidence, ethics, and values: A framework for health promotion. American Journal of Public Health, 101, 465–472. doi:10.2105/ AJPH.2010.195545
Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Hamric, A., Borchers, C., & Epstein, E. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9. doi:10.1080/21507716.2011.652337
Johns Hopkins University Bloomberg School of Public Health, Center for Communication Programs. (2002). Question- naire for values clarification. Retrieved from http://www .jhuccp.org/research/download/Valuesinstrument.pdf
Pieterse, A. H., de Vries, M., Kunneman, M., Stiggelbout, A. M., & Feldman-Stewart, D. (2013). Theory-informed design of values clarification methods: A cognitive psychological perspective on patient health-related decision making. Social Science & Medicine, 77, 156–163. doi:10.1016/ j.socscimed.2012.11.020
Pignone, M. P., Brenner, A. T., Hawley, S., Sheridan, S. L., Lewis, C. L., Jonas, D. E., & Howard, K. (2012). Conjoint analysis versus rating and ranking for values elicitation and clarification in colorectal cancer screening. Journal
of General Internal Medicine, 27, 45–50. doi:10.1007/ s11606-011-1837-z
Redman, B. K., & Fry, S. T. (1998). Ethical conflicts reported by certified registered rehabilitation nurses. Rehabilitation Nursing, 23, 179–184. doi:10.1002/j.2048-7940.1998 .tb01777.x
Shepard, A. (2010). Moral distress: A consequence of caring. Clinical Journal of Oncology Nursing,14, 25–27. doi:10.1188/10.CJON.25-27
Snellman, D. (2011). Professional values and nursing. Medicine, Health Care and Philosophy, 14, 203–208. doi:10.1007/s11019-010-9295-7
Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: A growing problem in the health professions? Hastings Center Report,40(1), 20–22. doi:10.1353/hcr.0.0222
Veatch, R. M. (2012). Hippocratic, religious, and secular medical ethics: The points of conflict. Washington, DC: Georgetown University Press.
Wiegand, D., & Funk, M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics, 19, 479–487. doi:10.1177/0969733011429342
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CLIENT: Megan AGE: 19 CURRENT MEDICAL DIAGNOSIS: Cystic Fibrosis, Pneumonia Medical History: Megan was diagnosed with cystic fibrosis when she was 3 months old. Her parents were very protective and home schooled her during cold and flu seasons to reduce her exposure to viruses. She has been hospitalized several times throughout her life, mostly for pulmonary infections, but has remained fairly healthy compared to others with cystic fibrosis. This is largely due to her parent’s vigilance in meeting her health care needs. Megan con- tracted influenza approximately 5 days ago and became increasingly short of breath. She has been unable to adequately clear pulmonary secretions, and has not been able to meet her caloric needs due to severe coughing episodes that cause vomiting, resulting in a 3.6-kg (8-lb) weight loss. Her temperature is 38.8°C (101.8°F) tympanically. Breath sounds reveal course crackles throughout, and her x-ray shows dense concentrations of fluid in the bases of both lungs.
Personal and Social History: After graduating from high school last year, Megan entered a college located approximately 100 miles from her parents, and is currently living in the dormitory. She has relished her independence, but recognizes her parents’ concerns. Her mother calls frequently to make sure she is eating properly, taking her medications, and doing her breathing exercises as prescribed. In order not to worry her mother, Megan did not tell her when her roommate contracted the flu. Then Megan dreaded having to call and tell her parents she herself had the flu and had been admitted to the hospital near her college. Her parents arrived at the hospital within 2 hours of learning their daughter had been admitted, and her mother seeks out the nurse assigned to her care shortly after greeting her daughter.
Questions American Nurses Association Standard of Professional Performance #7 is Ethics: The registered nurse delivers care in a manner that preserves and protects health care consumer au- tonomy, dignity, rights, values, and beliefs while upholding the client’s confidentiality within legal and regulatory parameters. 1. Megan’s mother asks the nurse to call Megan’s doctor so she
can speak with him and asks what the x-ray and diagnostic studies have indicated about her daughter’s condition. What information can the nurse legally share with Megan’s mother about Megan’s condition?
2. Megan’s doctor explains to Megan and her parents that her condition has worsened, and recommends intubation and place- ment on a mechanical ventilator. Megan says “No, I do not want to be placed on a ventilator,” but her mother urges compliance with the recommended treatment. Megan’s mother turns to the nurse and says, “Tell her she must agree to follow the doctor’s recommendations!” What is the nurse’s best response?
3. The doctor suggests Megan be included in a research study for people with cystic fibrosis who want to avoid mechanical ventila- tion. What are the nurse’s responsibilities in protecting Megan’s rights based on your reading in Chapter 2 ?
American Nurses Association Standard of Practice #1 is Assessment: The registered nurse collects comprehensive data pertinent to the client’s health and/or the situation by using appropri- ate evidence-based assessment techniques, instruments, and tools. 4. What is the nurse’s responsibility when caring for Megan once
she is enrolled in the research study? 5. If the nurse questions the currency of an assessment technique
found in the hospital’s policy and procedure manual, what steps can the nurse take to ensure that evidence-based practice is used?
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
1 Meeting the StandardsIn this unit we have explored the profession of nursing, moving from the history of nursing to the contemporary issues facing nurses today. Nurses must consider legal and ethical issues, theories and conceptual frameworks that guide nursing practice, and the increasing need to develop and maintain an evidence-based practice to provide optimal care to clients. This is occurring at a time when there is a rapidly evolving body of knowledge resulting from research both within nursing as well as other disciplines included in nursing practice. In the case study described below, you will explore how the nurse responds to client and family needs while upholding the standards essential to the nursing profession.
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UNIT
2 Contemporary Health Care
6 Health Care Delivery Systems 89
7 Community Nursing and Care Continuity 105
8 Home Care 118
9 Electronic Health Records and Information Technology 129
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INTRODUCTION A health care system is the totality of services offered by all health disciplines. It is one of the largest industries in the United States. Pre- viously, the major purpose of a health care system was to provide care to people who were ill or injured. However, with increasing awareness of health promotion, illness prevention, and levels of wellness, health care systems are changing, as are the roles of nurses in these areas. The services provided by a health care system are commonly categorized according to type and level.
TYPES OF HEALTH CARE SERVICES Health care services are often described in terms of how they are correlated with levels of disease prevention: (a) primary prevention, which consists of health promotion and illness prevention; (b) sec- ondary prevention, which consists of diagnosis and treatment; and (c) tertiary prevention, which consists of rehabilitation, health resto- ration, and palliative care.
Primary Prevention: Health Promotion and Illness Prevention Based on the notion of maintaining an optimum level of wellness, the World Health Organization (WHO) developed a project called Healthy People. The current U.S. Department of Health and Human Services (2010) project that evolved from the original work is called Healthy People 2020 and has four overarching goals: (1) Increase qual- ity and years of healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and (4) promote health and quality life across the life span.
Health promotion was slow to develop until the 1980s. Since that time, more and more people have recognized the advantages of
staying healthy and avoiding illness. Primary prevention programs address areas such as adequate and proper nutrition, weight con- trol and exercise, and stress reduction. Health promotion activities emphasize the important role clients play in maintaining their own health and encourage them to maintain the highest level of wellness they can achieve.
CLINICAL ALERT!
As insurance companies have realized that keeping people healthy is less expensive than treating illnesses, their insurance plans have begun to pay for preventive health care activities.
Illness prevention programs may be directed at the client or the community and involve such practices as providing immunizations, identifying risk factors for illnesses, and helping people take measures to prevent these illnesses from occurring. Significant examples are the smoking cessation campaigns that both assist individuals to stop smoking and protect the public from ill effects of secondhand smoke by regulating where people are permitted to smoke. Illness preven- tion also includes environmental programs that can reduce the inci- dence of illness or disability. For example, to decrease air pollution, automobile exhaust systems are inspected to ensure acceptable levels of fumes. Environmental protective measures are frequently legis- lated by governments and lobbied for by citizens groups.
Secondary Prevention: Diagnosis and Treatment In the past, the largest segment of health care services was dedicated to the diagnosis and treatment of illness. Hospitals and physicians’ of- fices have been the major agencies offering these complex secondary
LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Differentiate health care services based on primary, second-
ary, and tertiary disease prevention categories. 2. Describe the functions and purposes of the health care agen-
cies outlined in this chapter.
3. Identify the roles of various health care professionals. 4. Describe the factors that affect health care delivery. 5. Describe frameworks for the delivery of nursing care. 6. Compare various systems of payment for health care services.
KEY TERMS
accountable care organizations (ACOs), 102
case management, 99 coinsurance, 100 critical pathways, 99 diagnosis-related groups
(DRGs), 101 differentiated practice, 99
health care system, 89 health maintenance organization
(HMO), 102 independent practice associations
(IPAs), 102 integrated delivery system
(IDS), 102
licensed practical nurse (LPN), 94
licensed vocational nurse (LVN), 94
managed care, 98 Medicaid, 101 Medicare, 100
preferred provider arrangements (PPAs), 102
preferred provider organization (PPO), 102
safety-net hospitals, 92 Supplemental Security Income
(SSI) benefits, 101 team nursing, 99
6 Health Care Delivery Systems
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in the hospital, in the home, or in another agency within the commu- nity. Because the array of health care agencies and services is so great, nurses often need to help clients choose that which best suits their needs. Clients may be seen by any number and type of nurses and other providers, depending on their care requirements and ability to pay for the services.
Public Health Government (official) agencies are established at the local, state, and federal levels to provide public health services. Health agencies at the state, county, or city level vary according to the needs of the area. Their funds, usually generated from taxes, are administered by elected or appointed officials. Local health departments are respon- sible for developing programs to meet the health needs of the people, providing the necessary nursing and other staff and facilities to carry out these programs, continually evaluating the effectiveness of the programs, and monitoring changing needs (Figure 6–1 •). State health organizations are responsible for assisting the local health departments. In some remote areas, state departments also provide direct services to people.
The Public Health Service (PHS) of the U.S. Department of Health and Human Services is an official agency at the federal level. Its functions include conducting research and providing training in the health field, assisting communities in planning and developing health facilities, and assisting states and local communities through financing and provision of trained personnel. Also at the national level in the United States are research institutions such as the Na- tional Institutes of Health (NIH). The National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute of Mental Health work with federal, regional, and state agencies. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, administers a broad program related to surveillance of diseases and behaviors that lead to disease and dis- ability. By means of laboratory and epidemiologic investigations, data are made available to the appropriate authorities. The CDC also publishes recommendations about the prevention and control of in- fections and administers a national health program. The federal gov- ernment also administers a number of Veterans Affairs (VA) services in the United States.
prevention services. Hospitals continue to focus significant resources on clients who require emergency, intensive, and around-the-clock acute care.
Freestanding diagnostic and treatment facilities have also evolved and serve ever-growing numbers of clients. For example, magnetic resonance imaging (MRI) and related radiologic diagnos- tic procedures are commonly performed at physician- or corporate- owned centers. Similar structures exist in outpatient surgical units (surgi-centers).
Also included as a health promotion service is early detection of disease. This is accomplished through routine screening of the popu- lation and focused screening of those at increased risk of developing certain conditions. Examples of early detection services include regu- lar dental exams from childhood throughout life and bone density studies for women at menopause to evaluate for early osteoporosis. Community-based agencies have become instrumental in provid- ing these services. For example, clinics in some communities provide mammograms and education regarding the early detection of cancer of the breast. Voluntary HIV testing and counseling is another exam- ple of the shift in services to community-based agencies. Some malls and shopping centers have walk-in clinics that provide diagnostic tests, such as screening for cholesterol and high blood pressure.
Tertiary Prevention: Rehabilitation, Health Restoration, and Palliative Care The goal of tertiary prevention is to help people move to their previous level of health (i.e., to their previous capabilities) or to the highest level they are capable of given their current health status. Rehabilitative care emphasizes the importance of assisting clients to function adequately in the physical, mental, social, economic, and vocational areas of their lives. For example, someone with an injured neck or back from an au- tomobile crash may have restrictions in the ability to perform work or daily activities. If the injury is temporary, rehabilitation can assist in return to former function. If the injury is permanent, rehabilitation assists the client in adjusting the way activities are performed in or- der to maximize the client’s abilities. Rehabilitation may begin in the hospital, but will eventually lead clients back into the community for further treatment and follow-up once health has been restored.
An example of tertiary mental health prevention is an outreach program that follows individuals with mental disorders in the com- munity to ensure that they adhere to their medication regimens. These programs can reduce acute psychiatric hospital admissions and long-term institutionalization and enable individuals with men- tal disorders to live independently.
Sometimes, people cannot be returned to health. A growing field of nursing and tertiary prevention services is that of palliative care—providing comfort and treatment for symptoms. End-of-life care may be conducted in many settings, including the home.
TYPES OF HEALTH CARE AGENCIES AND SERVICES Health care agencies and services in the United States are both varied and numerous. Some health care agencies or systems provide ser- vices in different settings; for example, a hospital may provide acute inpatient services, outpatient clinic or ambulatory care services, and emergency department services. Hospice services may be provided
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Figure 6–1 • Health departments may provide screening services for all age groups. Michelle Bridwell/PhotoEdit.
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families. Private hospitals are often operated by churches, companies, communities, and charitable organizations. Private hospitals may be for-profit or not-for-profit institutions. Although hospitals are chiefly viewed as institutions that provide care, they have other functions, such as providing sources for health-related research and teaching.
Hospitals are also classified by the services they provide. General hospitals admit clients requiring a variety of services, such as medical, surgical, obstetric, pediatric, and psychiatric services (Figure 6–3 •). Other hospitals offer only specialty services, such as psychiatric or pediatric care. An acute care hospital provides assistance to clients whose illness and need for hospitalization are relatively short term, for example, several days.
The variety of health care services hospitals provide usually de- pends on their size and location. Large urban hospitals usually have inpatient beds, emergency services, diagnostic facilities, ambulatory surgery centers, pharmacy services, intensive and coronary care ser- vices, and multiple outpatient services provided by clinics. Some large hospitals have other specialized services such as spinal cord injury
Physicians’ Offices In North America, the physician’s office is a significant care setting. The majority of physicians either have their own offices or work with several other physicians in a group practice. Clients usually go to a physician’s office for routine health screening, illness diagnosis, and treatment. People seek consultation from physicians when they are experiencing symptoms of illness or when a significant other consid- ers the person to be ill.
In some medical office practices, such as those of family practice physicians or specialists such as dermatologists or surgeons, nurse practitioners (NPs) practice alongside physicians. Often, physicians’ offices do not require the expertise of registered nurses (RNs). In of- fices that do have RNs, the RNs have a variety of roles and respon- sibilities, including client registration, preparing the client for an examination, obtaining health information, and providing informa- tion. Other functions may include obtaining specimens, assisting with procedures, and providing some treatments. In offices without RNs, these tasks may be performed by medical assistants.
Ambulatory Care Centers Ambulatory care centers are used in many communities. Most am- bulatory care centers have diagnostic and treatment facilities that provide medical, nursing, laboratory, and radiologic services, and they may or may not be associated with an acute care hospital. Some ambulatory care centers provide services to people who require mi- nor surgical procedures that can be performed outside the hospital. After surgery, the client returns home, often the same day. These cen- ters offer two advantages: They permit the client to live at home while obtaining necessary health care, and they free up costly hospital beds for seriously ill clients. The term ambulatory care center has replaced the term clinic in many places.
Occupational Health Clinics The industrial (occupational) clinic is gaining importance as a setting for employee health care. The importance of employee health to pro- ductivity has long been recognized. Today, more companies recog- nize the value of healthy employees and encourage healthy lifestyles by providing exercise facilities and coordinating health promotion activities.
Community health nurses in the occupational setting have a variety of roles. Worker safety has always been a concern of occu- pational nurses. Today, nursing functions in industrial health care include work safety and health education, annual employee health screening for tuberculosis, and maintaining immunization informa- tion. Other functions may include screening for such health prob- lems as hypertension and obesity, caring for employees following injury, and counseling (Figure 6–2 •).
Hospitals Hospitals vary in size from the 12-bed rural hospital to the 1,500-bed metropolitan hospital. Hospitals can be classified according to their ownership or control as governmental (public) or nongovernmental (private). In the United States, governmental hospitals are either fed- eral, state, county, or city hospitals. The federal government provides hospital facilities for veterans and merchant mariners (VA hospi- tals). Military hospitals provide care to military personnel and their
Figure 6–2 • In occupational health clinics, primary care providers may examine clients with occasional symptoms. Hero Images/Getty Images.
Figure 6–3 • Most acute care hospitals have active operating room services. Chris Ryan/Getty Images.
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or custodial care. Because clients are being discharged earlier from acute care hospitals, some clients may still require supplemental care in a skilled nursing or extended care facility before they return home.
Because chronic illness occurs most often in older adults, long- term care facilities have programs that are oriented to the needs of this age group. Facilities are intended for people who require not only personal services (bathing, hygiene, eating) but also some regular nursing care and occasional medical attention. However, the type of care provided varies considerably. Some facilities admit and retain only residents who are able to dress themselves and are ambulatory. Other extended care facilities provide bed care for clients who are more incapacitated. These facilities can, in effect, become the client’s home, and consequently the people who live there are frequently re- ferred to as residents rather than patients or clients.
Specific guidelines govern the admission procedures for clients admitted to an extended care facility. Insurance criteria, treatment needs, and nursing care requirements must all be assessed beforehand. Extended care and skilled nursing facilities are becoming increasingly popular means for managing the health care needs of clients who do not meet the criteria for remaining in the hospital. Nurses in ex- tended care facilities assist clients with their daily activities, provide care when necessary, and coordinate rehabilitation activities.
CLINICAL ALERT!
Older adults may move among levels of care several times—from in- dependent living, to a hospital, to a rehabilitation center, to long-term care, and hopefully back to independent or assisted living. The se- quence varies as will the length of time in each setting.
Retirement and Assisted Living Centers Retirement or assisted living centers consist of separate houses, con- dominiums, or apartments for residents. Residents live relatively in- dependently; however, many of these facilities offer meals, laundry services, nursing care, transportation, and social activities. Some cen- ters have an affiliated hospital to care for residents with short-term or long-term illnesses. Often these centers also work collaboratively with other community services including case managers, social ser- vices, and a hospice agency to meet the needs of the residents who live there. The retirement or assisted living center is intended to meet the needs of people who are unable to remain at home but do not require hospital or nursing home care. Nurses in retirement and assisted liv- ing centers provide limited care to residents, usually related to the administration of medications and minor treatments, but conduct significant care coordination and health promotion activities.
Rehabilitation Centers Rehabilitation centers usually are independent community centers or special units. However, because rehabilitation ideally starts the moment the client enters the health care system, nurses who are em- ployed on pediatric, psychiatric, or surgical units of hospitals also help to rehabilitate clients. Rehabilitation centers play an important role in assisting clients to restore their health and recuperate. Drug and alcohol rehabilitation centers, for example, help free clients of drug and alcohol dependence and assist them to reenter the com- munity and function to the best of their ability. Today, the concept of rehabilitation is applied to all illness and injury (physical and
and burn units, oncology services, and infusion and dialysis units. In addition, some hospitals have substance abuse treatment units and health promotion units. Small rural hospitals often are limited to in- patient beds, radiology and laboratory services, and basic emergency services. The number of services a rural hospital provides is usually directly related to its size and its distance from an urban center.
Hospitals in the United States have undergone organizational changes in order to contain costs or to attract clients. Some hospitals have merged with other hospitals or have been purchased by large multihospital for-profit corporations (e.g., Hospital Corporation of America, Community Health Systems, and Tenet Healthcare). Other hospitals are providing innovative outpatient services, such as fit- ness classes, day care for older adults, nutrition classes, and alterna- tive birth centers. Hospitals that provide a significant level of care to low-income, uninsured, and vulnerable populations are referred to as safety-net hospitals.
Subacute Care Facilities Subacute care is a variation of inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process. Clients may be admitted after, or instead of, acute hospitalization or to administer one or more technically complex treatments. Gener- ally, the individual’s condition is such that the care does not depend heavily on high-technology monitoring or complex diagnostic pro- cedures. Subacute care requires the coordinated services of an inter- professional team including physicians, nurses, and other relevant professional disciplines. Subacute care is generally more intensive than long-term care and less intensive than acute care.
Extended (Long-Term) Care Facilities Extended care facilities, formerly called nursing homes, are now often multilevel campuses that include independent living quarters for se- niors, assisted living facilities, skilled nursing facilities (intermediate care), and extended care (long-term care) facilities that provide lev- els of personal care for those who are chronically ill or are unable to care for themselves without assistance (Figure 6–4 •). Traditionally, extended care facilities only provided care for older adult clients, but they now provide care to clients of all ages who require rehabilitation
Figure 6–4 • Nurses in long-term care facilities develop strong relationships with clients. fstop123/Getty Images.
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in rural areas. In 1997, the Balanced Budget Act authorized the Medi- care Rural Hospital Flexibility Program in order to continue to make available primary care access and improve emergency care for rural residents. This program established a new classification called critical access hospitals, which receive federal funding to remain open and provide the breadth of services needed for rural residents, including interfaces with regional tertiary care centers. Each state has an Office of Rural Health Programs that assesses and identifies interventions for the health care needs of the local population. Nurses in rural set- tings must be generalists who are able to manage a wide variety of clients and health care problems. Due to their training in providing comprehensive primary care across the life span, NPs are particularly suited to these roles.
Hospice Services Originally, a hospice was a place for travelers to rest. Recently the term has come to mean interprofessional health care service for the dying, provided in the home or another health care setting. The hospice movement subsumes a variety of services given to clients who are ter- minally ill, their families, and support persons. The central concept of the hospice movement, as distinct from the acute care model, is not saving life but improving or maintaining the quality of life until death. Hospice nurses serve primarily as case managers and super- vise the delivery of direct care by other members of the team. Clients in hospice programs are cared for at home, in hospitals, in freestand- ing hospice facilities, or in skilled nursing facilities. The place of health care delivery may vary as the client’s condition declines or as the ability of the family to care for the client changes. The hospice nurse performs ongoing assessments of needs of the client and family and helps to find the appropriate resources and additional services for them as needed.
Crisis Centers Crisis centers provide emergency services to clients experiencing life crises. These centers may operate out of a hospital or in the com- munity, and most provide 24-hour telephone service. Some also provide direct counseling to people at the center or in their homes. The primary purpose of the center is to help people cope with an immediate crisis and then provide guidance and support for long- term therapy.
Nurses working in crisis centers need well-developed communi- cation and counseling skills. The nurse must immediately identify the individual’s problem, offer assistance to help the individual cope, and perhaps later direct the individual to resources for long-term support.
Mutual Support and Self-Help Groups In North America today, there are more than 500 mutual support or self-help groups that focus on nearly every major health problem or life crisis people experience. These groups may be for the client or for the friends and family of the client, who also need education, guid- ance, and support. Such groups arose largely because people felt their needs were not being met by the existing health care system. Alcohol- ics Anonymous, which formed in 1935, served as the model for many of these groups. The American Self-Help Group Clearinghouse pro- vides information on current support groups and guidelines about how to start a self-help group. The nurse’s role in self-help groups is discussed in Chapter 27 .
mental) (Figure 6–5 •). Nurses in the rehabilitation setting coordi- nate client activities and ensure that clients are complying with their treatments. This type of nursing often requires specialized skills and knowledge.
Home Health Care Agencies The implementation of prospective payment programs (discussed later in this chapter) and the resulting earlier discharge of clients from hospitals have made home care an essential aspect of the health care delivery system. As concerns about the cost of health care have es- calated, the use of the home as a care delivery site has increased. In addition, the scope of services offered in the home has broadened. Home health care nurses and other staff offer education to clients and families and also provide comprehensive care to clients who are acutely, chronically, or terminally ill.
Day Care Centers Day care centers serve many functions and many age groups. Some day care centers provide care for infants and children while parents work. Other centers provide care and nutrition for adults who cannot be left at home alone but do not need to be in an institution. Older adult care centers often provide care involving socializing, exercise programs, and stimulation. Some centers provide counseling and physical therapy. Nurses who are employed in day care centers may provide medications, treatments, and counseling, thereby facilitating continuity between day care and home care.
Rural Care Rural primary care hospitals were created as a result of the 1987 Om- nibus Budget Reconciliation Act to provide emergency care to clients
Figure 6–5 • Physical therapy services are an integral service in rehabilitation centers. Ingram Publishing/Alamy.
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Alternative (Complementary) Care Provider Alternative or complementary health care refers to those practices not commonly considered part of Western medicine. See Chapter 19 for detailed descriptions of these. Chiropractors, herbalists, acupunc- turists, massage therapists, reflexologists, holistic health healers, and other health care providers are playing increasing roles in the con- temporary health care system. These providers may practice along- side Western health care providers, or clients may use their services in conjunction with, or in lieu of, Western therapies.
Case Manager The case manager’s role is to ensure that clients receive fiscally sound, appropriate care in the best setting. This role is often filled by the member of the health care team who is most involved in the client’s care. Depending on the nature of the client’s concerns, the case man- ager may be a nurse, a social worker, an occupational therapist, a physical therapist, or any other member of the health care team.
Dentist Dentists diagnose and treat mouth, jaw, and dental problems. Dentists (and their dental hygienists) are also actively involved in preventive measures to maintain healthy oral structures (e.g., teeth and gums).
Dietitian or Nutritionist A dietitian has special knowledge about the diets required to main- tain health and to treat disease. Dietitians in hospitals generally are concerned with therapeutic diets, supervise the preparation of meals to ensure that clients receive the proper diet, and may design special diets to meet the nutritional needs of individual clients.
A nutritionist is a person who has special knowledge about nutrition and food. The nutritionist in a community setting recom- mends healthy diets and provides broad advisory services about the purchase and preparation of foods. Community nutritionists often function at the preventive level. They promote health and prevent disease, for example, by advising families about balanced diets for growing children and pregnant women.
Emergency Medical Personnel Several different categories of providers are associated with ambu- lance or emergency medical services agencies (e.g., fire departments) that provide first-responder care in the community. Titles, education, and certification vary for emergency medical technicians (EMTs) and paramedics. In general, however, these personnel are trained to as- sess, treat, and transport clients experiencing a medical emergency, accident, or trauma.
Occupational Therapist An occupational therapist (OT) assists clients with impaired func- tion to gain the skills to perform activities of daily living (ADLs). For example, an OT might teach a man with severe arthritis in his arms and hands how to adjust his kitchen utensils so that he can continue to cook. The OT teaches skills that are therapeutic and at the same time provide some fulfillment. For example, weaving is a recreational activity but also exercises the arthritic man’s arms and hands.
PROVIDERS OF HEALTH CARE The providers of health care, also referred to as the health care team or health professionals, are nurses and health personnel from differ- ent disciplines who coordinate their skills to assist clients and their support people. Their mutual goal is to restore a client’s health and promote wellness. The choice of personnel for a particular client de- pends on the needs of the client. Health teams commonly include the nurse and several different personnel (Figure 6–6 •). Nurses’ roles are described in Chapter 1 and throughout this textbook. The fol- lowing sections on the nonnurse providers are in alphabetical order and do not represent an all-inclusive list of possible providers. The scope of practice, qualifications, education, licensure, certification, and/or accreditation of these providers is determined by the regula- tions of the state in which they practice.
Nurse The role of the nurse varies with the needs of the client, the nurse’s credentials, and the type of employment setting. An RN assesses a client’s health status, identifies health problems, and develops and co- ordinates care. A licensed vocational nurse (LVN), in some states known as a licensed practical nurse (LPN), provides direct cli- ent care under the direction of an RN, physician, or other licensed practitioner. As nursing roles have expanded, new dimensions for nursing practice have been established. Nurses can pursue a variety of practice specialties (e.g., critical care, mental health, oncology). Advanced practice registered nurses (APRNs) provide direct client care as NPs, nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. These nurses have education and cer- tifications that—depending on state regulations—may allow them to provide primary care, prescribe medications, and receive third-party (insurance) reimbursement directly for their services.
Figure 6–6 • Although all members of the health care team individualize care for the client based on the expertise of their own discipline, there are areas of overlap facilitated through teamwork.
73-year old with heart
failure, short of breath
Occupational therapist designs self-care activities
that reserve client's energy
MD develops medical care plan,
prescribes medications and
treatments
Physical therapist designs
strengthening and balance exercise plan
Dietitian creates
low-salt diet
RN develops nursing
care plan
Pharmacist supplies and
teaches about medications
Case manager
communicates care plan to
family and other providers
Respiratory therapist provides breathing treatments
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of osteopathy (DOs), a branch of medicine traditionally focused on primary care. Differences between allopathic and osteopathic physi- cians are becoming fewer (Walkowski, 2011).
Physician Assistant Physician assistants (PAs) perform certain tasks under the direction of a physician and are increasingly positioned to provide primary care. They treat various diseases, conditions, and injuries. In many states, nurses are not legally permitted to follow a PA’s orders unless they are co-signed by a physician. In some settings, PAs and NPs have similar job descriptions.
Podiatrist Doctors of podiatric medicine (DPM) diagnose and treat foot and ankle conditions. They are licensed to perform surgery and prescribe medications.
Respiratory Therapist A respiratory therapist is skilled in therapeutic measures used in the care of clients with respiratory problems. These therapists are knowl- edgeable about oxygen therapy devices, respirators, mechanical ven- tilators, and accessory devices used in inhalation therapy. Respiratory therapists administer many of the pulmonary function tests.
Social Worker A social worker counsels clients and their support persons regard- ing problems such as finances, marital difficulties, and adoption of children. They are particularly familiar with both public and pri- vate resources available to clients according to their socioeconomic qualifications. It is not unusual for health problems to produce problems in day-to-day living and vice versa. For example, an el- derly woman who lives alone and has a stroke resulting in impaired walking may find it impossible to continue to live in her third-floor apartment. Finding a more suitable living arrangement can be the responsibility of the social worker if the client has no support network in place.
Spiritual Support Personnel Chaplains, pastors, rabbis, priests, and other religious or spiritual advisers serve as part of the health care team by attending to the spiritual needs of clients. In most facilities, local clergy volunteer their services on a regular or on-call basis. Hospitals affiliated with specific religions, as well as many large medical centers, have full- time chaplains on staff. The nurse is often instrumental in iden- tifying the client’s desire for spiritual support and notifying the appropriate person.
Unlicensed Assistive Personnel Unlicensed assistive personnel (UAPs) are health care staff who assume delegated aspects of basic client care. These tasks include bathing, assisting with feeding, and collecting specimens. UAP titles include nurse’s aides, hospital attendants, nurse technicians, patient care technicians, and orderlies. Some of these categories of provider may have standardized education and job duties (e.g., certified nurse assistants), whereas others do not. The parameters regarding when a nurse can delegate to UAPs are delineated by state boards of nursing.
Paramedical Technologist Laboratory technologists, radiologic technologists, and nuclear med- icine technologists are just three kinds of paramedical technologists in the expanding field of medical technology. Paramedical means having some connection with medicine. Laboratory technologists examine specimens such as urine, feces, blood, and discharges from wounds to provide exact information that facilitates the medical di- agnosis and the prescription of a therapeutic regimen. The radiologic technologist assists with a wide variety of x-ray film procedures, from simple chest radiography to more complex fluoroscopy. The nuclear medicine technologist uses radioactive substances to provide diag- nostic information and can administer radioactive materials as part of a therapeutic regimen.
Pharmacist A pharmacist prepares and dispenses pharmaceuticals in hospital and community settings. The role of the pharmacist in monitoring and evaluating the actions and effects of medications on clients is becoming increasingly prominent. A clinical pharmacist is a special- ist who guides primary care providers in prescribing medications. Pharmacists also work directly with clients and with other health care team members to ensure safe integration of medications into the cli- ent’s comprehensive health plan.
CLINICAL ALERT!
Significant overlap may occur among those providers who can per- form certain health care activities. For example, an anesthesiologist (MD), a neonatal care nurse, or a respiratory therapist may be respon- sible for assisting a newborn baby with breathing problems. All provid- ers perform client teaching.
Physical Therapist The licensed physical therapist (PT) assists clients with musculo- skeletal problems. Physical therapists treat movement dysfunctions by means of heat, water, exercise, massage, and electric current. The functions of a PT include assessing client mobility and strength, pro- viding therapeutic measures (e.g., exercises and heat applications to improve mobility and strength), and teaching new skills (e.g., how to walk with an artificial leg). Some PTs provide their services in hospi- tals; however, independent practitioners establish offices in commu- nities and serve clients either at the office or in the home.
Physician The physician is responsible for medical diagnosis and for determin- ing the therapy required by a person who has a disease or injury. The physician’s role has traditionally been the treatment of disease and trauma (injury); however, many physicians include health promo- tion and disease prevention in their practice. Some physicians are primary care practitioners (also known as general or family practi- tioners); others are specialists such as dermatologists, neurologists, oncologists, orthopedists, pediatricians, psychiatrists, radiologists, or surgeons—to name a few. Physicians who specialize in the care of clients in hospitals are referred to as hospitalists and hospitalists who specialize in critical care are intensivists. Primary care physicians are those who provide the first point of contact for most clients and can include allopathic (Western) medical doctors (MDs) trained in areas such as internal medicine, gynecology, and geriatrics, and doctors
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plus the expense of training specialized personnel to perform the tests, each procedure can cost consumers hundreds or thousands of dollars.
Economics Paying for health care services is becoming a greater problem. The health care delivery system is very much affected by a country’s total economic status. According to the Centers for Medicaid and Medicare Services (2009), health spending in 2011 was estimated at $2.7 trillion in the United States and projected to reach $4.5 trillion by 2020, increasing substantially after 2014 with the implementation of the Affordable Care Act (ACA). This is currently equal to over $9,000 per year for every man, woman, and child and will increase to over $13,000 by 2020. About 29% are inpatient hospital expenses, 34% physician office and clinic expenses, 20% prescription drug expenses, and the remainder emergency department, home care, dental, and related services. The amount for hospital expenses has decreased, whereas outpatient and prescriptions costs doubled from 2007 to 2011. Approximately 40% of these costs are paid through pri- vate insurance, 36% through public programs, and 14% out of pocket (paid directly by the person) (Carper & Machlin, 2013).
The major reasons for cost increases are as follows:
• Existing equipment and facilities are continually becoming obso- lete as research uncovers new and better methods in health care. Health care providers and clients want the newest and the best, and replacing equipment costs more each year.
• Inflation increases all costs. • The total population is growing, especially the segment of older
adults who tend to have greater health care needs than younger people. Expenses for people over age 65 are more than 2.5 times as much as for those under age 65 (Carper & Machlin, 2013).
• In 2011, 63% of hospital costs were billed to Medicare and Medic- aid (Pfuntner, Wier, & Steiner, 2013).
• As more people recognize that health is everyone’s right, large numbers of people are seeking assistance in health matters. The average American sees a doctor three times per year, and the number of visits to specialist physicians is increasing (Hing & Shappert, 2012).
• The relative number of people who provide health care services has increased.
• The numbers of uninsured individuals are changing. The exact number changes daily, especially with implementation of the ACA. Fewer Americans were uninsured in 2011 than 2012, but the percentage of people covered by government health insur- ance, including Medicare, increased. More young adults gained coverage from a provision of the ACA that allows parents to keep their children on their policies longer. For adults between 26 and 64 years old, the major parts of ACA coverage expansion went into effect in 2014.
• The cost of prescription drugs is increasing. Medicare recipients are eligible for prescription drug coverage to help cover some basic and catastrophic medication costs.
Women’s Health The women’s movement has been instrumental in changing health care practices. Examples are the provision of childbirth services in more relaxed settings such as birthing centers, and the provision of
FACTORS AFFECTING HEALTH CARE DELIVERY Today’s health care consumers have greater knowledge about their health than in previous years, and they are increasingly influencing health care delivery. Formerly, people expected a primary care pro- vider to make decisions about their care; today, however, consumers expect to be involved in making any decisions. Consumers have also become aware of how lifestyle affects health. As a result, they desire more information and services related to health promotion and ill- ness prevention. A number of other factors affect the ability of the health care delivery system to meet the needs of the population.
Increasing Number of Older Adults By the year 2020, it is estimated that the number of U.S. adults over the age of 65 years will be more than 62 million (U.S. Census Bureau, 2012). Long-term illnesses are prevalent among this group, and they frequently require special housing, treatment services, financial sup- port, and social networks. The frail elderly, considered to be people over age 85, are projected to be the fastest growing population in the United States and will number almost 7 million by 2020 and 9 million by 2030 (U.S. Census Bureau, 2012). Because less than 5% of older adults are institutionalized with health problems, substantial home management and nursing support services are required to assist those living in their homes and communities.
Older adults also need to feel they are part of a community even though they are approaching the end of their lives. The feeling of being a useful, wanted, and productive citizen is essential to every person’s health. Special programs are being designed in communities so that the talents and skills of this group will be used and not lost to society.
Advances in Technology Scientific knowledge and technology related to health care are rap- idly increasing. Improved diagnostic procedures and sophisticated equipment permit early recognition of diseases that might otherwise have remained undetected. New medications are continually being manufactured to treat infections and multidrug-resistant organisms. Surgical procedures involving the heart, lungs, and liver that were nonexistent years ago are common today. Laser and microscopic procedures streamline the less invasive treatment of diseases that re- quired surgery in the past.
Computers, bedside charting, and the ability to store and retrieve large volumes of information in databases are becoming required of health care organizations. In addition, as a result of the availability of Internet access from numerous public and private locations, clients now have access to medical information similar to that of health care providers (although not all websites provide accurate information). One example of a reliable source of health care information for clients is the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) website.
Clients are increasingly likely to be treated in the community, utilizing resources, technology, and treatments outside the hospital. For example, years ago a person having cataract surgery had to re- main in bed in the hospital for 10 days; today, most cataract removals are performed in outpatient surgery centers.
Technological advances and specialized treatments and proce- dures may come, unfortunately, with a high price tag. Some diagnos- tic equipment may cost millions of dollars. Due to this expenditure
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the most (National Center for Health Statistics, 2012). One response to insufficient numbers of physicians qualified to provide hospital ser- vices has been the creation of hospitalist and intensivist specialties.
An increasing number of health care personnel provide special- ized services. Specialization can lead to fragmentation of care and, often, increased cost of care. To clients, it may mean receiving care from 5 to 30 people during their hospital experience. This seemingly endless stream of personnel and required paperwork is often confus- ing and frightening.
Access to Health Insurance Another problem plaguing individuals is access to health insurance. Without health insurance, people receive less preventive care, delay or avoid care and medications, are diagnosed later in their illnesses, and have higher mortality. In addition, because of low or absent re- imbursement for services, primary care providers may hesitate to provide care.
Lack of health insurance is related to income. Low income has been associated with relatively higher rates of infectious diseases (e.g., tuberculosis, AIDS), problems with substance abuse, rape, violence, and chronic diseases. Thus, those with the greatest need for health care are often those least able to pay for it.
Governmental sources of health insurance cover individuals at both ends of the age spectrum. Medicare covers those who are
overnight facilities for parents in children’s hospitals. Until recently, women’s health issues focused on the reproductive aspects of health, disregarding many health care concerns that are unique to women. Investigators are beginning to recognize the need for research that examines women equally to men in health issues such as osteopo- rosis, heart disease, and responses to various treatment modalities. Current provision of health care shows an increased emphasis on the psychosocial aspects of women’s health, including the impact of ca- reer, delayed childbearing, role of caregiver to older family members, and extended life span.
Uneven Distribution of Services Serious problems in the distribution of health services exist in the United States. Two facets of this problem are (a) uneven distribution and (b) increased specialization. In some areas, particularly remote and rural locations, the number of health care professionals and services available to meet the health care needs of individuals is insufficient. Rural clients may need to drive large distances to obtain the services they require. Uneven distribution is evidenced by the relatively higher number of nurses per capita in some of the New England and Midwest states and the lowest number in the Southwest (Figure 6–7 •). Phy- sicians are also unevenly distributed: In 2010, Mississippi, Idaho, and Wyoming had the fewest physicians per 100,000 people, whereas the District of Columbia, Massachusetts, Rhode Island, and Maryland had
Figure 6–7 • Registered nurses per 100,000 population, 2011. From the Kaiser Family Foundation StateHealthFacts.org., n.d. Retrieved from http://kff.org/other/state-indicator/registered-nurses-per-100000-population
581–780
791–891
893–1,001
1,005–1,561
ALASKA HAWAII
MAINE
VT. N.H.
MASS.
R.I. New York
CT. N.Y.
PA. N.J.
DEL.
MD. D.C.
VA.
NORTH CAROLINA
SOUTH CAROLINA
OHIO
M I C H
I G A
N
WISCONSIN
ILLINOIS IN DI
AN A
W. VA.
KENTUCKY
TENNESSEE
MINNESOTA NORTH DAKOTA
SOUTH DAKOTA
NEBRASKA
KANSAS
IOWA
MISSOURI
ARKANSASOKLAHOMA
MONTANA
WYOMING
COLORADO
CALIFORNIA
WASHINGTON
OREGON
IDAHO
NEVADA UTAH
ARIZONA NEW MEXICO
MISS. ALABAMA GEORGIA
FLORIDA
LOUISIANA TEXAS
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practices for each type of health care provider. These notices clearly state how and under what conditions individual health care records will be shared with other persons or agencies. Violation of HIPAA regulations by health care providers or agencies can result in heavy fines for this breach of trust.
SELF-CARE ALERT
Nurses must protect their own health and private information just as clients do. Be sure your personal health care team provides you with the appropriate HIPAA documents and safeguards your privacy. And remember, privacy regulations apply to care of all clients—even those who happen to be friends, family, or coworkers.
Demographic Changes The characteristics of the North American family have changed con- siderably in the past few decades. The numbers of single-parent fami- lies and alternative family structures have increased markedly. Most of the single-parent families are headed by women, many of whom work and require assistance with child care or when a child is sick at home.
Recognition of the cultural and ethnic diversity of the United States is also increasing. Health care professionals and agencies are aware of this diversity and are employing means to meet the chal- lenges it presents. For example, more agencies are employing nurses who are bilingual and who can communicate with clients whose pri- mary language is not English.
FRAMEWORKS FOR CARE A number of configurations for the delivery of nursing care support continuity of care and cost effectiveness. These include managed care, case management, differentiated practice, the case method, the functional method, team nursing, and primary nursing. These have evolved, some from each other, for reasons such as the need to decrease health care costs and to improve the utilization of limited human and physical resources. Some configurations are more suited for inpatient (hospital and long-term care) settings, whereas others are better suited to community or ambulatory settings. A particular agency may use more than one configuration—for example, a hos- pital may have team nursing on the medical—surgical units and pri- mary nursing on the cardiac surgery unit.
Managed Care Managed care describes a health care system whose goals are to provide cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. In managed care,
disabled or over age 65, and Medicaid and public children’s insurance programs cover those under age 18. Even though some government assistance is available, eligibility for government insurance programs and benefits varies considerably from state to state and is continually being reevaluated.
The Homeless and the Poor Because of the conditions in which homeless people live (in shelters, on the streets, in parks, in tents, under temporary covers and dwell- ings, in transportation terminals, or in cars), their health problems are often exacerbated and sometimes become chronic. Physical, mental, social, and emotional factors create health care challenges for the homeless and the poor (Box 6–1). These individuals may lack convenient or timely transportation to health care facilities, es- pecially if repeated visits are necessary. Limited access to health care services significantly contributes to the general poor health of people who are homeless and poor in the United States. However, low in- come does not always mean below-average access, quality, or health outcomes. In one study, for some U.S. states, many of the health care benchmarks for low-income populations were better than average and better than those for higher income or more educated individu- als in other states (Shoen et al., 2013). With the ACA, states will have an opportunity to greatly improve health and health care for vulner- able populations across the country.
Health Insurance Portability and Accountability Act One of the major alterations in how health care is practiced in this country may be attributed to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA regulations were instituted to protect the privacy of individuals by safeguarding indi- vidually identifiable health care records, including those housed in electronic media (Box 6–2). Protection of individual medical records extends not only to clinical health care sites but also to all ancillary health care providers such as pharmacies, laboratories, and third- party payers. Each health care provider dealing with client health care information must, by HIPAA regulations, provide for secure. limited access to that information. This is accomplished by restricting access to only those individuals who truly need to possess the information to aid the client, by locking documents in file cabinets, and by limit- ing access to computerized health care files.
The regulated privacy has altered the way health care provid- ers share information. Each client is provided a notice of privacy
Factors Contributing to Health Problems of the Homeless and the PoorBOX 6–1
• Poor physical environment resulting in increased susceptibility to infections
• Inadequate rest and privacy • Improper nutrition • Poor access to facilities for personal hygiene • Exposure to the elements • Lack of social support • Few personal resources • Questionable personal safety (physical assault is a constant
threat for the homeless) • Inconsistent health care • Difficulty with adherence to treatment plans
BOX 6–2
• Provides individuals with more control over their health information.
• Establishes limits for appropriate use and release of health care information.
• Requires health care providers and their agents to comply with safeguards to protect individual privacy related to health care information.
• Delineates a set of civil and criminal penalties holding HIPAA regulation transgressors accountable for actions if a client’s health care privacy is violated.
Intent of HIPAA Regulation
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resultant skill sets. Thus, differentiated practice models consist of specific job descriptions for nurses according to their education or training, for example, LVN, associate degree RN, BSN RN, MSN RN, or APRN. The model is customized within each health care institu- tion by the nurses employed there. The institution must first identify the nursing competencies required by the clients within the specific practice environment. This model further requires the delineation of roles between both licensed nursing personnel and UAPs. This en- ables nurses to progress and assume roles and responsibilities appro- priate to their level of experience, capability, and education. As with managed care and case management, differentiated nursing practice seeks to provide quality care at an affordable cost.
Case Method The case method, also referred to as total care, is one of the earliest nursing models developed. In this client-centered method, one nurse is assigned to and is responsible for the comprehensive care of a group of clients during an 8- or 12-hour shift. For each client, the nurse as- sesses needs, makes nursing plans, formulates nursing diagnoses, im- plements care, and evaluates the effectiveness of care. In this method, a client has consistent contact with one nurse during a shift but may have different nurses on other shifts. The case method, considered the precursor of primary nursing, continues to be used in a variety of practice settings such as intensive care nursing.
Functional Method The functional nursing method focuses on the jobs to be completed (e.g., bed making, temperature measurement). In this task-oriented approach, personnel with less preparation than the professional nurse perform less complex care requirements. It is based on a pro- duction and efficiency model that gives authority and responsibility to the person assigning the work, for example, the head nurse. Clearly defined job descriptions, procedures, policies, and lines of communi- cation are required. The functional approach to nursing is economi- cal and efficient and permits centralized direction and control. Its disadvantages are fragmentation of care and the possibility that non- quantifiable aspects of care, such as meeting the client’s emotional needs, may be overlooked.
Team Nursing Team nursing is the delivery of nursing care to individual clients by a group of providers led by a professional nurse. A nursing team
health care providers and agencies collaborate to render the most ap- propriate, fiscally responsible care possible. Managed care denotes an emphasis on cost controls, customer satisfaction, health promotion, and preventive services. Health maintenance organizations and pre- ferred provider organizations are examples of provider systems com- mitted to managed care.
Managed care can be used with primary, team, functional, and alternative nursing care delivery systems. Although managed care has been embraced as a model for health care reform, many question the application of this business approach to a commodity as precious as health.
Case Management Case management describes a range of models for integrating health care services for individuals or groups. Generally, case man- agement involves multidisciplinary teams that assume collaborative responsibility for planning, assessing needs, and coordinating, imple- menting, and evaluating care for groups of clients from preadmission to discharge or transfer and recuperation. A case manager, however, may be a nurse, social worker, or other appropriate professional. In some areas of the United States, case managers may be referred to as discharge planners. Key responsibilities for case managers/discharge planners are shown in Box 6–3.
Case management may be used as a cost-containment strategy in managed care. Both case management and managed care systems often use critical pathways to track the client’s progress. A critical pathway is a plan or tool that specifies interprofessional assessments, interventions, treatments, and outcomes for health-related condi- tions across a time line. Critical pathways are also called critical paths, interprofessional plans, anticipated recovery plans, and action plans.
Differentiated Practice Differentiated practice is a system in which the best possible use of nursing personnel is based on their educational preparation and
Among the greatest challenges in health care is meeting the needs of those with multiple chronic conditions. In this study, Gulley, Rasch, and Chan (2011) used the Medical Expenditure Panel Sur- vey data to examine differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. More than half of working-age people with disabilities reported having more than one chronic condition. Among those with ADL or instrumental ADL limitations, 35% reported four or more chronic conditions at a time. They found considerable variability in access problems and service use. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.
IMPLICATIONS The overall prevalence of chronic conditions among the U.S. working- age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diag- nosis are required to track the ongoing needs for health services that these populations present. Nurses are often the health care provid- ers who have the most contact with clients who have disabilities and chronic health conditions. Knowledge of the interface between these two characteristics and the complexity of the health care delivery sys- tem places nurses in an ideal position to assist clients in obtaining the care they need at the most appropriate facilities and cost.
Responsibilities of Case Managers/ Discharge PlannersBOX 6–3
• Assessing clients and their homes and communities • Coordinating and planning cost-effective client care • Collaborating with other health professionals • Monitoring clients’ progress • Evaluating client outcomes
Evidence-Based Practice How Do Chronic Conditions and Disabilities Interact in Clients Accessing Health Care Services? EVIDENCE-BASED PRACTICE
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organization, through which individuals and small businesses can purchase insurance.
• Modified private health insurance plans allow extended coverage for children and options for individuals with preexisting health problems.
• Established a nonprofit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments
• Established the National Prevention, Health Promotion, and Pub- lic Health Council to coordinate federal prevention, wellness, and public health activities.
Payment Sources in the United States In most situations, a health care agency receives funding from sev- eral of the available payment sources. For example, an older adult client may have Medicare coverage and supplement Medicare with private insurance plus the need to pay some out-of-pocket expenses (Figure 6–8 •). Almost all insurance plans include a per-visit or per-prescription copayment.
MEDICARE AND MEDICAID In the United States, the 1965 Medicare amendments (Title 18) to the Social Security Act provided a national and state health insurance program for older adults. By the mid-1970s, virtually everyone over 65 years of age was protected by hospital insurance under Part A, which also includes post-hospital extended care and home health benefits. In 1972, its coverage was broadened to include workers with permanent disabilities and their dependents who are eligible for dis- ability insurance under Social Security. In 1988, Congress expanded Medicare to include extremely expensive hospital care, “catastrophic care,” and expensive drugs.
The Medicare plan is divided into parts: Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescrip- tion drug plan begun in January 2006. Most clients pay a monthly premium for Parts B and D coverage.
All Medicare clients pay a deductible and coinsurance. Coinsurance is the percentage share (usually 20%) of a government-
consists of RNs, LPNs, and UAPs. This team is responsible for provid- ing coordinated nursing care to a set of clients for a specific period of time, for example, one shift.
The RN retains responsibility and authority for client care but delegates appropriate tasks to the other team members. Proponents of this model believe the team approach increases the efficiency of the RN. Opponents state that clients’ high acuity of illness leaves little to be delegated to non-RNs.
Primary Nursing Primary nursing is a system in which one nurse is responsible for overseeing the total care of a number of hospitalized clients 24 hours a day, 7 days a week, even if he or she does not deliver all of the care personally. It is a method of providing comprehensive, individual- ized, and consistent care.
Primary nursing uses the nurse’s technical knowledge and man- agement skills. The primary nurse assesses and prioritizes each client’s needs, identifies nursing diagnoses, develops a plan of care with the client, and evaluates the effectiveness of care. Associates provide some care, but the primary nurse coordinates it and communicates informa- tion about the client’s health to other nurses and other health profes- sionals. Primary nursing encompasses all aspects of the professional role, including teaching, advocacy, decision making, and continuity of care. The primary nurse is the first-line manager of the client’s care with all its inherent accountabilities and responsibilities. Primary nurses should be those who work consistently on the nursing unit. Thus, one of the challenges with primary nursing is the variable number of part- time nurses who may not be appropriate for the primary nurse role.
FINANCING HEALTH CARE Although efforts have been made to control the costs of health care, these costs continue to increase. Employers, legislators, insurers, and health care providers continue to collaborate in efforts to resolve is- sues surrounding how to best finance health care costs. Among these efforts, the United States has implemented some cost-containment strategies including health promotion and illness prevention activi- ties, managed care systems, and alternative insurance delivery sys- tems. The U.S. Center for Outcomes and Evidence (COE) conducts and supports studies on the outcomes and effectiveness of diagnostic, therapeutic, and preventive health care services and procedures, in- cluding cost.
On March 23, 2010, President Obama signed comprehensive U.S. health care reform, the Patient Protection and Affordable Care Act (commonly referred to as the ACA), into law. The primary pur- pose of the ACA is to require most Americans and legal residents to have some form of health insurance. The legalities and practicalities of the ACA have caused much controversy, and its full impact will not be known for many years. Some key features of the very complex ACA are as follows:
• Individuals will be fined if they do not have health insurance (the individual mandate).
• Employers must offer insurance coverage if they meet specific requirements.
• Eligibility for Medicaid is significantly expanded (see below). • State-based American Health Benefit Exchanges and Small Busi-
ness Health Options Program (SHOP) Exchanges were created. They are administered by a governmental agency or nonprofit
Figure 6–8 • Medicare helps defray the costs of health care. Photo Researchers/Getty Images.
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This legislation limits the amount paid to hospitals that are reimbursed by Medicare. Reimbursement is made according to a classification system known as diagnosis-related groups (DRGs). The system has categories that establish pretreatment diagnosis billing categories.
Under this system, the hospital is paid a predetermined amount for clients with a specific diagnosis. For example, a hospital that ad- mits a client with a diagnosis of uncomplicated asthma is reimbursed a specified amount, such as $1,300, regardless of the cost of services, the length of stay, or the acuity or complexity of the client’s illness. Prospective payment or billing is formulated before the client is even admitted to the hospital; thus, the record of admission, rather than the record of treatment, now governs payment. DRG rates are set in advance of the prospective year during which they apply and are con- sidered fixed except for major, uncontrollable occurrences.
In efforts to decrease costs and encourage attention to prevent- able conditions, for discharges occurring after October 1, 2008, hos- pitals no longer receive additional payment for cases in which one of several identified preventable conditions was not present on admis- sion. That is, the case would be paid as though the secondary diagnosis were not present. Examples of hospital-acquired conditions (HACs) are pressure ulcers and urinary tract infections following catheteriza- tion. In addition, certain HAC “never events” have been identified that can result in fines to the health care provider on top of the missed re- imbursement. Examples of never events are objects accidentally left in the body during surgery or incorrect blood type transfusions.
Insurance Plans A variety of plans have come into existence to finance health care in the United States. These include private insurance and group insur- ance. Each individual and group plan offers different options for con- sumers to consider.
Commonly, health care providers bill the insurance company directly for their services and the consumer may be responsible for a copayment or deductible. In some situations, the consumer must pay the provider fees and then submit a claim to the insurance company for eligible reimbursements. Another type of insurance that is usually a reimbursed plan is long-term care insurance. This covers a portion of the cost of care in the home or at assisted living, adult day care, re- spite care, hospice care, nursing home, and Alzheimer’s facilities.
PRIVATE INSURANCE In the United States, numerous commercial health insurance carriers offer a wide range of coverage plans. The two types of private insur- ance are not-for-profit (e.g., Blue Shield) and for-profit (e.g., Metro- politan Life, Travelers, and Aetna) insurance. Private health insurance pays either the entire bill or, more often, 80% of the costs of health care services. With private insurance health plans, the insurance company reimburses the health care provider a fee for each service provided (fee-for-service). The term third-party reimbursement refers to the in- surance company that pays the client’s (first party) bill to the provider (second party).
These insurance plans may be purchased either as an individual plan or as part of a group plan through an individual’s employer, union, student association, or similar organization. For private insurance not covered by an employer, the individual usually pays a monthly pre- mium for health care insurance. Group plans offer lower premiums that may be paid for completely by the employer, completely by group members, or by some combination of the two.
approved charge that is paid by the client; the remaining percent is paid by the plan.
Medicare does not cover dental care, dentures, eyeglasses, hear- ing aids, or examinations to prescribe and fit hearing aids. Most pre- ventive care, including routine physical examinations and associated diagnostic tests, is also not included. However, as part of the 1997 Bal- anced Budget Act, annual screening mammograms for women over age 40 are a fully covered cost under Medicare.
Medicaid was also established in 1965 under Title 19 of the So- cial Security Act. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes. Medicaid is paid by federal and state gov- ernments. Each state program is distinct. Some states provide very limited coverage, whereas others pay for dental care, eyeglasses, and prescription drugs.
In 1972, Congress directed the U.S. Department of Health, Education, and Welfare to create professional standards review or- ganizations to monitor the appropriateness of hospital use under the Medicare and Medicaid programs. In 1974, the National Health Planning and Resources Development Act established health sys- tems agencies throughout the United States for comprehensive health planning. In 1978, the Rural Health Clinics Act provided for the de- velopment of health care in medically underserved rural areas. This act opened the door for NPs to provide primary care.
SUPPLEMENTAL SECURITY INCOME People with disabilities or those who are blind may be eligible for special payments called Supplemental Security Income (SSI) benefits. These benefits are also available to people not eligible for Social Security, and payments are not restricted to health care costs. Clients often use this money to purchase medicines or to cover costs of extended health care.
CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) The CHIP was established by the U.S. government in 1997 to provide insurance coverage for poor and working-class children. The pro- gram expands coverage for children under Medicaid and subsidizes low-cost state insurance alternatives. Coverage includes visits to pri- mary health care providers, prescription medicines, and hospitaliza- tion. In early 2009, President Obama signed the Children’s Health Insurance Program Reauthorization Act (CHIPRA), which renews and expands coverage of CHIP from 7 million children to 11 million children. State eligibility requirements vary, but generally, those with family incomes of less than twice the federal poverty line are eligible.
WOMEN, INFANTS, AND CHILDREN PROGRAM The Special Supplemental Nutrition Program for Women, Infants, and Children, popularly known as WIC, provides nutritious foods to supplement diets, information on healthy eating, and referrals to health care for mothers and for children up to age 5. WIC provides federal grants to states for low-income pregnant, breast-feeding, and non–breast-feeding postpartum women, and to infants and children who are found to be at nutritional risk. It is administered by the Food and Nutrition Service of the U.S. Department of Agriculture.
PROSPECTIVE PAYMENT SYSTEM To curtail health care costs in the United States, Congress in 1983 passed legislation putting the prospective payment system into effect.
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PREFERRED PROVIDER ORGANIZATIONS The preferred provider organization (PPO) consists of a group of providers and perhaps a health care agency (often a hospital) that provide an insurance company or employer with health services at a discounted rate. One advantage of the PPO is that it provides clients with a choice of health care providers and services. Providers can belong to one or several PPOs, and the client can choose among the providers belonging to the PPO. A disadvantage of PPOs is that they tend to be more expensive than HMO plans, and if individuals wish to join a PPO, they might have to pay more for the additional choices.
PREFERRED PROVIDER ARRANGEMENTS Preferred pro- vider arrangements (PPAs) are similar to PPOs. The main difference is that the PPAs can be contracted with individual health care providers, whereas PPOs involve an organization of health care providers. A PPA plan can be limited or unlimited. A limited PPA restricts the client to using only preferred providers of health care; an unlimited PPA permits the client to use any health care provider in the area who accepts the contractual agreement of the plan. Again, with PPAs, more choices in health care providers may mean more cost to the enrollee.
INDEPENDENT PRACTICE ASSOCIATIONS Independent pra- ctice associations (IPAs) are somewhat like HMOs and PPOs. The IPA provides care in offices, just as the providers belonging to a PPO do. The difference is that clients pay a fixed prospective payment to the IPA, and the IPA pays the provider. In some instances, the health care provider bills the IPA for services; in others, the provider receives a fixed fee for services given. At the end of the fiscal year, any surplus money is divided among the providers; any loss is assumed by the IPA.
PHYSICIAN/HOSPITAL ORGANIZATIONS Physician/hospital organizations (PHOs) are joint ventures between a group of private practice physicians and a hospital. PHOs combine both resources and personnel to provide managed care alternatives and medical services. PHOs work with a variety of insurers to provide services. A typical PHO will include primary care providers and specialists.
A PHO may be part of an integrated delivery system (IDS). Such a system incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services. Most in- tegrated delivery systems provide care throughout the life span. Insur- ers can contract with IDSs to provide all required services, rather than the insurer contracting with multiple agencies for the same services. Ideally, an IDS enhances continuity of care and communication be- tween professionals and various agencies providing managed care.
GROUP PLANS Health care group plans provide blanket medical service in exchange for a predetermined monthly payment. A variety of group plans have come into existence to finance health care in the United States. These include health maintenance organizations, accountable care organizations, preferred provider organizations, preferred provider arrangements, independent practice associations, and physician/ hospital organizations. Each group plan offers different options for consumers to consider when choosing a prepaid health care program.
HEALTH MAINTENANCE ORGANIZATIONS A health mainte- nance organization (HMO) is a group health care agency that provides health maintenance and treatment services to voluntary enrollees. A fee is set without regard to the amount or kind of services provided.
The HMO plan emphasizes client wellness; the better the health of the person, the fewer the HMO services that are needed and the greater the agency’s profit. Members of HMOs choose a primary care provider (PCP) such as an internal medicine physician, general prac- titioner, or NP who evaluates their health status and coordinates their care. If the primary care provider cannot treat a particular problem because of its special nature, he or she may make a referral to a spe- cialist provider. To reduce costs, HMOs will pay for specialty services only if the PCP has made a referral to the specialist. It is an expec- tation between the HMO and PCPs being reimbursed under their plans that PCPs will treat clients and reduce costs whenever possible.
Thus, under HMO plans, clients are limited in their ability to select health care providers and services, but available services are at a reduced and predetermined cost to the client. Because health promotion and illness prevention are highly emphasized in HMOs, nurses in HMOs focus on these aspects of care. Companies that pro- vide HMO plans such as Kaiser Permanente, United Healthcare, and Aetna have been established across the United States, although not in every community.
ACCOUNTABLE CARE ORGANIZATIONS Accountable care organizations (ACOs) are characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. In many ways, they are similar to HMOs. There are incentives to hospitals, physicians, post–acute care facilities, and other providers to facilitate coordination of care delivery. Beginning in 2012, ACOs were able to contract to provide services for persons covered under Medicare.
LIFESPAN CONSIDERATIONS Assessing Older Adults’ Functional Levels
Assessing the functional levels of older adults on an ongoing ba- sis will provide guidelines for detecting needs for special care, resources, and services. It helps to determine their level of inde- pendence and changes as they occur. The two most common as- sessments are to evaluate the following activities of daily living and instrumental activities of daily living:
ACTIVITIES OF DAILY LIVING • Bathing • Dressing • Toileting • Transferring • Continence • Feeding
INSTRUMENTAL ACTIVITIES OF DAILY LIVING • Ability to use the telephone • Shopping • Food preparation • Housekeeping • Laundry • Mode of transportation • Responsibility for own medication • Ability to handle finances The case study in this chapter’s Critical Thinking Checkpoint is an example of how these assessments and needs might change for older adults. Mobilizing appropriate resources to help maintain older adults’ functioning ability is important in providing nursing care.
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Critical Thinking Checkpoint
Mr. Mendel is an 83-year-old married man. He has a history of severe osteoarthritis leading to bilateral hip replacements and one knee re- placement. He has mild hypertension controlled by oral medication. His last orthopedic surgery was done to replace a hip component that failed due to repeated dislocations. At that time, he developed a severe urinary tract infection resulting in weight loss, fatigue, and weakness. After stabilizing, he was sent to the skilled nursing unit of the hospital for 2 weeks until ready to go back home. Occupational therapists consulted with him and his wife during his hospitalization.
He lives in a three-story house with the bedrooms on the top floor, kitchen and living room on the middle/main floor, and family room on the bottom floor. He has not driven since the last operation, but would like to. He has smoked cigars for years and sits on the front porch to smoke. Physical therapists have come to the house three times a
week for several months. A home health nurse has also been con- sulted periodically to assist with nutrition and elimination difficulties. 1. In what ways has Mr. Mendel used (a) health promotion and
illness prevention (primary prevention), (b) diagnosis and treat- ment (secondary prevention), and (c) rehabilitation and health restoration (tertiary prevention) health care services?
2. Name three types of health care agencies he has used. What are the strengths of each of these?
3. Mr. Mendel’s insurance company has assigned him a case manager. What would this person’s responsibilities be in his particular case?
4. What other members of the health care profession would most likely be on the case manager’s team and why?
See Critical Thinking Possibilities on student resource website.
• Health care delivery services can be categorized by the type of service: (a) primary prevention: health promotion and illness pre- vention, (b) secondary prevention: diagnosis and treatment, and (c) tertiary prevention: rehabilitation, health restoration, and pallia- tive care.
• Hospitals provide a wide variety of services on an inpatient and outpatient basis. Hospitals can be categorized as public or private, for-profit or not-for-profit, and acute care or long-term care. Many other settings, such as clinics, offices, and day care centers, also provide care.
• Various providers of health care coordinate their skills to assist a client. Their mutual goal is to restore a client’s health and promote wellness.
• The role of the nurse in providing care to clients will vary depending on the employment setting, the nurse’s credentials, and the needs of the client.
• The many factors affecting health care delivery include the increas- ing number of older adults, advances in knowledge and technol- ogy, economics, increased emphasis on women’s health, uneven distribution of health services, access to health insurance, health care for the homeless and poor, HIPAA, and demographic changes.
• Delivery of nursing care that supports continuity of client-focused care and is cost effective may be implemented by any of the fol- lowing methods: managed care, case management, differentiated practice, the case method, the functional method, team nursing, and primary nursing.
• In the United States, health care is financed largely through gov- ernment agencies and private organizations that provide health care insurance, prepaid plans, and federally funded programs. Government-financed plans include Medicare and Medicaid. Private plans include Blue Cross and Blue Shield. Prepaid group plans include HMOs, ACOs, PPOs, PPAs, IPAs, and PHOs.
CHAPTER HIGHLIGHTS
1. Which of the following is an example of a primary prevention activity? 1. Antibiotic treatment of a suspected urinary tract infection 2. Occupational therapy to assist a client in adapting his or her
home environment following a stroke 3. Nutrition counseling for young adults with a strong family
history of high cholesterol 4. Removal of tonsils for a client with recurrent tonsillitis
2. Which of the following statements is true regarding types of health care agencies? 1. Hospitals provide only acute, inpatient services. 2. Public health agencies are funded by governments to
investigate and provide health programs. 3. Surgery can only be performed inside a hospital setting. 4. Skilled nursing, extended care, and long-term care facilities
provide care for older adults whose insurance no longer covers hospital stays.
TEST YOUR KNOWLEDGE
Chapter 6 Review
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5. A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with 1. Medicare. 2. An individual fee-for-service insurance. 3. A preferred provider organization (PPO). 4. A health maintenance organization (HMO).
See Answers to Test Your Knowledge in Appendix A.
3. In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following? 1. Family practice physician 2. Physical therapist 3. Case manager/discharge planner 4. Pharmacist
4. The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following? 1. Number of children according to the family’s income 2. Numbers of uninsured and underinsured persons 3. Number of physicians and nurses nationwide 4. Competition among drug and medical equipment
manufacturers
Suggested Reading Grabowski, D. C., Huckfeldt, P. J., Sood, N., Escarce, J. J., &
Newhouse, J. P. (2012). Medicare postacute care pay- ment reforms have potential to improve efficiency of care, but may need changes to cut costs. Health Affairs, 31, 1941–1950. The Affordable Care Act mandates changes in payment policies for Medicare postacute care services. In addition to reducing annual payment increases to providers under the existing prospective payment systems, the act calls for demonstration projects of bundled payment, account- able care organizations, and other strategies to promote care coordination and reduce spending. Experience with the adoption of Medicare prospective payment systems in postacute care settings suggests that current reforms could produce undesirable effects such as decreased access for less profitable clients, poorer client outcomes, and only short-lived curbs on spending. Policy makers will need to be vigilant in monitoring the impact of the Afford- able Care Act reforms and be prepared to amend policies as necessary to ensure that the reforms exert persistent controls on spending without compromising the delivery of client-appropriate postacute services.
Related Research Li, Y., Glance, L. G., Yin, J., & Mukamel, D. B. (2011). Racial
disparities in rehospitalization among Medicare patients in skilled nursing facilities. American Journal of Public Health,101, 875–882. doi:10.2105/AJPH.2010.300055
References Carper, K., & Machlin, S. R. (2013). National health care
expenses in the U.S. civilian noninstitutionalized population, 2010 (Medical Expenditure Panel Survey Statistical Brief #396). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.meps.ahrq.gov/ mepsweb/data_files/publications/st396/stat396.pdf
Centers for Medicaid and Medicare Services. (2009). National health expenditure projections 2011–2021. Retrieved from http://www.cms.gov/Research-Statistics- Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/Proj2011PDF.pdf
Gulley, S. P., Rasch, E. K., & Chan, L. (2011). The complex web of health: Relationships among chronic conditions, disability, and health services. Public Health Reports, 126, 495–507.
Hing, E., & Shappert, M. S. (2012). Generalist and specialty physicians: Supply and access, 2009–2010 (NCHS Data Brief No. 105). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/ databriefs/db105.pdf
Kaiser Family Foundation StateHealthFacts.org. (n.d.). Registered nurses per 100,000 population, 2011. Retrieved from http://www.statehealthfacts.org/comparemaptable .jsp?ind=439&cat=8
National Center for Health Statistics. (2012). Health: United States, 2012. Hyattsville, MD: Author. Retrieved from http://www.cdc.gov/nchs/data/hus/hus12.pdf
Pfuntner, A., Wier, L. M., & Steiner, C. (2013, December). Costs for hospital stays in the United States, 2011 (HCUP Statistical Brief #168). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http:// www.hcup-us.ahrq.gov/reports/statbriefs/sb168-Hospital- Costs-United-States-2011.jsp
Shoen, C., Radley, D., Riley, P., Lippa, J., Berenson, J., Dermody, C., & Shih, S. (2013). Health care in the two Americas: Findings from the scorecard on state health system performance for low-income populations, 2013. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/~/media/Files/ Publications/Fund%20Report/2013/Sep/1700_Schoen_ low_income_scorecard_FULL_REPORT_FINAL_v4.pdf
U.S. Census Bureau. (2012). Table 2. Projections of the population by selected age groups and sex for the United States: 2015 to 2060. Retrieved from http://www .census.gov/population/projections/data/national/2012/ summarytables.html
U.S. Department of Health and Human Services. (2010). Healthy people 2020. Retrieved from http://healthypeople .gov/2020/about/default.aspx
Walkowski, S. A. (2011). Current and distinctive terminology: Osteopath and physician. Journal of the American Osteopathic Association, 111,141–142.
Selected Bibliography American Association of Colleges of Nursing. (1995). A
model for differentiated nursing practice. Washington, DC: Author.
Chin, M. H., Clarke, A. R., Nocon, R. S., Casey, A. A., Goddu, A. P., Keesecker, N. M., & Cook, S. C. (2012). A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. Journal of General Internal Medicine, 27, 992–1000. doi:10.1007/ s11606-012-2082-9
Hagland, M. (2012). Readmissions and the mechanics of care transitions. Healthcare Informatics, 29(5), 38–40.
Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. (2013). Compendium of federal data sources to support health workforce analysis. Retrieved from http://bhpr.hrsa.gov/healthworkforce/data/ compendiumfederaldatasources.pdf
Institute of Medicine. (2009). America’s uninsured crisis: Consequences for health and health care. Washington, DC: National Academies Press.
Kaiser Commission on Medicaid and the Uninsured and the Health Care Marketplace Project. (2011). Summary of new health reform law. Retrieved from http://www.kff.org/ healthreform/8061.cfm
Kirch, D. G., Henderson, M. K., & Dill, M. J. (2012). Physician workforce projections in an era of health care reform. Annual Review of Medicine, 63, 435–445. doi:10.1146/annurev-med-050310-134634
Kongstvedt, P. R. (2013). Essentials of managed health care (6th ed.). Boston, MA: Jones & Bartlett.
Kovner, A. R., & Knickman, J. R. (2011). Jonas & Kovner’s health care delivery in the United States (10th ed.). New York, NY: Springer.
Sredl, D., Melnyk, B., Hsueh, K., Jenkins, R., Ding, C., & Durham, J. (2011). Health care in crisis! Can nurse executives’ beliefs about and implementation of evidence- based practice be key solutions in health care reform? Teaching and Learning in Nursing, 6, 73–79. doi:10.1016/j. teln.2010.06.001
READINGS AND REFERENCES
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INTRODUCTION The health care system is continuously undergoing change. Escalating health care costs, advancements in technology, chang- ing patterns of demographics, shorter hospital stays, increased cli- ent acuity, and limited access to health care are some of the factors motivating change. The location of client care is expanding out of traditional settings into the community and neighborhoods. For example, health care activities such as intravenous fluid admin- istration or mechanical ventilation, once considered safe only in hospital settings, are now available for clients in their homes (see Chapter 8 ) and in ambulatory surgical, rehabilitation, and dialysis centers.
It is difficult to document the shifting of care from hospitals to the community. One resource to track changes is the annual survey of health care dollar expenditures conducted by the U.S. government. The most recent data show that the percentage of total health care dollars spent for hospital care continues to decrease (National Center for Health Statistics, 2013). Although hospitals and other health care institutions remain key components of the health care system, the trend is toward an integrated health care system—one that is commu- nity based. The shift from institutional to community care also brings changes in the roles and responsibilities of health care professionals.
Many things influence whether clients select to have their care in hospitals or in community settings. Some variables include clients’ knowledge and awareness of community resources, cost, availability of home care, and perceived safety of home care. More research is needed to show differences in health outcomes based on location of care.
THE MOVEMENT OF HEALTH CARE TO THE COMMUNITY Health care professionals, consumers, and legislators have expressed major dissatisfaction with the current health care system, which fo- cuses on expensive, acute, hospital-based care. Nurses, professional organizations, and consumers influence health care reform. Nurses provide a unique perspective on the health care system because of their constant presence in a variety of settings and their contact both with consumers who receive the benefits of the system’s most com- plex services and with those who have problems with the system’s inefficiencies. The larger numbers of advanced practice nurses in recent years have resulted in the provision of primary care to many consumers who had previously been neglected—those living in rural areas, the poor, undocumented immigrants, older adults, and women and infants.
Through nurses’ major organizations, nursing has presented a strong voice in describing what a new system should include and what nursing’s contributions should be. In 1991, the American Nurses Association (ANA) published Nursing’s Agenda for Health Care Reform, which set forth the ANA’s recommendations for health care reform. Although the agenda called for “immediate” changes, the majority of the recommendations have still not been implemented more than 20 years later. In 2008, the ANA published a revision of its 2005 Health System Reform Agenda. The revision reiterated the need to move to a balance between providing care in hospitals with their high-technology equipment and providing care via community-based and preventive care programs, with an em- phasis on the latter.
LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Discuss factors influencing health care reform. 2. Describe various community-based health care frameworks,
including integrated health care systems, community initia- tives and conditions, and case management.
3. Differentiate community health care settings from traditional settings.
4. Differentiate community-based nursing from traditional institutional-based nursing.
KEY TERMS
collaboration, 112 community, 108 community-based health care
(CBHC), 107
community-based nursing (CBN), 111
community health nursing, 108 community nursing centers, 110
continuity of care, 113 discharge planning, 114 integrated health care
system, 109
population, 108 primary care (PC), 107 primary health care (PHC), 106
7 Community Nursing and Care Continuity
5. Discuss competencies community-based nurses need for practice, including the Pew Health Professions Commission recommendations for health competencies for future health practitioners.
6. Explain essential aspects of collaborative health care: defini- tions, objectives, benefits, and the nurse’s role.
7. Describe the role of the nurse in providing continuity of care.
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• Grants to programs preparing nurses to work with older adults and in long-term care settings
• A grant program for states to establish community-based inter- professional teams to support primary care practices
• Grants for nurse-managed clinics and school-based health centers • A Public Health Workforce Loan Repayment Program to ensure
an adequate supply of public health professionals. Under this program, the U.S. Department of Health and Human Services (USDHHS) will repay up to one-third of loans incurred by a public health or health professions student in exchange for that student’s agreement to accept employment with a public health agency for at least 3 years.
Primary Health Care and Primary Care Another major influence promoting health care reform has been the work on Healthy People (USDHHS, 2010). This project pre- sents health-related objectives that provide a framework for national health promotion, health protection, and disease prevention. Details of Healthy People 2020 are discussed in Chapter 16 .
The forerunner of Healthy People and Nursing’s Agenda for Health Care Reform was the 1978 World Health Organization (WHO) report Primary Health Care. The term primary health care (PHC) was coined in the World Health Assembly by WHO and the United Nations In- ternational Children’s Emergency Fund (UNICEF). Primary health care (PHC) is defined as follows:
. . . essential health care based on practical, scientifically sound and socially acceptable methods and technology made univer- sally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their de- velopment in the spirit of self-reliance and self-determination. (WHO, 1978, p. 35)
Primary health care incorporates five principles:
• Equitable distribution • Appropriate technology • A focus on health promotion and disease prevention • Community participation • A multisectoral approach.
Deep concern about health care for the majority of the world’s population, specifically low life expectancies and high mortality rates among children, led to the global health strategy of primary health care. The WHO declaration emphasized health or well-being as a fun- damental right and a worldwide social goal. It attempted to address inequality in health status of individuals in all countries and to target government responsibility for policies that would promote economic, social, and health development. Both economic and social develop- ment were considered basic to the achievement of health for all. Thus, PHC extends beyond the boundaries of traditional health care ser- vices. It involves issues of the environment, agriculture, housing, and other social, economic, and political issues such as poverty, transporta- tion, unemployment, and economic development to sustain the popu- lation. A major feature of PHC is that consumers, governments, and public institutions such as public health departments and city councils should be involved in the planning and delivery of health care.
Consumers are also effecting major changes in health care delivery systems. Consumers are adopting health-related values that include the following:
• Health means more than the absence of disease; it encompasses well-being and quality of life.
• Quality of life is related to a healthy community, which includes healthy families and a healthy environment.
• Individuals can actively participate in promoting and maintaining their health through behavior and lifestyle changes.
• Disease prevention is important.
These values indicate that consumers support an increased emphasis on health care services and programs that promote wellness and res- toration and prevent disease.
After significant debate and negotiation, President Obama signed the most significant change in health care legislation in American history on March 23, 2010: the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA). The ANA (2012c), in response to the ACA, stated:
As the largest single group of clinical health care professionals within the health system, registered nurses are educated and practice within a holistic framework that views the individual, family and community as an interconnected system that can keep us well and help us heal. Registered nurses are fundamen- tal to the critical shift needed in health services delivery, with the goal of transforming the current “sick care” system into a true “health care” system. The ANA is actively engaging with federal policymakers and regulators to advocate for system transformation that includes the valuable contributions of nursing and nurses. (p. 1)
Two of the key components of the ACA are preventing insur- ance companies from denying coverage to persons with previous health conditions and expansion of the criteria for persons to be eli- gible for federal and state health insurance.
This legislation will assist the Health Resources and Services Administration (HRSA), administered by registered nurse Mary Wakefield, PhD (appointed by President Obama in 2009), to meet its goals. The HRSA focuses on uninsured, underserved, and special needs populations and aims to:
1. Improve access to health care. 2. Improve health outcomes. 3. Improve the quality of health care. 4. Eliminate health disparities. 5. Improve the public health and health care systems. 6. Enhance the ability of the health care system to respond to public
health emergencies. 7. Achieve excellence in management practices.
For nurses, the ACA means
• Expanded scholarships and loan forgiveness programs for nurses at both entry-level and advance practice levels who are willing to work with underserved populations
• Increased funding for nurses wishing to become faculty • Support for programs that allow diploma and associate-degree
nurses to obtain their BSN degrees
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PHC differs from primary care (PC). Primary care addresses personal health services and not population-based public health services. Primary care (PC), according to the Institute of Medicine (IOM), is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health services, developing a sustained partnership with clients, and practicing in the context of family and community” (Donaldson, Yordy, Lohr, & Vanselow, 1996, p. 1). The constituents of PC are shown in Figure 7–1 •.
PHC is community based and driven and requires active com- munity involvement in making decisions to improve health. PC, on the other hand, is expert driven and involves health professionals who advise individuals and communities about what is best for their health. Other differences are shown in Table 7–1.
PHC and PC also have similarities. Both acknowledge the pre- vention and promotion components of health and well-being. Both strive for universal access to and affordability of health care, support empowerment of the client, and target those at risk for preventable health problems.
COMMUNITY-BASED HEALTH CARE Community-based health care (CBHC) is a PHC system that provides health-related services within the context of people’s daily lives—that is, in places where people spend their time, for example, in the home, in shelters, in long-term care residences, at work, in
Figure 7–1 • The interdependence of the constituents of primary care showing the centrality of the clinician–patient relationship in the context of family and community and as furthered by teams and integrated delivery systems. From Primary Care: America’s Health in a New Era (p. 34), by M. S. Donaldson, K. D. Yordy, K. N. Lohr, & N. A. Vanselow (Eds.), 1996, Washington, DC: National Academy Press. Retrieved from http://books.nap.edu/catalog.php?record_id=5152.
Clinician
Integrated Delivery
System Community
Team
Patient
Family
schools, in senior citizens’ centers, in ambulatory settings, and in hos- pitals. The care is directed toward a specific group within the geo- graphic neighborhood (Figure 7–2 •). The group may be established by a physical boundary, an employer, a school district, a managed care insurance provider, or a specific medical need or category. In contrast to the traditional health care system that focuses primarily on those who are ill or injured, community-based care is holistic. It involves a
Figure 7–2 • Communities may consist of several types of neighborhoods. Porterfield-Chickering/Getty Images.
TABLE 7–1 Differences Between Primary Care and Primary Health Care
Primary Care Primary Health Care • Community participation is provider directed. • The professional’s role is expert, provider, authority,
and team leader. • Collaboration occurs among members of the health care team. • The individual or family is the focus. • Access is limited. • Health care is available within given health care institutions. • Empowerment is a provider-assisted process.
• Community participation is client directed. • The professional’s role is that of facilitator, consultant,
and resource. • Collaboration goes beyond the health care sector. • The community or some aggregate is the focus. • Access is universal. • Health care is available where people live and work. • Empowerment is a collaborative, enabling process.
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broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public.
To be truly effective, a CBHC system needs to (a) provide easy access to care, (b) be flexible in responding to the care needs that in- dividuals and families identify, (c) promote care between and among health care agencies through improved communication mechanisms, (d) provide appropriate support for family caregivers, and (e) be af- fordable. With the ACA, a key task is to create sustainable implemen- tation of community-based models of primary care integrated with public health (IOM, 2012).
COMMUNITY HEALTH A community is a collection of people who share some attribute of their lives and interact with each other in some way. They may live in the same locale, attend a particular church, or even share a particu- lar interest such as art. Groups that constitute a community because of common member interests are often referred to as communities of interest (e.g., religious and cultural groups). A community can also be defined as a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Five of the main functions of a commu- nity are described in Box 7–1. In community health, the community may be viewed as having a common health problem, such as a high incidence of infant mortality or of tuberculosis, HIV infection, or another communicable disease. Box 7–2 lists the characteristics of a healthy community. A population is composed of people who share some common characteristic but who do not necessarily interact with each other. Community health nursing focuses on promot- ing and preserving the health of population groups.
BOX 7–1
1. Production, distribution, and consumption of goods and services. These are the means by which the community provides for the economic needs of its members. This function includes not only the supplying of food and clothing but also the provision of water, electricity, and police and fire protection and the disposal of refuse.
2. Socialization. Socialization refers to the process of trans- mitting values, knowledge, culture, and skills to others. Communities usually contain a number of established institu- tions for socialization: families, churches, schools, media, voluntary and social organizations, and so on.
3. Social control. Social control refers to the way in which order is maintained in a community. Laws are enforced by the police; public health regulations are implemented to protect people from certain diseases. Social control is also exerted through the family, church, and schools.
4. Social interparticipation. Social interparticipation refers to community activities that are designed to meet people’s needs for companionship. Families and churches have traditionally met this need; however, many public and private organizations also serve this function.
5. Mutual support. Mutual support refers to the community’s ability to provide resources at a time of illness or disaster. Although the family is usually relied on to fulfill this function, health and social services may be necessary to augment the family’s assistance if help is required over an extended period.
Five Main Functions of a Community
Ten Characteristics of a Healthy CommunityBOX 7–2
A HEALTHY COMMUNITY • Is one in which members have a high degree of awareness
of being a community. • Uses its natural resources while taking steps to conserve
them for future generations. • Openly recognizes the existence of subgroups and welcomes
their participation in community affairs. • Is prepared to meet crises. • Is a problem-solving community; it identifies, analyzes, and
organizes to meet its own needs. • Possesses open channels of communication that allow
information to flow among all subgroups of citizens in all directions.
• Seeks to make each of its systems’ resources available to all members.
• Has legitimate and effective ways to settle disputes that arise within the community.
• Encourages maximum citizen participation in decision making.
• Promotes a high level of wellness among all its members.
Communities, like individuals and families, are living entities. As such, the nurse will need to carry out an assessment of this com- munity as the client. Several community assessment frameworks have been devised. Students who enroll in a community health nursing course will study these in some detail. In one framework, Anderson and McFarlane (2011) identified eight subsystems of the community for analysis. The subsystems are illustrated around a core, which consists of the people and their characteristics, values, history, and beliefs. The first stage in assessment is to learn about the people in the community. These community-level subsystems may be thought of as analogous to the physiological subsystems of an individual. Box 7–3 shows major aspects of a community sub- systems assessment. Box 7–4 shows sources of community data that the nurse may draw on to help identify health care concerns and to aid in intervention planning for any acknowledged community health issues.
Planning community health may be oriented toward im- proved crisis management, disease prevention, health mainte- nance, or health promotion. The responsibility for planning at the community level is usually broadly based and needs to in- clude as many of the community partners as possible. The exact resources and skills of members of the community often depend on the size of the community. A broadly based planning group is most likely to create a plan that is acceptable to members of the community. Also, people who are involved in planning become educated about the problems, the resources, and the interrelation- ships within the system.
When setting priorities, health planners must work with con- sumers, interest groups, or other involved persons to prioritize health problems. It is important to take into consideration the values and interests of community members, the severity of the problems, and the resources available to identify and act on the problems. Because any plan is likely to result in change, members of the planning group should understand and use planned change theory.
In community health, evaluation determines whether the planned interventions have led to the achievement of the established goals and
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Sources of Community Assessment DataBOX 7–4
• City maps to locate community boundaries, roads, churches, schools, parks, hospitals, and so on
• State census data for population composition and characteristics
• Chamber of commerce for employment statistics, major in- dustries, and primary occupations
• County or state health departments for location of health fa- cilities, occupational health programs, numbers of health pro- fessionals, numbers of welfare recipients, and so on
• City or regional health planning boards for health needs and practices
• Telephone book for location of social, recreational, and health organizations, committees, and facilities
• Public and university libraries for district social and cultural research reports
• Health facility administrators for information about employee caseloads, prevalent types of problems, and dominant needs
• Recreational directors for programs provided and participation levels
• Police department for incidence of crime, vandalism, and drug addiction
• Teachers and school nurses for incidence of children’s health problems and information on facilities and services to maintain and promote health
• Local newspapers for community activities related to health and wellness, such as health lectures or health fairs
• Online computer services that may provide access to public documents related to community health
BOX 7–3
PHYSICAL ENVIRONMENT Consider the natural boundaries, size, and population density; types of dwellings; and incidence of crime, vandalism, and substance abuse.
EDUCATION Consider educational facilities; existing school health facilities; type and amount of health services handled by the school; school lunch programs; extracurricular sports, libraries, and counseling services; continuing education or extended education programs; and extent of parental involvement in the schools.
SAFETY AND TRANSPORTATION Consider fire, police, and sanitation services; sources of water and its treatment; quality of the air; garbage disposal service; availability and safety of public transportation; and availability of ambulance services.
POLITICS AND GOVERNMENT Consider kind of government; organizations active in the commu- nity; influential people in the community; issues that have recently appeared on local ballots; and the average election turnout.
HEALTH AND SOCIAL SERVICES Consider existing hospitals, health care facilities, and health care services; number, type, and routine caseloads of community health
professionals; geographic, economic, and cultural accessibility to health care services; sources of health information; level of immuni- zation among children and adults; life expectancy in the community; availability of home health care and long-term care services; and availability of transportation service to all major health facilities.
COMMUNICATION Consider local newspapers; radio and TV stations, postal services, Internet access, and telephone services; frequency of public forums; and presence of informal bulletin boards.
ECONOMICS Consider the main industries and occupations; percentage of the population employed or attending school; income levels and qual- ity and type of housing; occupational health programs; and major employers in the community.
RECREATION Consider recreational facilities in the community and outside the community; theaters and movie houses; number and types of church and religious services; number and utilization of playgrounds, pools, parks, and sports facilities; level of participation in various church programs; and number and types of social committees, organiza- tions, and clubs available. From Community as Partner: Theory and Practice in Nursing (6th ed., pp. 186–213), by E. T. Anderson and J. McFarlane, 2011, Philadelphia, PA: Lippincott Williams & Wilkins.
Major Aspects of a Community Subsystems Assessment
objectives; for example, was the immunization rate of preschool children improved? Because community health is usually a collaborative process among health providers, community leaders, politicians, and consum- ers, all may be involved in the evaluation process. Often the community health nurse is the agent of evaluation, collecting and assessing the data that determine the effectiveness of implemented programs.
Community-Based Frameworks Various approaches are emerging to address community health. Some of these are an integrated health care system, community ini- tiatives, community coalitions, managed care, case management, and outreach programs using lay health workers.
An integrated health care system makes all levels of care available in an integrated form—primary care, secondary care, and tertiary care (Figure 7–3 •). Its goals are to facilitate care across set- tings, recovery, positive health outcomes, and the long-term benefits of modifying harmful lifestyles through health promotion and dis- ease prevention. In many parts of the country, hospitals are reflecting this concept by changing their names to health care organization or in- tegrated health care system. This type of system is sometimes referred to as seamless care.
Community initiatives are being sponsored by some hospitals or local community agencies. These initiatives, called healthy cities and healthier communities, involve members of the community in es- tablishing health priorities, setting measurable goals, and determin- ing actions to reach these goals. If a community agency is initiating this project, the associated hospital generally contributes human re- sources to assist in this endeavor.
Community coalitions bring together individuals and groups for the shared purpose of improving the community’s health. Nurses are major participants and contributors in these coalitions and often assume leadership positions. Community coalitions may focus on a single or multifaceted problem. Examples include establishment of an abuse program, a gang prevention program, an older adult assess- ment program, or an immunization program for a high-risk group.
In managed care, which is a common model in health care restructuring, health care providers (hospitals, physicians, nurse practitioners, insurance carriers, and so on) join to meet health needs across the care continuum. The managed care organization serves as a “go-between” or “gatekeeper” with the client, provider, and payer. Providers are organized into groups, and the client must
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COMMUNITY NURSING CENTERS Community nursing centers provide primary care to specific populations and are staffed by nurse practitioners and community health nurses. Although the nurses are the primary providers of care to clients visiting the center, a physician’s consultation is available as needed. Nursing centers may be located in schools, workplaces, or other community agencies, or be freestanding. Nursing centers must interface with nurse-managed services in other settings across the health care continuum, that is, services being provided to clients in their home, hospital, or long-term care facility. There are various cat- egories of community nursing centers:
• Community outreach centers. Relatively small freestanding clinics providing services similar to those traditionally pro- vided by large public health clinics but focused on a narrower population.
• Institution-based centers. Associated with a large parent organi- zation such as a hospital, corporation, or university or college.
• School-based centers. Placed within school facilities from kin- dergarten through college level to provide services such as emer- gency first aid, diagnosis of acute illnesses, health promotion and maintenance programs, as well as health education of school-age populations.
• Wellness centers. Provide services such as health promotion, health maintenance, education, counseling, and screening. In some settings, wellness centers are staffed by members of the health care team other than nurses (e.g., physical therapists or oc- cupational therapists).
PARISH NURSING Parish nursing was founded in the United States in Illinois in the mid-1980s by Reverend Granger Westberg (Church Health Center, n.d.) and became a specialty recognized by the ANA in 1998. The
select one from the group to which he or she belongs. Managed care aims in this way to enhance the quality and cost effectiveness of health care.
Case management is an integrative health care model that tracks clients’ needs and services through a variety of care settings to ensure continuity. The case manager is familiar with the clients’ health needs and resources available through their insurance coverage so they can receive cost-effective care. Another important aspect of case man- agement is assisting the client and family to understand and navigate their way through the health care system.
Outreach programs using lay health workers are one method of linking underserved or high-risk populations with the formal health care system. They can minimize or reduce barriers to health care, in- crease access to services, and thus improve the health status of the community. They involve partnerships between nurses and mem- bers of the community. Interested and committed lay health workers are identified who will assist their neighbors through outreach net- works. Nurses provide training, consultation, and support to these individuals.
Community-Based Settings Traditionally, community nursing services have been provided in county and state health departments (public health nursing), in schools (school nursing), in workplaces (occupational nurs- ing), and in homes (home health care and hospice nursing). Over the years, numerous other settings have been established, includ- ing day care centers, senior centers, storefront clinics, homeless shelters, mental health centers, crisis centers, drug rehabilitation programs, and ambulatory care centers. More recent settings for community nursing practice include nurse-managed community nursing centers, parish nursing, corrections nursing, and tele- health projects.
Figure 7–3 • Model of an integrated health care delivery system.
primary care providers
technicians specialists
clinic
pharmacy
extended care facilityhospital
insurance company
laboratory
client/family
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Church Health Center (2013) describes the roles of the parish nurse as follows:
• Personal health counselor who discusses health issues and prob- lems with individuals and makes home, hospital, and nursing home visits as needed
• Health educator who educates and supports individuals through health education activities that promote an understanding of the relationship between values, attitudes, lifestyle, faith, and well-being
• Referral source who acts as a liaison to other congregational and community resources
• Facilitator who recruits and coordinates volunteers within the congregation and develops support groups
• Integrator of faith and health.
An estimated 15,000 parish nurses serve churches, synagogues, and temples in the United States. The role of a parish nurse is governed by the ANA publication Faith Community Nursing: Scope and Stan- dards of Practice (2012b). Most parish nurses are volunteers, but about one third are employees paid by the congregation or an affiliated insti- tution such as a health system or community agency. Parish nursing is nondenominational and includes nurses of all religious faiths. Parish nursing is one of the few community-based nursing roles found with a similar structure and focus in nations around the world.
CORRECTIONS NURSING Corrections nursing includes the care of clients placed in jails, pris- ons, group homes, detention centers, and other correctional facilities. Corrections nursing is a subset of the broader category of forensic nursing, which encompasses criminal investigations (including that for assault, rape, or suspected abuse), death investigations, and expert legal testimony. Corrections nursing is the “practice of nursing and the delivery of patient care within the unique and distinct environ- ment of the criminal justice system” (ANA, 2007, p. 1). One example of the work of corrections nurses is to assist with implementation of the standards for compliance with the Prison Rape Elimination Act of 2003. In addition to this example of work specific to the care of incarcerated clients, the more than 18,000 corrections nurses encom- pass the full range of nursing—from health promotion through ill- ness and end-of-life care (Trossman, 2011).
TELEHEALTH Telehealth projects use communication and information technol- ogy to provide health information and health care services to people in rural, remote, or underserved areas. Video conferences or “video clinics” enable health care workers to provide distant consultation to assess and treat ambulatory clients who have a variety of health care needs. These video conferences are similar to any outpatient clinic visit except that the client and health care specialist are miles apart. A related development to telehealth is telenursing, in which nurses provide client teaching and health promotion to distant clients. Tele- monitoring allows transmittal of data from client to health care pro- viders and immediate responses. The literature describes the use of telehealth in a wide variety of clinical conditions. With clients who have chronic conditions such as lung disease or heart failure, a tele- health nurse may be better able to prioritize which clients to see in person and, thus, to manage many times more clients than without the technology (Watson, 2012).
COMMUNITY-BASED NURSING Community-based nursing (CBN) is nursing care directed to- ward specific individuals. However, community-based nursing involves nursing care that is not confined to one practice setting. It extends beyond institutional boundaries and involves a network of nursing services: nursing wellness centers, ambulatory care, acute care, long-term care nursing services, telephone advice, home health, school health, and hospice services. For example, a nurse case manager may be involved in (a) visiting a newly admitted client in the hospital to take a detailed nursing history, confer with the pri- mary nurse, and begin discharge planning; (b) making several home visits to monitor a client recently transferred from a hospital to a long-term care agency to discuss the client’s progress with the nurs- ing staff; or (c) making consultative telephone calls to other health professionals (physicians, social workers, respiratory therapists, and so on) and to clients who are managing self-care independently but who may need support.
CLINICAL ALERT!
Community-based nursing and community health nursing are not the same concept. Community-based nursing focuses on care of indi- viduals in geographically local settings, whereas community health nursing emphasizes the promotion and preservation of the health of groups (populations or aggregates).
Other nurses who work in community-based settings, such as case managers, occupational health nurses, school nurses, and pub- lic health department nurses, need to be prepared to make home visits. Home visits can provide information that is not obtainable in other ways.
Competencies Required for Community-Based Care Nurses practicing in community-based integrated health care sys- tems need to have specialized knowledge and skills. In 1998, the Pew Health Professions Commission (O’Neil & Pew Health Professions Commission) identified 21 competencies that future health profes- sionals would require (Box 7–5). Note that the competencies include the need for knowledge and skills in the areas of primary care, pre- ventive care, population-based care, health care access, community partnerships, interprofessional teams, and public policy—all essential for effective community-based nursing. Although nurses educated at the diploma and associate degree levels are introduced to concepts and experiences of caring for clients in the community, coursework addressing the breadth and depth of knowledge and skills for com- munity health nursing is usually taught in baccalaureate and higher degree programs.
Collaborative Health Care Collaboration among health care professionals becomes increasingly important as more practitioners specialize in progressively more nar- row areas of expertise while others take on the generalist role. Over time, the boundaries and legal scope of practice of each health care profession may change. To deliver optimal health care to the client, nurses must work as a member of the team providing comprehensive health care.
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Executives issued a joint statement of principles for enhancing col- laborative relationships between clinical nurses and nurse managers.
THE NURSE AS A COLLABORATOR Nurses collaborate with nurse colleagues and other health care pro- fessionals. They frequently collaborate about client care but may also be involved, for example, in collaborating on bioethical issues, on legislation, on health-related research, and with professional or- ganizations. Box 7–6 outlines selected aspects of the nurse’s role as a collaborator.
To fulfill a collaborative role, nurses need to assume account- ability and increased authority in practice areas. Education is in- tegral to ensuring that the members of each professional group understand the collaborative nature of their roles, specific contri- butions, and the importance of working together. Each professional needs to understand how an integrated delivery system centers on the client’s health care needs rather than on the particular care given by one group.
COMPETENCIES BASIC TO COLLABORATION Key elements necessary for collaboration include effective commu- nication skills, mutual respect, trust, and a decision-making process.
In 1992, the ANA Congress on Nursing Practice adopted the following operational definition of the concept of collaboration:
Collaboration means a collegial working relationship with another health care provider in the provision of (to supply) patient care. Collaborative practice requires (may include) the discussion of patient diagnosis and cooperation in the man- agement and delivery of care. (ANA, 1992)
A number of different organizations have issued standards and guidelines for collaboration among health care providers. Of the six Quality and Safety Education for Nurses competencies, one is “Teamwork and Collaboration,” defined as the ability to “function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (Cronenwett et al., 2007, p. 125). One ANA Standard of Professional Performance (2010) is collaboration. Key words in the competencies for that standard include that the nurse partners, communicates, cooperates, participates, and engages with other members of the team. In 2011, six organizations repre- senting nursing, medicine, pharmacy, dentistry, and public health issued Core Competencies for Interprofessional Collaborative Prac- tice, and in 2012, the ANA and the American Organization of Nurse
BOX 7–5
1. Embrace a personal ethic of social responsibility and service. 2. Exhibit ethical behavior in all professional activities. 3. Provide evidence-based, clinically competent care. 4. Incorporate the multiple determinants of health in clinical care. 5. Apply knowledge of the new sciences. 6. Demonstrate critical thinking, reflection, and problem-solving
skills. 7. Understand the role of primary care. 8. Rigorously practice preventive health care. 9. Integrate population-based care and services into practice.
10. Improve access to health care for those with unmet health needs.
11. Practice relationship-centered care with individuals and families.
12. Provide culturally sensitive care to a diverse society. 13. Partner with communities in health care decisions.
14. Use communication and information technology effectively and appropriately.
15. Work in interdisciplinary teams. 16. Ensure care that balances individual, professional, system,
and societal needs. 17. Practice leadership. 18. Take responsibility for quality of care and health outcomes
at all levels. 19. Contribute to continuous improvement of the health care
system. 20. Advocate for public policy that promotes and protects the
health of the public. 21. Continue to learn and help others learn.
From Recreating Health Professional Practice for a New Century, by E. H. O’Neil and the Pew Health Professions Commission, 1998, San Francisco, CA: Pew Health Professions Commission.
Pew Commission Competencies for Future Practitioners
BOX 7–6
WITH NURSE COLLEAGUES • Shares personal expertise with other nurses and elicits the
expertise of others to ensure quality client care. • Develops a sense of trust and mutual respect with peers that
recognizes their unique contributions.
WITH OTHER HEALTH CARE PROFESSIONALS • Recognizes the contribution that each member of the interpro-
fessional team can make by virtue of his or her expertise and view of the situation.
• Listens to each individual’s views. • Shares health care responsibilities in exploring options, setting
goals, and making decisions with clients and families. • Participates in collaborative interprofessional research to
increase knowledge of a clinical problem or situation.
WITH PROFESSIONAL NURSING ORGANIZATIONS • Seeks opportunities to collaborate with and within professional
organizations. • Serves on committees in state and national nursing
organizations or specialty groups. • Supports professional organizations in political action to create
solutions for professional and health care concerns.
WITH LEGISLATORS • Offers expert opinions on legislative initiatives related to
health care. • Collaborates with other health care providers and consumers
on health care legislation to best serve the needs of the public.
The Nurse as a Collaborator
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client’s health status. In 2012, the ANA issued a position statement on the registered nurse’s role in care coordination. This statement pro- motes the responsibility of the nurse to be prepared to partner with the client to provide quality and access to appropriate health care re- sources across a variety of settings (ANA 2012a).
To provide continuity of care, nurses need to accomplish the following:
• Initiate discharge planning for all clients when they are admitted to any health care setting.
• Involve the client and the client’s family or support persons in the planning process.
• Collaborate with other health care professionals as needed to en- sure that biopsychosocial, cultural, and spiritual needs are met.
Achieving continuity, however, assumes that needed client data are shared with other providers while implementing strategies to pro- tect client privacy. The Health Insurance Portability and Account- ability Act of 1996 (HIPAA) requires that health information about clients be secured in such a way that only those with the right and need to acquire the information are able to do so.
The privacy aspect of HIPAA results in a balance between protecting disclosure of confidential client information and the need for certain data to be released to specific agencies. Ultimately, clients have increased control over their own information, and those who violate the rule face significant penalties. Community nursing practice has altered in the face of the HIPAA regulations. Case managers and public health nurses need to maintain vigi- lance to protect the privacy of client health care information when sending and receiving telephone messages, faxes, and electronic documentation when in field settings as well as within health care facilities.
Care Across the Life Span The majority of children and older adults receive their health care in their communities rather than in hospitals. From home births, to school-based childhood immunization programs, to sex education for teens, to chronic disease management in adults, to hospice care, the nurse works with clients and a wide variety of community health organizations to provide wellness and illness care. A wide variety of initiatives focused on care provided in the community for children is found at the American Academy of Pediatrics website.
COMMUNICATION Collaborating to solve complex problems requires effective communication skills. Effective communication can occur only if the involved parties are committed to understanding each other’s professional roles and appreciating each other as individuals. Additionally, they must be sensitive to differences among communication styles. Instead of focusing on distinctions, a group of professionals needs to center on their common ground: the client’s needs.
MUTUAL RESPECT AND TRUST Mutual respect occurs when two or more people show or feel honor or esteem toward one another. Trust occurs when a person is confident in the actions of another person. Both mutual respect and trust imply a mutual process and outcome. They must be expressed both verbally and nonverbally.
DECISION MAKING The decision-making process at the team level involves shared responsibility for the outcome. To create a solution, the team must follow each step of the decision- making process, beginning with a clear definition of the problem. Team decision making must be directed at the objectives of the specific effort. It requires full consideration and respect for diverse viewpoints. Members must be able to verbalize their perspectives in a nonthreatening environment.
An important aspect of decision making is satisfied when the interprofessional team focuses on the client’s priority needs and organizes interventions accordingly. The discipline best able to address the client’s needs is given priority in planning and is re- sponsible for providing its interventions in a timely manner. For example, a social worker may first direct attention to a client’s social needs when these needs interfere with the client’s ability to respond to therapy. Nurses, by the nature of their holistic practice, are often able to help the team identify priorities and areas requiring further attention.
CONTINUITY OF CARE A major responsibility of the nurse is to ensure continuity of care. Continuity of care is the coordination of health care services by health care providers for clients moving from one health care setting to another and between and among health care professionals. Con- tinuity ensures uninterrupted and consistent services for the client from one level of care to another. When coordinated appropriately, it maintains client-focused individualized care and helps optimize the
The purpose of the study by Krantz, Coronel, Whitley, Dale, Yost, and Estacio (2013) was to determine if a program combining the work of community health nurses and primary care providers could reduce coronary heart disease risk. Building on the effectiveness of a previous program, the authors implemented tailored health educa- tion, assessment of readiness for behavior change, motivational in- terviewing, and longitudinal follow-up for the almost 700 participants in the study. Results showed statistically significant improvement in diet, weight, blood pressure, blood lipids, and cardiovascular risk score among those who received follow-up calls and retesting com- pared to those who did not receive the subsequent care.
IMPLICATIONS This study is an excellent example of extending the work of previ- ous programs and research and integrating the expertise of both community health workers and primary care providers. When work- ing with clients in the community, especially, it is important for each member of the health care team to collaborate with the others in identifying health risks and coordinating interventions. In addition, such studies provide the evidence nurses need to design and imple- ment effective programs.
Evidence-Based Practice Can Community Health Nurses Reduce the Risks of Cardiovascular Disease? EVIDENCE-BASED PRACTICE
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community supports; hazards or barriers that the home environment presents; and need for health care assistance in the home. Box 7–7 outlines details for each of these parameters.
The data are used to establish which nursing activities are re- quired before the client can be discharged. These activities most often include teaching the client to cope with continuing self-care at home and a home care referral.
Medication Reconciliation When a client moves from one location or level of care to another, current information regarding medications must be communicated within the health care team to prevent errors and unintended con- sequences. The Joint Commission (2012) continues to emphasize medication reconciliation as one of the National Patient Safety Goals for hospitals, ambulatory and behavioral health care, and home care settings. Medication reconciliation is the process of comparing all of the medications a client is taking (and should be taking) with newly ordered or changed medications. The comparison addresses duplica- tions, omissions, and interactions. Reconciliation must occur during transitions in care both within and outside of the organization and in- clude client education on safe medication use, and communications with other providers. The organization obtains the client’s medication information at the beginning of an episode of care. The information is updated when the client’s medications change. The responsibility for conducting medication reconciliation often falls to the nurse.
Home Health Care Teaching Clients need help to understand their health condition, to make health care decisions, and to learn new health behaviors. Because of today’s shortened hospital stays, it is often unrealistic to teach clients everything they need to know prior to discharge. Referral to a home health agency for follow-up teaching may be neces- sary. Essential information before discharge includes information about medications, dietary and activity restrictions, signs of com- plications that need to be reported to the primary care provider,
Discharge Planning Discharge planning is the process of preparing a client to leave one level of care for another within or outside the current health care agency. Usually, discharge planning refers to the client leaving the hospital for home. However, discharges occur among many other settings. Within a facility, it can occur from one unit to another. For example, a client with a stroke may move from a medical unit to a rehabilitation unit, or a client with trauma may move from the emer- gency department to an intensive care unit. Clients may move from a hospital to a long-term care agency, from a rehabilitation center to home, or from a home health care setting to a hospital, and so on.
Each agency generally has its own policies and procedures re- lated to discharge. Many agencies have case managers or discharge planners, a health or social services professional who coordinates the transition and acts as a link between the discharging agency and the receiving facility. Often, a nurse assumes this responsibility of provid- ing continuity of care.
Discharge planning needs to begin as soon as a client is admit- ted to the agency, especially in hospitals where stays are relatively short. Effective discharge planning involves ongoing assessment to obtain comprehensive information about the client’s ongoing needs and nursing care plans to ensure that the client’s and receiving agency caregivers’ needs are met. In some situations discharge planning necessitates health team conferences and family conferences. At a health team conference, health care professionals focus on ways to individualize care for the client. At a family conference, both health professionals and the family discuss family issues related to the client. Both types of conferences give the client, family, and health care pro- fessionals the opportunity to mutually plan care and set goals.
Preparing Clients to Go Home Nurses preparing to send clients home from the hospital need to as- sess their clients’ personal and health data; ability to perform activities of daily living; any physical, cognitive, or other functional limitations; caregivers’ responses and abilities; adequacy of financial resources;
BOX 7–7
PERSONAL AND HEALTH DATA Age; sex; height and weight; cultural beliefs and practices; medical history; current health status; prognosis; surgery
ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING Abilities for dressing; eating; toileting; bathing (tub, shower, sponge); ambulating (with or without aids such as a cane, crutches, walker, wheelchair); transferring (from bed to chair, in and out of bath, in and out of car); meal preparation; transportation; shopping
DISABILITIES/LIMITATIONS Sensory losses (auditory, visual); motor losses (paralysis, amputa- tion); communication disorder; mental confusion or depression; incontinence
CAREGIVERS’ RESPONSES/ABILITIES Principal caregiver’s relationship to client; thoughts and feelings about client’s discharge; expectations for recovery; health and cop- ing abilities; comfort with performing needed care
FINANCIAL RESOURCES Financial resources and needs (note equipment, supplies, medica- tions, special foods required)
COMMUNITY SUPPORTS Family members, friends, neighbors, volunteers; resources such as Medicaid; food stamps; nutrition services; health centers; com- munity health nurses; day programs; legal assistance; home care; respite care
HOME HAZARD APPRAISAL Safety precautions (stairs with or without handrails; lighting in rooms, hallways, stairways; night-lights in hallways or bathroom; grab bars near toilet and tub; firmly attached carpets and rugs); self-care barri- ers (lack of running water, lack of wheelchair access to bathroom or home, lack of space for required equipment, lack of elevator) (Note: A detailed home hazard appraisal is provided in Chapter 8 .) NEED FOR HEALTH CARE ASSISTANCE Home-delivered meals; special dietary needs; volunteers for tele- phone reassurance, friendly visiting, transportation, shopping; as- sistance with bathing; assistance with housekeeping; assistance with wound care, ostomies, tubes, intravenous medications
Discharge Planning: Home Assessment Parameters
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follow-up appointments and telephone numbers, and where sup- plies can be obtained. Clients or caregivers also need to demon- strate safe performance of any necessary treatments. Information needs to be provided verbally and in writing. Details about effec- tive teaching strategies are provided in Chapter 27 . Reinforce- ment of acute care discharge information will often fall in the domain of the community-oriented nurse. Client issues related to health literacy, language barriers, and access to resources to carry out the provided health care instruction are major concerns of community nurses.
Referrals The referral process is a systematic problem-solving approach that helps clients to use resources that meet their health care needs. The process involves knowledge of community resources and an ability to solve problems, set priorities, coordinate, and collaborate. Home care referrals are often made before discharge for the following clients:
• Older adults • Children with complex conditions • Frail persons who live alone
LIFESPAN CONSIDERATIONS Health Care Delivery
CHILDREN The Search Institute has identified evidence-based assets charac- teristic of healthy communities and of different age groups of chil- dren. These assets are both external and internal to the individual, and if promoted in communities, will contribute to the healthy de- velopment of children and families and the positive life of the com- munity. The impact of these assets has been studied in children from birth through adolescence, and many communities across the United States are using them to structure programs for children and youth. Among the assets are such things as family support, fam- ily values of equality and social justice, involvement of children and youth with adults and community organizations, constructive use of young people’s time, and engagement in learning. The institute also has five action strategies for transforming communities for the betterment of youth: engaging adults, mobilizing youth, activating organizations, expanding programs, and influencing policy.
OLDER ADULTS Due to the changes caused by aging and the increase of chronic illnesses in older adults, various levels of health care delivery are often required. Clients may go back and forth between these levels as their needs fluctuate. At various times and situations, they might need care from hospitals, home care, extended care facilities, am- bulatory care, and assisted living. Maintaining communications and providing continuity of care during these changes are essential.
Caregivers of older adults are often older themselves and may have health problems of their own. Attention should be given to signs of emotional and physical fatigue and other problems that might arise for them. Community health nurses have the opportunity to do ongoing assessments of this as they see clients and caregiv- ers in their home environment. They can then provide support and resources as needed.
• Those who lack or have a limited support system • Those who have a caregiver whose health is failing • Those whose home presents barriers to their safety (e.g., stairs).
Referrals need to present as much information as possible about the client and the hospitalization to the agency. Most agencies have well-established protocols and detailed referral forms. The assess- ment parameters in Box 7–7 may also be used as a guide. The nurse caring for the hospital client is responsible for confirming and docu- menting that the relevant referrals have been made. To identify and recommend referrals, the nurse must already be familiar with the resources that are available in the community. Using this knowledge, plus information regarding the client’s previous awareness and choice of community resources, hospital nurses play a key role in maintain- ing effective continuity of health care.
To ensure appropriate reimbursement to the home health agency, the primary care provider must provide a written order for a home care referral and subsequent home visits. Clients must meet specific criteria to have Medicare or other third-party payers reim- burse them for home care services. Chapter 8 provides details about home health nursing.
Critical Thinking Checkpoint
Nurses are, and should be, taking an active role in influencing the direction of health care. Recognizing that there are finite limits to the amount of money and health care providers available, desirable out- comes often compete for resources. Consider a clinical situation such as the so-called “drive-through (or 24-hour) mastectomies” in which clients are moved through the acute care (hospital) system extremely quickly compared to previously. The ANA’s Health System Reform Agenda (ANA, 2008) states that (a) health care should be provided in settings that provide treatment and follow-up care that is reason- ably priced with copayments based on the person’s ability to pay; (b) health care should be available during convenient hours, locations, and waiting times to accommodate working families, people with dis- abilities, and people across the life span; and (c) health care services
should be culturally appropriate, respectful of clients and their families, and inclusive of client involvement in treatment decisions. 1. How does the mastectomy clinical example reflect or not reflect
the agenda? 2. Which of the three agenda items listed do you consider the most
important and why? 3. How might different community-based frameworks manage the
clinical example? 4. How would the nurse use collaboration with insurance payers,
women, or surgeons to resolve any concerns with the clinical example?
See Critical Thinking Possibilities on student resource website.
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• Consumers support an increased emphasis on health care mea- sures that promote wellness.
• The ANA’s Health System Reform Agenda (2008) and Healthy People 2020 by the USDHHS (2010) have set forth recommenda- tions for health care reform. These focus on accessibility of health care services, health promotion and disease prevention, and steps to consider how health care costs can be reduced.
• Health care costs, access to health care, and the quality of health care are major areas of concern surrounding the current health care system.
• Community-based health care, akin to primary health care, provides health-related services in places where people spend their time—in homes, in shelters, in long-term care residences, at work, in schools, in senior citizen centers, and so on.
• A community is a collection of people who share some attribute of their lives.
• For community assessment, eight subsystems proposed by Anderson and McFarlane (2011) can be used: physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation.
• Approaches are emerging to address community-based care. These include an integrated health care system, community ini- tiatives, community coalitions, managed care, case management, and outreach programs using lay health workers.
• Numerous community settings have been established. Ones that are more recent include nurse-managed community nursing cen- ters, parish nursing, corrections nursing, and telehealth projects.
• Community-based nursing directs nursing care toward specific individuals. It is not confined to one practice setting; it extends beyond institutional boundaries involving a network of nursing ser- vices: nursing wellness centers, ambulatory care, long-term care, telephone advice, home health, school health, and hospice care.
• To practice in community health care systems, nurses need knowl- edge and skills in primary care, preventive care, population-based care, health care access, community partnerships, interprofes- sional teams, and public policy.
• Collaboration among health care providers is key to providing comprehensive health care.
• A major responsibility of the nurse is to ensure continuity of care as clients move from one level of care to another.
• Continuity of care involves (a) discharge planning that begins when clients are admitted to an agency, (b) cooperation with the client and support persons, and (c) interprofessional collaboration.
• Nurses need to ensure that clients have essential information and skills to manage self-care before being discharged to their homes. In some situations, referral to a home health agency is necessary.
CHAPTER HIGHLIGHTS
Chapter 7 Review
1. The ANA’s Health System Reform Agenda (2008) included which of the following? 1. Primary health care should be based in acute care hospitals. 2. A minimum standard of health care for all persons should be
paid for completely with public funds. 3. Case management should be focused on clients with
enduring health care needs. 4. Essential services should be initiated simultaneously to avoid
gaps. 2. The Pew Commission competencies for future practitioners included
the need for providers to become skilled in which of the following? 1. Use of technology 2. Emphasizing practice in tertiary settings 3. Traditional clinical approaches 4. Making decisions for incompetent clients
3. Which of the following is characteristic of nursing care provided in community-based health? 1. Clients are primarily those with identified illnesses. 2. Clients are individuals in groups according to their
geographic commonalities. 3. Care is paid for by the community as a whole rather than by
individuals. 4. All clients are case managed.
4. When performing collaborative health care, the nurse must implement which of the following? 1. Assume a leadership role in directing the health care team. 2. Rely on the expertise of other health care team members. 3. Be physically present for the implementation of all aspects of
the care plan. 4. Delegate decision-making authority to each health care provider.
5. The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client states which of the following? 1. “As soon as I get home, the nurse will come out, look at
where I live, and see what kind of care I will need.” 2. “All I need are my medications and a ride home. Then I’m all
ready for discharge.” 3. “When I visit my doctor in 10 days, they will show me how to
change my bandages.” 4. “I have the phone numbers of the home care nurse and the
therapist who will visit me at home tomorrow.” 6. A large disaster in a community resulted in the destruction of
many family homes and many individuals were injured. The as- sistance of community health nurses and home health nurses is needed. The home health nurse is most likely to perform which of the following? 1. Provide for a safe water supply. 2. Monitor for communicable diseases. 3. Establish communication and support systems. 4. Assess and treat individual clients.
See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
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Suggested Reading Nosbusch, J., Weiss, M., & Bobay, K. (2011). An
integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning. Journal of Clinical Nursing, 20, 754–774. doi:10.1111/j.1365-2702.2010.03257.x This article summarizes publications about practices, per- ceptions, and experiences of bedside staff nurses relative to hospital discharge planning. Preparation for hospital discharge should begin at or prior to admission. Forces in the acute care environment, however, often impede com- prehensive discharge planning. Evidence-based redesign of discharge planning processes is a priority for nurses and health care leaders. Seven themes were identified across the studies: intra- and interdisciplinary communication; systems and structures; time; role confusion; care continu- ity; knowledge; and the invisibility of the staff nurse role in discharge planning.
Related Research Falk-Rafael, A., & Betker, C. (2012). The primacy of relation-
ships: A study of public health nursing practice from a criti- cal caring perspective. Advances in Nursing Science, 35, 315–322. doi:10.1097/ANS.0b013e318271d127
Kirkpatrick, P., Wilson, E., & Wimpenny, P. (2012). Research to support evidence-based practice in COPD commu- nity nursing. British Journal of Community Nursing, 17, 486–492.
Phillips, L. R., & Ziminski, C. (2012). The public health nursing role in elder neglect in assisted living facilities. Public Health Nursing, 29, 499–509. doi:10.1111/j.1525-1446.2012.01029.x
References American Nurses Association (ANA). (1991). Nursing’s agenda
for health care reform. Kansas City, MO: Author. American Nurses Association (ANA). (1992). House of
delegates report: 1992 convention, Las Vegas, Nevada (pp. 104–120). Kansas City, MO: Author.
American Nurses Association (ANA). (2007). Corrections nursing: Scope and standards of practice. Silver Spring, MD: Author.
American Nurses Association (ANA). (2008). ANA’s health system reform agenda. Silver Spring, MD: Author. Retrieved from http://www.nursingworld.org/Content/ HealthcareandPolicyIssues/Agenda/ ANAsHealthSystemReformAgenda.pdf
American Nurses Association (ANA). (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
American Nurses Association. (2012a). Care coordination and registered nurses’ essential role. Retrieved from http:// nursingworld.org/MainMenuCategories/Policy-Advocacy/ Positions-and-Resolutions/ANAPositionStatements/
Position-Statements-Alphabetically/Care-Coordination- and-Registered-Nurses-Essential-Role.html
American Nurses Association (ANA). (2012b). Faith community nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
American Nurses Association (ANA). (2012c). Health care transformation: The Affordable Care Act and more. Retrieved from http://nursingworld.org/ TransformingHealthcareDoc.aspx
American Nurses Association & American Organization of Nurse Executives. (2012). ANA/AONE principles for col- laborative relationships between clinical nurses and nurse managers. Retrieved from http://www.aone.org/resources/ PDFs/ANA_AONE_Principles_of_Collaborative_ Relationships.pdf
Anderson, E. T., & McFarlane, J. (2011). Community as part- ner: Theory and practice in nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Church Health Center. (2013). Job description for the ministry of parish nursing practice. Retrieved from http:// churchhealthcenter.org/samplejobdescription
Church Health Center. (n.d.). History: The beginnings. Retrieved from http://churchhealthcenter.org/fcnhistory
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006
Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanselow, N. A. (Eds.). (1996). Primary care: America’s health in a new era. Washington, DC: National Academies Press. Retrieved from http://books.nap.edu/catalog.php?record_id=5152
Institute of Medicine. (2012). Primary care and public health: Exploring integration to improve population health. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=13381
The Joint Commission. (2012). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_ information/npsgs.aspx
Krantz, M. J., Coronel, S. M., Whitley, E. M., Dale, R., Yost, J., & Estacio, R. O. (2013). Effectiveness of a community health worker cardiovascular risk reduction program in public health and health care settings. American Journal of Public Health, 103(1), e19–27. doi:10.2105/ AJPH.2012.301068
National Center for Health Statistics. (2013). Health: United States, 2013. Hyattsville, MD: Author.
O’Neil, E. H., & Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. San Francisco, CA: Pew Health Professions Commission.
Trossman, S. (2011). Ensuring standards are standard behind bars. The American Nurse, 43(6), 12–13.
U.S. Department of Health and Human Services (USDHHS). (2010). Healthy people 2020. Retrieved from http:// www.healthlypeople.gov/2020/default.aspx
Watson, D. (2012). Case study: The use of telehealth technol- ogy in a community setting. British Journal of Community Nursing, 17, 520–521.
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Selected Bibliography American Nurses Association. (2007). Public health nursing:
Scope and standards of practice. Washington, DC: American Nurses Publishing.
Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Hunt, R. (2012). Introduction to community-based nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Retrieved from http://www.nap.edu/ catalog.php?record_id=10027
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Retrieved from http://www.aacn.nche.edu/education-resources/ ipecreport.pdf
Maitlen, L. A., Bockstahler, A. M., & Belcher, A. E. (2012). Using community-based participatory research in parish nursing: A win–win situation! Journal of Christian Nursing, 29, 222–227. doi:10.1097/CNJ.0b013e318267c862
Maurer, F. A., & Smith, C. M. (2012). Community/public health nursing practice: Health for families and populations (5th ed.). St. Louis, MO: Elsevier.
Miller, L. C., Rosas, S. R., & Hall, K. (2012). Using concept mapping to describe sources of information for public health and school nursing practice. Journal of Research in Nursing, 17, 466–481. doi:10.1177/1744987111403883
Nies, M. A., & McEwen, M. (2011). Community/public health nursing: Promoting the health of populations (5th ed.). St. Louis, MO: Elsevier Saunders.
Pappas-Rogich, M. (2012). Faith community nurses: Protecting our elders through immunizations. Journal of Christian Nursing, 29, 232–237. doi:10.1097/ CNJ.0b013e318266efe5
Stanhope, M., & Lancaster, J. (2010). Foundations of nursing in the community: Community-oriented practice (3rd ed.). St. Louis, MO: Mosby/Elsevier.
Stanhope, M., & Lancaster, J. (2011). Public health nursing: Population-centered health care in the community (8th ed.). St. Louis, MO: Elsevier.
READINGS AND REFERENCES
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INTRODUCTION Historically, home care consisted primarily of nurses providing pri- vate duty care in clients’ homes and care of the ill by their own family members. However, the delivery of professional nursing services in home settings has increased in frequency, scope, and complexity in the past decades. Home care today involves a wide range of health care professionals providing services in the home setting to people recovering from an acute illness or injury or those with a disability or a chronic condition. A number of factors have contributed to this trend, among them rising health care costs, an aging population, and a growing emphasis on managing chronic illness and stress, preventing illness, and enhancing the quality of life. In the not- too-distant past, home health care occurred at the end of the client care continuum—that is, after discharge from an acute care facility. Today the trend is changing to use of home health care services to avoid hospitalization. According to The Joint Commission (2011), approximately 8.6 million individuals currently receive primary care, pre-acute care intervention, postacute services, and hospice/palliative care at home.
Direct nursing care may be provided by nurses from dif- ferent educational backgrounds. Although associate degree and diploma-prepared nurses usually do not work in community health (see Chapter 7 ), they may be employed by home care agencies. Because home health nurses must function indepen- dently in a variety of home settings and situations, some employ- ers prefer that the nurse be prepared at the baccalaureate level or above. The American Nurses Credentialing Center (ANCC) provides certification for home health nursing at both the general- ist and advanced practice levels. Advanced practice certification requires a master’s degree in nursing and recognizes the need for home health clinical specialists who can provide direct care, man- age client care, and engage in consulting, education, administra- tion, and research activities.
HOME HEALTH NURSING The delivery of nursing services in the home has been called a variety of terms, including home health care nursing and visiting nursing. For example, the Visiting Nurse Associations of America’s mission is to assist both visiting nurses’ associations and home health care agen- cies in their work. Home health care nursing or visiting nursing includes the nursing services and products provided to clients in their homes that are needed to maintain, restore, or promote their physical, psychological, and social well-being. The focus of home health care nursing is individuals and their families. This differs somewhat from the focus of community health nursing, which focuses on individu- als, families, and aggregate groups (see Chapter 7 ). Of course, a home may consist of a wide variety of settings from individual dwell- ings to group housing. Even those who are considered homeless may require care from a home health nurse and this could occur in a shel- ter, a mobile care unit, or wherever the person has their belongings.
Hospice nursing, support and care of the dying person and family, is often considered a subspecialty of home health nursing because hospice services are frequently delivered to clients who are terminally ill in their residence. See Chapter 43 for further infor- mation about hospice care.
Home nursing care is one of the growing sectors of the health care system. Expenditures for home health are significantly in- fluenced by increasing or decreasing Medicare payment policies, but they increase approximately 10% each year. The number of Medicare-certified hospice providers increased 56% from 2000 to 2011, and Medicare payments for hospice services increased 517% between 2000 and 2012 (National Center for Health Statistics, 2013). Factors that have contributed to the growth of home health care in- clude (a) the increase in the older population, who are frequent re- cipients of home care; (b) third-party payers who favor home care to control costs; (c) the ability of agencies and institutions to successfully deliver high-technology services in the home; and (d) consumers
caregiver role strain, 123 durable medical equipment (DME)
company, 120
home care, 118 home health care nursing, 118
hospice nursing, 118 registry, 120
visiting nursing, 118
KEY TERMS
After completing this chapter, you will be able to: 1. Define home health care. 2. Compare the characteristics of home health nursing to those
of institutional nursing care. 3. Describe the types of home health agencies, including refer-
ral and reimbursement sources. 4. Describe the roles of the home health nurse.
LEARNING OUTCOMES
8 Home Care
5. Identify the essential aspects of the home visit. 6. Discuss the safety and infection control dimensions appli-
cable to the home care setting. 7. Identify ways the nurse can recognize and minimize caregiver
role strain.
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benefit from the services of an agency with direct connections to a medical equipment company. Payment for home health is accom- plished through private-pay sources, third-party reimbursement, or a combination of sources.
Referral Process Clients may be referred to home health care providers by a phy- sician, nurse, social worker, therapist (e.g., physical therapist), discharge planner, or family member. Families often initiate the process by approaching one of these referral sources or by di- rectly contacting the home health agency to make inquiries. Home care cannot begin, however, without a physician’s order and a physician-approved treatment plan. This is a legal and reimburse- ment requirement.
Hospital nurses may be responsible for assisting with the home health transition by obtaining consent for transfer of confidential records, establishing the initial communication between home care and client, and completing a thorough set of transfer documents. These documents must include a detailed description of the changes in medications from prehospitalization, through hospitalization, and to home orders. This is Goal 3 of the National Patient Safety Goals established by The Joint Commission to help accredited organiza- tions address specific areas of concern in regards to client safety. In addition, client and family teaching, along with a description of their understanding of potential complications and whom and when to contact should those occur, must be included.
After an initial set of physician’s orders is obtained, a nursing evaluation visit is scheduled to enroll the client and identify the cli- ent’s needs. The initial visit, often referred to as “opening the case,” should include the client and the immediate family involved with the client’s care. At this visit, the nurse develops a plan of care, which must be reviewed, approved, authorized, and signed by the attend- ing physician before home health agency providers can continue with services.
SAFETY ALERT!
2014 The Joint Commission National Patient Safety Goals (2013)
GOAL 3: IMPROVE THE SAFETY OF USING MEDICATIONS 1. Obtain and/or update information on the medications the patient
currently takes. 2. Define the types of medication information (for example, name,
dose, route, frequency, purpose) to be collected in different settings and patient circumstances.
3. Compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.
4. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she leaves the organization’s care (for example, name, dose, route, frequency, purpose).
5. Explain the importance of managing medication information to the patient.
Home Health Agencies Home health agencies offer coordinated professional, skilled, and paraprofessional services. Because clients often require the services of several professionals, case coordination (case management) is
who prefer to receive care in the home rather than in an institution. A common misperception by the general public is that home health nursing is only custodial in its scope of practice. However, health promotion is used by home health nurses to promote client self-care. Home care nurses are actively engaged in providing support and edu- cation for family caregivers as well as clients.
Unique Aspects of Home Health Nursing Home care nurses must function independently in a variety of un- familiar home settings and situations. Because the home is the fam- ily’s territory, power and control issues in delivering nursing care differ from those in the hospital. For example, entry into a home is granted, not assumed; the nurse must therefore establish trust and rapport with the client and family. Due to the limited time for visits and the possibly lengthy interval between visits, this process does not always occur as quickly as it might when nursing within a resi- dential care facility.
Health care that is provided in the home is often given with other family members present. Families may feel freer to question ad- vice, to ignore directions, to do things differently, and to set their own priorities and schedules. Home care nurses implement every step of the nursing process, using critical thinking skills in designing, imple- menting, and evaluating the plan of care.
Home health nurses have identified significant advantages in caring for individuals and families in the home. The home setting is intimate; this intimacy fosters familiarity, sharing, connections, and caring among clients, families, and their nurse. Behaviors are more natural, cultural beliefs and practices are more visible, and multigen- erational interactions tend to be displayed. Nurses often get to know the client and family well because they may care for clients over weeks or months.
Home health nurses have also identified issues that negatively affect care in the home. More than any other care providers, these nurses have firsthand knowledge and experience about the burden of caregiving and the role of family dynamics in health care practices. In the interest of cutting health care costs, policy makers, third-party payers, and medical providers are placing increasingly complex re- sponsibilities on clients’ families and significant other(s). Family care- giving demands may go on for months or years, placing the caregivers themselves (many of whom are older adults) at risk for physiological and psychosocial problems. Additionally, nurses enter homes where the living conditions and support systems may be inadequate.
Nurses caring for clients in rural home settings have challenges different from those in urban or suburban environments. These in- clude the need for flexibility (since clients may live far distances from the nurse and require care in the evening or at night), creativity, the ability to practice independently because fewer resources (including other nurses) are available, and the ability to work in an environment over which the nurse has little control. Thus, those nurses who re- quire a high degree of certainty, structure, and consistency are less likely to be successful in rural home health locations.
THE HOME HEALTH CARE SYSTEM The need for home health care may be identified by any person in- volved with the client. Clients are referred to a home health agency or private-duty nursing agency. Individuals with extremely complex needs, beyond those that direct nursing care alone can provide, may
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for home health care. For example, the client must (a) need reason- able and necessary home care including skilled care; (b) be home- bound, that is, confined to the home except for occasional outings for medical treatment, for a trip to the barber, or for a drive; and require the use of supportive devices, special transportation, or the escort of another person; (c) have a plan of care that includes all of Medicare’s criteria; and (d) need nursing care on an intermittent basis (Centers for Medicare and Medicaid Services, 2011). The agency too must meet specific conditions.
Payers other than Medicare or Medicaid, such as Blue Cross, Blue Shield, and HealthNet, typically negotiate reimbursement rates for home health care services. Not-for-profit agencies, like the visiting nurses associations (VNAs), are reimbursed by public and private in- surance plus charitable donations to the agency. Most long-term care insurance plans include coverage for care in the home.
All health care agencies need to adhere to established guide- lines and provide care within the predetermined reimbursement levels. Treatment plans (developed by the home health agency pro- viders and authorized by the physician) are used by the reimburse- ment source. Only interventions identified on the treatment plan are paid for. Periodically the reimbursement source may request the home health provider’s notes to substantiate what is being done in the home. This is a major reason why accurate documentation is critical.
ROLES OF THE HOME HEALTH NURSE Historically, nurses who provided direct services in the home were strong generalists who focused on long-term preventive, educational, and rehabilitative outcomes. Today many home health nurses possess high-technology skills that were formerly used only in acute care set- tings. For example, nurses provide a variety of intravenous therapies in the home setting and monitor clients who are dependent on tech- nologically complex medical equipment, such as ventilators. These nurses collaborate with physicians and other health care profession- als in providing care. They play a key role in facilitating an effective plan of care as clients move among hospitals, home, school, work, and other care settings such as clinics or long-term care.
The major roles of the home health nurse are those of advocate, caregiver (provider of direct care), educator, and case manager or coordinator.
Advocate Advocacy begins on the first visit. The nurse explores and supports the client’s choices in health care; all viable options are considered. Advocacy includes having discussions about the client’s rights, ad- vance medical directives, living wills, and durable power of attorney for health care. It also usually involves providing assistance to access community resources, to make informed decisions, to recognize and cope with necessary changes in lifestyle, to negotiate medical insurance, and to understand ways to effectively use the complex medical system.
Indirect care is provided by the home health nurse to the client each time the nurse consults with other health care providers about ways to improve nursing care for the client. This consultation about client care issues often manifests itself in multidisciplinary care con- ferences where the role of the home health nurse is as client advocate.
essential. This responsibility generally rests with the registered nurse. Depending on the agency, additional providers may include nurse practitioners, practical nurses, nursing assistants, home health care aides, physical therapists, occupational therapists, respiratory thera- pists, speech therapists, social workers, dietitians, and a pastoral care minister or chaplain. In addition, it is not unusual for home health agencies to offer the services of specialized nurses such as wound- ostomy-continence nurses or diabetes educators. The care plan im- plemented by the home health agency may require services once or twice a day, up to 7 days a week. The minimum time of each period of care, or visit, is usually 1 hour.
There are several different types of home health agencies:
• Official or public agencies are operated by state or local govern- ments and financed primarily by tax funds.
• Voluntary or private not-for-profit agencies are supported by do- nations, endowments, charities such as the United Way, and third- party reimbursement.
• Private, proprietary agencies are for-profit organizations and are governed by either individual owners or national corporations. Some of these agencies participate in third-party reimbursement; others rely on “private-pay” sources.
• Institution-based agencies operate under a parent organization, such as a hospital, and are funded by the same sources as the parent.
Regardless of the type of agency, all home health agencies must meet specific standards for licensing, certification, and accreditation.
Private Duty Agencies This type of agency may be referred to as a registry, which contracts with individual practitioners (e.g., nurses, home health aides) to care for the client in the home. The client may require care coverage from the agency for 4 to 24 hours a day. Private duty agencies also supply staff to hospitals, clinics, and other care settings, so they do not af- ford the coordinated focus of a home care agency. Private duty care is expensive. Commercial insurance generally provides limited reim- bursement. Otherwise, the client must pay privately.
Durable Medical Equipment Companies A durable medical equipment (DME) company provides health care equipment for the client at home. The types of equipment can range from hospital beds and bedside commodes to ventilators, oxy- gen units, and apnea monitors. Because of the cost associated with medical equipment, the nurse needs to ensure that clients have a pri- mary care provider’s order and either Medicare/Medicaid or a DME benefit within their commercial insurance, or that they are able to pay privately. Before billing Medicare for any DME, the nurse should consult the list of equipment for which Medicare will reimburse the client. Most DME companies today seek accreditation from The Joint Commission to ensure compliance with quality standards for equip- ment and services.
Reimbursement Health care agencies in the United States receive reimbursement for services they provide from various sources: Medicare and Medicaid, private insurance companies, and private pay. The Medicare and Medicaid programs have strict guidelines governing reimbursement
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Case Manager or Coordinator The home health nurse coordinates the activities of all other home health team members involved in the client’s treatment plan. Coor- dination can occur individually, in person, or by telephone, with a specific team member such as the dietitian or respiratory therapist, or during a team conference where each team member provides infor- mation about the client’s health status. The nurse is the main contact to report any changes in the client’s condition and to bring about a re- vision in the plan of care as needed. Documentation of care coordina- tion is a legal and reimbursement requirement and must be recorded on the client’s medical record.
PERSPECTIVES OF HOME CARE CLIENTS Home care clients include a diverse population that encompasses all ages, a variety of health problems, and families of different structures and cultural backgrounds. Home care clients have a wide range of health problems, including disabilities, perinatal problems, men- tal illnesses, and acute and chronic illnesses. The nurse should not assume that the client understands the various personnel and their roles in providing home health care.
Although the person receiving care is considered the primary client in home care, the client’s family can be considered secondary clients because often they are associated with caregiving and have a major impact on the client’s wellness status. The home health nurse will encounter many different family structures ranging from single families to extended families and dwellings that house multiple fami- lies. In the home setting, family members may include not only per- sons related by birth and marriage, but also friends, other significant individuals, and animals.
Various cultural influences also affect the client’s health care beliefs and practices. The home health nurse needs to be culturally sensitive; that is, to be aware of the client’s culture and form a nursing care plan with the client that incorporates his or her culture. See Chapter 18 for detailed information about making cultural assessments and pro- viding culturally competent and responsive care.
SELECTED DIMENSIONS OF HOME HEALTH NURSING Selected dimensions of home health care include assessing the home for safety features, infection control, and caregiver support.
Client Safety Hazards in the home are major causes of falls, fire, poisoning, and other accidents, such as those caused by improper use of household equipment (e.g., tools and cooking utensils). The appraisal of such hazards and suggestions for remedies is an essential nursing func- tion. See Home Care Considerations for a home hazard appraisal and Chapter 32 for a discussion of potential hazards and preven- tive actions for individuals of all ages.
Obviously home health nurses cannot expect to change a fam- ily’s living space and lifestyle. However, they can express their con- cern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family’s response to instruction, and make ongoing assessments about the family’s use of safety precautions.
Advocacy can be a particular challenge when family members’ or other caregivers’ views differ from those of the client. In the event of conflict, the nurse, being the client’s primary advocate, ensures that the client’s rights and desires are upheld.
Caregiver The home health nurse’s major role as caregiver is to assess and di- agnose the client’s actual and potential health problems, plan care, and evaluate the client’s outcomes. Home health nurses routinely perform physical assessments, change wound dressings, insert and maintain intravenous access for various therapies, establish and monitor indwelling urinary catheters, and monitor exercise or nu- tritional therapies (Figure 8–1 •). Direct personal care activities such as bathing, changing linens, feeding, and light housekeeping activities to maintain a clean and safe home environment are usu- ally provided by a family member or a home health aide arranged by the nurse.
Educator The educator role of the home health nurse focuses on teaching ill- ness care, the prevention of problems, and the promotion of optimal wellness or well-being to the client, the family, caregivers, and other support persons. A common example is that of guiding the health and development of newborns. Some clients of all ages have acute illnesses that will resolve, while others have chronic conditions that will last the lifetime. The nurse’s teaching and learning methods will vary based on the need of these clients. Nurses clarify misconcep- tions about the course of the illness, the treatment plan, and medica- tions and potential interactions with over-the-counter drugs. They also educate the client and family on how to access the health care system appropriately.
The nurse may also be involved in teaching others with whom the client interacts such as the schoolteachers of children with special needs. Education is ongoing and can be considered the crux of home care practice; its goal is to help clients learn to manage as indepen- dently as possible. All home health nurses need to be skilled in teach- ing and learning principles and strategies that facilitate learning. (See Chapter 27 for detailed information.)
Figure 8–1 • Home care nurses perform skilled direct care such as changing dressings. David SucsyGetty Images.
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Other aspects of client safety relate to emergency situations. The home health nurse can assist the client and caregivers as follows:
• Post a list of all emergency telephone numbers (ambulance, fire, police, primary care provider) at each telephone.
• Post a list of all the client’s medications and potential side effects in a central location, such as on the refrigerator.
• Help the client and family apply for a medical alert system such as a bracelet or necklace (Figure 8–2 •). Information on the MedicAlert System can be obtained by contacting MedicAlert Foundation International.
• Enroll the client in a program that places all the client’s vital medi- cal information in one place for emergency personnel to have in the event of a life-threatening situation. The program can be joined through a pharmacy, a primary care provider’s office, a VNA, or other community support groups. The kit contains a plastic vial, a medical information form, a decal, and an instruction sheet. The
Figure 8–2 • MedicAlert emblems. Reproduced with permission: 2014. All rights reserved. MedicAlert® is a federally Registered Trademark and Service Mark.
information form is filled out, rolled, and placed in the vial. The vial is placed in the refrigerator, and emergency personnel are trained to routinely check there. The decal is placed on the refrig- erator as a signal that the vial is inside.
• Recommend the client purchase an emergency response system. These systems provide a small device with a help button that at- taches to a wrist or neck chain. The home base station can require the client to send a signal daily that indicates that he or she is OK. If the signal is not sent or if the portable device is activated, the system automatically calls the client and then dials a previously established list of emergency contacts. This system is particularly useful for clients who are alone because if they should fall, for in- stance, and be unable to reach a telephone, they might be left help- less for extended periods of time.
Nurse Safety Some less desirable living locations can pose personal safety con- cerns for the nurse. Many home health agencies have contracts with security firms to escort nurses needing to see clients in potentially unsafe neighborhoods. The nurse should avoid taking any personal belongings during these visits and have a preestablished mechanism to signal for help. Home health agencies provide training for nurses in ways to decrease personal risk. Little has been published on this important subject.
Home care nurses may also be susceptible to occupational injuries—especially musculoskeletal ones—due to limited resources available in the home. The nurse’s safety is influenced by the function- ality and availability of assistive personnel and devices, number of cli- ents who are obese or dependent, presence of pets, and varying house and yard arrangements. A combination of ergonomics (interactions between the body and the environment that maximize performance) and self-care activities can help keep the nurse safe (Hitt et al., 2012). Both the nurse and the employing agency must assume responsibility for protecting the nurse.
Infection Prevention The goal of infection prevention in the home is to protect clients, care- givers, and the general community from the transmission of disease.
Home Care Assessment Home Hazard Appraisal for Adults
CLIENT AND ENVIRONMENT • Walkways and stairways (inside and outside): Note uneven
sidewalks or paths, broken or loose steps, absence of handrails or placement on only one side of stairways, insecure handrails, congested hallways or other traffic areas, and adequacy of lighting at night.
• Floors: Note uneven and highly polished or slippery floors and any unanchored rugs or mats.
• Furniture: Note hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support.
• Bathroom(s): Note presence of grab bars around tubs and toi- lets, nonslip surfaces in tubs and shower stalls, handheld show- erhead, adequacy of night lighting, need for raised toilet seat or bath chair in tub or shower, ease of access to shelves, and water temperature regulated at a maximum of 49°C (120°F).
• Kitchen: Note pilot lights (gas stove) in need of repair, inacces- sible storage areas, and hazardous furniture.
• Bedrooms: Note adequacy of lighting, in particular the avail- ability of night-lights and accessibility of light switches; ease of access to commode, urinal, or bedpan; and need for hospital bed or bed rails.
• Electrical: Note unanchored or frayed electrical cords and out- lets that are overloaded or near water.
• Fire protection: Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan, and improper storage of combustibles (e.g., gasoline) or corrosives (e.g., rust remover).
• Toxic substances: Note improperly labeled cleaning solutions. • Communication devices: Note presence of method to call for
help, such as a telephone or intercom in the bedroom and elsewhere (e.g., kitchen), and access to emergency telephone numbers.
• Medications: Note medications kept beyond date of expiration, adequacy of lighting for medication cabinet or storage, and method of disposal of sharp objects such as needles used for injections.
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laundry; shopping; house repairs; yard work; transportation; doctor’s or hairdresser’s appointments; or respite.
Activities that are commonly done by nurses and aides, such as changing an occupied bed and transferring a client from bed to chair, may be overwhelming to a caregiver who has not performed them before. Demonstrating them in the home and allowing caregivers to perform them with the nurse’s supervision increases their confidence and increases the likelihood of them asking for assistance in other situations.
When activities for which assistance is required are identified, the nurse and caregiver need to identify possible sources of help. Both volunteer and agency sources need to be explored. Volunteer sources of help may include family members (cousins, siblings), neighbors, friends, church associates, or caregiver support groups in the com- munity. Other sources include, for example, a home health aide for light housekeeping and grocery shopping, Meals-on-Wheels, day care, transportation, and counseling and social services. Families with a member who is chronically ill may benefit from a weekend respite—a program some hospitals provide in which the client is admitted to a skilled unit for observation and care, enabling the care- giver to take a break from ongoing health care needs.
Caregivers need to be reminded of the importance of caring for themselves by getting adequate sleep, eating nutritious meals, asking for help, delegating household chores, and making time for leisure activities or simply some time alone. Family members other than the caregiver also may need help to learn ways to support the caregiver. The nurse may discuss the importance to the caregiver of regular phone calls, cards, letters, and visits; offer encourage- ment to take day trips or a vacation; listen without giving advice; acknowledge the burden of caregiving and the need to feel appreci- ated; and so on.
A particular challenge exists when the nurse is in a position to be a caregiver to a family member. Although the nurse’s clinical exper- tise and familiarity with the client and setting can be especially use- ful, negotiating the professional distancing that is sometimes needed when providing care to clients can be difficult with family. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse must have the oppor- tunity to step back and experience the role and emotions of being a family member—not only those of being a nurse.
THE PRACTICE OF NURSING IN THE HOME The home health nurse assesses the health care demands of the client and family and the home and community environment. This process actually begins when the nurse contacts the client for the initial home visit and reviews documents received from the referral agency. The goal of the initial visit is to obtain a comprehensive clinical picture of the client’s needs.
Most agencies have a packet that includes forms for consent to treatment; physical, psychosocial, and spiritual assessment; medi- cations; pain assessment; family data; financial assessment includ- ing insurance verification; client’s bill of rights; care plan; and daily visit notes. During the initial home visit, the home health nurse obtains a health history from the client (Figure 8–3 •), examines the client, observes the relationship of the client and caregiver, and assesses the home and community environment. Parameters
This is particularly important for clients who are immunocompro- mised, who have infectious or communicable diseases, or who have wounds, drainage tubes, or invasive access devices. The nurse’s major role in infection prevention is health teaching. Clients and caregivers need to learn about effective hand washing, use of gloves, handling of linens, and disposal of wastes and soiled dressings. Infection preven- tion can present a challenge to the home health nurse, especially if the home care facilities are not conducive to basic aseptic requirements such as running water for hand washing.
An important aspect of infection prevention involves handling the home health nurse’s equipment and supplies. Supplies may in- clude materials for hand cleansing; assessment equipment such as a stethoscope, blood pressure cuff and manometer, thermometer, and tape measure; infection control items such as gowns, goggles, masks, gloves, and blood spill kit; and antimicrobial cleaning agents.
The same organizations that accredit hospitals evaluate home health nurses’ practice. Although some modifications in technique may be indicated in the home setting, such as the use of clean rather than sterile technique in caring for chronic wounds, all of the basic principles still apply. Nurses need to follow agency protocol about aseptic practice in the home.
Caregiver Support Caregiving may be requested for individuals of any age and varies from short term to long term according to the physical or mental dis- abilities of the care receivers. For example, some children who have permanent disabilities and adults who experience progressive dete- rioration such as those with Alzheimer’s disease or multiple sclerosis require care on a permanent basis. Others who are recovering from a surgical procedure require only temporary care. Most caregivers have close relationships with the care receiver, that is, a spouse/partner, parent, child, friend, or other significant relationship. Many caregiv- ing relationships, therefore, represent a change from the caring and caregiving intrinsic to all close relationships to an extraordinary and unequal burden for the caregiver. Caregivers may experience caregiver role strain when they have physical, emotional, social, and financial burdens that can seriously jeopardize their own health and well-being.
The home health nurse needs to recognize signs of caregiver role strain and suggest ways to minimize or alleviate this problem. Signs of caregiver overload include the following:
• Difficulty performing routine tasks for the client • Reports of declining physical energy and insufficient time for
caregiving • Concern that caregiving responsibilities interfere with other roles
such as those of parent, spouse, worker, friend • Anxiety about ability to meet future care needs of client • Feelings of anger and depression • Dramatic change in the home environment’s appearance.
The nurse needs to encourage caregivers to express their feel- ings and at the same time convey understanding about the difficulties associated with caregiving and acknowledge the caregivers’ compe- tence. The nurse can obtain a realistic appraisal of the situation by asking a caregiver to describe a typical day and daily or weekly leisure and social activities. It is also helpful to identify activities for which assistance is desired. These activities may include client care needs such as hygiene, mobility, feeding, or treatments; house cleaning;
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supervises ancillary personnel; and advocates for the client’s right to self-determination.
Even though the client and family may become independent in self-care skills, the home health nurse still has the ultimate re- sponsibility for evaluating the effectiveness of the plan. Ongoing communication with the primary care provider about the client’s progress is critical, and the nurse must make ongoing assess- ments to determine if modifications in the care plan are required (Figure 8–4 •).
On subsequent home visits, the nurse observes the same pa- rameters assessed on the initial home visit and relates findings to the expected outcomes or goals (Figure 8–5 •). The nurse can also teach caregivers parameters of evaluation so that they can obtain professional intervention if needed. Documentation of care given and the client’s progress toward goal achievement at each visit is es- sential. Notes must also reflect plans for subsequent visits and when the client may be sufficiently prepared for self-care and discharge from the agency.
for assessment of the home environment include client and care- giver mobility, client ability to perform self-care, the cleanliness of the environment, the availability of caregiver support, safety, food preparation, financial supports, and the emotional status of the cli- ent and caregiver.
Following this initial client examination, the nurse determines whether further consults and support personnel are needed. For ex- ample, is a home health aide needed to assist with activities of daily living and homemaker tasks? Is a social worker needed to help with financial resources or future care needs such as placement in a nurs- ing home? What additional supplies does the client need?
Before completing the initial interview, the nurse also discusses what the client and family can expect from home care, what other health care providers may be needed to help the client achieve inde- pendence, and the frequency of home visits.
Establishing Health Issues As in other care environments, the nurse identifies both actual and potential client problems. One of the most common examples of health issues that nurses address with clients in home care settings is lack of knowledge related to health conditions and self-care. Because client education is considered a skill reimbursed by Medicare and other commercial insurance carriers, it is important for the nurse to include knowledge deficits within the plan of care.
Planning and Delivering Care In planning care, the nurse needs to encourage and permit clients to make their own decisions regarding goals. Alternatives may need to be suggested if the nurse identifies potential harm from a chosen course of action. Strategies to meet goals include teach- ing the client and family techniques of care and identifying ap- propriate resources to assist the client and family in maintaining self-sufficiency. Box 8–1 lists the data required by Medicare for the nursing plan of care.
To implement the plan, the home health nurse performs nurs- ing interventions, including teaching; coordinates and uses refer- rals and resources; provides and monitors all levels of technical care; collaborates with other disciplines and providers; identifies clinical problems and solutions from research and other health literature;
Figure 8–3 • Interviewing the home care client. Sarah Garner/Getty Images.
Figure 8–4 • The nurse monitors the client’s response to treatments and therapy. JGI/Tom Grill/Getty Images.
Medicare’s Required Data for the Nursing Plan of CareBOX 8–1
1. All pertinent diagnoses 2. A notation of the beneficiary’s mental status 3. Types of services, supplies, and equipment ordered 4. Frequency of visits to be made 5. Client’s prognosis 6. Client’s rehabilitation potential 7. Client’s functional limitations 8. Activities permitted 9. Client’s nutritional requirements
10. Client’s medications and treatments 11. Safety measures to protect against injuries 12. Discharge plans 13. Any other items the home health agency or physician wishes
to include From Medicare Benefit Policy Manual: Chapter 7, Home Health Services (CMS Publication 100–02), by Centers for Medicare and Medicaid Services, 2011. Retrieved from http://www .cms.hhs.gov/Regulations-and-Guidance/Guidance/manuals/Downloads/bp102c07.pdf
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expert advice easily accessible to home care clinicians, from any computer.
For Medicare-approved home health agencies, the Outcome and Assessment Information Set (OASIS) is a group of data elements that represent core items of a comprehensive assessment for an adult home care client and form the basis for measuring client outcomes for the purposes of outcome-based quality improvement. For ex- ample, OASIS standardizes definitions and coding for pressure ulcers and surgical wounds.
The Program of All-Inclusive Care for the Elderly (PACE) is an- other CMS program. PACE supports individuals ages 55 and older with chronic care needs who wish to reside at home. Participants are screened by a team of physicians, nurses, and other health profession- als. PACE provides medical and supportive services along the entire continuum of care, including adult day care with nursing; physical, occupational, and recreational therapies; meals; nutritional counsel- ing; social work; personal care; and respite care. Care is coordinated by a PACE physician familiar with the history, needs, and preferences of each participant. All necessary prescription drugs are provided, as well as medical specialty services including audiology, dentistry, optometry, podiatry, and speech therapy.
THE FUTURE OF HOME HEALTH CARE What is the future for home health care? More studies are needed to determine the practicality, safety, effectiveness, cost, and satisfaction with home care—especially new models of “hospital-at-home” care. However, there is no question that home health nursing will be an expanding area of practice. Trends in the home health care industry include the following:
1. Ethics committees to handle ethical issues that arise in the home. These committees may be necessary for agencies to receive accreditation.
2. Third-party reimbursement for community clinical nurse spe- cialists and psychiatric nurse specialists. These advanced prac- tice nurses can provide education, support, counseling, and therapy for clients and their families.
3. Third-party reimbursement for social workers. Social workers can assist clients and their families in the home with financial and household problems, freeing the nurse to focus on nurs- ing care.
4. Nurse pain specialists to assess and manage pain in the home, thus avoiding costly hospitalizations and procedures.
5. Pet care for clients who may become too ill to care for them. Clients can make arrangements for the care of a pet if they are hospitalized or die.
6. Electronic home visits. A computerized system can obtain information, such as blood pressure readings, allowing case managers to review a client’s progress from off-site. There is great potential for implementing more information technol- ogy in the home but many barriers still exist (Stolee, Steeves, Glenny, & Filsinger, 2010).
Figure 8–5 • Determining the success of the care plan includes comparing assessment findings to previous values. Comparing this baby’s weight to previous values can determine if changes are occurring in the desired direction. Barros & Barros/Getty Images.
Resources for Home Health Nursing With the expansion and increasing complexity of home care nursing, the nurse must remain aware of the various sources of regulations, tools, and supports available for both nurse and client. The Centers for Medicare and Medicaid Services’ (CMS) Home Health Quality Improvement (HHQI) National Campaign provides free evidence- based educational resources, individualized data reports, networking opportunities, and assistance for home health and cross-setting pro- viders to reduce avoidable hospitalizations and improve care quality. For example, in early 2013, HHQI published the Underserved Popula- tions Best Practice Intervention Package.
Collaboration for Homecare Advances in Management and Practice (CHAMP), based at the Center for Home Care Policy & Research of the Visiting Nurse Service of New York, is the first na- tional initiative to advance home care excellence for older people. CHAMP makes the latest evidence-based tools, e-learning, and
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Critical Thinking Checkpoint
Mr. Madden is a 67-year-old African American male with a 20-year history of hypertension and diabetes mellitus. He has recently under- gone amputation of three toes due to poor circulation.
Because he is progressing well and his diabetes is under control, he is being discharged from the acute care setting to go home. He has been referred to a hospital-based home health agency, which will assign a nurse to change his foot dressings, administer IV antibiotics, and monitor his blood glucose levels.
1. When delivering care in the home environment, how will the nurse’s role be similar to and different from that of the nurse’s role in the acute care environment?
2. What rights does the client have when being cared for at home that may not be afforded him while institutionalized?
3. What factors could negatively affect the care of Mr. Madden in his own home?
4. Speculate about personal and financial savings derived by clients being cared for at home rather than in a hospital or other institution.
See Critical Thinking Possibilities on student resource website.
LIFESPAN CONSIDERATIONS Home Care
CHILDREN One goal of Healthy People 2020 is to reduce the number of chil- dren and youth with disabilities (21 years and under) living in con- gregate care facilities with 16 beds or more (U.S. Department of Health and Human Services, 2010). Ideally, all children with disabili- ties would live in a secure, “permanent” family environment. Such an environment is one that supports family strengths, connects families to their community, and fosters ongoing, secure relationships. At times, children with disabilities may need to be placed in adoptive or medical foster homes. Home health nurses can strengthen family functioning by: • Providing information, advice, and instruction on care of the
child • Identifying natural support systems (e.g., extended family,
neighbors, friends) • Helping families find community resources to meet their needs
(e.g., respite care, technical and equipment services) • Assisting families with alternative placement options as needed
(e.g., medical foster care) • Advocating for families with other health care providers and
policy makers.
OLDER ADULTS Clients who have been hospitalized are often discharged after short stays and may still be acutely ill. This becomes a challenge for home
health nurses when planning and implementing care. Special areas of concern for older adults in this situation include the following: • Healing time is slower due to changes that normally occur in
aging, such as impaired circulation and alteration in immune response.
• Changes in medications or lingering traces of anesthesia may alter cognitive status, even though it is usually temporary.
• Weakness and fatigue create safety issues, such as risk for falling.
• Chronic diseases already present may have been complicated by other conditions acquired while hospitalized.
• Assessment should be initiated while the client is in the hospital to determine the need for assistive devices or environmental changes when the client returns home. Some examples of these devices are walkers, raised toilet seats, safety bars in the bathroom, and better lighting. Good planning eases the transi- tion to home care for the client and caregiver.
In the future, although the number of older adults will increase, fewer family caregivers may be available. However, older adults usually appreciate receiving care from family members, and nurses should facilitate this when possible.
The aim of this study by Furåker (2012) was to describe the everyday work of RNs and their views on what skills they use, require, and wish to develop when looking after individuals in the home. Twenty home care nurses were interviewed and a qualitative analysis of the data revealed four themes: nursing content in home care, the home as a workplace, leadership in home care, and competence in home care. Most of the RNs’ everyday work consisted of nursing care beyond basic skills: making judgments, making adequate assessments, and solving crucial problems. Many RNs regarded handling techni- cal equipment as challenging. They also regarded communicating with individuals with advanced cancer or severe psychiatric illness or dealing with clients’ next of kin as demanding. Nurses recognized
that they were practicing as a guest in the client’s home and required adequate time to develop a therapeutic relationship.
IMPLICATIONS The researcher indicated that these home care nurses did not base practice on evidence nor did they show much interest in improving their knowledge and skills. Although this study was conducted in Sweden, it is likely that similar results would be found in the United States and other countries. Nurses everywhere, in all practice set- tings, must engage in lifelong learning and continuously strive to provide care and care planning based on the available supporting evidence. Home care practice is no exception.
Evidence-Based Practice How Do Home Care Nurses View Their Practice? EVIDENCE-BASED PRACTICE
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• Home health care is an alternative to provision of care in acute and subacute health care facilities. The trend has changed from using home health care after hospitalization to using it to avoid hospitalization.
• Hospice nursing, often considered a subspecialty of home nursing, supports clients who are terminally ill and their families during the last stages of life and bereavement.
• Referrals for home health services may be made by the client’s physician, nurse, social worker, therapist, discharge planner, or family member. Home care, however, requires a physician’s order and an approved treatment plan in order for insurance to provide reimbursement.
• Home health agencies offer skilled professional and paraprofes- sional services. Because clients often require the services of sev- eral professionals simultaneously, case coordination is essential.
• There are several types of home health agencies: official or public agencies, voluntary or private not-for-profit agencies, private pro- prietary agencies, and institution-based agencies. All home health agencies must meet specific standards for licensing, certification, and accreditation.
• Private duty agencies provide professional nursing and home health aide care.
• Health care agencies in the United States receive reimbursement for services they provide from various sources: Medicare and Medicaid, private insurance companies, and private-pay sources. The Medicare and Medicaid programs have strict guidelines for reimbursement.
• The major roles of the home health nurse are those of advocate, caregiver, educator, and case manager.
• Home care clients include a diverse population that encompasses all ages, a variety of health problems, and families of different struc- tures and cultural backgrounds. The home health nurse needs to be culturally sensitive, that is, be aware of the client’s culture, and form a nursing care plan with the client that incorporates the client’s culture.
• Important dimensions of home health nursing include assessing the home for safety features, infection prevention, and caregiver support.
• The home health nurse assesses the care needs of clients in their home; plans, implements, and supervises that care; teaches cli- ents and their families self-care; and mobilizes the resources of hospitals, primary care providers, and community agencies in meeting the needs of the clients and their families.
• Resources for the nurse and client regarding home care are avail- able from the Centers for Medicare and Medicaid Services.
CHAPTER HIGHLIGHTS
Chapter 8 Review
1. Care in the home is an alternative to hospital placement. Which of the following is one major difference associated with in-home care? 1. Does not focus on curative and lifesaving approaches. 2. Is less able to manage complex symptoms. 3. Facilitates extensive involvement of significant others/family. 4. Permits use of pain medication regimens not allowed in the
hospital. 2. If a primary care provider prescribed the following, which could
be delegated to the home health aide? 1. Feeding and bathing the client 2. Teaching the client about medications 3. Assessing wound healing progress 4. Adjusting oxygen flow
3. After the nurse instructed a client about the rationale for sitting with feet elevated to enhance venous return, the client refuses to perform the activity. Which statement by the nurse would be most useful? 1. “If you won’t cooperate, I can’t help you.” 2. “Tell me the reasons you won’t put your feet up.” 3. “It is essential that you do this.” 4. “I’ll notify your doctor that you are unable to keep your
feet up.” 4. A home health nurse is providing care for a client who has paral-
ysis on one side and whose spouse provides most of the care. Which of the following may be a sign of caregiver role strain? 1. The caregiver loses weight and has insomnia. 2. The caregiver asks other family and friends for help. 3. The caregiver asks the nurse what other ways he or she can
help the client. 4. The caregiver seems sad whenever the client’s prognosis is
discussed.
5. A client is scheduled to be discharged from the hospital. Which should the discharge planner at the hospital acquire first before home nursing care can be initiated? 1. Insurance coverage 2. An in-home caregiver 3. A curable health problem 4. A physician’s authorization
6. The nurse doing home health care recognizes that the practice includes which of the following? Select all that apply. 1. Hospice care 2. Visiting clients who live in skilled nursing facilities 3. Care of both the client and the family 4. Absence of high-tech equipment and procedures 5. Care of clients who cannot afford to go to the doctor’s office
or clinic 6. Performing physical, psychosocial, and emotional
interventions 7. Which of the following indicates the client and family require
some added safety teaching or teaching? 1. Client wears a medical alert bracelet at all times. 2. A list of medications is posted on the refrigerator. 3. Area rugs have been removed. 4. Client puts on an emergency response necklace whenever
leaving home. See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
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Suggested Reading Dossa, A., Bokhour, B., & Hoenig, H. (2012). Care transi-
tions from the hospital to home for patients with mobility impairments: Patient and family caregiver experiences. Rehabilitation Nursing, 37, 277–285. doi:10.1002/rnj.047 This research study described client and caregiver experiences with care transitions following hospital discharge to home for clients with mobility impairments receiving physical and occupational therapy. Four domains appeared to impact continuity of care and client recovery following hospital discharge, all related to different types of communication difficulties: (a) poor communication between clients and hospital providers regarding ongoing care at home, (b) whom to contact after discharge, (c) provider response to phone calls following discharge, and (d) provider-to-provider communication.
Related Research Brämberg, E., & Sandman, L. (2013). Communica-
tion through in-person interpreters: A qualitative study of home care providers’ and social workers’ views. Journal of Clinical Nursing, 22(1–2), 159–167. doi:10.1111/j.1365-2702.2012.04312.x
Markle-Reid, M., Browne, G., & Gafni, A. (2013). Nurse-led health promotion interventions improve quality of life in frail older home care clients: Lessons learned from three randomized trials in Ontario, Canada. Journal of Evaluation in Clinical Practice, 19(1), 118–131. doi:10.1111/j.1365-2753.2011.01782.x
References Centers for Medicare and Medicaid Services. (2011). Medicare
benefit policy manual: Chapter 7 home health services (CMS Publication 100-02). Baltimore, MD: U.S. Depart- ment of Health & Human Services. Retrieved from http:// www.cms.hhs.gov/Regulations-and-Guidance/Guidance/ manuals/Downloads/bp102c07.pdf
Furåker, C. (2012). Registered nurses’ views on competencies in home care. Home Health Care Management & Practice, 24(5), 221–227. doi:10.1177/1084822312439579
Hitt, J. M., Tatum, E., McNair, M., Harrington, M., Stanton, S. D., Askew, R., . . . Robertson, A. (2012). Self-care management practices for the home health nurse. Home Healthcare Nurse, 30, 295 –305. doi:10.1097/ NHH.0b013e318252c49a
Home Health Quality Improvement. (2013). Underserved populations best practice intervention package. Retrieved from http://www.homehealthquality.org/Education/ Best-Practices.aspx
The Joint Commission. (2011). Home: The best place for health care. Oakbrook Terrace, IL: Author. Retrieved from http://www.jointcommission.org/assets/1/18/Home_Care_ position_paper_4_5_11.pdf
The Joint Commission. (2013). National patient safety goals effective January 1, 2014: Home care accreditation program. Oakbrook Terrace, IL: Author. Retrieved from http://www.jointcommission.org/assets/1/6/OME_NPSG_ Chapter_2014.pdf
National Center for Health Statistics. (2013). Health: United States, 2012. Hyattsville, MD: Author.
Stolee, P., Steeves, B., Glenny, C., & Filsinger, S. (2010). The use of electronic health information systems in home care: Facilitators and barriers. Home Healthcare Nurse, 28, 167–181. doi:10.1097/01.NHH.0000369769.32246.92
U.S. Department of Health and Human Services. (2010). Healthy people 2020. Retrieved from http://www .healthypeople.gov/2020/default.aspx
Selected Bibliography American Nurses Association. (2007). Home health nursing:
Scope and standards of practice. Washington, DC: American Nurses Publishing.
Anderson, E. T., & McFarlane, J. (2011). Community as part- ner: Theory and practice in nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Hunt, R. (2012). Introduction to community-based nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
The Joint Commission. (2012). 2012 standards for home health, personal care and support services, and hospice. Oakbrook Terrace, IL: Author.
Martel, D. (2012). Infusion therapy in the home care setting: A clinical competency program at work. Home Healthcare Nurse, 30(9), 506–514. doi:10.1097/ NHH.0b013e31826a679c
Maurer, F. A., & Smith, C. M. (2012). Community/public health nursing practice: Health for families and populations (5th ed.). St. Louis, MO: Elsevier.
Samartkit, N., Kasemkitvattana, S., Thosingha, O., & Vorapongsathorn, T. (2010). Caregiver role strain and rewards: Caring for Thais with a traumatic brain injury. Pacific Rim International Journal of Nursing Research, 14, 297–314.
Samwell, B. (2012). From hospital to home: Journey of a child with complex care needs. Nursing Children & Young People, 24(9), 14–19.
St-Amant, O., Ward-Griffin, C., DeForge, R. T., Oudshoorn, A., McWilliam, C., Forbes, D., . . . Hall, J. (2012). Making care decisions in home-based dementia care: Why con- text matters. Canadian Journal on Aging, 31, 423–434. doi:10.1017/S0714980812000396
READINGS AND REFERENCES
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INTRODUCTION Computers have become a part of everyday life for many people, in- cluding nurses. Computers are used for educating nursing students and clients; assessing, documenting, and testing clients’ health conditions; managing medical records; communicating among health care provid- ers and with clients; and conducting nursing research. All nurses must have a basic level of computer literacy (the knowledge and ability to use computers or technology) in order to perform their jobs.
GENERAL CONCEPTS Informatics refers to the science of computer information sys- tems. It is a Quality and Safety Education in Nursing (QSEN) competency defined as “Use information and technology to com- municate, manage knowledge, mitigate error, and support decision- making” (Cronenwett et al., 2007, p. 129). Health informatics, or health information technology, then, is the management of health care information, using computers. Nursing informatics is the science of using computer information systems in the practice of nursing. It is defined by the American Nurses Association (ANA) (2008) as “A specialty that integrates nursing science, computer sci- ence, and information science to manage and communicate data, information, and knowledge in nursing practice . . . to support pa- tients, nurses, and other providers in their decision-making in all roles and settings” (p. 1).
The first nursing information systems conference was held in the United States in 1977. Nurses have taken significant strides since then to design and adapt computer processes to enhance client care, education, administration and management, and nursing research.
Advanced practice in nursing informatics is a growing specialty. The first ANA certification examination in nursing informatics was given in October 1995. Nursing informaticists or nursing informatics specialists are currently in much demand. Job descriptions for these practitioners often include the important roles of interfacing between the client care and information technology departments and assisting with the development, implementation, and evaluation of initiatives in clinical information systems.
The use of computers to systematically solve problems is re- ferred to as information technology (IT). In nursing, the Tech- nology Informatics Guiding Education Reform (TIGER) Initiative began in 2006 to identify information/knowledge management best practices and effective technology capabilities for nurses. TIGER is focused on designing plans to (a) enhance the nurse’s ability to use electronic health records to improve health care delivery, (b) have more nurses engaged in influencing the national health care informa- tion systems infrastructure, and (c) speed the adoption of technol- ogy that can enhance health care safety and effectiveness (Hebda & Calderone, 2012).
The terminology used to describe the parts and functions of computer technology can be confusing. New terms emerge daily and it is a challenge to keep up with them. See Tables 9–1 and 9–2 for lists of common computer-related acronyms and definitions.
CLINICAL ALERT!
Nurses increasingly use smart phones or PDAs as calendar/date books, address books, drug and disease database storage devices, and data entry and retrieval devices.
clinical decision support systems, 134
computer-based patient records (CPRs), 134
computer literacy, 129
data warehousing, 132 distance learning, 132 electronic health records
(EHRs), 134 health informatics, 129
hospital information system (HIS), 131
informatics, 129 information technology
(IT), 129
management information system (MIS), 130
nurse informaticist, 134 nursing informatics, 129 telemedicine, 136
KEY TERMS
After completing this chapter, you will be able to: 1. Describe the uses of computers and technology in nursing
education. 2. Discuss the advantages of and concerns about computer-
ized client documentation systems. 3. Identify computer applications used in client assessment
and care.
LEARNING OUTCOMES
9 Electronic Health Records and Information Technology
4. List ways technology may be used by nurse administrators in the areas of human resources, facilities management, finance, quality assurance, and accreditation.
5. Identify the role of technology in each step of the research process.
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TABLE 9–1 Common Computer-Related Acronyms
Acronym Meaning CAI Computer-assisted instruction CPOE Computerized provider (or physician) order entry
CPR Computer-based patient record
EDI Electronic data interchange
EHR Electronic health record
HIS Hospital information system
LAN; WAN Local-area network; wide-area network
MB; GB; TB Megabyte; gigabyte; terabyte
MIS Management information system
PDA Personal digital assistant
PHI Protected health information
PHR Personal health record
RSS Really Simple Syndication; Rich Site Summary
URL Universal resource locator (web address)
VPN Virtual private network
WWW World Wide Web
Sample Criteria for Evaluating Internet Health InformationBOX 9–1
• Author/sponsor: Who created and updates the site? Are their credentials listed and appropriate?
• Purpose: Is it clear whether the site is informational or com- mercial? Who is the intended audience? Sometimes, the website URL provides some of this information; for example, .gov for government sites, .org for professional organizations, .edu for educational institutions, and .com for companies.
• Recency: When was the information in the site last updated? • Accuracy/sourcing: Where does the site get its information?
Are factual statements cited? The complexity and breadth of computer applications are expand- ing exponentially. Computer access is rapidly increasing, while computer costs have decreased over time. Technology is evolv- ing in the areas of virtual reality, remote access, task automation, robotics, and bioengineering. Simultaneously, however, concerns regarding privacy, access by persons with disabilities and in un- derdeveloped countries, piracy, intellectual property debates (who owns web content), destructive programs (computer viruses), and ergonomic injuries continue to arise.
Computers have significantly expanded access to information from around the globe for both health care team members and con- sumers. Nurses should evaluate health websites as they access them and assist clients in doing the same. Tools for doing this include (as of this publication) the HONcode Site Evaluation Form from the Health on the Net Foundation, User’s Guide to Finding and Evalu- ating Health Information on the Web from the Medical Library As- sociation, and Evaluating Internet Health Information Tutorial from the National Library of Medicine. Criteria should always include those described in Box 9–1.
COMPUTER SYSTEMS A computer system—not in the sense of one machine but of a network of computers, users, programs, and procedures in an organization— assists the health care team with decision making and communi- cation. The two most common types of computer systems used by nurses are management information systems and hospital informa- tion systems.
Management Information Systems A management information system (MIS) is designed to facilitate the structure and application of data used to manage an organization or department. The system provides analyses used for
TABLE 9–2 Computer Terminology
Term Definition App Application; a small computer program that performs useful tasks
Blog/weblog Website that contains dated text entries in reverse chronologic order (most recent first) about a particular topic
Database Groups of computer-accessible information records made up of variables or fields
Internet Worldwide computer network
Network System of interconnected computers
Online Computer-to-computer or computer-to-network connection
Podcast Syndicated digital audio or video that is downloaded onto a computer or portable media player
RSS feed Rich Site Summary or Really Simple Syndication. Frequently updated information published on a website, accessed manually or through subscription
Smart phone
Social media
Mobile phone with computer-like capability such as e-mail, Internet access, audiovisual players, camera, and computer programs optimized for mobile use with applications (or apps)
Activities that integrate technology, telecommunications, and social interaction
Social network Online directories of members that allow posts, blogs, photo sharing (e.g., Facebook, MySpace, LinkedIn)
Spreadsheet Data in rows and columns that can be mathematically manipulated
Tablet PC Portable computer that uses a touchscreen as its primary input device (e.g., iPad, Kindle Fire)
Twitter Website/service in which short text messages called tweets are posted to multiple persons who have chosen to follow another person
Widget Small on-screen tool or application that displays dynamic content (e.g., clock, games)
Wiki Collaborative websites that can be edited by multiple persons
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Teaching and Learning Computers enhance academics for both students and faculty in at least four ways. These include access to literature, computer-assisted instruction, classroom technologies, and strategies for learning at a distance.
LITERATURE ACCESS AND RETRIEVAL In our information age, it is a challenge to keep abreast of the informa- tion on any subject. Computers have significantly improved our abili- ties in this respect by presenting materials in a way that can be searched systematically. Previously, users needed to leaf through multiple collections of printed indexes, one keyword or topic at a time. Now continuously updated cumulative indexes of related materials can be searched electronically in a fraction of the time. Searchers can specify the recency, language, document type, and other characteristics as they look for desired materials. Once a list of search matches is displayed on the computer screen, users can select all or certain citations and either print them or store them on their own local computers. Box 9–2 lists commonly used bibliographic systems and databases.
In addition to searching lists of documents, actual complete pub- lications and materials are available in computerized formats. These include medical textbooks, the full texts of journals, drug references, digitized x-rays or scans, and graphics including clip art. Through the Internet, both classic and current information can be found on any topic. Users can access statistics from the Centers for Disease Control
strategic planning, decision making, and evaluation of management activities. All levels of management benefit from the ability to access accumulated data.
Hospital Information Systems A hospital information system (HIS) is an MIS that focuses on the types of data needed to manage client care activities and health care organizations. As with any system, the goal is to provide people with the data they need to determine appropriate actions and control them. Typically, an HIS will have subsystems in the areas of admis- sions, medical records (Figure 9–1 •), clinical laboratory, pharmacy, order entry, and finance. The personnel in these areas record the data needed to allow management of billing, quality assurance, scheduling, and inventory both within their own areas and across the institution. Increasingly, accrediting organizations mandate the use of an HIS and require that reports be submitted using computerized formats. Eventually, integrated HISs—those that allow access and exchange of information among all end users—will form the center of all record keeping and analysis for interdisciplinary health care. Integrated sys- tems allow nurses to communicate care plans across the health care continuum without needing to regather or repeat information.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established legal requirements for the protection, se- curity, and appropriate sharing of client personal health information (referred to as protected health information or PHI). Because PHI is now stored electronically, HIPAA regulations have mandated strict control over access and communication of HIS data. Each health care agency in which students and nurses work will orient them to the specific technologic controls in place.
TECHNOLOGY IN NURSING EDUCATION Computers are used extensively in all aspects of nursing education. Nursing programs require computerized access to library resources; faculty members use technologic teaching strategies in the classroom and for outside assignments, as well as for demonstrating and using applications in clinical rotations; and academic record keeping is fa- cilitated by database programs.
Figure 9–1 • Patient Dashboard. This is an example of the view the nurse sees when logging into the EHR. This view shows their assigned patients, their status and any alerts, activities, orders, or results. From here, the nurse can link to the full patient chart. “Patient Dashboard” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Common Health-Related Bibliographic Systems and DatabasesBOX 9–2
Acquired immunodeficiency syndrome information (AIDSinfo) Alt HealthWatch CANCER LITerature (CANCER LIT) Cochrane Library Cumulative Index to Nursing and Allied Health Literature
(CINAHL) Educational Resources Information Center (ERIC) National Library of Medicine’s bibliographic database (MEDLINE) Nursing & Allied Health Collection Psychological Abstracts (PsychINFO)
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and Prevention, census data, National Institutes of Health, and the National Library of Medicine, among others.
COMPUTER-ASSISTED INSTRUCTION Nursing has benefited from the computer revolution in the form of computer-assisted instruction (CAI). Dozens of software programs help nursing students and nurses learn and demonstrate learning. Programs cover topics from drug dosage calculations to ethical deci- sion making and are classified according to format: tutorial, drill and practice, simulation, or testing. CAI can contain diagrams, graphics, animations, video, and audio and may be accessed on CD-ROMs or via the Internet. All forms of CAI allow almost instant access to any section of the program and can be designed to branch to different sections depending on the user’s responses.
Tutorials on electrocardiogram (ECG) interpretation, drug interactions, and legal aspects of nursing are examples of CAI pro- grams. Students who become familiar with CAI will also find that they have an easier time adjusting to the software programs many employers require them to complete for annual competency testing mandated by accrediting bodies in certain areas (e.g., bloodborne pathogens, HIPAA, and fire safety). Completion of CAI programs may also be an acceptable means of demonstrating continuing edu- cation activities required for registered nurse license renewal.
CLASSROOM TECHNOLOGY Most new educational buildings are wired to accommodate tech- nology. This includes electric outlets for students to plug in laptop computers and access local networks or the Internet. For the faculty, “smart” classrooms with projectors that display the content of com- puter screens and document cameras that display objects and print materials for the entire classroom to view are becoming standard. Other classroom technology includes the use of audience response systems (often referred to as “clickers”) and class-capture systems that record and post lectures and visuals to the Internet.
Computer technology has significantly enhanced the realism provided in the traditional nursing skills laboratory. Mannequins and other tools have been created that can better simulate realistic health care of clients. These tools range from systems that use computers and small devices to provide skills practice (referred to as task trainers), such as learning to insert an intravenous catheter, to full-sized adults, children, and infants (referred to as high-fidelity human patient sim- ulators) with the ability to breathe, speak, and display digital readouts that reflect the impact of nursing interventions. Case scenarios can be automated in which one or more care providers interact with the simulated client(s) to role-play a specific situation. Clinical Simulation in Nursing, the official journal of the International Nursing Associa- tion for Clinical Simulation and Learning (INACSL), is one resource for more information about nursing and health care education and practice using simulation and technology.
DISTANCE LEARNING There are several different models of distance learning— educational opportunities delivered under situations in which the teacher and the learner are not physically in the same place at the same time. Distance learning may be categorized as asynchronous when the individuals involved are not interacting at the same “real” time or as synchronous when teachers and students are communicating simulta- neously. In one model of asynchronous distance learning, the student receives course materials, communicates with the faculty and other
students, and submits assignments completely by mail, phone, fax, e- mail, website, or electronic “dropbox” (a server folder accessible from the Internet). Another type of computerized delivery of knowledge is through e-books. Entire textbooks are available on a computer or PDA and can be annotated and searched. PDAs can also contain ref- erence materials such as drug handbooks for instant, up-to-date in- formation. In addition, lectures can be delivered through podcasts.
Many schools use a learning management system such as Black- board, Canvas, eCollege, or Moodle to make course documents and activities available through Internet access. Faculty can post syllabi, handouts, assignments, and examinations in individual course shells, and students can submit papers and hold discussions online.
Technology even allows us to create virtual communities. In these interactive web-based environments, faculty and students cre- ate a virtual self, known as an avatar. Using one’s avatar, you can navi- gate through simulated worlds and communicate using audio-video lectures, discussions, and posters. One example of such interac- tive virtual communities in health care and education is the three- dimensional simulated world of Second Life.
A model of synchronous distance learning involves groups of students in classrooms at different sites participating in a class ses- sion using two-way videoconferencing. Students who are not at the site where the faculty member is located can communicate via voice- activated microphones or response pads. These pads have buttons that permit the students to indicate that they wish to ask a question or even to respond to multiple-choice test questions. Synchronous distance learning can also be accomplished through the use of chat, instant messaging, and one-to-one video chat.
Testing The computer is ideal for conducting certain types of learning evalu- ations. Surveys can be completed online, including anonymous ques- tionnaires. Large banks of potential test items can be written that allow the computer to generate different exams for each student de- pending on the selection criteria designated by the faculty. Students’ answers can be scored electronically and the overall exam results ana- lyzed quickly. Since 1994, the National Council Licensure Examina- tion for RNs (NCLEX-RN®) in the United States has been taken on computer. Applicants can complete the computerized exam in less than 5 hours, and exams can be taken at many different locations, dates, and times. The computer determines if the applicant passed the examination by using a scoring algorithm that ensures all required competencies have been evaluated fairly.
Student and Course Record Management Computers are also very useful for maintaining results of students’ grades or attendance. Often student answer sheets are imported directly into a gradebook on the computer. The program can then calculate percentages, assign letter grades, and make results available to both students and faculty.
Students are frequently asked to evaluate faculty and courses on- line or using machine-readable forms. These data are also stored in the computer, allowing cumulative results to be calculated. This is an example of what is called data warehousing—the accumulation of large amounts of data that are stored over time and can be examined for output in different types of reports (charts and tables).
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TECHNOLOGY IN NURSING PRACTICE Many activities of the registered nurse involve collecting, record- ing, and using data. Computers are well suited to assist the nurse in these functions. Specifically, the nurse records client information in computer records, accesses other departments’ information on the client from centralized computers, uses computers to manage client scheduling, and uses programs for unique applications such as home health nursing and case management. Improvement in both clinical and nonclinical processes can occur through the uses of technology in biomedical monitoring, communication, client safety systems, de- cision support, and education. As a component of accreditation of schools of nursing as well as health organizations, nurses are expected to have knowledge about the benefits and limitations of technology, skills in using technology for communication and decision making, and attitudes needed to value technology and use informatics to both support and protect clients.
Documentation of Client Status and Medical Record Keeping How might a computer assist individual nurses with their daily ac- tivities? In the typical day of a nurse providing direct client care, as much as one third of the time may be spent recording in the client’s record. Additional time is spent trying to access data about the cli- ent that may be somewhere in the medical record or elsewhere in the health care agency. Nurses need access to standardized forms, poli- cies, and procedures. Also, nurses need to be able to gather broader client information such as length of stay for specific diagnoses. Com- puters can assist with each of these tasks.
BEDSIDE DATA ENTRY There are several different types of computerized bedside data en- try systems. These allow recording of medication administration ( Figures 9–2 and 9–3 •), client assessments, progress notes, care plan updating, client acuity, and accrued charges (Figure 9–4 •). The
Figure 9–3 • The nurse uses a handheld reader to scan the bar code on the client’s identification band prior to administering medications and other treatments. David Joel/Getty Images.
Figure 9–2 • This screen shows a MAR (medication administration record) for several regularly scheduled and prn medications. The worksheet displays the next time the medications may be administered. “MAR” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Figure 9–4 • The nurse is using a laptop computer to record data at the client’s bedside.
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terminal can be fixed or handheld, and hardwired to the central sys- tem or wireless with the ability to transmit the data to distant sites, such as from the client’s home to the agency office. A slightly different type of bedside terminal is the point-of-care or point-of-service com- puter. In this case, the terminal is located near, but not necessarily at, the client. When using bedside terminals, the nurse must remain sen- sitive to client concerns related to the technology. Learn how to navi- gate and troubleshoot the device before using it at the bedside so the client does not observe any frustration if you experience difficulties. Always address the client before using the computer. Explain what the computer is for and how the client’s confidentiality is assured.
COMPUTER-BASED CLIENT RECORDS Electronic health records (EHRs) or computer-based patient records (CPRs) permit electronic client data entry and retrieval by caregivers, administrators, accreditors, and other persons who re- quire the data. An EHR can improve health care in at least four ways: (1) constant availability of client health information across the life span, (2) ability to monitor quality, (3) access to warehoused (stored) data, and (4) ability for clients to share in knowledge and activities influencing their own health. The Centers for Medicare and Med- icaid Services (CMS) Electronic Health Record Incentive Program provides financial incentives to providers who demonstrate that they have made “meaningful use” of EHR technology. The program estab- lished core required objectives such as to maintain an active medica- tion allergy list for clients. In this example, the objective will be met if review of the provider’s electronic system shows that more than 80% of all clients seen have at least one entry in the category of allergies (or an indication that the client has no known medication allergies).
Because of the way computers provide access to EHRs, pro- viders can easily retrieve specific data such as trends in vital signs (Figure 9–5 •), immunization records, and current problems. The system can be designed to warn providers about conflicting medi- cations or client parameters that indicate dangerous conditions ( Figure 9–6 •). Sophisticated systems allow replay of audio, graphic, or video data for comparison with current status. Challenges with reading handwriting are eliminated and all text is searchable.
There are several areas of concern with EHRs. Maintaining the privacy and security of data is a significant issue. One way in which computers can protect data is by user authentication via passwords or biometric identifiers (e.g., fingerprint or retinal scans)—only those persons who have a legitimate need to access the data receive the pass- word. Additional policies and procedures for protecting the confiden- tiality of EHRs are evolving as the use of computer records becomes more widespread. One role of the nurse informaticist, an expert who combines computer, information, and nursing sciences, is to
Figure 9–5 • This screen displays the client’s vital signs. They can be entered by the nurse (or anyone with the security rights to do so) at the bedside, and then displayed wherever needed. “Vital Signs” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
develop policies and procedures that promote effective and secure use of computerized records by nurses and other health care professionals.
Implementing an EHR is a significant undertaking for a health care agency. Hundreds of hours are needed to design, test, and train individu- als in its use. Studies have shown that the use of an EHR is not without risk. Failure to ensure that all components of the system communicate and a lack of double-checks that the initial data have been accurately entered into the system by users are two examples of potential risks. In particular, the Institute of Medicine (2011) reports that research on qual- ity and safety in the use of HIT is inconsistent or lacking and must be standardized and analyzed so that quality and safety can be enhanced.
Different from an EHR is a personal health record (PHR), which is an electronic document that contains the client’s medical, personal, and health information but is controlled by the client, rather than the health care provider. The PHR can be stored on a computer database, in an electronic computer file, or on a portable “smart card” similar to a credit card. A significant advantage of a PHR stored in a commonly ac- cessible format (e.g., word processor document or portable document format [pdf]) is that clients can transport and give the information to any care provider they wish, whenever necessary. A challenge is to keep the information current, however. Ideally, the PHR interfaces with the EHR, but this requires the use of a unique electronic identifier for each person, and these standards are not yet in place (Sewell & Thede, 2012).
CLINICAL DECISION SUPPORT SYSTEMS For many years, nurses have used charts, templates, algorithms, and other tools to assist in reaching decisions regarding client care. Clinical decision support systems are electronic forms of these tools, which incorporate evidence from the literature into particu- lar client situations in order to guide care planning. In particular, with these systems, characteristics of individual clients are used to
Figure 9–6 • One of the strengths of an electronic health record is its ability to alert the clinician to potential adverse drug interactions, providing warnings like the one displayed. “Strength of Electronic Health Record (EHR)” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
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generate client-specific assessments or recommendations that are then presented to clinicians for consideration (Lobach et al., 2012). Such systems’ usefulness in nursing relates, in part, to the inability of humans to retain or recall sufficient quantities of the immense amount of knowledge needed to provide safe care. Many different computer systems exist. Some are simple alarms that appear when medical orders conflict with another aspect of the client’s situation (e.g., allergies, contraindicated treatments). Other systems provide step-by-step online tools to assist emergency department nurses in determining which clients should receive the most immediate atten- tion or are comprehensive programs integrated with a system-wide EHR. As EHRs become more prevalent, clinical decision support systems for nursing practice are likely to become more common also.
DATA STANDARDIZATION AND CLASSIFICATIONS There are many reasons why nursing benefits from the use of stan- dard classifications and terms to describe and measure clinical, dis- ease, procedure, and outcomes data. One reason is that, for nursing to be recognized for the value it adds to client well-being, research that shows client improvement must be based on accepted stan- dards. This necessitates the use of common, consistent, clear, and rule-based standards.
Standards for clinical data such as laboratory test results and their documentation in the EHR have been proposed by the American National Standards Institute Healthcare Information Technology Standards Panel, the American Society for Testing and Materials, the European Technical Committee for Standardization, the International Standards Organization, and the Workgroup for Electronic Data Interchange. Disease classification standards are in use in a variety of forms. The most common are the World Health Organization’s International Classification of Diseases (ICD), the World Organization of National Colleges’ International Classification of Primary Care (ICPC), and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).
Figure 9–7 • Numerical results can be graphed to show trends. “Graph/Trends” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Nursing classifications or taxonomies have also been developed. The Nursing Minimum Data Set (NMDS) contains 16 elements of nurs- ing data, along with their definitions, in three categories: nursing care, client demographics, and service. The NMDS can be used for data col- lection and documentation and allows sharing of information regarding the quality, cost, and effectiveness of nursing. Other classification sys- tems include the NANDA International nursing diagnosis taxonomy, the Omaha System, the Home Health Care Classification (HHCC), the Nursing Interventions Classification (NIC), the Nursing Outcomes Classification (NOC), the International Council of Nurses’ International Classification for Nursing Practice, and the International Health Termi- nology Standards Development Organization’s Systematized Nomen- clature of Medicine—Clinical Terms (SNOMED CT). It may take years to determine which standards will allow optimal access to and manipu- lation of computerized records and who will be the determining body.
TRACKING CLIENT STATUS Once an EHR has been established, the nurse can retrieve and dis- play a client’s physiological parameters across time (Figure 9–7 •). In addition to the rather straightforward viewing of trends in vital signs, for example, the nurse can also track more global client prog- ress. Standardized nursing care plans, care maps, critical pathways, or other prewritten treatment protocols can be stored in the computer and easily placed in the EHR electronically. Then the nurse and other health care personnel can examine progress toward and variance from the expected plan directly on the computer. EHR vendors often include components for authoring nursing care plans and tracking care delivery and outcomes.
Electronic Access to Client Data Besides computers designed for record keeping, other computers are used extensively in health care to assess and monitor clients’ conditions. The data accumulated from various electronic devices can be part of the EHR and also stored for research purposes. Electronic records take
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up much less space than paper records and may be stored more se- curely. Copies can be made easily on various types of electronic media that tend to be more compact and durable than paper. Data can also be transmitted electronically to a consulting specialist in another location.
CLIENT MONITORING AND COMPUTERIZED DIAGNOSTICS Nursing has benefited greatly from the myriad of client monitors. In everyday practice, nurses use digital or tympanic thermometers, digi- tal scales, pulse oximetry, ECG/telemetry/hemodynamic monitoring, apnea monitors, fetal heart monitors, blood glucose analyzers, ventila- tors, and intravenous (IV) pumps. Most of these monitors are applied externally, implanted, or even ingested (swallowed), and are proving to have great value. For example, a surgically placed wireless sensor can measure the pressure inside a bulging weakened blood vessel (aneu- rysm) and warn of potential rupture. These instruments can be used in any care setting, from intensive care to the home. Most keep a record of the most recent values. Some can transmit their data to a more so- phisticated computer or print out a paper record. Some have digital displays that “talk” to the user, giving instructions or results. Most also have error detection or alarms to indicate either that the instrument is malfunctioning or that the assessed value is outside predetermined parameters. These devices, with their powerful computer chips, make it possible to extend the nurse’s observations and provide valid and re- liable data. Although these devices are extremely useful, they also raise concerns about cost and privacy (Sarasohn-Kahn, 2013).
In various specialty areas of health care, clients undergo diagnos- tic procedures in which computers play a major role. Computerized axial tomography (CAT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans use computers exten- sively to perform tests and analyze the findings. Blood gas analyzers, pulmonary function test machines, and intracranial pressure monitors all use computer processing (Figure 9–8 •). All of these can be linked directly to an EHR, which stores the test results (Figure 9–9 •). There are many more examples of ways in which computers assist nurses in monitoring and diagnosing client conditions.
TELEMEDICINE/TELEHEALTH One of the most exciting areas being developed in computer- assisted health care is telemedicine. Telemedicine or telehealth
The EHR provides a consistent and comprehensive template that is used to remind nurses to record the presence of a pressure ul- cer (PU) and its stage, size, location, risk assessment, nursing di- agnoses, goals, and planned interventions. The purpose of Li and Korniewicz’s (2013) project was to track the electronic documenta- tion of PUs on a medical–surgical unit and compare the electronic with the written medical record. Data on 11 clients who developed PUs were reviewed. In only four cases was there documentation of the PU in both the electronic and the written record. Four cases were documented in the EHR but not the written record, and three cases were found in the written but not the electronic record.
Results of this study illustrated that neither EHRs nor written records were reflective of hospital policies for the documentation of PUs. Increased education related to the use of the EHR for PU documentation is indicated. In addition, the study suggests a need for guidelines to standardize and routinely evaluate EHR documen- tation in clinical practice.
IMPLICATIONS This single study may be unique in that both electronic and writ- ten records were kept on the same clients. The reason for having both records is not stated in the article but it is clear that nurses were expected to record PUs in both. Thus, the data indicate that neither method was superior in accomplishing the goals of tracking and communicating PU status. Differences between the two charting methods extended across all the categories of PU characteristics and nurses’ work shifts. The authors appropriately identify the need for larger studies that could specifically identify barriers to complete documentation of PUs. As EHRs become more pervasive, it may be possible to address solutions to the barriers during the creation and implementation of the electronic systems. Nurses should be active participants in such studies and in the design of EHRs.
Evidence-Based Practice Is the Documentation of Pressure Ulcers Better in EHRs or Paper-Based Records? EVIDENCE-BASED PRACTICE
Figure 9–8 • Client undergoing an electroencephalogram (EEG), a graphic record of a brain’s electrical activity. Phanie/Photo Researchers, Inc.
uses technology to transmit electronic data about clients to persons at distant locations. In one example, two-way audiovisual commu- nication allows an international expert to examine and consult on a client’s case from thousands of miles away. X-rays, scans, stored computer data, and almost anything imaginable can be “sent” using computers. Another example is the ability for a few health care pro- viders to provide primary health care to people living in remote ar- eas using the kinds of monitors described previously plus telephone, fax, and other relatively simple equipment in the client’s home.
Concerns regarding telemedicine relate to legal and ethical issues. Who has responsibility for the client when a teleconsult is used? Does the care provider need to be licensed in the state or province where the client’s primary care is given? The National Council of State Boards of Nursing has declared that the applicable regulations are those for where the client resides and not where the provider is located. This is also one of the reasons for the initiation of the mutual recognition compact that boards of nursing are promulgating to facilitate nurse li- censure in several states (see Chapter 4 ). How is the client’s privacy protected? For example, if a provider in state A was teleconsulting with providers in states B, C, and D, which state’s privacy laws should take
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Internet, or e-mail a health care provider with questions or concerns. Clients can also record data about their health status that can be transmitted to the health care provider at the central network com- puter. Examples that have been successful using this approach in- clude monitoring women at risk for preterm labor, individuals with AIDS, and clients with Alzheimer’s. Digital cameras connected to the computer, often referred to as webcams, permit the health care pro- vider to actually examine the client to some degree (Figure 9–10 •). Home alert systems that allow the client to signal the base station in an emergency are also widely used.
Nurses who visit clients in their homes are using notebook computer systems to record assessments and transmit data to the main office. Similar systems have been developed so that nursing students in community health courses can communicate with their faculty.
CASE MANAGEMENT Case managers must be able to track a group of clients—the caseload. Software programs allow the case manager to enter client data and in- tegrate this with predesigned care-tracking templates. In addition, the case manager must keep abreast of the latest regulations affecting eligi- bility for health care benefits, the reporting requirements of the payer agencies, and detailed facts about the variety of service providers the client may need to access. All of these data can be placed in integrated
precedence over others? What if they conflict? HIPAA and several other projects are under way to answer these questions and to deter- mine the most effective designs for telemedicine programs.
Practice Management Beyond direct client care, computers also assist nurses in many ways in the management of their work. In hospitals, data terminals are commonly used to order supplies, tests, meals, and services from other departments, a process called computerized provider order entry (CPOE). Tracking of these orders allows the nursing service to determine the most frequent or most costly items used by a particu- lar nursing unit. This information may lead to decisions to modify a budget, provide different staffing, move supplies to a different loca- tion, or make other changes for more efficient and higher quality care.
Computers are used extensively for scheduling. Client appoint- ments can be easily entered or changed. Special notes or tags can be applied to the appointment as a reminder to the provider to perform particular services. The schedule for a single day can be printed so that all personnel have a copy. Staffing patterns must also be coordinated. Special requests for days off or continuing education classes can be en- tered, and the schedule can be viewed for a day, week, month, or year.
Each practice needs to keep track of procedures health care workers perform, client diagnoses, and time spent with clients so that billing can be accurate. Medicare and most other insurance compa- nies require electronic submission of health care billing. In keeping with HIPAA regulations, electronic data interchange (EDI) proto- cols are used to maximize privacy and minimize the chances of in- appropriate sharing of confidential client data. With managed care, information tracking is also aimed at determining trends in health problems and the need for providers with specific skills. The use of computerized databases filled with unique codes for each medica- tion, medical and nursing diagnosis, treatment, and supply allows for accurate and timely management of these data.
Specific Applications of Computers in Nursing Practice As previously described, numerous systems are in use for collecting and classifying the various types of data used in nursing practice. Some of these systems have been found particularly useful in specific settings.
COMMUNITY AND HOME HEALTH Computer networks are being used in innovative ways in home set- tings. A computer placed in a high-risk client’s or family’s home al- lows them to access information on a variety of topics, search the
Figure 9–9 • This screen displays a flowsheet view of available results for a particular client. The information can be reported from most summarized to most detailed so that the user gets an overview first and can then “drill down” to see the details. “Graph/Trends” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Figure 9–10 • The nurse wears headphones as she listens to and records a client’s heart rate using a home telecare device. A growing number of health care providers are using video monitoring to check in on clients. AP Photo/ Jim McKnight.
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uncertain times, the ability to perform “what if ” calculations is espe- cially valuable.
Quality Assurance and Utilization Review Both internal and external stakeholders in health care organizations need to know that the services and activities of the organization have positive results. Once standards, pathways, key indicators, and other vital data have been identified and described, computers can facilitate the accumulation and analysis of data for individuals and groups of clients. Quality is considered a process and not an end point. Apply- ing this perspective, computerized systems are ideal for taking a snap- shot view of the institution’s quality indices at any time.
Utilization review consists of examining trends and propos- ing advantageous use of resources (specifically, length of stay). For example, might clients who have had a fractured hip repaired have equivalent outcomes at lesser cost if transferred from the hospital to a skilled nursing facility sooner? Studies can be conducted with com- puter analyses to answer such questions.
Accreditation The Joint Commission has mandated that hospitals have online mechanisms to monitor quality indicators, so as to reduce the dif- ficulty and time involved in the accreditation process. Health care agencies must maintain databases of policies and procedures, stan- dards of care, and employee accomplishment of The Joint Com- mission requirements such as continuing education and in-service trainings. The Joint Commission has also required a move to com- puter systems that assess outcomes rather than processes.
Another aspect of accreditation review is demonstrating ad- equate staffing for the number and acuity of clients. Each agency, whether hospital, outpatient, or home care, must use a method of determining the number of hours of nursing care required for its current clients. Computers used to implement this method can in- corporate the severity of the clients’ illnesses, length of time needed to perform certain procedures, training and expertise of the nursing staff, and any other parameters desired into the calculations. Com- puters facilitate review of required hours across time.
TECHNOLOGY IN NURSING RESEARCH Computers are valuable assistants when conducting both quanti- tative and qualitative nursing research. In each step of the research process, computers facilitate generation, refinement, analysis, and output of data. Computer resources are an important component of the planning phase of any research project. The speed and processing power of the computer and its storage capacity must be adequate for the amount and type of data that will be collected, and the proper software programs must be in place to manage and analyze the data. Computerized word processing is also an integral component in the publication and dissemination of research.
Problem Identification The first step of the research process is to identify and describe the problem of interest. The computer can be useful in locating current literature about the problem and related concepts. Perhaps, unknown to the researcher, a solution to the problem has already been found
computer software programs. Finally, the case manager must document quality; that is, demonstrate client outcomes related to dollars spent.
TECHNOLOGY IN NURSING ADMINISTRATION As indicated in the section of this chapter on computers in nursing practice, the volume of data that nurses need to have available and the additional volume of data generated by nurses can and must be managed electronically. Nursing administrators require these data to develop strategic plans for the organization.
Human Resources All employers must maintain a database on each employee. In ad- dition to the usual demographic and salary data, the database for li- censed or certified health care personnel has unique fields for areas such as life support certification, health requirements (e.g., tubercu- losis testing, hepatitis immunization, rubella titers), and performance appraisals. Administrators can use this human resources database to communicate with employees, examine staffing patterns, and create budget projections.
Medical Records Management Medical records must be maintained for many years in case the data are needed for client care or research. Storage of paper documen- tation can be cumbersome and costly. Although it is expensive to store records, the cost of human time and energy plus inefficiency in accessing the contents is even more expensive. Therefore, nurses require computer programs that allow client records to be searched for data such as the most common diagnoses, number of cases by diagnosis-related groups, most expensive cases, length of stay or to- tal number of days the case was open, client outcomes, and so on. Nurse informaticists can assist with the design and implementation of systems that allow such searches to be generated, analyzed, printed, and distributed. Computerized records increase the ability to demon- strate the value of nursing care.
Facilities Management Many aspects of managing buildings and nonnursing services can be facilitated by computer. Heating, air conditioning, ventilation, and alarm systems are computer controlled. Security devices such as readers that scan identification cards, bar codes, or magnetic strips permit only authorized personnel to enter client or private areas. Computers also manage and report inventory, tracking everything from pillowcases to syringes.
Budget and Finance Advantages of computerized billing are that claims are transmitted much more quickly and have a greater likelihood of being com- plete and accurate compared to handwritten documents. If this is the case, claims will be paid sooner and the agency will have bet- ter control over its financial status. Computers can also affect cost savings by reducing the clerical services time needed for accounts payable and receivable. In cases where nursing can directly bill and be reimbursed by payers, the same benefits of computerized ac- counting apply.
The budget itself is generally a spreadsheet program. This software allows tracking as well as forecasting and planning. In
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and reported. A search of existing documents, websites, and e-mail to colleagues, may help define the problem.
Literature Review An exhaustive review of the literature can be time consuming. With- out computer access to online or CD-ROM bibliographic databases, the researcher must wade through huge volumes of publications. The software programs that facilitate searches contain thesauruses so that the most appropriate terms can be selected. If the researcher deter- mines that little has been published on the topic of interest, closely related terms and topics must also be searched. It is not unusual for a researcher to collect more than 100 pertinent research or theoreti- cal references during a literature review. The increase in availability of full-text journal articles online has made the electronic literature search process even more productive.
Research Design The design of a research study, including the choice of specific re- search method, is always driven by the research question. At the de- sign stage the investigator determines whether the study will use a qualitative or quantitative approach, what instruments will be used to collect data, and the types of analyses that will be carried out on the data to answer the research questions. Computers may be used dur- ing this step to search the literature for instruments that have already been established or to design and test instruments that need to be de- veloped for the particular study. In addition, the investigator would not likely select an instrument or design that requires extensive com- puter or mathematical analysis if such resources are not available.
Data Collection and Analysis Once the types of data to be collected have been determined, the in- vestigator will create forms on the computer for collecting the data. These may include the informed consent document, a tool to col- lect demographic data, and recording forms for research variables. If possible, computer-readable forms are created so that the data can be scanned into the computer or the participant can key responses directly into the computer (e.g., an online survey). This eliminates the
errors that can occur if the researcher must enter the data into the computer manually.
It is particularly important for all variables that will be computer analyzed to be identified in a way that the computer can recognize and manipulate. This may mean determining how to code the data for optimal manipulation. For example, will age be recorded in spe- cific years or by categories such as 1–10, 11–15, 16–20, and so on? Software programs can assist with the analysis and coding of quali- tative data. Such programs as Ethnograph, NVivo, and QDA Miner assist the researcher in finding and coding sections of text and orga- nizing coded material.
When the variables have been coded, other programs can be used to calculate descriptive and analytic statistics. Calculations that formerly were extremely time consuming and complex can now be done by computer programs quickly and accurately. Commonly used software programs for quantitative data analysis include SPSS (Statistical Package for the Social Sciences), SAS (Statistical Analysis System), and SYSTAT. These programs perform analyses and display output in tables, charts, lists, and other easily read formats.
Research Dissemination Research is of limited value if the findings are not widely dispersed to the practitioners who can use the findings to improve their practice. Computer word processing programs are used to author the final re- search reports and send them to various readerships. Many journals now require that manuscripts submitted for publication include elec- tronic versions. As noted earlier in this chapter, the number of elec- tronic journals is increasing. With the rapid growth of e-mail, authors can also send an article or data to interested persons instantaneously. Computers speed completion of a research project and the availabil- ity of the findings to the public.
Computers are frequently used to present research at meetings. Using computer projectors to display screens of data and findings allows the researcher to highlight, modify, and manipulate content in an instant. In addition, companies and universities often post re- search papers and projects on their organizations’ websites. There is also computer conferencing where researchers collaborate on a study
LIFESPAN CONSIDERATIONS Computer Use
CHILDREN AND ADULTS Computer programs, both CD and Internet based, are available for children and adults to learn everything from a foreign language to algebra.
Many concerns are raised by the frequent and extended use of computers by all ages. In particular, repetitive motion injuries (es- pecially of the hand) can occur with extensive typing and use of the computer mouse, eye strain can occur from computer monitor viewing, and musculoskeletal damage is related to inadequate er- gonomic arrangement of desk chairs, surface height, and monitor placement. Students and adults who use computers daily should be thoroughly evaluated and instructed in the prevention of these conditions.
Parents need to be reminded of potential risks to children from Internet contact with strangers and adult-only websites. They also need to monitor schoolchildren’s use of computers to ensure they are not being sidetracked from homework into computer games and messaging.
All individuals should be wary about protecting their financial and personal information when conducting business via computer.
OLDER ADULTS Computer classes are being taught to increasing numbers of older adults. Use of the computer provides them with an avenue of com- munication and exposure to a vast amount of health care informa- tion. Although nurses have little control over what Internet sites will be accessed, it is important to teach clients and the general public to evaluate information from the site and to be aware that misinfor- mation can also be presented. Important guidelines that increase the validity of a site are as follows: • The article or information lists the author and credentials and/or
the institution from which the information came. • A date is listed that states when information was updated. • If health care information is presented, a disclaimer should be
included. The disclaimer presents limitations of the information and should say that it is not medical advice.
Computer-assisted programs can be very effective teaching aids for older adults. They may provide audio and visual instruction and may even be interactive. They are useful for teaching about medi- cal conditions and medications and for providing information about procedures and surgeries to be performed.
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Critical Thinking Checkpoint
As a nurse working for a home care agency in a small, rural town, you would like your clients to receive up-to-date and accurate health in- formation and care. High-speed computer access is available in your office, and many of the residents have computers in their homes since it provides a low-cost way of communicating with friends and relatives who are far away (for example, using e-mail and sending digitized photos). 1. You have a difficult clinical case and want to investigate possible
interventions. What are some of the ways computers could assist in this endeavor?
2. You decide that sending photos of the client would be useful to your colleagues in providing input. Because time is an issue,
you determine that sending them electronically would be most expeditious. The client agrees to the photos but is worried about privacy in sending them through the computer. How would you handle this?
3. A client shares with you a website that states it can guarantee a cure to the client’s illness. How would you respond?
4. Since you are in a rural town and not near an on-campus nursing program, you are considering enrolling in an advanced degree program that is offered online. What would be some of the advantages and disadvantages of such a program?
See Critical Thinking Possibilities on student resource website.
• Nursing informatics is the science of using computer information systems in the practice of nursing.
• A hospital information system (HIS) organizes data from various areas in the hospital such as admissions, medical records, clinical laboratory, pharmacy, order entry, and finance.
• Concerns regarding privacy and confidentiality of health records have arisen as electronic databases and communications have proliferated.
• Computers are used extensively to locate and access data through online databases and Internet searching. Many nursing journals are electronic.
• Computer-assisted instruction programs include tutorial, drill and practice, simulation, or testing.
• In distance learning, the faculty and student may be located far apart and communicate via computer, phone, fax, and video technologies.
• Electronic health records (EHRs) enable data to be collected on a client and made available to all health care providers who require it. Such data warehousing also enables research to be conducted on quality of care, client outcomes, and a variety of other parameters. However, no national standards exist for the structure or content of these records.
• Nurses need to participate in the creation of classifications for electronic data. Existing models include the World Health Orga- nization’s International Classification of Diseases (ICD), the World Organization of National Colleges’ International Classification of Primary Care (ICPC), the American Psychiatric Association’s Di- agnostic and Statistical Manual of Mental Disorders (DSM), the NANDA International nursing diagnosis taxonomy, the Omaha
System, the Home Health Care Classification (HHCC), the Nurs- ing Interventions Classification (NIC), the Nursing Outcomes Clas- sification (NOC), the International Council of Nurses’ International Classification for Nursing Practice, the Nursing Minimum Data Set (NMDS), and the Systematized Nomenclature of Medicine— Clinical Terms (SNOMED CT).
• Computer monitoring and diagnosing of client conditions is wide- spread. Examples include digital or tympanic thermometers, digital scales, pulse oximetry, ECG, telemetry, hemodynamic monitoring, apnea monitors, fetal heart monitors, blood glucose analyzers, ventilators, IV pumps, CAT scans, and MRI.
• Telemedicine or telehealth, which allows health care professionals to provide care via electronic means of communication, is a grow- ing area that generates both excitement and concerns.
• Data terminals in health care settings allow placing of order re- quests and retrieval of client data and accounts. Appointments can be scheduled using computers.
• Computers are used by home health nurses to record client data and to communicate with the main office. Clients can also have computers in the home that allow them to monitor their own health status and send information about their condition to the nurse.
• Specialized computer software programs enable case managers to track clients’ needs, resources, and health care outcomes.
• Computers are used in nursing administration to manage human resources, medical records, facilities, budgets, quality assurance, utilization review, and accreditation.
• Each step of the nursing research process makes use of computer technology. In particular, computers are used to access literature, analyze data, and report findings.
CHAPTER HIGHLIGHTS
Chapter 9 Review
proposed study. Funds may also be requested to pay people to enter data into the computer and to run the statistical analyses.
Information about available grant funding is most easily found online. The U.S. federal government makes all of the grant applications for nursing projects available only by downloading them from Internet sites. Forms to be completed are computer generated and often must be submitted to the funding agency in electronic format.
from distant locations and can examine and analyze the data simul- taneously onscreen.
Research Grants Funds are available from a variety of resources to support the conduct of nursing research. The budget in a grant application may include a request to purchase computers or software needed to carry out the
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1. In nursing administration, technology facilitates which activities? Select all that apply. 1. Institutional compliance with accreditation health and safety
requirements 2. Tracking the most expensive client conditions 3. Determining which employees are doing the best job 4. Current budget expenditures 5. Client satisfaction with care
2. What is the challenge most associated with the utilization of an electronic client record system? 1. Cost 2. Accuracy 3. Privacy 4. Durability
3. What is one disadvantage associated with electronic (e.g., Internet-based) courses? 1. They take longer. 2. Interpersonal communication is not possible. 3. Everyone has to “log on” at the same time. 4. It is harder to establish a sense of community.
4. What is the primary advantage of using computers while conducting nursing research? 1. Locating potential participants 2. Designing the steps of the research plan 3. Analyzing the quantitative data 4. Disseminating the research findings
5. A client insists that the practitioner use a treatment method discovered on an Internet website. Which is the most appropriate nursing response? 1. “The treatment must be examined to see if it is appropriate.” 2. “Most website treatments have not been studied or
researched.” 3. “The person establishing the website is the only one who
can use it on clients.” 4. “Websites are like advertising; they are biased and may not
be legitimate.” See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
Suggested Reading League, K., Christenbery, T., Sandlin, V., Arnow, D., Moss, K., &
Wells, N. (2012). Increasing nurses’ access to evidence through a web-based resource. Journal of Nursing Administration, 42(11), 531–535. doi:10.1097/NNA .0B013E3182714476 This article describes an institution’s efforts to help nurses integrate evidence into practice through the development of a web-based resource. After assessing nurses’ attitudes and use of evidence resources, a website was created to provide a central location for accessing and using evi- dence. Nurses who utilized the website had more favorable attitudes toward evidence-based practice and were more likely to access evidence resources.
Related Research Kern, L. M., Malhotra, S., Barrón, Y., Quaresimo, J.,
Dhopeshwarkar, R., Pichardo, M., . . . Kaushal, R. (2013). Accuracy of electronically reported “ meaningful use” clinical quality measures: A cross-sectional study. Annals of Internal Medicine, 158, 77–83.
Kulhanek, B. (2011). EMR development . . . Always be prepared. Nursing Management, 42(12), 24–28. doi:10.1097/01.NUMA.0000407575.88737.e8
References American Nurses Association. (2008). Scope and standards of
nursing informatics practice. Washington, DC: Author. Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J.,
Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006
Hebda, T. L., & Calderone, T. L. (2012). Informatics competen- cies for healthcare professionals: The Technology Informat- ics Guiding Education Reform (TIGER) Initiative model. Drug Metabolism and Drug Interactions, 27, 145–149. doi:10.1515/dmdi-2012-0013
Institute of Medicine. (2011). Health IT and patient safety: Building safer systems for better care. Washington, DC: National Academies Press. Retrieved from http://www.iom .edu/Reports/2011/Health-IT-and-Patient-Safety-Building- Safer-Systems-for-Better-Care.aspx
Li, D., & Korniewicz, D. M. (2013). Determination of the effec- tiveness of electronic health records to document pressure ulcers. MEDSURG Nursing, 22(1), 17–25.
Lobach, D., Sanders, G. D., Bright, T. J., Wong, A., Dhurjati, R., Bristow, E., . . . Kendrick, A. S. (2012). Enabling health care decisionmaking through clinical decision support and knowledge management (Evidence Report No. 203, AHRQ
Publication No. 12-E001-EF). Rockville, MD: Agency for Healthcare Research and Quality.
Sarasohn-Kahn, J. (2013). Making sense of sensors: How new technologies can change patient care. Oakland, CA: California HealthCare Foundation. Retrieved from http:// www.chcf.org/publications/2013/02/making-sense-sensors
Sewell, J., & Thede, L. Q. (2012). Informatics and nursing: Opportunities and challenges (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Selected Bibliography Agency for Healthcare Research and Quality. (2009). Impact
of consumer health informatics applications. Rockville, MD: Author. Retrieved from http://www.ahrq.gov/clinic/tp/ chiapptp.htm
Agency for Healthcare Research and Quality. (2012). Enabling health care decision making through the use of clinical decision support and knowledge management. Rockville, MD: Author. Retrieved from http://www.ahrq.gov/clinic/tp/ knowmgttp.htm
Agency for Healthcare Research and Quality. (2013). Findings and lessons from the improving quality through clinician use of health IT grant initiative (AHRQ Publication No. 13-0011- EF). Rockville, MD: Author. Retrieved from http://psnet.ahrq.gov/resource.aspx?resourceID=26713
Ball, M. J., Douglas, J. V., Walker, P. H., DuLong, D., Gugerty, B., Hannah, K. J., . . . Troseth, M. R. (2011). Nursing informatics: Where technology and caring meet. New York, NY: Springer.
Burke, L., & Weill, B. (2012). Information technology for the health professions (4th ed.). Upper Saddle River, NJ: Prentice Hall.
Ciampa, M., & Revels, M. (2012). Introduction to healthcare information technology. Boston, MA: Cengage.
Clark, K., & Normile, L. (2012). Nursing informatics and data collection from the electronic medical record: Study of characteristics, factors and occupancy impacting out- comes of critical care admissions from the emergency department. Health Informatics Journal, 18, 309–319. doi:10.1177/1460458212454023
Davis, N., & LaCour, M. (2014). Health information technology (3rd ed.). St. Louis, MO: Elsevier Saunders.
Gartee, R. (2011). Health information technology and manage- ment. Upper Saddle River, NJ: Prentice Hall.
Gugerty, B., & Delaney, C. (2009). Informatics competencies for every practicing nurse: Recommendations from the TIGER collaborative. Retrieved from http://www .tigersummit.com/uploads/3.Tiger.Report_Competencies_ final.pdf
Hebda, T., & Czar, P. (2012). Handbook of informatics for nurses & healthcare professionals (5th ed.). Upper Saddle River, NJ: Prentice Hall.
Joos, I., Smith, M., & Nelson, R. (2010). Introduction to com- puters for healthcare professionals (5th ed.). Sudbury, MA: Jones & Bartlett.
McGonigle, D., & Mastrian, K. (Eds.) (2012). Nursing informat- ics: A foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett.
National Center for Health Statistics. (2009). Health, United States, 2009: With special feature on medical technology. Hyattsville, MD: Author. Retrieved from www.cdc.gov/nchs/ data/hus/hus09.pdf
Nehring, W. M., & Lashley, F. R. (2010). High fidelity patient simulation in nursing education. Boston, MA: Jones & Bartlett.
Office of the National Coordinator for Health Information Technology. (2013). Health information technology patient safety action & surveillance plan. Washington, DC: Author. Retrieved from http://www.healthit.gov/ policy-researchers-implementers/health-it-and-patient-safety
Ridgway, L., Mitchell, C., & Sheean, F. (2011). Information and communication technology (ICT) use in child and family nursing: What do we know and where to now? Contemporary Nurse, 40(1), 118–129.
Roper, R. A., Anderson, K. M., Marsh, C. A., & Flemming, A. C. (2013). Health IT-enabled quality measurement: Perspec- tives, pathways, and practical guidance (AHRQ Publication No. 13-0059-EF). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://psnet.ahrq .gov/resource.aspx?resourceID=26841
Saba, V. K., & McCormick, K. A., (2011). Essentials of nursing informatics (5th ed.). New York, NY: McGraw-Hill.
Schwirian, P. M., & Thede, L. (2011). Informatics: The standardized nursing terminologies: A national survey of nurses’ experiences and attitudes. Online Journal of Issues in Nursing, 16(2), 1. doi:10.3912/OJIN .Vol16No02InfoCol01
Schwirian, P. M., & Thede, L. (2012). Informatics: The standardized nursing terminologies: A national survey of nurses’ experience and attitudes—SURVEY II: Participants, familiarity and information sources. Online Journal of Issues in Nursing, 17(2), 1. doi:10.3912/OJIN.Vol17No2InfoCol01
Srinivasan, D. (2013). Impact of healthcare informatics on quality of patient care and health services. Boca Raton, FL: Taylor & Francis.
Watson, D. (2012). Case study: The use of telehealth technol- ogy in a community setting. British Journal of Community Nursing, 17, 520–521.
READINGS AND REFERENCES
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CLIENT: Rhett AGE: 66 CURRENT MEDICAL DIAGNOSIS: Prehypertension Medical History: Rhett had many of the usual childhood diseases and several of the rarer ones including polio and rickets. He recov- ered almost completely from each, with only slight residual weakness in the upper extremities. He has borderline diabetes mellitus that is controlled by diet, weight management, and exercise. His most recent blood analyses showed all values within normal limits except for a slightly elevated fasting blood sugar. He takes 81 mg of aspirin daily. His only prescription medications are simvastatin for high cho- lesterol and, since his last primary care provider visit 1 month ago, a very low dose of the angiotensin-converting enzyme (ACE) inhibitor medication lisinopril for blood pressure. The primary care provider recommended that Rhett measure his blood pressure at home twice each day and send that information to the office every 2 weeks.
Personal and Social History: Rhett is divorced with one grown daughter. He moved to the United States at age 30 from a European country. He has several college degrees and now works as a trans- lator. His work is computer based so he works from his home. He loves all forms of technology, from smart phones, to tablet personal computers, to web-based games. He is diligent about doing physi- cal exercise daily, alternating cardiovascular with weight-training routines.
Rhett’s diet leans toward high carbohydrates and he takes a variety of vitamin supplements including fish oils. He has two glasses of wine daily and does not smoke. There are no known genetic or inherited diseases in the family. He has health insurance through a health maintenance organization (HMO).
Questions American Nurses Association Standard of Practice #5 is Implementation: The competencies include that the nurse uses technology to support evidence-based nursing practice that facilitates improved client outcomes.
As you learned in Chapter 9 , technology plays an important role in modern health care. During a visit to the clinic at the HMO, Rhett asks you if he can track his blood pressures online and send the measurements in electronically. 1. What would be the advantages and disadvantages of using
technology for the purposes Rhett suggested? Include both general considerations and those unique to this client.
American Nurses Association Standard of Practice #5A is Coordination of Care: The nurse is expected to coordinate and document care and assist the client in selecting the best type of care provision. 2. In coordinating care to meet the competency, the nurse must
consider if the client requires primary, secondary, or tertiary pre- vention as described in Chapter 6 . How would you describe Rhett’s needs? Is an HMO an effective insurance plan based on his history and current health status?
3. Chapter 7 discusses community-based health resources. What are some categories of community resources that may be appropriate for Rhett?
4. Chapter 8 describes home health. If Rhett requests that a nurse come to his home to check his blood pressure, how might you respond?
American Nurses Association Standard of Professional Performance #11 is Communication: The nurse communi- cates effectively in a variety of formats in all areas of practice, and in ways that are appropriate for the client’s preferred style. In addition, the nurse questions routines that do not seem to support the best interests of the client. 5. Rhett’s knowledge and skill in technology may be greater than
your own. How might you answer his question about online submission of blood pressure information?
6. The clinic has a policy that requires all reports of client data to be submitted in hard copy with an original signature. Does this policy meet the expected competency? If not, what action would you take next?
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
2 Meeting the StandardsThis unit presented an overview of the broad world of the health care system and described care provided outside the hospital—including in cyberspace. In order for nurses to be effective members of the health care team, we must be knowledgeable about the variety of methods of delivering and paying for health care, the diverse members of the health care team, the unique aspects of nursing care delivered in the community and clients’ homes, and the uses of information technology in clients’ lives and in health care. To provide the best possible nursing care under all of these different circum- stances, nurses must demonstrate critical thinking using evidence-based strategies and theoretical underpinnings.
In the case described below, a client uses one method of health care delivery and financing and accesses care outside of the hospital. The nurse remains an integral part of the client’s health experience.
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UNIT
3 The Nursing Process
10 Critical Thinking and Clinical Reasoning 144
11 Assessing 155
12 Diagnosing 175
13 Planning 189
14 Implementing and Evaluating 208
15 Documenting and Reporting 221
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10 Critical Thinking and Clinical Reasoning
INTRODUCTION The term “thinking like a nurse” was introduced by Dr. Christine Tanner in 2006. To think like a nurse, critical thinking and clinical reasoning must be defined and understood. This chapter examines the influence of critical thinking and clinical reasoning on the care of clients. Both these terms describe the mental processes nurses use to ensure that they are doing their best thinking and decision making.
The practice of nursing requires critical thinking and clinical reasoning. Critical thinking is the process of intentional higher level thinking to define a client’s problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care. Clinical reasoning is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the rel- evance of the information, and decide on possible nursing actions to improve the client’s physiological and psychosocial outcomes. Clini- cal reasoning requires the integration of critical thinking in the iden- tification of the most appropriate interventions that will improve the client’s condition. The concept of clinical reasoning “evolved from the application of decision-making to the health care professions” (Simmons, 2010, p. 1153). “Clinical reasoning also guides nurses in assessing, assimilating, retrieving, and/or discarding components of information that affect patient care” (p. 1151). Clinical reasoning is often defined in practice-based disciplines, such as nursing and med- icine, as the “application of critical thinking to the clinical situation” (Victor-Chmil, 2013, p. 35).
PURPOSE OF CRITICAL THINKING Critical thinking involves the differentiation of statements of fact, judgment, and opinion. The process of critical thinking requires the nurse to think creatively, use reflection, and engage in analytical thinking (Alfaro-LeFevre, 2013). Alfaro-LeFevre’s 4-Circle Critical
Thinking Model provides a visual representation of critical think- ing abilities and promotes making meaningful connections between nursing research and critical thinking and practice (Figure 10–1 •). Critical thinking is an essential skill needed for the identification of client problems and the implementation of interventions to promote effective care outcomes (Bittencourt & Crossetti, 2012). The process of providing feedback and reflection is vital to the improvement of nursing practice. A study by Asselin (2011) revealed that students who reflected on new knowledge developed new insights regarding practice. The insights nurses acquired led to changes in their ap- proach to practice.
According to Scheffer and Rubenfeld (2010), critical thinking is a metaphorical bridge between information and action. Criti- cal thinking in nursing involves habits of the mind and requires the implementation of cognitive skills. In 2000, Scheffer and Ruben- feld conducted a landmark study in which internationally diverse expert nurses from nine countries defined ten habits of the mind (affective components) and seven skills (cognitive components) of critical thinking in nursing. The ten affective components are con- fidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. The seven skills are analyzing, applying standards, dis- criminating, information seeking, logical reasoning, predicting, and transforming knowledge. Lunney (2010) used the affective and cog- nitive components to demonstrate the use of critical thinking in the diagnostic process and the identification of an accurate nursing di- agnosis. The study indicated that nurses need to utilize all 17 critical thinking concepts in the identification of nursing diagnoses.
Nurses use critical thinking skills in a variety of ways:
• Nurses use knowledge from other subjects and fields. Nurses use critical thinking skills when they reflect on knowledge derived
LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Describe the significance of developing critical thinking abili-
ties in order to practice safe, effective, and professional nurs- ing care.
2. Describe the actions of clinical reasoning in the implementa- tion of the nursing process.
3. Discuss the attitudes and skills needed to develop critical thinking and clinical reasoning.
KEY TERMS
clinical judgment, 147 clinical reasoning, 144 cognitive processes, 149 concept mapping, 151
creativity, 145 critical analysis, 145 critical thinking, 144 deductive reasoning, 146
inductive reasoning, 146 intuition, 147 metacognitive processes, 149 nursing process, 147
problem solving, 147 Socratic questioning, 146 trial and error, 147
4. Describe the components of clinical reasoning. 5. Integrate strategies to enhance critical thinking and clinical
reasoning as the provider of nursing care. 6. Describe the process of concept mapping to enhance
critical thinking and clinical reasoning for the provision of nursing care.
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Figure 10–1 • Alfaro-LeFevre’s 4-Circle Critical Thinking Model. Adapted with permission from Critical Thinking Indicators (CTIs): 2014 Evidence-Based Version, by R. Alfaro-LeFevre, 2014. Retrieved from http://www.alfaroteachsmart.com/2014CTIrichJan.pdf.
Theoretical & Experiential Knowledge Intellectual Skills / Competencies
CT Characteristics (Attitudes / Behaviors)
Technical Skills / Competencies
Starting at the top and going clockwise around the circles above, here’s what you need to do to develop your ability to think critically. 1. Develop a critical thinking character. Hold yourself to high standards. Make a commitment to developing critical thinking characteristics such as; honesty, fair-mindedness, creativity, patience, and confidence. 2. Take responsibility and seek out learning experiences to help you get the theoretical and experiential knowledge to think critically. Practice intellectual skills such as assessing systematically and comprehensively. Just as practicing physical skills improves your ability to perform physically, practicing thinking skills improves your ability to perform intellectually. 3. Gain interpersonal skills such as teamwork, resolving conflict, and being an advocate. Keep in mind that “being too nice” problems (e.g., not giving constructive criticism because of concerns of not offending someone) can be as bad as “not being very nice” problems (e.g., demonstrating arrogance, sarcasm, and or intolerance of other ways of doing things). Learn how to give and take feedback. To improve you must get through the negative aspects of criticism. 4. Practice related technical skills (e.g., using computers, managing IV’s). Until these skills become like second natures, they create a “brain drain” making it difficult to focus on other important things such as monitoring patient responses to care.
Interpersonal Skills / Competencies
Critical Thinking Ability
from other interdisciplinary subject areas such as the biophysi- cal and behavioral sciences and the humanities in order to pro- vide holistic nursing care. For example, when providing care to a client at the end of life, it is important to have knowledge of culture and religion to enhance the delivery of culturally sensi- tive care and enhance the client’s spiritual well-being to promote a good death.
• Nurses deal with change in stressful environments. A client’s condition may rapidly change and routine protocol may not be adequate to cover every unexpected situation. Critical thinking enables the nurse to recognize important cues, re- spond quickly, and adapt interventions to meet specific client needs at the right time. Box 10–1 lists some personal critical thinking indicators.
• Nurses make important decisions. Every day, and every moment during the day, nurses use critical thinking skills and clinical rea- soning to make judgments about a client’s care. For example, de- termining which observations must be reported to the primary
care provider immediately and which can be noted in the electronic medical record for later consulta- tion with the primary care provider requires critical thinking. Also clients have different health needs simultaneously. For example, a client who is experi- encing an acute asthma attack with air hunger will also experience anxiety. The nurse must administer a medication to improve breathing before addressing the client’s anxiety.
Critical thinking cognitively fuels the intellectual artistic activity of creativity. When nurses incorporate creativity, they are able to find unique solutions to unique problems. Creativity is thinking that results in the de- velopment of new ideas and products. Creativity in prob- lem solving and decision making is the ability to develop and implement new and better solutions for health care outcomes.
Creativity is required when the nurse encounters a new situation or a client situation in which traditional interventions are not effective. Creative thinkers must assess a problem and be knowledgeable about the un- derlying facts and principles that apply. An example would be a 4-year-old child who has sustained a severe burn and has been discharged from the hospital. The home care nurse has orders to soak and cleanse the wound in the bathtub. After arriving at the child’s home, the nurse determines the family does not have hot water service due to an inability to pay the gas bill. The nurse warms water on the electric stove so the wound can be cleansed in the bathtub as ordered by the primary care provider. Next the nurse contacts the social worker to help the family obtain financial assistance so the gas bill can be paid and the hot water restored.
In this clinical scenario the nurse has utilized cre- ativity by warming the water on the stove. The nurse has also utilized knowledge of the role the social worker plays in providing care to the child and family. The use of creativity provides the nurse with the ability to:
• Generate many ideas rapidly. • Be generally flexible and natural; that is, able to change viewpoints
or directions in thinking rapidly and easily. • Create original solutions to problems. • Be independent and self confident, even when under pressure. • Demonstrate individuality.
TECHNIQUES IN CRITICAL THINKING In addition to the ten affective and seven cognitive components of critical thinking, the nurse uses other techniques to ensure effective problem solving and decision making. These techniques include critical analysis, inductive and deductive reasoning, making valid inferences, differentiating facts from opinions, evaluating the cred- ibility of information sources, clarifying concepts, and recognizing assumptions.
Critical analysis is the application of a set of questions to a particular situation or idea to determine essential information and
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BOX 10–1 Personal Critical Thinking Indicators: Behaviors, Attitudes, and Characteristics
• Self-aware: Clarifies biases, inclinations, strengths, and limitations; acknowledges when thinking may be influenced by emotions or self-interest.
• Genuine/authentic: Shows true self; demonstrates behaviors that indicate stated values.
• Effective communicator: Listens well (shows deep understand- ing of others’ thoughts, feelings, and circumstances); speaks and writes with clarity.
• Health: Promotes a healthy lifestyle; uses healthy behaviors to manage stress.
• Careful and prudent: Knows own limits—seeks help as needed; suspends or revises judgment as indicated by new or incomplete data.
• Confident and resilient: Expresses faith in ability to reason and learn; overcomes disappointments.
• Honest and upright: Seeks the truth, even if it sheds unwanted light; upholds standards; admits flaws in thinking.
• Curious and inquisitive: Looks for reasons, explanations, and meaning; seeks new information to broaden understanding.
• Alert to context: Looks for changes in circumstances that warrant a need to modify thinking or approaches.
• Analytical and insightful: Identifies relationships; expresses deep understanding.
• Logical and intuitive: Draws reasonable conclusions (if this is so, then it follows that . . . because . . .); uses intuition as a guide to search for evidence; acts on intuition only with knowledge of risks involved.
• Open and fair-minded; Shows tolerance for different viewpoints; questions how own viewpoints are influencing thinking.
• Sensitive to diversity: Expresses appreciation of human differences related to values, culture, personality, or learning style preferences; adapts to preferences when feasible.
• Creative: Offers alternative solutions and approaches; comes up with useful ideas.
• Realistic and practical: Admits when things are not feasible; looks for user-friendly solutions.
• Reflective and self-corrective: Carefully considers meaning of data and interpersonal interactions, asks for feedback; corrects own thinking, is alert to potential errors by self and others, finds ways to avoid future mistakes.
• Proactive: Anticipates consequences, plans ahead, acts on opportunities.
• Courageous: Stands up for beliefs, advocates for others, does not hide from challenges.
• Patient and persistent: Waits for the right moment; perseveres to achieve best results.
• Flexible: Changes approaches as needed to get the best results.
• Empathetic: Listens well; shows ability to imagine others’ feelings and difficulties.
• Improvement-oriented (self, patients, systems): Self— identifies learning needs; finds ways to overcome limitations, seeks out new knowledge. Patients—promotes health care systems; promotes safety, quality, satisfaction, and cost-containment.
From Critical Thinking Indicators (CTIs): 2014 Evidence-Based Version (p. 7), by R. Alfaro-LeFevre, 2014, Stuart, FL, p. 7. Reprinted with permission. Retrieved from http://www.alfaroteachsmart.com/2014CTIrichJan.pdf.
ideas and discard unimportant information and ideas. The questions are not sequential steps; rather they are a set of criteria for judging an idea. Not all questions will need to be applied to every situation, but one should be aware of all of the questions in order to choose those questions appropriate to a given situation.
Socrates was a Greek philosopher who developed the method of posing questions and seeking an answer. Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Box 10–2 lists Socratic questions to use in critical analysis. Nurses should employ Socratic questioning when reporting about a client’s condition and current status, reviewing a client’s his- tory and progress notes, and planning care.
Two other critical thinking skills are inductive and deductive reasoning. In inductive reasoning, generalizations are formed from a set of facts or observations. When viewed together, certain bits of information suggest a particular interpretation. Inductive reasoning moves from specific examples (premises) to a generalized conclusion—for example, after touching several hot flames (prem- ise), we conclude that all flames are hot. A nurse who observes a client who has dry skin, poor turgor, sunken eyes, and dark amber urine and who is determined to be dehydrated (premise) concludes that the presence of those signs in other clients indicates that they are dehydrated.
Deductive reasoning, by contrast, is reasoning from general premise to the specific conclusion. If you begin with the premise
BOX 10–2 Socratic Questions
QUESTIONS ABOUT THE DECISION (OR PROBLEM) • Is this question clear, understandable, and correctly
identified? • Is this question important? • Could this question be broken down into smaller parts? • How might _____________ state this question?
QUESTIONS ABOUT ASSUMPTIONS • You seem to be assuming _____________; is that so? • What could you assume instead? Why? • Does this assumption always hold true?
QUESTIONS ABOUT POINT OF VIEW • You seem to be using the perspective of _____________.
Why? • What would someone who disagrees with your
perspective say? • Can you see this any other way?
QUESTIONS ABOUT EVIDENCE AND REASONS • What evidence do you have for that? • Is there any reason to doubt the evidence? • How do you know? • What would change your mind?
QUESTIONS ABOUT IMPLICATIONS AND CONSEQUENCES • What effect would that have? • What is the probability that will actually happen? • What are the alternatives?
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that the sum of the angles in any triangle is always 180 degrees, you can conclude that the sum of the angles in the triangle you happen to have is also 180 degrees. A nurse might start with a premise that all children love peanut butter sandwiches. Thus, if the nurse is try- ing to encourage a child to eat, then the nurse should offer the child a peanut butter sandwich. This is an example in which the premise is not always valid and, thus, the conclusion also may not be valid. Nurses use critical thinking to help analyze situations and establish which premises are valid.
In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. Table 10–1 shows how these statements may be applied to nursing care. Evaluating the credibil- ity of information sources is an important step in critical thinking. Unfortunately, we cannot always believe what we read or are told. The nurse must ascertain the accuracy of information by checking other documents or with other informants. Hence, the expanding need for evidence-based nursing practice. To comprehend a client situation clearly, the nurse and the client must agree on the mean- ing of terms. For example, if the clients says to the nurse “I think I have a tumor,” the nurse needs to clarify what the word means to the client—the medical definition of a tumor (a solid mass) or the common lay meaning of cancer—before responding. People also live their lives under certain assumptions. Some people view humans as having a basically generous nature, whereas others believe that the human tendency is to act in their own best interest. The nurse may believe that life should be considered worth living no matter what the condition, whereas the client may believe that quality of life is more important than quantity of life. If the nurse and client recog- nize that they make choices based on these assumptions, they can still work together toward an acceptable plan of care. Difficulty arises when people do not take the time to consider what assumptions un- derlie their beliefs and actions.
APPLYING CRITICAL THINKING TO NURSING PRACTICE When a nurse uses intentional thinking, a relationship develops among the knowledge, skills, and attitudes that are ascribed to criti- cal thinking and clinical reasoning, the nursing process, and the problem-solving process.
Implementation of the nursing process provides nurses with a creative approach to thinking and doing to obtain, categorize, and analyze client data and plan actions that will meet the client’s needs. The nursing process is a systematic, rational method of planning and providing individualized nursing care. It begins with assessment
Statement Description Example Facts Can be verified through investigation Blood pressure is affected by blood volume.
Inferences Conclusions drawn from the facts; going beyond facts to make a statement about something not currently known
If blood volume is decreased (e.g., in hemorrhagic shock), the blood pressure will drop.
Judgments Evaluation of facts or information that reflects values or other criteria; a type of opinion
It is harmful to the client’s health if the blood pressure drops too low.
Opinions Beliefs formed over time; include judgments that may fit facts or be erroneous
Nursing interventions can assist in maintaining the client’s blood pressure within normal limits.
TABLE 10–1 Differentiating Types of Statements
of the client and use of clinical reasoning to identify client problems. The phases of the nursing process are assessing, diagnosing, plan- ning, implementing, and evaluating. These phases are described in detail in Chapters 11 through 14 .
Problem Solving Problem solving is a mental activity in which a problem is identified that represents an unsteady state. It requires the nurse to obtain infor- mation that clarifies the nature of the problem and suggests possible solutions. Throughout the problem-solving process the implementa- tion of critical thought may or may not be required in working toward a solution (Wilkinson, 2012). The nurse carefully evaluates the pos- sible solutions and chooses the best one to implement. The situation is carefully monitored over time to ensure that its initial and continued effectiveness returns the client to a steady state. The nurse does not discard the other solutions, but holds them in reserve in the event that the first solution is not effective. Therefore, problem solving for one situation contributes to the nurse’s body of knowledge for problem solving in similar situations. Commonly used approaches to problem solving include trial and error, intuition, and the research process.
TRIAL AND ERROR One way to solve problems is through trial and error, in which a number of approaches are tried until a solution is found. However, without considering alternatives systematically, one cannot know why the solution works. The use of trial-and-error methods in nurs- ing care can be dangerous because the client might suffer harm if an approach is inappropriate. However, nurses often use trial and error in the home setting due to logistics, equipment, and client lifestyle. For example, when teaching a client to perform a colostomy irriga- tion, a bent coat hanger hung on the shower curtain rod provides an appropriate height to perform the irrigation. In the hospital setting a lowered intravenous (IV) pole is more likely utilized.
INTUITION Intuition is a problem-solving approach that relies on a nurse’s in- ner sense. It is a legitimate aspect of a nursing judgment in the imple- mentation of care (Wilkinson, 2012). Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. As a problem-solving approach, intuition is viewed by some people as a form of guessing and, as such, an inappropriate basis for nursing de- cisions. However, others view intuition as an essential and legitimate aspect of clinical judgment acquired through knowledge and experi- ence. Clinical judgment in nursing is a decision-making process to
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2012). Fair-mindedness helps one to consider opposing points of view and to try to understand new ideas fully before rejecting or ac- cepting them. Critical thinkers strive to be open to the possibility that new evidence could change their minds. The nurse listens to the opinions of all members of a family, young and old. Sometimes the traditional approach will emerge as the most effective strategy, whereas at other times a new and possibly unproven approach should be tried. In every case, the nurse must be able to provide the rationale for any action taken.
Insight into Egocentricity Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their think- ing. They actively try to examine their own biases and bring them to awareness each time they think or make a decision. By failing to reflect on personal biases, the nurse may reach inappropriate conclu- sions for the individual client. For example, a nurse spends extensive time teaching a client who is obese about nutrition and weight loss to prevent recurrence of back pain, but is mystified when the client ap- pears uninterested and does not follow the nurse’s advice. The nurse’s bias of assuming that all clients will incorporate preventive care (just because the nurse would do this) resulted in an inaccurate assess- ment of the client’s motivation; both the nurse’s and the client’s time was wasted. Possibly, the client’s cultural views of weight are differ- ent from those of the nurse. Had the nurse assessed the client’s back- ground and beliefs about weight and collected sufficient evidence, the nurse might have identified a problem more relevant to the client’s priorities and, thus, developed a better care plan.
Intellectual Humility Intellectual humility means having an awareness of the limits of one’s own knowledge. Critical thinkers are willing to admit what they do not know; they are willing to seek new information and to rethink their conclusions in light of new knowledge. They never assume that what everybody believes to be right will always be right, because new evidence may emerge. A hospital nurse might be unable to imagine how an older adult’s wife will care for her husband who has recently had a stroke. However, the nurse also recognizes that it is not really possible to know what the couple can achieve.
Intellectual Courage to Challenge the Status Quo and Rituals With an attitude of courage, a nurse is willing to consider and exam- ine fairly his or her own ideas or views, especially those to which the nurse may have a strongly negative reaction. This type of courage comes from recognizing that beliefs are sometimes false or mislead- ing. Values and beliefs are not always acquired rationally. Rational beliefs are those that have been examined and found to be supported by solid reasons and data. After such examination, it is inevitable that some beliefs previously held to be true will be found to contain questionable elements and that some truth will emerge from ideas considered dangerous or false. Courage is needed to be true to new thinking in such cases, especially if social penalties for nonconfor- mity are severe. For example, many nurses previously believed that allowing family members to observe emergency procedures (such as cardiopulmonary resuscitation) would be psychologically harmful to the family and that members would get in the health care team’s
ascertain the right nursing action to be implemented at the appro- priate time in the client’s care. The nurse must first have the knowl- edge base necessary to practice in the clinical area and then use that knowledge in clinical practice. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions.
Experience is important in improving intuition because the ra- pidity of the judgment depends on the nurse having seen similar cli- ent situations many times before. Sometimes nurses use the words “I had a feeling” to describe the critical thinking element of considering evidence. These nurses are able to judge quickly which evidence is most important and to act on that limited evidence. Nurses in critical care often pay closer attention than usual to a client when they sense that the client’s condition could change suddenly.
Although the intuitive method of problem solving is gaining recognition as part of nursing practice, it is not recommended for novices or students, because they usually lack the knowledge base and clinical experience on which to make a valid judgment.
RESEARCH PROCESS The research process, discussed in Chapter 2 , is a formalized, logi- cal, systematic approach to problem solving. The classic quantitative research process is most useful when the researcher is working in a controlled situation. Health professionals, often working with people in uncontrolled situations, require a modified approach for solving problems. For example, unlike many experiments with animals in which the environment can be strictly regulated, the effects of diet on health in humans are complicated by a person’s genetic variations, lifestyle, and personal preferences. However, it is becoming increas- ingly important for nurses to identify evidence that supports effective nursing care. One critical source of this evidence is research.
ATTITUDES THAT FOSTER CRITICAL THINKING Certain attitudes are crucial to critical thinking. These attitudes are based on the assumption that a rational person is motivated to de- velop, learn, grow, and be concerned with what to do or believe. A critical thinker works to develop the following nine attitudes or traits: independence, fair-mindedness, insight, intellectual humility, intellectual courage, integrity, perseverance, confidence, and curiosity.
Independence Critical thinking requires that individuals think for themselves. People acquire many beliefs as children, not necessarily based on reason but in order to have an explanation they comprehend. As they mature and acquire knowledge and experience, critical thinkers examine their be- liefs in the light of new evidence. Critical thinkers consider seriously a wide range of ideas, learn from them, and then make their own judg- ments about them. Nurses are open-minded about considering different methods of performing technical skills—not just the single way they may have been taught in school. Nurses should not ignore what other people think, but they should consider a wide range of ideas, learn from them, and then take the time to build their own judgments (Wilkinson, 2012).
Fair-Mindedness Critical thinkers are fair-minded and make impartial judgments. They assess all viewpoints with the same standards and do not base their judgments on personal or group bias or prejudice ( Wilkinson,
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something else work? What would happen if we did it another way? Who says that is so? The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid. The nurse may, for example, apply these questions to the issue of mov- ing responsibility for a procedure such as the drawing of arterial blood samples among the nursing, respiratory therapy, or laboratory department staff.
COMPONENTS OF CLINICAL REASONING Clinical reasoning is the analysis of a clinical situation as it unfolds or develops. It requires the nurse to use cognitive and metacognitive processes. Cognitive processes are the thinking processes based on the knowledge of aspects of client care. Cognitive skills are learned through reading and applying health-related literature. Cognitive skills are enhanced through the use of critical thought to understand and apply content the nurse has previously learned. Metacognitive processes include reflective thinking and awareness of the skills learned by the nurse in caring for the client. The nurse reflects on the client’s status, and through the use of critical thinking skills deter- mines the most effective plan of care.
Benner, Sutphen, Leonard, and Day (2010) state that thinking like a nurse requires clinical reasoning (p. 85). They identify clini- cal reasoning as the ability to reason about a clinical situation as it unfolds (p. 46). It is important for the nurse to be “tuned in” to the cli- ent’s experiences and concerns. As the client’s condition changes, the nurse must assess the client and then identify the interventions that will lead to the improvement of the client’s health-related outcomes. Changes in a client’s condition can occur in an instant. It is the respon- sibility of the nurse to detect these changes, implement nursing as- sessments and interventions, notify members of the health care team, and evaluate the client’s response. Benner et al. (2010) describe the components of clinical reasoning to include setting priorities, devel- oping rationales, learning how to act, clinical reasoning-in- transition, and responding to changes in the client’s condition. It is also impor- tant to reflect on the care provided and the client’s response.
Setting Priorities In the current nursing world, nurses have to think quickly to resolve problems. In the often fast-paced clinical environment, the nurse must know what assessments, tasks, requests, and concerns need to be completed first. Priority setting needs to be dynamic or flex- ible because the clinical environment can change quickly, requiring changes in priorities. Beginning nursing students often view every- thing as being of equal importance. They are often task oriented and focused on what needs to be done and not necessarily on what is most important. As they gain more clinical experience, they start to determine which data are most relevant and important to each cli- ent’s situation. Most nursing programs require beginning students to complete preclinical preparation. This is a strategy to help them set their priorities based on information they gathered before the actual clinical experience. It is important for students to remember that, once they begin providing client care, the priorities they set in the preclinical preparation may change based on the current client situa- tion. See Box 10–3 for examples of questions for nursing students to ask themselves before and during client care that will help increase their clinical reasoning abilities.
way. Others felt that blanket exclusion of family members was unnec- essary and extremely stressful for some of them. As a result, nurses initiated research that has demonstrated that family presence can be accomplished without detrimental effects to the nurse, the client, or the family. This is also an example of how evidence, rather than just tradition, guides our nursing practice.
Integrity Intellectual integrity requires that individuals apply the same rigor- ous standards of proof to their own knowledge and beliefs as they ap- ply to the knowledge and beliefs of others. Critical thinkers question their own knowledge and beliefs as quickly and thoroughly as they challenge those of another. They are readily able to admit and evalu- ate inconsistencies within their own beliefs and between their own beliefs and those of another. A nurse might believe that wound care always requires sterile technique. Reading a new article on the use and outcomes of clean technique for some wounds leads the critically thinking nurse to reconsider.
Perseverance Because critical thinking is a lifelong endeavor, nurses who are critical thinkers show perseverance in finding effective solutions to client and nursing problems. This determination enables them to clarify concepts and sort out related issues, in spite of difficulties and frustrations. Confusion and frustration are uncomfortable, but critical thinkers resist the temptation to find a quick and easy answer. Important questions tend to be complex and confusing and there- fore often require a great deal of thought and research to arrive at an answer. The nurse needs to continue to address the issue until it is resolved. For example, the nurses on a unit have tried to establish a policy for selected clients to leave the hospital on a pass rather than have to be discharged and readmitted in the same day. The need for involvement of nursing, medical, administrative, and accounting staff gradually generates solutions to obstacles. The development of the policy moves forward, although very slowly.
Confidence Critical thinkers believe that well-reasoned thinking will lead to trustworthy conclusions. Therefore, they cultivate an attitude of confidence in the reasoning process and examine emotion-laden arguments using the standards for evaluating thought, by asking questions such as these: Is that argument fair? Is it based on sufficient evidence? Consider nurses attempting to determine the best way to allocate holiday time off for staff. Should they go by seniority, use ran- dom selection (lottery), give preference to those who have children, use “first-come, first-served,” or use another method?
The critical thinker develops skill in both inductive reasoning and deductive reasoning. As the nurse gains greater awareness of the thinking process and more experience in improving such thinking, confidence in the process will grow. This nurse will not be afraid of disagreement and indeed will be concerned when others agree too quickly. Such a nurse can serve as a role model to colleagues, inspiring and encouraging them to think critically as well.
Curiosity The mind of a critical thinker is filled with questions: Why do we believe this? What causes that? Does it have to be this way? Could
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Responding to Changes in the Client’s Condition Nurses spend more time with clients than do other health care pro- viders. As a result, an important aspect of nursing practice and the nurse’s responsibility is to detect changes in the client’s condition, recognize a change in priorities, adjust nursing care, and alert the pri- mary care provider when appropriate.
Clinical reasoning involves an understanding and assessment of the client’s relevant history and current condition and how it may be changing. By closely monitoring and comparing any changes from previous assessment data, the nurse is able to recognize a change in status that may prevent an adverse outcome.
Reflection Reflection is a key to the success of clinical reasoning. Through re- flection the nurse identifies factors that improved client care and those that required changing or elimination. It is important to reflect on whether the client was assessed accurately and in a timely man- ner. The nurse thinks back on the interventions implemented and whether they were effective. Most importantly, reflection includes in- formation on the outcome of care. The nurse also reflects on previous clinical experiences similar to this one to determine if the outcomes of care improved the clients’ conditions.
INTEGRATION OF CRITICAL THINKING AND CLINICAL REASONING Nurses use critical thinking and clinical reasoning skills when mak- ing decisions about client care. The decision-making process includes prioritizing care not only with one client but when providing care to many clients. Nurses must make decisions and also assist clients to
Developing Rationales After assessing the data and determining what is relevant to the client’s condition and concerns, the nurse identifies interventions and sets pri- orities for the most urgent needs (Benner et al., 2010). This is when the nurse transfers nursing knowledge to the clinical situation to justify the plan of care. Nursing students are often asked to explain the “why” of their priority setting and subsequent interventions. Being able to state the rationale, based on nursing knowledge, acts as a check for potential errors, justifies the nurse’s actions, contributes to client safety, and helps the beginning nursing student learn how a nurse thinks in practice.
Learning How to Act The nurse must know how and when to respond in a clinical situation by recognizing what is most urgent or significant. To take action, the nurse needs to understand the relevant medical and nursing informa- tion and translate this knowledge into a plan of care (Benner et al., 2010). An example is thinking about potential complications given the client’s current problems. Applying this knowledge increases the nurse’s ability to quickly identify assessment data that indicate a po- tential complication. Thus, the nurse can initiate nursing interven- tions or actions quickly because he or she prepared for the possibility. Avoiding potential complications promotes client safety.
Clinical Reasoning-in-Transition It is important to realize that clinical situations are complex and al- ways changing, especially given the acuity level of clients in today’s hospital settings. Clinical reasoning-in-transition is the ability to recognize subtle changes in a client’s condition over time. It includes the evaluation of nursing interventions and the trending of relevant assessment data. Nurses need to develop a sense of what is most im- portant in each changing clinical situation and remember that the primary focus is on the client’s well-being.
BOX 10–3 Questions to Develop Clinical Reasoning
QUESTIONS TO ASK BEFORE PROVIDING CLIENT CARE 1. What clinical data from the client’s chart is relevant and must
be recognized as significant to the nurse? 2. What nursing priority will guide the plan of care? 3. What is the desired client outcome? 4. What nursing interventions will be initiated based on this
priority and desired outcome? 5. How will the effectiveness of the nursing interventions be
evaluated? 6. What assessment(s) will be focused on based on the client’s
primary problem or nursing care priority?
QUESTIONS TO ASK WHILE PROVIDING CLIENT CARE 7. What recently collected clinical assessment data are relevant
and must be recognized as significant? 8. What relevant clinical assessment data need to be closely
watched to detect a possible change in status? 9. What is the worst possible/most likely complication(s) to
anticipate today with this client? 10. What nursing assessments need to be initiated to identify if this
complication develops? © 2014 Keith Rischer, RN, MA, CEN, CCRN/http://www.keithrn.com/downloads/ clinical-reasoning.questions-develop-nurse-thinking/
Home Care Considerations Communication and Clinical Reasoning
• Interview the client in a nonthreatening, relaxing setting. • Utilize the client’s words when describing the chief complaint. • Communicate with the family to gain insight into the changes in
the client’s condition. • Inform the primary care provider of the client’s physiological and
psychosocial status. • Consult with other health care team members to deter-
mine if they have experience with clients who have had
similar health problems whose conditions changed. Ask them what interventions were implemented and the outcome of care.
• If the client’s status has not improved, consult with the health care team and continue to implement critical thinking strategies to address the client’s health-related outcomes.
TEAMWORK AND COLLABORATION
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(Alfaro-LeFevre, 2014). The concept map allows the nurse to map words on a page and focus on concepts and relationships. A gen- eral benefit of these maps is that they are quicker than note taking and highlight key ideas (Alfaro-LeFevre, 2014). This text contains more than a dozen concept maps that demonstrate care planning and physiological processes.
Concept Mapping and Enhancing Critical Thinking and Clinical Reasoning Concept mapping provides nurses with a link between existing nurs- ing knowledge and new information. This learning strategy enhances the critical thinking process and can assist the nursing student in understanding complex concepts (Chabeli, 2010). Concept maps foster the demonstration that nurses and health care providers have acquired the body of knowledge and understanding of concepts per- tinent to the delivery of safe and effective care (Daley & Torre, 2010). Rather than address one single client problem, the concept map can incorporate multiple problems. This allows the nurse to demon- strate interrelationships among a client’s problems and determine care based on the complexity of those problems (Billings & Halstead, 2012). Thus, concept mapping may be a valuable tool to improve critical thinking. Four basic types of maps are described in Box 10–4 and Figure 10–2 •.
make decisions. When faced with several client needs at the same time, the nurse must prioritize and decide which client to assist first.
In the home care setting, the nurse must decide if the client’s condition can be managed in the home or requires hospitalization. The nurse must assess the ability of the caregiver and client to under- stand and follow all aspects of the health care teaching the nurse has provided.
The nurse must consider the client’s cultural and religious back- ground because both influence the outcomes of care. For example, in the Muslim religion, it is traditional for female relatives to care for a new baby, thus allowing the new mother time to rest. If the nurse fails to review cultural practices and insists that the new mother provide the parenting, then the nurse has not utilized critical thought in the process of clinical reasoning during the implementation of care.
Logical reasoning is a critical thinking skill that closely aligns with clinical reasoning. In the planning of care, nurses must question whether knowledge they possess about the care of the client is consis- tent with the most current evidence-based practice. The nurse must review the most current nursing and health-related literature prior to implementing care.
A nurse’s ability to accurately implement and integrate critical thinking, clinical judgment, and clinical reasoning is enhanced with a commitment to lifelong learning. Andersson, Klang, and Petersson (2012) conducted a study of clinical reasoning in a pediatric facility. They found that experience and increased education or training were important in the development of professional competence and also enhanced clinical reasoning.
CONCEPT MAPPING Concept mapping is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking. Also known as mind mapping, concept maps are context dependent and can be used to develop analytical skills. The attributes of the concept are linked, making meaning of the concept they represent. Concept maps provide an opportunity to visualize things in your own way
BOX 10–4 Types of Concept Maps
• Hierarchical maps—concept and attributes arranged in a hierarchical pattern and typically constructed in a descending order of importance. Relationships are identified between and among a concept and its attributes (see Figure 10–2A)
• Spider maps—depict the interrelatedness of the concept and its attributes in the map (see Figure 10–2B)
• Flowchart maps—linear diagrams demonstrating sequence or cause-and-effect relations (see Figure 10–2C)
• Systems maps—inputs and outputs illustrate relationships among the concept and its attributes (see Figure 10–2D)
Figure 10–2 • Types of concept maps: A, hierarchical; B, spider; C, flowchart; D, systems.
A. B.
C. D.
INPUT
OUTPUT
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Critical Thinking Checkpoint
Mr. W. is a 63-year-old recently retired engineer with a history of irri- table bowel syndrome that causes frequent diarrhea and rectal bleed- ing. His wife is a schoolteacher. In mid-December he comes to the acute care clinic complaining about “not feeling good.” You conclude he is having a recurrence of his intestinal problem. 1. What questions would you ask yourself to check this
assumption? 2. How would you demonstrate that you are using the critical think-
ing attitude of “confidence in reasoning”?
3. Socrates might ask you about the consequences of your conclu- sion by posing the question “What are the implications of your thinking?” How would you answer? Consider the implications if you are correct and if you are incorrect in your assumption.
4. Critical thinkers look for subtle cues. Which cues in this situation require follow-up?
See Critical Thinking Possibilities on student resource website.
LIFESPAN CONSIDERATIONS Health Care Decisions
CHILDREN Parents most often make decisions about the health care of chil- dren. Growing children, however, can participate in those decisions in age-appropriate ways. As described by Piaget, the ability of chil- dren to reason and think critically about themselves and their situa- tion develops gradually (see Chapter 20 ). At each stage, nurses should be aware of the ways children think and be sensitive to how they can be involved in health care decisions: • Infants progress from reflexive behavior to simple, repetitive be-
havior and then to imitative behaviors, learning the concepts of cause and effect and object permanence. Though not involved in making decisions, they need to be comforted and secure as care is given.
• Toddlers and preschoolers are very egocentric and engage in magical thinking. They cannot reason out the implications of care, but need explanations in language they can understand. Play therapy and use of dolls and toys can help them adjust to care, and they can sometimes be given options (e.g., do you want your dressing changed before breakfast or after?).
• School-age children tend to be concrete thinkers. They ben- efit from simple, direct explanations; hands-on exploration of equipment and materials; and helping the care provider as
appropriate during procedures. Involving these children in care can increase cooperation and decrease anxiety.
• Adolescents are increasingly able to think abstractly and may make many of their own health care decisions. They should be actively consulted as a part of the family system.
OLDER ADULTS It is important to include all adult clients in decision making and plan- ning nursing care, but it is especially difficult to do this when working with older adults who have impaired cognitive abilities as is seen with, for example, Alzheimer’s disease. The nurse should allow them as much control and input as possible, keeping things simple and direct so they understand. Older adults with impairments are usu- ally unable to perform multiple tasks or even to think of more than one step at a time. The nurse must have patience and be willing to calmly repeat instructions if necessary. Presenting and discussing issues in basic terms helps to maintain respect and dignity and al- lows older adults to participate in their own care for as long as pos- sible. If the older adult is unable to perform self-care activities such as bathing or health-related activities such as a dressing change, the nurse should seek appropriate alternative methods for assisting the older adult with these.
Dickson and Flynn (2012) conducted a study to understand nurses’ experiences in preventing medication errors. The authors gathered the data for the study by visiting nurses in the hospitals where they were employed. They interviewed 50 medical–surgical nurses from 10 mid-Atlantic hospitals in the United States. The first research question was “What are the thoughts and actions hospital nurses use to identify medication errors and prevent them from reaching their clients?” The second question was “What factors in the en- vironment have an impact on the medication safety care practices identified by hospital nurses?”
The researchers found that the nurses ensure client safety when administering medications by interacting with the client and the fam- ily. The nurses acknowledged that it was crucial for them to admin- ister the right drug, to the right client, in the right dose, at the right
time, and via the right route. However, they felt that safe medication administration practices did not end with the five rights. The nurses stated that they needed to analyze the data from evidence-based practice articles and engage in clinical reasoning to administer medi- cations safely. They also revealed that they experience strong and lasting emotions after making a medication error.
IMPLICATIONS When administering medications to clients, nurses must ensure cli- ent safety by taking the time to understand the medication effects and maintaining a quiet zone while medications are administered. They must also utilize clinical reasoning to advocate for the client and coordinate care with health care providers, experienced nurses, and other members of the health care team.
Evidence-Based Practice How Does Clinical Reasoning Affect Client Safety in the Administration of Medications? EVIDENCE-BASED PRACTICE
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• Nurses need critical thinking skills and attitudes to be safe, compe- tent, skillful practitioners.
• Nurses use clinical reasoning skills to assess each client’s condi- tion and identify interventions that improve clients’ physiological and psychosocial outcomes.
• Creativity enhances critical thinking. Creative nurses generate many ideas rapidly, are flexible and natural, create original solu- tions to problems, tend to be independent and self-confident, and demonstrate individuality.
• Critical thinking skills include the ability to do critical analysis, per- form inductive and deductive reasoning, make valid inferences, dif- ferentiate facts and opinions, evaluate the credibility of information sources, clarify concepts, and recognize assumptions.
• Critical thinkers have certain attitudes: independence, fair- mindedness, insight, intellectual humility, intellectual courage to challenge the status quo and rituals, integrity, perseverance, con- fidence, and curiosity.
• Nurses utilize cognitive processes in clinical reasoning, and their thinking is based on the knowledge of the aspects of client care.
• Nurses also utilize metacognitive processes in clinical reasoning through the knowledge they gain in the care of clients.
• Clinical reasoning-in-transition is the ability to recognize subtle changes in a client’s condition over time.
• Reflection is the identification of factors that improve client’s care.
CHAPTER HIGHLIGHTS
1. A client with diarrhea also has a primary care provider’s order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, “The pri- mary care provider does not know the client has diarrhea.” What type of statement is this? 1. A fact 2. An inference 3. A judgment 4. An opinion
2. A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is
hungry enough to eat. 3. Notify the primary care provider that tube feeding may be
indicated soon. 4. Believe the client is not really hungry.
3. A client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and re- flects on a previous client with the same clinical manifestations. What do these actions represent? 1. Clinical judgment 2. Clinical reasoning 3. Reflection 4. Intuition
4. The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision making is the nurse engaging in? 1. The research method 2. The trial-and-error method 3. Intuition 4. The nursing process
5. In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the follow- ing before implementing a plan? 1. Reexamines the purpose for making the decision. 2. Consults the client and family members to determine their
view of the criteria. 3. Identifies and considers various means for reaching the
outcomes. 4. Determines the logical course of action should intervening
problems arise. 6. The nurse is concerned about a client who begins to breathe
very rapidly. Which action by the nurse reflects clinical reasoning? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest x-ray. 4. Call the rapid response team.
7. The nurse is teaching a client about wound care during a follow- up visit in the client’s home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence- based practice when the client states, “I just don’t know how I can afford these dressings”? 1. Integrity 2. Intellectual humility 3. Confidence 4. Independence
8. When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? 1. Creating environments that support critical thinking 2. Tolerating dissonance and ambiguity 3. Self-assessment 4. Seeking situations where good thinking is practiced
TEST YOUR KNOWLEDGE
Chapter 10 Review
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9. A client in a cardiac rehabilitation program says to the nurse, “I have to eat a low-sodium diet for the rest of my life, and I hate it!” Which is the most appropriate response by the nurse? 1. “I will get a dietary consult to talk to you before next week.” 2. “What do you think is so difficult about following a
low-sodium diet?” 3. “At least you survived a heart attack and are able to return
to work.” 4. “You may not need to follow a low-sodium diet for as long
as you think.”
10. Which reasoning process describes the nurse’s actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition 2. Research process 3. Trial and error 4. Problem solving
See Answers to Test Your Knowledge in Appendix A.
Suggested Reading Deschenes, M., Charlin, B. Gagnon, R., & Goudreau, J.
(2011). Use of a script concordance test to assess development of clinical reasoning in nursing stu- dents. Journal of Nursing Education, 50(7), 381–387. doi:10.3928/0148434-10110331- In response to the lack of evidence for assessing and measuring the clinical reasoning skills of nurses, the au- thors developed a script concordance test. This test is an examination of prototypical clinical practice situations that possess ambiguous, complex, and incomplete information. The scoring of the instrument is based on the responses of 15 expert panelists. Thirty first-year nursing students com- pleted the test. The students’ responses are compared to the responses of the expert panel. The study revealed that script concordance tests allow educators to assess the quality of students’ organization of knowledge. They also evaluate students’ ability to make appropriate decisions related to nursing interventions and professional practice.
Related Research Fossum, M., Alexander, G. L., Goransson, K. E.,
Ehnfors, M., & Ehrenberg, A. (2011). Registered nurses’ thinking strategies on malnutrition and pressure ul- cers in nursing homes: A scenario-based think-aloud study. Journal of Clinical Nursing, 20, 2425–2435. doi:10.1111/j.1365-2702.2010.03578.x
Lapkin, S., & Levett-Jones, T. (2011). A cost-utility analysis of medium versus high-fidelity human patient simulation mani- kins in nursing education. Journal of Clinical Nursing, 20, 3543–3552. doi:10.1111/j.1365-2702.2011.03843.x
References Alfaro-LeFevre, R. (2013). Critical thinking and clinical judg-
ment: A practical approach to outcome-focused thinking (5th ed.). Philadelphia, PA: W. B. Saunders Elsevier.
Alfaro-LeFevre, R. (2014). Critical thinking indicators (CTIs): 2014 evidence-based version. Retrieved from http:// www.alfaroteachsmart.com/2014CTIrichJan.pdf
Andersson, N., Klang, B., & Petersson, G. (2012). Differences in clinical reasoning among nurses working in highly spe- cialised paediatric care. Journal of Clinical Nursing, 21, 870–879. doi:10.1111/j.1365-2702.2011.03935.x
Asselin, M. E. (2011). Using reflection strategies to link course knowledge to clinical practice: The RN-to-BSN student experience. Journal of Nursing Education, 50, 125–132. doi:10.3928/01484834-20101230-08
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educat- ing nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
Billings, D., & Halstead, J. (2012). Teaching in nursing (4th ed.). St. Louis, MO: Elsevier.
Bittencourt, K., & Crosetti, M. (2012). Theoretical model of critical thinking in diagnostic processes in nursing. Online Brazilian Journal of Nursing, 11(2), 563–567.
Chabeli, M. M. (2010). Concept-mapping as a teaching method to facilitate critical thinking in nursing education: A review of the literature. Health SA Gesondheid, 15(1), 1–7.
Daley, B. J., & Torre, D. M. (2010). Concept maps in medical education: An analytical literature review. Medical Educa- tion, 44, 440–448. doi:10.1111/j.1365-2923.2010.03628.x
Dickson, G. L., & Flynn, L. (2013). Nurses’ clinical reasoning: Pro- cesses and practices of medication safety. Qualitative Health Research, 22, 3–16. doi:10.1177/1049732311420448
Lunney, M. (2010). Use of critical thinking in the diagnostic pro- cess. International Journal of Nursing Terminologies and Clas- sifications, 21, 82–88. doi:10.1111/j.1744-618X.2010.01150.x
Scheffer, B., & Rubenfeld, M. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359.
Scheffer, B., & Rubenfeld, M. G. (2010). Critical thinking TACTICS for nurses. Boston, MA: Jones & Bartlett.
Simmons, B. (2010). Clinical reasoning: Concept analy- sis. Journal of Advanced Nursing, 66(5), 1151–1158. doi:10.1111/j.1365-2648.2010.05262.x
Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.
Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment, differential diagnosis. Nurse Edu- cator, 38(1), 34–36. doi:10.1097/NNE.0b013e318276dfbe
Wilkinson, J. M. (2012). Nursing process and critical thinking (5th ed.). Upper Saddle River, NJ: Pearson.
Selected Bibliography Beyer, D. A. (2011). Reverse case study: To think like a
nurse. Journal of Nursing Education, 50(1), 48–50. doi:10.3928/01484834-20101029-06
Chang, M. J., Chang, Y.-J., Kuo, S.-H., Yang, Y.-H., & Chou, F.-H. (2011). Relationships between critical thinking ability and nursing competence in clinical nurses. Journal of Clinical Nursing, 20, 3224–3232. doi:10.1111/j.1365-2702.2010.03593.x
Krupat, E., Sprague, J. M., Wolpaw, D., Haidet, P., Hatem, D., & O’Brien, B. (2011). Thinking critically about critical think- ing: Ability, disposition, or both? Medical Education, 45, 625–635. doi:10.1111/j.1365-2923.2010.03910.x
Lewis, R., Strachan, A., & McKenzie-Smith, M. (2012). Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of current evidence. The Open Nursing Journal, 6, 82–89. doi:10.2174/1874434601206010082
Noonan, P. (2011). Using concept maps in perioperative edu- cation. Association of Operating Room Nurses Journal, 94, 469–478. doi:10.1016/j.aorn.2011.02.013
Thompson, C., & Stapley, S. (2011). Do educational interventions improve nurses’ clinical decision mak- ing and judgment? A systematic review. International Journal of Nursing Studies, 48, 881–893. doi:10.1016j. ijnurstu.2010.12.005
Wotton, K., Davis, J., Button, D., & Kelton, M. (2010). Third-year undergraduate nursing students’ perceptions of high-fidelity simulation. Journal of Nursing Education, 49, 632–639. doi:10.3928/01484834-20100831-01
READINGS AND REFERENCES
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11 Assessing
INTRODUCTION The nursing process is a systematic, rational method of planning and providing individualized nursing care. Its purposes are to iden- tify a client’s health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. The client may be an individual, a family, a community, or a group.
Hall originated the term nursing process in 1955, and Johnson (1959), Orlando (1961), and Wiedenbach (1963) were among the first to use it to refer to a series of phases describing the practice of nursing. Since then, various nurses have described the process of nursing and organized the phases in different ways.
OVERVIEW OF THE NURSING PROCESS The use of the nursing process in clinical practice gained ad- ditional legitimacy in 1973 when the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice. Figure 11–1 • illustrates the nursing process in action.
Phases of the Nursing Process The Standards of Practice within the most current Scope and Stan- dards of Nursing Practice include six phases of the nursing process: assessment, diagnosis, outcomes identification, planning, implemen- tation, and evaluation (ANA, 2010). The national licensure exami- nation for registered nurses (NCLEX) uses five phases: assessment,
analysis, planning, implementing, and evaluation. This text, and most others, uses five phases: assessing, diagnosing (which includes outcomes identification and analysis), planning, implementing, and evaluating. Although nurses may use different terms to describe the phases (or steps) of the nursing process, the activities of the nurse us- ing the process are similar. For example, implementing may be called implementation, intervention, or intervening.
An overview of the five-phase nursing process is shown in Table 11–1. Each of the five phases is discussed in depth in this and subsequent chapters of this unit. The phases of the nursing process are not separate entities but overlapping, continuing subprocesses (Figure 11–2 •). For example, assessing, which may be considered the first phase of the nursing process, is also carried out during the implementing and evaluating phases. For instance, while actually administering medications (implementing), the nurse continuously notes the client’s skin color, level of consciousness, and so on.
Each phase of the nursing process affects the others; they are closely interrelated. For example, if inadequate data are obtained dur- ing assessing, the nursing diagnoses will be incomplete or incorrect; inaccuracy will also be reflected in the planning, implementing, and evaluating phases.
Characteristics of the Nursing Process The nursing process has distinctive characteristics that enable the nurse to respond to the changing health status of the client. These characteristics include its cyclic and dynamic nature, client centered- ness, focus on problem solving and decision making, interpersonal
assessing, 159 cephalocaudal, 167 closed questions, 164 cues, 171 data, 159 database, 160
directive interview, 164 focused interview, 164 inferences, 171 interview, 164 leading question, 165 neutral question, 165
nondirective interview, 164 nursing process, 155 objective data, 160 open-ended questions, 164 rapport, 164 review of systems, 167
screening examination, 167 signs, 160 subjective data, 160 symptoms, 160 validation, 171
KEY TERMS
After completing this chapter, you will be able to: 1. Describe the phases of the nursing process. 2. Identify major characteristics of the nursing process. 3. Identify the purpose of assessing. 4. Identify the four major activities associated with the assess-
ing phase. 5. Differentiate objective and subjective data and primary and
secondary data. 6. Identify three methods of data collection, and give examples
of how each is useful.
LEARNING OUTCOMES
7. Compare directive and nondirective approaches to interviewing.
8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.
9. Describe important aspects of the interview setting. 10. Contrast various frameworks used for nursing assessment.
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and collaborative style, universal applicability, and use of critical thinking and clinical reasoning.
• Data from each phase provide input into the next phase. Findings from the evaluation phase feed back into assessment. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle) that is continuously changing (dynamic) rather than stay- ing the same (static).
• The nursing process is client centered. The nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to deter- mine the client’s habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible.
• The nursing process is an adaptation of problem solving (see Chapter 10 ) and systems theory (see Chapter 24 ). It can be viewed as parallel to but separate from the process used by phy- sicians (the medical model). Both processes (a) begin with data
gathering and analysis, (b) base action (intervention or treatment) on a problem statement (nursing diagnosis or medical diagnosis), and (c) include an evaluative component. However, the medical model focuses on physiological systems and the disease process, whereas the nursing process is directed toward a client’s responses to real or potential disease and illness.
• Decision making is involved in every phase of the nursing pro- cess. Nurses can be highly creative in determining when and how to use data to make decisions. They are not bound by standard responses and may apply their repertoire of skills and knowledge to assist clients. This facilitates the individualization of the nurse’s plan of care.
• The nursing process is interpersonal and collaborative. It requires the nurse to communicate directly and consistently with clients and families to meet their needs. It also requires that nurses col- laborate, as members of the health care team, in a joint effort to provide quality client care.
Figure 11–1 • The nursing process in action.
IMPLEMENTING • Reassess the client • Determine the nurse’s need for assistance • Implement the nursing interventions • Supervise delegated care • Document nursing activities
DIAGNOSING • Analyze data • Identify health problems, risks, and strengths • Formulate diagnostic statements
PLANNING • Prioritize problems/diagnoses • Formulate goals/desired outcomes • Select nursing interventions • Write nursing interventions
EVALUATING • Collect data related to outcomes • Compare data with outcomes • Relate nursing actions to client goals/outcomes • Draw conclusions about problem status • Continue, modify, or terminate the client’s care plan
The nursing process is a systematic, rational method of planning and providing nursing care. Its purpose is to identify a client’s health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs. The nursing process is cyclical; that is, its components follow a logical sequence, but more than one component may be involved at one time. At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified.
ASSESSING • Collect data • Organize data • Validate data • Document data
ASSESSING
DIAGNOSING
PLANNING
IMPLEMENTING
EVALUATING
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DIAGNOSING After analysis, Nurse Medina formulates a nursing diagnosis: Ineffective Airway Clearance related to accumulated mucus obstructing airways.
PLANNING Nurse Medina and Margaret collaborate to establish goals (e.g., restore effective breathing pattern and lung ventilation); set outcome criteria (e.g., have a symmetrical respiratory excursion of at least 4 cm, and so on); and develop a care plan that includes, but is not limited to, coughing and deep-breathing exercises q3h, fluid intake of 3,000 mL daily, and daily postural drainage.
EVALUATING Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.
Margaret O’Brien is a 33-year-old nursing student. She is married and has a 13-year-old daughter and 5-year-old son. She is admitted to the hospital with an elevated temperature, a productive cough, and rapid, labored respirations. While taking a nursing history, Mary Medina, RN, finds that Margaret has had a “chest cold” for 2 weeks and has been experiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to experience “pain” in her “lungs.”
ASSESSING Nurse Medina’s physical assessment reveals that Margaret’s vital signs are: Temperature, 39.4°C (103°F); pulse 92 beats/min; respirations 28/min; and blood pressure, 122/80 mmHg. Nurse Medina observes that Margaret’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.
IMPLEMENTING Margaret agrees to practice the deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake and to plan her morning activities to accommodate postural drainage.
Figure 11–1 • Continued
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Phase and Description Purpose Activities ASSESSING Collecting, organizing, validating, and documenting client data
To establish a database about the client’s response to health concerns or illness and the ability to manage health care needs
Establish a database: • Obtain a nursing health history. • Conduct a physical assessment. • Review client records. • Review nursing literature. • Consult support persons. • Consult health professionals. Update data as needed. Organize data. Validate data. Communicate/document data.
DIAGNOSING Analyzing and synthesizing data To identify client strengths and health
problems that can be prevented or resolved by collaborative and independent nursing interventions To develop a list of nursing and collaborative problems
Interpret and analyze data: • Compare data against standards. • Cluster or group data (generate tentative
hypotheses). • Identify gaps and inconsistencies. Determine client’s strengths, risks, and problems. Formulate nursing diagnoses and collaborative problem statements. Document nursing diagnoses on the care plan.
PLANNING Determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner
To develop an individualized care plan that specifies client goals/desired out- comes, and related nursing interventions
Set priorities and goals/outcomes in collaboration with client. Write goals/desired outcomes. Select nursing strategies/interventions. Consult other health professionals. Write nursing interventions and nursing care plan. Communicate care plan to relevant health care providers.
IMPLEMENTING Carrying out (or delegating) and documenting the planned nursing interventions
To assist the client to meet desired goals/ outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning
Reassess the client to update the database. Determine the nurse’s need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented: • Document care and client responses to care. • Give verbal reports as necessary.
EVALUATING Measuring the degree to which goals/outcomes have been achieved and identifying factors that posi- tively or negatively influence goal achievement
To determine whether to continue, modify, or terminate the plan of care
Collaborate with client and collect data related to desired outcomes. Judge whether goals/outcomes have been achieved. Relate nursing actions to client goals/outcomes. Make decisions about problem status. Review and modify the care plan as indicated or terminate nursing care. Document achievement of outcomes and modification of the care plan.
TABLE 11–1 Overview of the Nursing Process
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Figure 11–2 • The five overlapping phases of the nursing process. Each phase depends on the accuracy of the other phases. Each phase involves critical thinking.
Planning
Implementing
Evaluating
Assessing
Diagnosing
Critical Thinking
Examples of Critical Thinking in the Nursing ProcessTABLE 11–2
Nursing Process Phase
Critical Thinking Activities
Assessing Making reliable observations Distinguishing relevant from irrelevant data
Distinguishing important from unimportant data
Validating data
Organizing data
Categorizing data according to a framework
Recognizing assumptions
Identifying gaps in the data
Diagnosing Finding patterns and relationships among cues Making inferences
Suspending judgment when lacking data
Stating the problem
Examining assumptions
Comparing patterns with norms
Identifying factors contributing to the problem
Planning Forming valid generalizations Transferring knowledge from one situation to another Developing evaluative criteria
Hypothesizing
Making interdisciplinary connections
Prioritizing client problems
Generalizing principles from other sciences
Implementing Applying knowledge to perform interventions Testing hypotheses
Evaluating Deciding whether hypotheses are correct Making criterion-based evaluations
Wilkinson, Judith M., Nursing Process and Critical Thinking, 5th Ed., © 2012. Reprinted and Electronically reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.
• The universally applicable characteristic of the nursing process means that it is used as a framework for nursing care in all types of health care settings, with clients of all age groups.
• Nurses must use a variety of critical thinking skills to carry out the nursing process (see Chapter 10 ). Table 11–2 provides ex- amples of critical thinking in the nursing process.
• Nurses must utilize clinical reasoning throughout the delivery of nursing care. By reflecting the nurse determines whether the out- come of care was appropriate. Figure 11–3 • provides an over- view of the nursing process and reflection questions to be asked by the nurse while providing care and during the evaluation of care.
ASSESSING Assessing is the systematic and continuous collection, orga- nization, validation, and documentation of data (information) ( Figure 11–4 •). In effect, assessing is a continuous process carried out during all phases of the nursing process. For example, in the eval- uation phase, the client is reassessed to determine the outcomes of the nursing strategies and to evaluate goal achievement. All phases of the nursing process depend on the accurate and complete collection of data. The four different types of assessments are the initial nursing as- sessment, problem-focused assessment, emergency assessment, and time-lapsed reassessment (Table 11–3). Assessments vary according to their purpose, timing, time available, and client status.
Nursing assessments focus on a client’s responses to a health problem. A nursing assessment should include the client’s perceived needs, health problems, related experience, health practices, values, and lifestyles. To be most useful, the data collected should be rele- vant to a particular health problem. Therefore, nurses should think critically about what to assess. In 2008 The Joint Commission es- tablished a nursing practice guideline stating that each client should have an initial nursing assessment consisting of a history and physical
examination performed and documented within 24 hours of admis- sion as an inpatient. The guideline states further that an LPN may gather the data but the RN is responsible for care and must assess the data determining the needs of the client. The RN also has the respon- sibility for developing the client’s plan of care.
The 2010 revision of ANA Standard 1: Assessment adds several important aspects to this step of the nursing process. The registered nurse is responsible for the collection of comprehensive data, includ- ing physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments. The nursing assessment also involves the elicitation of clients’ own perspectives on their condition; identifying barriers to communication; recognizing the impact of the nurse’s own attitudes, values, and beliefs on the assessment process; including family dynamics in assessment; and increased emphasis on protec- tion of the privacy of data (ANA, 2010, p. 32).
COLLECTING DATA Data collection is the process of gathering information about a cli- ent’s health status. Data collection must be both systematic and
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Figure 11–3 • Critical thinking, clinical reasoning, and the nursing process.
Critical Thinking
Clinical Reasoning
Nursing Process
Assessing
Gather subjective and objective data
Identify the client's chief complaint
Diagnosing
Based on the data collected identify a
nursing diagnosis from NANDA International
Consult evidence practice literature
Planning
Goal Development
Recall nursing and health related knowledge
Consult with the primary care provider and client
Review outcomes of prior clinical situations
Implementing
Identify and implement interventions to assist in the attainment of goals and resolution of the
nursing diagnosis
Evaluating
Evaluate the client's response to the care
provided
Reflecting
Was care provided in a timely manner?
Was the client assessed accurately?
Were the interventions appropriate?
Were the goals attained?
Was the nursing diagnosis resolved?
continuous to prevent the omission of significant data and reflect a client’s changing health status.
A database contains all the information about a client; it in- cludes the nursing health history (Box 11–1), physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Client data should include past history as well as current problems. For example, a history of an allergic reaction to peni- cillin is a vital piece of historical data. Past surgical procedures, folk healing practices, and chronic diseases are also examples of historical data. Current data relate to present circumstances, such as pain, nausea, sleep patterns, and religious practices. To collect data accurately, both the client and nurse must actively participate. Data can be of the subjective or objective and constant or variable
types, and from a primary or secondary source. The collection of data allows the nurse, client, and health care team to identify health-related problems or risk factors that could cause changes in a client’s health status.
Types of Data Subjective data, also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feelings of worry are examples of subjective data. Subjective data include the client’s sensations, feel- ings, values, beliefs, attitudes, and perception of personal health sta- tus and life situation.
Objective data, also referred to as signs or overt data, are de- tectable by an observer or can be measured or tested against an ac- cepted standard. They can be seen, heard, felt, or smelled, and they
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frequently, or rarely and include such data as blood pressure, level of pain, and age.
A complete database provides a baseline for comparing the cli- ent’s responses to nursing and medical interventions. Examples of subjective and objective data are shown in Table 11–4.
Sources of Data Sources of data are primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary or indirect sources. In fact, all sources other than the client are considered secondary sources. All data from secondary sources should be validated if possible.
CLIENT The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. The nurse is often much closer to the client than other members of the health care team. In the acute care setting, nurse–client relationships will develop due to the close and frequent contact with the client (Fawcett & Rhynas, 2012). The client can provide subjective data that no one else can offer. Most often, primary data consist of statements made by the client but also include those objective data that can be directly obtained by the nurse from the client such as gender. Some clients cannot or do not wish to provide accurate data. Family members or significant others can be secondary sources of data if the client cannot speak for themselves, is a poor historian, or is a young child. If the client is hesitant to pro- vide data, remind the client that the privacy of all data collected is protected and can only be shared with persons who have a legitimate health-related need to know it. If necessary, review for yourself the mandates of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) so you can explain this in a way that the client can understand. Summarized information about HIPAA in terms under- standable to both nurses and the client is available on the U.S. Depart- ment of Health and Human Services website.
Type Time Performed Purpose Example Initial assessment Performed within specified
time after admission to a health care agency
To establish a complete database for problem identification, refer- ence, and future comparison
Nursing admission assessment
Problem-focused assessment Ongoing process integrated with nursing care
To determine the status of a specific problem identified in an earlier assessment
Hourly assessment of client’s fluid intake and urinary output in an ICU Assessment of client’s ability to perform self-care while assisting a client to bathe
Emergency assessment During any physiological or psychological crisis of the client
To identify life-threatening problems To identify new or overlooked problems
Rapid assessment of an individu- al’s airway, breathing status, and circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence
Time-lapsed reassessment Several months after initial assessment
To compare the client’s current status to baseline data previously obtained
Reassessment of a client’s func- tional health patterns in a home care or outpatient setting or, in a hospital, at shift change
TABLE 11–3 Types of Assessment
Figure 11–4 • Assessing. The assessment process involves four closely related activities.
Planning
Implementing
Evaluating
Diagnosing
Assessing • Collect data • Organize data • Validate data • Document data
are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data. During the physical examination, the nurse obtains objective data to validate subjective data and to complete the assessment phase of the nursing process.
Constant data is information that does not change over time such as race or blood type. Variable data can change quickly,
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SUPPORT PEOPLE Family members, friends, and caregivers who know the client well often can supplement or verify information provided by the client. They might convey information about the client’s response to illness, the stresses the client was experiencing before the illness, family at- titudes on illness and health, and the client’s home environment.
Support people are an especially important source of data for a client who is very young, unconscious, or confused. In some cases—a
BOX 11–1 Components of a Nursing Health History
BIOGRAPHIC DATA Client’s name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care.
CHIEF COMPLAINT OR REASON FOR VISIT The answer given to the question “What is troubling you?” or “De- scribe the reason you came to the hospital or clinic today.” The chief complaint should be recorded in the client’s own words.
HISTORY OF PRESENT ILLNESS • When the symptoms started • Whether the onset of symptoms was sudden or gradual • How often the problem occurs • Exact location of the distress • Character of the complaint (e.g., intensity of pain or quality of
sputum, emesis, or discharge) • Activity in which the client was involved when the problem
occurred • Phenomena or symptoms associated with the chief complaint • Factors that aggravate or alleviate the problem
PAST HISTORY • Illnesses, such as chickenpox, mumps, measles, rubella
(German measles), rubeola (red measles), streptococcal infections, scarlet fever, rheumatic fever, hepatitis, polio, and other significant illnesses
• Immunizations and the date of the last tetanus shot • Allergies to drugs, animals, insects, or other environmental
agents, the type of reaction that occurs, and how the reaction is treated
• Accidents and injuries: how, when, and where the incident oc- curred, type of injury, treatment received, and any complications
• Hospitalization for serious illnesses: reasons for the hospitaliza- tion, dates, surgery performed, course of recovery, and any complications
• Medications: all currently used prescription, over-the-counter medications, such as aspirin, nasal spray, vitamins, or laxatives, and herbal supplements
FAMILY HISTORY OF ILLNESS To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health or, if they are deceased, the cause of death are obtained. Particular attention should be given to disorders such as heart disease, cancer, diabe- tes, hypertension, obesity, allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.
LIFESTYLE • Personal habits: the amount, frequency, and duration of sub-
stance use (tobacco, alcohol, coffee, cola, tea, and illegal or recreational drugs)
• Diet: description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shops for food, ethnic food patterns, and allergies
• Sleep patterns: usual daily sleep/wake times, difficulties sleep- ing, and remedies used for difficulties
• Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion
• Instrumental ADLs: any difficulties experienced in food prepa- ration, shopping, transportation, housekeeping, laundry, and ability to use the telephone, handle finances, and manage medications
• Recreation/hobbies: exercise activity and tolerance, hobbies and other interests, and vacations
SOCIAL DATA • Family relationships/friendships: the client’s support system
in times of stress (who helps in time of need?), what effect the client’s illness has on the family, and whether any family problems are affecting the client (See also the discussion of family assessment in Chapter 24 .)
• Ethnic affiliation: health customs and beliefs; cultural practices that may affect health care and recovery (See also the detailed ethnic/cultural assessment guide in Chapter 18 .)
• Educational history: data about the client’s highest level of edu- cation attained and any past difficulties with learning
• Occupational history: current employment status, the number of days missed from work because of illness, any history of ac- cidents on the job, any occupational hazards with a potential for future disease or accident, the client’s need to change jobs because of past illness, the employment status of spouses or partners and the way child care is handled, and the client’s overall satisfaction with the work
• Economic status: information about how the client is paying for medical care (including what kind of medical and hospitalization coverage the client has) and whether the client’s illness pre- sents financial concerns
• Home and neighborhood conditions: home safety measures and adjustments in physical facilities that may be required to help the client manage a physical disability, activity intolerance, and activities of daily living; the availability of neighborhood and community services to meet the client’s needs.
PSYCHOLOGICAL DATA • Major stressors experienced and the client’s perception of them • Usual coping pattern for a serious problem or a high level of
stress • Communication style: ability to verbalize appropriate emo-
tion; nonverbal communication—such as eye movements, gestures, use of touch, and posture; interactions with support persons; and the congruence of nonverbal behavior and verbal expression
PATTERNS OF HEALTH CARE All health care resources the client is currently using and has used in the past. These include the primary care provider, specialists (e.g., ophthalmologist or gynecologist), dentist, folk practitioners (e.g., herbalist or curandero), health clinic, or health center; whether the client considers the care being provided adequate; and whether access to health care is a problem.
client who is physically or emotionally abused, for example—the person giving information may wish to remain anonymous. Before eliciting data from support people, the nurse should ensure that the client, if mentally able, authorizes such input. The nurse should also indicate on the nursing history that the data were obtained from a support person.
Information supplied by family members, significant others, or other health professionals is considered subjective if it is not based on
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numerous previous records. These are very useful and contribute to a full understanding of the health history, especially if the client’s memory is impaired.
HEALTH CARE PROFESSIONALS Because assessment is an ongoing process, verbal reports from other health care professionals serve as other potential sources of infor- mation about a client’s health. Nurses, social workers, primary care providers, and physiotherapists, for example, may have information from either previous or current contact with the client. Sharing of information among professionals is especially important to ensure continuity of care when clients are transferred to and from home and health care agencies.
LITERATURE The review of nursing and related literature, such as professional journals and reference texts, can provide additional information for the database. A literature review includes but is not limited to the fol- lowing information:
• Standards or norms against which to compare findings (e.g., height and weight tables, normal developmental tasks for an age group)
• Cultural and social health practices • Spiritual beliefs • Assessment data needed for specific client conditions • Nursing interventions and evaluation criteria relevant to a client’s
health problems • Information about medical diagnoses, treatment, and prognoses • Current methodologies and research findings.
Data Collection Methods The principal methods used to collect data are observing, interview- ing, and examining. Observing occurs whenever the nurse is in con- tact with the client or support persons. Interviewing is used mainly while taking the nursing health history. Examining is the major method used in the physical health assessment.
In reality, the nurse uses all three methods simultaneously when assessing clients. For example, during the client interview the nurse observes, listens, asks questions, and mentally retains information to explore in the physical examination.
fact. If the client’s daughter says, “Dad is very confused today,” that is secondary subjective data because it is an interpretation of the client’s behavior by the daughter. The nurse should attempt to verify the re- ported confusion by interviewing the client directly. However, if the daughter says, “Dad said he thought it was the year 1941 today,” that may be considered secondary objective data since the daughter heard her father state this directly.
CLIENT RECORDS Client records include information documented by various health care professionals. Client records also contain data regarding the client’s occupation, religion, and marital status. By reviewing such records before interviewing the client, the nurse can avoid asking questions for which answers have already been supplied. Repeated questioning can be stressful and annoying to clients and cause con- cern about the lack of communication among health professionals. Types of client records include medical records, records of therapies, and laboratory records.
Medical records (e.g., medical history, physical examination, operative report, progress notes, and consultations done by primary care providers) are often a source of a client’s present and past health and illness patterns. These records can provide nurses with informa- tion about the client’s coping behaviors, health practices, previous ill- nesses, and allergies.
Records of therapies provided by other health professionals, such as social workers, nutritionists, dietitians, or physical therapists, help the nurse obtain relevant data not expressed by the client. For example, a social agency’s report on a client’s living conditions or a home health care agency’s report on a client’s ability to cope at home help the nurse conducting an assessment.
Laboratory records also provide pertinent health information. For example, the determination of blood glucose level allows health professionals to monitor the administration of oral hypoglycemic medications. Any laboratory data about a client must be compared to the agency or performing laboratory’s norms for that particular test and for the client’s age, gender, and other characteristics. Commonly ordered diagnostic studies are discussed in Chapter 34 .
The nurse must always consider the information in client re- cords in light of the current situation. For example, if the most re- cent medical record is 10 years old, the client’s health practices and coping behaviors are likely to have changed. Older clients may have
Subjective Objective “I feel weak all over when I exert myself.” Blood pressure 90/50 mmHg*
Apical pulse 104 beats/min Skin pale and diaphoretic
Client states he has a cramping pain in his abdomen. States, “I feel sick to my stomach.”
Vomited 100 mL green-tinged fluid Abdomen firm and slightly distended Active bowel sounds auscultated in all four quadrants
“I’m short of breath.” Lung sounds clear bilaterally; diminished in right lower lobe
Wife states: “He doesn’t seem so sad today.” (This is subjective and secondary source data.)
Client cried during interview
“I would like to see the chaplain before surgery.” Holding open Bible Has small silver cross on bedside table
*Blood pressure obtained using an external cuff and manometer may be considered secondary or indirect data since it does not directly measure the pressure within the arteries.
TABLE 11–4 Examples of Subjective and Objective Data
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mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission assessment. In a focused interview the nurse asks the client specific questions to collect information related to the client’s problem. This allows the nurse to collect information that may have previously been missed and yields more in-depth information (D’Amico & Barbarito, 2013).
There are two approaches to interviewing: directive and nondi- rective. The directive interview is highly structured and elicits spe- cific information. The nurse establishes the purpose of the interview and controls the interview, at least at the outset. The client responds to questions but may have limited opportunity to ask questions or discuss concerns. Nurses frequently use directive interviews to gather and to give information when time is limited (e.g., in an emergency situation).
By contrast, during a nondirective interview, or rapport- building interview, the nurse allows the client to control the purpose, subject matter, and pacing. Rapport is an understanding between two or more people.
A combination of directive and nondirective approaches is usu- ally appropriate during the information-gathering interview. The nurse begins by determining areas of concern for the client. If, for example, a client expresses worry about surgery, the nurse pauses to explore the client’s worry and to provide support. Simply noting the worry, without dealing with it, can leave the impression that the nurse does not care about the client’s concerns or dismisses them as unimportant.
TYPES OF INTERVIEW QUESTIONS Questions are often classified as closed or open ended, and neutral or leading. Closed questions, used in the directive interview, are restrictive and generally require only “yes” or “no” or short factual answers that provide specific information. Closed questions often begin with “when,” “where,” “who,” “what,” “do (did, does),” or “is (are, was).” Examples of closed questions are “What medication did you take?” “Are you having pain now? Show me where it is.” “How old are you?” “When did you fall?” Closed questions are often used when information is needed quickly, such as in an emergency situation. The highly stressed person and the person who has difficulty communicating will find closed questions easier to answer than open- ended questions.
Open-ended questions, associated with the nondirective in- terview, invite clients to discover and explore, elaborate, clarify, or il- lustrate their thoughts or feelings. An open-ended question specifies only the broad topic to be discussed, and invites answers longer than one or two words. Such questions give clients the freedom to divulge only the information that they are ready to disclose. The open-ended question is useful at the beginning of an interview or to change topics and to elicit attitudes.
Open-ended questions may begin with “what” or “how.” Exam- ples of open-ended questions are “How have you been feeling lately?” “What brought you to the hospital?” “How did you feel in that situa- tion?” “Would you describe more about how you relate to your child?” “What would you like to talk about today?”
The type of question a nurse chooses depends on the needs of the client at the time. Nurses often find it necessary to use a combi- nation of closed and open-ended questions throughout an interview to accomplish the goals of the interview and obtain needed informa- tion. See Table 11–6 for advantages and disadvantages of open-ended and closed questions.
OBSERVING To observe is to gather data by using the senses. Observing is a con- scious, deliberate skill that is developed through effort and with an organized approach. Although nurses observe mainly through sight, most of the senses are engaged during careful observations. Examples of client data observed through the senses are shown in Table 11–5.
Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data. A nurse who observes that a cli- ent’s face is flushed must relate that observation to findings such as body temperature, activity, environmental temperature, and blood pressure. Errors can occur in selecting, organizing, and interpreting data. For ex- ample, a nurse might not notice certain signs, either because they are unexpected or because they do not conform to preconceptions about a client’s illness. Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing, therefore, in- volves distinguishing data in a meaningful manner. For example, nurses caring for newborns learn to ignore the usual sounds of machines in the nursery but respond quickly to an infant’s cry or movement.
The experienced nurse is often able to attend to an intervention (e.g., give a bed bath or monitor an intravenous infusion) and at the same time make important observations (e.g., note a change in re- spiratory status or skin color). The beginning student must learn to make observations and complete tasks simultaneously.
Nursing observations must be organized so that nothing signifi- cant is missed. Most nurses develop a particular sequence for observ- ing events, usually focusing on the client first. For example, a nurse walks into a client’s room and observes, in the following order:
1. Clinical signs of client distress (e.g., pallor or flushing, labored breathing, and behavior indicating pain or emotional distress)
2. Threats to the client’s safety, real or anticipated (e.g., a lowered side rail)
3. The presence and functioning of associated equipment (e.g., in- travenous equipment and oxygen)
4. The immediate environment, including the people in it.
INTERVIEWING An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of
Using the Senses to Observe Client DataTABLE 11–5
Sense Example of Client Data Vision Overall appearance (e.g., body size, general weight,
posture, grooming); signs of distress or discomfort; facial and body gestures; skin color and lesions; abnormalities of movement; nonverbal demeanor (e.g., signs of anger or anxiety); religious or cultural artifacts (e.g., books, icons, candles, beads)
Smell Body or breath odors
Hearing Lung and heart sounds; bowel sounds; ability to communicate; language spoken; ability to initiate conversation; ability to respond when spoken to; orientation to time, person, and place; thoughts and feelings about self, others, and health status
Touch Skin temperature and moisture; muscle strength (e.g., hand grip); pulse rate, rhythm, and volume; palpable lesions (e.g., lumps, masses, nodules)
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interview is influenced by time, place, seating arrangement or dis- tance, and language.
TIME Nurses need to plan interviews with clients when the client is physically comfortable and free of pain, and when interruptions by friends, family, and other health professionals are minimal. Nurses should schedule interviews with clients in their homes at a time se- lected by the client.
PLACE A well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions encourages communication. In addition, a place where others cannot overhear or see the client is desirable.
SEATING ARRANGEMENT By standing and looking down at a client who is in bed or in a chair, the nurse risks intimidating the cli- ent. When a client is in bed, the nurse can sit at a 45-degree angle to the bed. This position is less formal than sitting behind a table or standing at the foot of the bed. During an initial admission interview, a client may feel less confronted if there is an overbed table between the client and the nurse. Sitting on a client’s bed hems the client in and makes staring difficult to avoid.
A seating arrangement with the nurse behind a desk and the client seated across creates a formal setting that suggests a business meeting between a superior and a subordinate. In contrast, a seat- ing arrangement in which the parties sit on two chairs placed at right angles to a desk or table or a few feet apart, with no table between, creates a less formal atmosphere, and the nurse and client tend to feel on equal terms. In groups, a horseshoe or circular chair arrangement can avoid a superior or head-of-the-table position.
DISTANCE The distance between the interviewer and inter- viewee should be neither too small nor too great, because people
A neutral question is a question the client can answer with- out direction or pressure from the nurse, is open ended, and is used in nondirective interviews. Examples are “How do you feel about that?” “What do you think led to the operation?” A leading question, by contrast, is usually closed, used in a directive in- terview, and thus directs the client’s answer. Examples are “You’re stressed about surgery tomorrow, aren’t you?” “You will take your medicine, won’t you?” The leading question gives the client less op- portunity to decide whether the answer is true or not. Leading ques- tions create problems if the client, in an effort to please the nurse, gives inaccurate responses. This can result in inaccurate data.
Try to avoid asking “why” questions. These questions can be per- ceived as a form of interrogation by the client (Kneisl & Trigoboff, 2013). Because the goal of questioning is to elicit as much purposeful information as possible, anything that puts the client on the defensive will interfere with reaching that goal. However, in an emergency situ- ation the use of probing and direct questioning may be appropriate to gain a greater volume of data in a shorter period of time (Kneisl & Trigoboff, 2013).
PLANNING THE INTERVIEW AND SETTING Before beginning an interview, the nurse reviews available information, for example, the operative report, information about the current illness, or literature about the client’s health problem. The nurse also reviews the agency’s data collection form to identify which data must be collected and which data are within the nurse’s discretion to collect based on the specific client. If a form is not available, most nurses prepare an interview guide to help them remember areas of information and determine what questions to ask. The guide includes a list of topics and subtopics rather than a series of questions.
Both nurses and clients are made comfortable in order to en- courage an effective interview by balancing several factors. Each
OPEN-ENDED QUESTIONS Advantages Disadvantages
1. They let the interviewee do the talking. 2. The interviewer is able to listen and observe. 3. They reveal what the interviewee thinks is important. 4. They may reveal the interviewee’s lack of information,
misunderstanding of words, frame of reference, prejudices, or stereotypes.
5. They can provide information the interviewer may not ask for. 6. They can reveal the interviewee’s degree of feeling about
an issue. 7. They can convey interest and trust because of the freedom
they provide.
1. They take more time. 2. Only brief answers may be given. 3. Valuable information may be withheld. 4. They often elicit more information than necessary. 5. Responses are difficult to document and require skill in
recording. 6. The interviewer requires skill in controlling an open-ended
interview. 7. Responses require insight and sensitivity from the
interviewer.
CLOSED QUESTIONS Advantages Disadvantages
1. Questions and answers can be controlled more effectively. 2. They require less effort from the interviewee. 3. They may be less threatening, since they do not require
explanations or justifications. 4. They take less time. 5. Information can be asked for sooner than it would be
volunteered. 6. Responses are easily documented. 7. Questions are easy to use and can be handled by unskilled
interviewers.
1. They may provide too little information and require follow-up questions.
2. They may not reveal how the interviewee feels. 3. They do not allow the interviewee to volunteer possibly
valuable information. 4. They may inhibit communication and convey lack of interest
by the interviewer. 5. The interviewer may dominate the interview with questions.
TABLE 11–6 Selected Advantages and Disadvantages of Open-Ended and Closed Questions
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Establishing rapport is a process of creating goodwill and trust. It can begin with a greeting (“Good morning, Mr. Johnson”) or a self- introduction (“Good morning. I’m Becky James, a nursing student”) accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. The nurse must be careful not to overdo this stage; too much superficial talk can arouse anxiety about what is to follow and may appear insincere.
In orientation, the nurse explains the purpose and nature of the interview, for example, what information is needed, how long it will take, and what is expected of the client. The nurse tells the client how the information will be used and usually states that the client has the right not to provide data.
The following is an example of an interview introduction:
Step 1. Establish Rapport
Nurse: Hello, Ms. Goodwin, I’m Ms. Fellows. I’m a nursing student, and I’ll be assisting with your care here today. Client: Hi. Are you a student from the college? Nurse: Yes, I’m in my final year. Are you familiar with the campus? Client: Oh, yes! I’m an avid football fan. My nephew graduated in 2012, and I often attend football games with him. Nurse: That’s great! Sounds like fun. Client: Yes, I enjoy it very much.
Step 2. Orientation
Nurse: May I sit down with you here for about ten minutes to talk about your care while you’re here? Client: All right. What do you want to know? Nurse: Well, to plan your care after your operation, I’d like to get some information about your usual daily activities and what you expect here in the hospital. I’ll take notes while we talk to get the important points and have them available to the other staff who will also look after you. Client: OK. That’s all right with me. Nurse: If there is anything you don’t want to talk about, please feel free to say so. Everything you tell me will be confidential and shared only with others who have the legal right to know it. Client: Sure, that will be fine.
THE BODY In the body of the interview, the client communi- cates what he or she thinks, feels, knows, and perceives in response to questions from the nurse. Effective development of the interview demands that the nurse use communication techniques that make both parties feel comfortable and serve the purpose of the interview (see Chapter 26 ). For communicating during an interview, see the Practice Guidelines.
THE CLOSING The nurse terminates the interview when the needed information has been obtained. In some cases, however, a client terminates it, for example, when deciding not to give any more information or when unable to offer more information for some other reason—fatigue, for example. The closing is important for maintaining rapport and trust and for facilitating future interactions. The following techniques are commonly used to close an interview:
1. Offer to answer questions: “Do you have any questions?” “I would be glad to answer any questions you have.” Be sure to allow time for the person to answer, or the offer will be regarded as insincere.
2. Conclude by saying “Well, that’s all I need to know for now” or “Well, those are all the questions I have for now.” Preceding a
feel uncomfortable when talking to someone who is too close or too far away. Proxemics is the study of use of space. As a species, humans are highly territorial but we are rarely aware of it unless our space is somehow violated. Most people feel comfortable maintaining a dis- tance of 2 to 3 feet during an interview. Some clients require more or less personal space, depending on their cultural and personal needs. For additional information, see Chapter 18 .
LANGUAGE Failure to communicate in language the client can understand is a form of discrimination. The nurse must convert com- plicated medical terminology into common English usage, and inter- preters or translators are needed if the client and the nurse do not speak the same language or dialect (a variation in a language spoken in a par- ticular geographic region). Translating medical terminology is a special- ized skill because not all persons fluent in the conversational form of a language are familiar with anatomic or other health terms. Interpreters, however, may make judgments about precise wording but also about subtle meanings that require additional explanation or clarification ac- cording to the specific language and ethnicity. They may edit the origi- nal source to make the meaning clearer or more culturally appropriate.
If giving written documents to clients, the nurse must determine that the client can read in his or her native language. Live translation is preferred since the client can then ask questions for clarification. Nurses must be cautious when asking family members, client visi- tors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication. Services such as AT&T Language Line are available 24 hours a day in about 170 languages, for a fee paid by the health care provider. Many large agencies possess their own on-call translator services for the languages or dialects commonly spoken in their area.
Even among clients who speak English, there may be differences in understanding terminology. Clients from different parts of the country may have strong accents, or clients less well educated and teen clients may ascribe different meanings to words. For example, “cool” may imply something good to one client and something not warm to another. The nurse must always confirm accurate understandings.
STAGES OF AN INTERVIEW An interview has three major stages: the opening or introduction, the body or development, and the closing.
THE OPENING The opening can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview. The purposes of the opening are to establish rapport and orient the interviewee.
Personal Space
• Accepted distance between individuals in conversation varies with ethnicity. In some cultures the distance may be closer than a foot (some Middle Eastern cultures), or greater than a foot (some European cultures), and up to 3 feet (some Asian cultures).
• Men of all cultures usually require more space than women do. • Anxiety increases the need for space. • Direct eye contact increases the need for space. • Physical contact is used only if it has a therapeutic
purpose. Touch, even a simple hand on the shoulder, can be misinterpreted—especially between persons of opposite gender.
PATIENT-CENTERED CARE Culturally Responsive Care
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here each Monday, Tuesday, and Wednesday between eight o’clock and noon. At those times, we can adjust your care as needed.”
6. Provide a summary to verify accuracy and agreement. Summa- rizing serves several purposes: It helps to terminate the inter- view, it reassures the client that the nurse has listened, it checks the accuracy of the nurse’s perceptions, it clears the way for new ideas, and it helps the client to note progress and a forward direc- tion. “Let’s review what we have just covered in this interview.” Summaries are particularly helpful for clients who are anxious or who have difficulty staying with the topic. “Well, it seems to me that you are especially worried about your hospitalization and chest pain because your father died of a heart attack five years ago. Is that correct? I’ll discuss this with you again tomorrow, and we’ll decide what plans need to be made to help you.”
EXAMINING The physical examination or physical assessment is a systematic data collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct the examination, the nurse uses techniques of inspection, auscultation, palpation, and percussion (see Chapter 30 ).
The physical examination is carried out systematically. It may be organized according to the examiner’s preference, in a head-to-toe ap- proach or a body systems approach. Usually, the nurse first records a general impression about the client’s overall appearance and health sta- tus: for example, age, body size, mental and nutritional status, speech, and behavior. Then the nurse takes such measurements as vital signs, height, and weight. The cephalocaudal or head-to-toe approach be- gins the examination at the head; progresses to the neck, thorax, ab- domen, and extremities; and ends at the toes. The nurse using a body systems approach investigates each system individually, that is, the re- spiratory system, the circulatory system, the nervous system, and so on. During the physical examination, the nurse assesses all body parts and compares findings on each side of the body (e.g., lungs). These techniques are discussed in detail in Chapters 29 and 30 .
Instead of giving a complete examination, the nurse may fo- cus on a specific problem area noted from the nursing assessment, such as the inability to urinate. On occasion, the nurse may find it necessary to resolve a client complaint or problem (e.g., shortness of breath) before completing the examination. Alternatively, the nurse may perform a screening examination. A screening examination, also called a review of systems, is a brief review of essential func- tioning of various body parts or systems. An example of a screening examination is the nursing admission assessment form shown in Figure 11–5 •. Data obtained from this examination are measured against norms or standards, such as ideal height and weight standards or norms for body temperature or blood pressure levels.
ORGANIZING DATA The nurse uses a written (or electronic) format that organizes the assessment data systematically. This is often referred to as a nursing health history, nursing assessment, or nursing database form. The format may be modified according to the client’s physical status such as one focused on musculoskeletal data for orthopedic clients.
Conceptual Models/Frameworks Most schools of nursing and health care agencies have developed their own structured assessment format. Many of these are based on selected nursing models or frameworks (see Chapter 3 ). Three
remark with the word “well” generally signals that the end of the interaction is near.
3. Thank the client: “Thank you for your time and help. The ques- tions you have answered will be helpful in planning your nursing care.” You may also shake the client’s hand.
4. Express concern for the person’s welfare and future: “I hope all goes well for you.”
5. Plan for the next meeting, if there is to be one, or state what will happen next. Include the day, time, place, topic, and purpose: “Let’s get together again here on the fifteenth at nine a.m. to see how you are managing then.” Or “Ms. Goodwin, I will be responsible for giv- ing you care three mornings per week while you are here. I will be
PRACTICE GUIDELINES
Communication During an Interview
• Listen attentively, using all your senses, and speak slowly and clearly.
• Use language the client understands, and clarify points that are not understood.
• Plan questions to follow a logical sequence. • Ask only one question at a time. Multiple questions limit the
client to one choice and may confuse the client. • Acknowledge the client’s right to look at things the way they
appear to him or her and not the way they appear to the nurse or someone else.
• Do not impose your own values on the client. • Avoid using personal examples, such as saying, “If I were
you. . . .” • Nonverbally convey respect, concern, interest, and
acceptance. • Be aware of the client’s and your own body language. • Be conscious of the client’s and your own voice inflection,
tone, and affect. • Sit down to talk with the client (be at an even level). • Use and accept silence to help the client search for more
thoughts or to organize them. • Use eye contact and be calm, unhurried, and sympathetic.
LIFESPAN CONSIDERATIONS Assessment
CHILDREN Consider this example: A 4-year-old girl is admitted following emergency surgery for a ruptured appendix. She is awake and alert, but refuses to talk. Her parents have had little sleep for more than 24 hours and are extremely anxious. • Gathering assessment data in this situation requires the nurse
to be sensitive to the parents’ needs for sleep and assur- ance. At the same time, the nurse must collect information to compile an adequate database for appropriate nursing care decisions. Assessment will involve monitoring the condition of the child as she recovers from surgery and being alert to potential problems.
• The parents become the major source of subjective data, although the child should be encouraged to tell the nurse how she is feeling.
• Objective data collected include vital signs including level of and response to pain; bleeding or discharge from the incision; mobility; integrity of dressings, intravenous lines, catheters, nasogastric tubes or other medical devices; and mental status.
• Since children are a part of families, assessment will include observation of family dynamics and questions that could lead to care of the family system.
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Figure 11–5 • Assessment for Margaret O’Brien. 168
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Figure 11–5 • Continued “Assessment” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
examples are Gordon’s functional health pattern framework, Orem’s self-care model, and Roy’s adaptation model.
Gordon (2010) provides a framework of 11 functional health patterns. The eleven functional health patterns are health perception and management, nutritional, metabolic, elimination, activity, sleep, cognitive, self perception and concept, role relationship, sexuality, coping and stress, and value belief systems. Gordon uses the word pattern to signify a sequence of recurring behavior. The nurse collects data about dysfunctional as well as functional behavior. Thus, by us- ing Gordon’s framework to organize data, nurses are able to discern emerging patterns.
Orem’s self-care model (2001) delineates eight universal self- care requisites of humans. The model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development. Roy (2009) outlines the data to be collected according to the Roy adaptation model and classifies observable behavior into four categories: physiological, self-concept, role function, and interdependence (Box 11–2).
Figure 11–5 is a concise data collection tool that is organized ac- cording to body systems and specific nursing concerns (e.g., screening for falls and allergies); it does not use one particular nursing model.
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In Box 11–3, the data for the case study client Margaret O’Brien from Figure 11–5 are shown after being organized according to Gordon’s 11 functional health patterns. Note how the categories in the box differ somewhat from those in Figure 11–5. As a rule, the nurse organizes the data using the same model on which the data collection tool is based. However, different models are provided here to demon- strate differences in organizing frameworks, and to show that the nurse is not limited to the exact framework provided by the data collection tool.
Wellness Models Nurses use wellness models to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values,
BOX 11–2 Roy’s Adaptation Model
ADAPTIVE MODES 1. Physiological needs
• Activity and rest • Nutrition • Elimination • Fluid and electrolytes • Oxygenation • Protection • Regulation: temperature • Regulation: the senses • Regulation: endocrine system
2. Self-concept • Physical self • Personal self
3. Role function 4. Interdependence
The Roy Adaptation Model by Sister Callista Roy. Copyright © 2009 by PrenticeHall.
BOX 11–3 Data for Margaret O’Brien, Organized According to Functional Health Patterns
HEALTH PERCEPTION/HEALTH MANAGEMENT • Aware/understands medical diagnosis • Gives thorough history of illnesses and surgeries • Complies with Synthroid regimen • Relates progression of illness in detail • Expects to have antibiotic therapy and “go home in a day
or two” • States usual eating pattern “three meals a day”
NUTRITIONAL/METABOLIC • 158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 lb) • Usual eating pattern “three meals a day” • “No appetite” since having “cold” • Has not eaten today; last fluids at noon • Nauseated • Oral temperature 39.4°C (103°F) • Decreased skin turgor
ELIMINATION • Usually no problem • Decreased urinary frequency and amount × 2 days • Last bowel movement yesterday, formed, states was
“normal”
ACTIVITY/EXERCISE • No musculoskeletal impairment • Difficulty sleeping because of cough • “Can’t breathe lying down” • States “I feel weak” • Short of breath on exertion • Exercises daily
COGNITIVE/PERCEPTUAL • No sensory deficits • Pupils 3 mm, equal, brisk reaction • Oriented to time, place, and person • Responsive, but fatigued • Responds appropriately to verbal and physical stimuli • Recent and remote memory intact • States “short of breath” on exertion • Reports “pain in lungs,” especially when coughing • Experiencing chills • Reports nausea
ROLES/RELATIONSHIPS • Lives with husband, 13-year-old daughter, and 5-year-old son • Husband out of town; will be back tomorrow afternoon
• Children are with their grandparents until husband returns • States “good” relationships with friends and coworkers • Nursing student and part-time home health aid
SELF-PERCEPTION/SELF-CONCEPT • Expresses “concern” and “worry” over leaving her children with
their grandparents until husband returns • Anxiety related to missing her nursing classes, missing her
medical–surgical clinical day, and inability to study • Well-groomed; says, “Too tired to put on makeup”
COPING/STRESS • Anxious: “I can’t breathe” • Facial muscles tense; trembling • Expresses concerns about work: “I’ll never get caught up”
VALUE/BELIEF • Catholic • No special practices desired except anointing of the sick • Middle-class, professional orientation • No wish to see chaplain or priest at present
MEDICATION/HISTORY • Synthroid 0.1 mg per day • Client has history of appendectomy, partial thyroidectomy
NURSING PHYSICAL ASSESSMENT • 33 years old • Height 158 cm (5 ft, 2 in.); weight 56 kg (125 lb) • TPR 39.4°C (103°F), 92 beats/min, 28/min • Radial pulses weak, regular • Blood pressure 122/80 mmHg sitting • Skin hot and pale, cheeks flushed • Mucous membranes dry and pale • Respirations shallow; chest expansion , 3 cm • Cough productive of small amounts of pale pink sputum • Inspiratory crackles auscultated throughout right upper and
lower chest • Diminished breath sounds on right side • Abdomen soft, not distended • Old surgical scars: anterior neck, RLQ abdomen • Diaphoretic
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and attitudes that influence levels of wellness. Such models generally include the following:
• Health history • Physical fitness evaluation • Nutritional assessment • Life-stress analysis • Lifestyle and health habits • Health beliefs • Sexual health • Spiritual health • Relationships • Health risk appraisal.
See Chapter 17 for details.
Nonnursing Models Frameworks and models from other disciplines may also be helpful for organizing data. These frameworks are narrower than the model required in nursing; therefore, the nurse usually needs to combine these with other approaches to obtain a complete history.
BODY SYSTEMS MODEL The body systems model focuses on abnormalities of the following anatomic systems:
• Integumentary system • Respiratory system • Cardiovascular system • Nervous system • Musculoskeletal system • Gastrointestinal system • Genitourinary system • Reproductive system • Immune system.
MASLOW’S HIERARCHY OF NEEDS Maslow’s hierarchy of needs clusters data pertaining to the following:
• Physiological needs (survival needs) • Safety and security needs • Love and belonging needs • Self-esteem needs • Self-actualization needs.
See Chapter 16 for details.
DEVELOPMENTAL THEORIES Several physical, psychosocial, cognitive, and moral developmental theories may be used by the nurse in specific situations. Examples in- clude the following:
• Havighurst’s age periods and developmental tasks • Freud’s five stages of development • Erikson’s eight stages of development • Piaget’s phases of cognitive development • Kohlberg’s stages of moral development.
See Chapter 20 for additional information.
VALIDATING DATA The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual. Validating data helps the nurse complete these tasks:
• Ensure that assessment information is complete. • Ensure that objective and related subjective data agree. • Obtain additional information that may have been overlooked. • Differentiate between cues and inferences. Cues are subjective or
objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. Inferences are the nurse’s interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an in- cision is red, hot, and swollen; the nurse makes the inference that the incision is infected).
• Avoid jumping to conclusions and focusing in the wrong direc- tion to identify problems.
Not all data require validation. For example, data such as height, weight, birth date, and most laboratory studies that can be measured with an accurate scale can be accepted as factual. As a rule, the nurse validates data when there are discrepancies between data obtained in the nurs- ing interview (subjective data) and the physical examination (objective data), or when the client’s statements differ at different times in the as- sessment. Guidelines for validating data are shown in Table 11–7.
To collect data accurately, nurses need to be aware of their own biases, values, and beliefs and to separate fact from inference, inter- pretation, and assumption (see Chapter 10 ). For example, a nurse seeing a man holding his arm to his chest might assume that he is experiencing chest pain, when in fact it is his hand that hurts.
To build an accurate database, nurses must validate assumptions regarding the client’s physical or emotional behavior. In the previous example, the nurse should ask the client why he is holding his arm to his chest. The client’s response may validate the nurse’s assumptions or prompt further questioning. Figure 11–5 indicates that the nurse auscultated Margaret O’Brien’s heart and lungs to validate her state- ment that she had “lung pain” and “shortness of breath” on exertion. Failure to validate assumptions can lead to an inaccurate or incom- plete nursing assessment and could compromise client safety.
DOCUMENTING DATA To complete the assessment phase, the nurse records client data. Ac- curate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. For example, the nurse records the client’s breakfast intake (objective data) as “coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast,” rather than as “appetite good” (a judgment). A judgment or conclusion such as “appetite good” or “normal appetite” may have different meanings for different people. To increase accuracy, the nurse records subjective data in the client’s own words, using quota- tion marks. Restating in other words what someone says increases the chance of changing the original meaning (see Chapter 15 ).
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Critical Thinking Checkpoint
Eighty-two-year-old Ms. T. is in the hospital for hip replacement surgery. 1. What are the key areas of information to obtain regarding her
past history? 2. Which physiological systems are the most important for data
collection before her surgery?
3. What exactly would you say to her to determine if someone will be at home to assist her after discharge?
4. Which other sources of data might be appropriate to access in her case?
See Critical Thinking Possibilities on student resource website.
• The nursing process is a systematic, rational method of planning and providing individualized nursing care for individuals, families, communities, and groups.
• The goals of the nursing process are to identify a client’s health status and actual or potential health care needs, to establish plans to meet the identified needs, and to deliver and evaluate specific nursing interventions to meet those needs.
• The nursing process is organized into five interrelated, interdepen- dent phases: assessing, diagnosing, planning, implementing, and evaluating.
• The nursing process can be used in all health care settings. It is cyclic and dynamic, client centered, focuses on problem solving and decision making, interpersonal and collaborative, universally applicable, and requires critical thinking and clinical reasoning.
• Clinical reasoning allows the nurse to reflect on the care delivered throughout the phases of the nursing process.
• Assessing involves collecting, organizing, validating, and docu- menting data.
• Diagnosing is analyzing data, identifying a client’s potential or ac- tual health problems, and formulating diagnostic statements.
• Planning involves setting priorities, formulating goals/desired out- comes, and selecting nursing interventions.
• Implementing is carrying out the nursing interventions. It includes reassessing the client, determining the nurse’s need for assistance, supervising delegated care, and documenting nursing activities.
• Evaluating is the process of comparing data to outcomes to deter- mine the status of the problem. It includes review and modification of the care plan.
CHAPTER HIGHLIGHTS
Chapter 11 Review
Guidelines Example Compare subjective and objective data to verify the client’s statements with your observations.
Client’s perceptions of “feeling hot” need to be compared with measurement of the body temperature.
Clarify any ambiguous or vague statements. Client: “I’ve felt sick on and off for 6 weeks.” Nurse: “Describe what your sickness is like. Tell me what you mean by ‘on and off.’”
Be sure your data consist of cues and not inferences. Observation: Dry skin and reduced tissue turgor Inference: Dehydration Action: Collect additional data that are needed to make the inference in the diagnosing phase. For example, determine the client’s fluid intake, amount and appearance of urine, and blood pressure.
Double-check data that are extremely abnormal. Observation: A resting pulse of 30 beats/min or a blood pressure of 210/95 mmHg Action: Repeat the measurement. Use another piece of equipment as needed to confirm abnormalities, or ask someone else to collect the same data.
Determine the presence of factors that may interfere with accurate measurement.
A crying infant will have an abnormal respiratory rate and will need quieting before accurate assessment can be made.
Use references (textbooks, journals, research reports) to explain phenomena.
A nurse considers tiny purple or bluish-black swollen areas under the tongue of an older adult client to be abnormal until reading about physical changes of aging. Such varicosities are common.
TABLE 11–7 Validating Assessment Data
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1. Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs 2. Organizing data in the client’s family history 3. Establishing short-term and long-term goals 4. Administering an antibiotic
2. Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Proposes hypotheses. 2. Generates desired outcomes. 3. Reviews results of laboratory tests. 4. Documents care.
3. Which of the following elements is best categorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the
last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremities. 4. Client states severe pain when walking up stairs.
4. The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. “What did the doctor tell you about your diagnosis?” 2. “Are you worried about how the diagnosis will affect you in
the future?” 3. “Tell me about your reactions to the diagnosis.” 4. “How is your family responding to the diagnosis?”
5. The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health
care team 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care 4. Collection of all necessary information for a thorough
appraisal 6. Which of the following is the purpose of assessing?
1. Establish a database of client responses to his or her health status.
2. Identify client strengths and problems. 3. Develop an individualized plan of care. 4. Implement care, prevent illness, and promote wellness.
7. In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data. 2. Applies a framework to the collected data. 3. Confirms data are complete and accurate. 4. Records data in the client record.
8. A major characteristic of the nursing process is which of the following? 1. A focus on client needs 2. Its static nature 3. An emphasis on physiology and illness 4. Its exclusive use by and with nurses
9. Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense. 2. Observing is done only when no other nursing interventions
are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any
particular order. 4. Observed data should be interpreted in relation to other
sources of collected data. 10. Which of the following represent effective planning of the
interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the
client’s eyes. 2. Ensure that no one can overhear the interview
conversation. 3. Stand near the client’s head while he or she is in the bed
or chair. 4. Keep approximately 3 feet from the client during the
interview. 5. Use a standard form to be sure all relevant data are
covered in the interview. See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
• Assessment involves active participation by the client and nurse in obtaining subjective and objective data about the client’s health status.
• Subjective data are the client’s personal perceptions, often gath- ered during the nursing health history.
• Objective data (e.g., data observed and/or collected during the physical examination) are detectable by an observer.
• The client is the primary source of data. Secondary sources are family members and other support persons, other health profes- sionals, records and reports, laboratory and diagnostic analyses, and relevant literature.
• The primary methods of data collection are observing, interview- ing, and examining.
• Observation is a conscious, deliberate skill involving use of the senses.
• The nurse uses a combination of directive and nondirective inter- viewing (including closed and open-ended questions) to obtain the nursing health history.
• Nursing models provide formats for collecting and organizing cli- ent data.
• The nursing assessment must be complete and accurate because nursing diagnoses and interventions are based on this information.
• Some data must be validated. Subjective data can be used to vali- date objective data, and vice versa.
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Suggested Reading Chatterjee, J. (2012). Improving pain assessment for patients
with cognitive impairment: Development of a pain assess- ment toolkit. International Journal of Palliative Nursing, 18, 581–590. In this article the authors identified dementia as being common in clients receiving palliative care. Upon admis- sion 34% to 45% of clients possess some level of cognitive impairment. Prior to death the percentage rises to 83%. In these clients assessing pain can become more complex. A pain assessment tool was augmented by a behavioral assessment tool, allowing nurses a greater ability to meet the needs of clients with cognitive impairments who are at the end of life.
Related Research Greenberg, M. E. (2009). A comprehensive model of the
process of telephone nursing. Journal of Advanced Nursing, 65, 2621–2629. doi:10.1111/j.1365-2648.2009 .05132.x
Starkweather, A. (2010). Improving patient-centered medical– surgical nursing practice with quality-of-life assessment. Medical Surgical Nursing, 19(4), 224–232.
References American Nurses Association. (1973). Standards of nursing
practice. Kansas City, MO: Author. American Nurses Association. (2010). Nursing: Scope and
standards of nursing practice (2nd ed.). Silver Spring, MD: Author.
D’Amico, D., & Barbarito, C. (2013). Health & physical assess- ment in nursing (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Fawcett, T., & Rhynas, S. (2012). Taking a patient history: The role of the nurse. Nursing Standard, 26(24), 41–46. doi:10.7748/ns2012.02.26.24.41.c8946
Hall, L. (1955, June). Quality of nursing care. Public Health News. Newark, NJ: State Department of Health.
Johnson, D. E. (1959). A philosophy of nursing. Nursing Outlook, 7, 198–200.
The Joint Commission. (2008). Provision of care treatment, and services: LPNs performing assessments. Retrieved from: http://www.jointcommission.org/standards_ information/jcfaqdetails.aspx?StandardsFAQId= 122&StandardsFAQChapterId=78
Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiatric– mental health nursing (3rd ed.) Upper Saddle River, NJ: Prentice Hall.
Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.
Orlando, I. (1961). The dynamic nurse–patient relationship. New York, NY: Putnam.
Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
Wiedenbach, E. (1963). The helping art of nursing. American Journal of Nursing, 63(11), 54–57. doi:10.2307/ 3453018
Wilkinson, J. M. (2012). Nursing process and critical thinking (5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Selected Bibliography Alfaro-LeFevre, R. A. (2010). Applying the nursing process:
The foundation for clinical reasoning (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Alfaro-LeFevre, R. A. (2013). Critical thinking and clinical judg- ment: A practical approach to outcome-focused thinking (5th ed.). St. Louis, MO: Elsevier.
Fennessey, A., & Wittmann-Price, R. A. (2011). Physical assess- ment: A continuing need for clarification. Nursing Forum, 46(1), 45–50. doi:10.1111/j.1744-6198.2010.00209.x
Gordon, M. (2010). Manual of nursing diagnosis (12th ed.). Boston, MA: Jones & Bartlett.
The Joint Commission. (2013). Hospital accreditation standards. Oakbrook Terrace, IL: Author.
Massey, D., & Meredith, T. (2010). Respiratory assessment 1: Why do it and how to do it? British Journal of Cardiac Nursing, 5, 537–541.
Rylance, R., Chapman, H., & Harrison, J. (2012). Who as- sesses physical health of inpatients. Mental Health Prac- tice, 16(2), 14–20. doi:10.7748/mhp2012.10.16.2.14 .c9340
Stewart, C. J., & Cash, Jr., W. B. (2010). Interviewing principles and practices (13th ed.). New York, NY: McGraw-Hill.
Wright, K., McGlen, I., & Dykes, S. (2012). Mental health emergencies: Using a structured assessment framework. Emergency Nurse, 19(10), 28–36.
Zambas, S. I. (2010). Purpose of the systematic physical assessment in everyday practice: Critique of a “sacred cow.” Journal of Nursing Education, 49(6), 305–310. doi:10.3928/01484834-20100224-03
READINGS AND REFERENCES
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175
defining characteristics, 177 dependent functions, 177 diagnosis, 175 diagnostic labels, 175
etiology, 175 health promotion diagnosis, 176 independent functions, 177 norm, 178
nursing diagnosis, 175 PES format, 182 qualifiers, 176 risk factors, 176
risk nursing diagnosis, 176 standard, 178 syndrome diagnosis, 176 taxonomy, 175
KEY TERMS
After completing this chapter, you will be able to: 1. Differentiate nursing diagnoses according to status. 2. Identify the components of a nursing diagnosis. 3. Compare nursing diagnoses, medical diagnoses, and collab-
orative problems. 4. Identify the basic steps in the diagnostic process.
LEARNING OUTCOMES
12 Diagnosing
INTRODUCTION Diagnosing is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems. Diagnosing is a pivotal step in the nursing process. Activities preceding this phase are directed toward formulating the nursing diagnoses; the care planning activities following this phase are based on the nursing diagnoses (Figure 12–1 •).
The identification and development of nursing diagnoses began formally in 1973, when two faculty members of Saint Louis Uni- versity, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify nurses’ roles in an ambulatory care setting. The first national conference to identify nursing diagnoses was sponsored by the Saint Louis University School of Nursing and Allied Health Professions in 1973. Subsequent national conferences occurred in 1975, in 1980, and every 2 years thereafter.
International recognition came with the First Canadian Confer- ence in Toronto in 1977 and the International Nursing Conference in May 1987 in Calgary, Alberta, Canada. In 1982, the conference group accepted the name North American Nursing Diagnosis Association (NANDA), recognizing the participation and contributions of nurses in the United States and Canada. In 2002, the organization changed its name to NANDA International to further reflect the worldwide interest in nursing diagnosis.
The purpose of NANDA International is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. A taxonomy is a classification system or set of categories arranged based on a single principle or set of prin- ciples. The members of NANDA include staff nurses, clinical special- ists, faculty, directors of nursing, deans, theorists, and researchers. The group has currently approved more than 200 nursing diagnosis labels for clinical use and testing. The current version, Taxonomy II, can be found in Appendix C on the student resource website.
NANDA NURSING DIAGNOSES To use the concept of nursing diagnoses effectively in generating and completing a nursing care plan, the nurse must be familiar with the definitions of terms used and the components of nursing diagnoses.
Definitions The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phe- nomenon. The standardized NANDA names for the diagnoses are called diagnostic labels; and the client’s problem statement, consist- ing of the diagnostic label plus etiology (causal relationship between a problem and its related or risk factors), is called a nursing diagnosis.
The official NANDA definition of a nursing diagnosis is: “. . . a clinical judgment concerning a human response to health con- ditions/life processes, or a vulnerability for that response, by an indi- vidual, family, group, or community” (Herdman & Kamitsuru, 2014, p. 464). In 2009 the NANDA-I Think Tank statement was developed. It states, “A nursing diagnosis provides the basis for selection of nurs- ing interventions to achieve outcomes for which the nurse has ac- countability” (Herdman & Kamitsuru, 2014, p. 464). This definition is consistent with the following:
• Professional nurses (registered nurses) are responsible for mak- ing nursing diagnoses, even though other nursing personnel may contribute data to the process of diagnosing and may imple- ment specified nursing care. The American Nurses Association’s Nursing: Scope and Standards of Practice, Second Edition (2010) states that nurses are accountable for analyzing data to determine diagnoses or issues. The standard also specifies that nurses should use standardized classification systems when naming diagnoses.
• The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat. For example, gener- alist nurses are not educated to diagnose or treat diseases such as
5. Describe various formats for writing nursing diagnoses. 6. List guidelines for writing a nursing diagnosis statement. 7. Describe the evolution of the nursing diagnosis movement,
including work currently in progress.
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2. A health promotion diagnosis relates to clients’ preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness for Enhanced Nutrition.
3. A risk nursing diagnosis is a clinical judgment that a prob- lem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibil- ity of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.
4. A syndrome diagnosis is assigned by a nurse’s clinical judg- ment to describe a cluster of nursing diagnoses that have similar interventions (Herdman & Kamitsuru, 2014, p. 23).
Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics. Each component serves a specific purpose.
PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION The problem statement, or diagnostic label, describes the client’s health problem or response for which nursing therapy is given. It describes the client’s health status clearly and concisely in a few words. The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nurs- ing interventions.
To be clinically useful, diagnostic labels need to be specific; when the word Specify follows a NANDA label, the nurse states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments).
Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement, for example:
• Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)
• Impaired (made worse, weakened, damaged, reduced, deteriorated) • Decreased (lesser in size, amount, or degree) • Ineffective (not producing the desired effect) • Compromised (to make vulnerable to threat).
diabetes mellitus; this task is defined legally as within the practice of medicine. Yet nurses can diagnose and treat Deficient Knowledge, Ineffective Coping, or Imbalanced Nutrition, all of which are the hu- man responses to the medical diagnosis of diabetes mellitus.
• A nursing diagnosis is a judgment made only after thorough, sys- tematic data collection.
• Nursing diagnoses describe a continuum of health states: devia- tions from health, presence of risk factors, and areas of enhanced personal growth.
Status of the Nursing Diagnoses “Status of the nursing diagnosis refers to the actuality or potentiality of the problem/syndrome or the categorization of the diagnosis as a health promotion diagnosis” (Herdman & Kamitsuru, 2014, p. 100). The kinds of nursing diagnoses according to status are actual, health promotion, risk, and syndrome.
1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pat- tern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms.
Figure 12–1 • Diagnosing—the pivotal second phase of the nursing process.
Planning
Implementing
Evaluating
Assessing
Diagnosing • Analyze data • Identify health problems, risks, and strengths • Formulate diagnostic statements
Paans, Nieweg, van der Schans, and Sermeus (2011) sought to identify the factors that influence the prevalence and accuracy of nursing diagnoses in the clinical practice setting. The authors searched MEDLINE and CINAHL databases to identify articles with the keywords of nursing diagnosis, nursing documentation, hos- pitals, influence, utilization, quality implementation, and accuracy. They identified 24 studies.
Four domains of factors influenced the prevalence and accuracy of nursing diagnoses. The domains were the nurse as a diagnosti- cian, diagnostic education and resources, complexity of the client’s situation, and the hospital’s policy. The study revealed that nurses with the greatest amount of clinical experience possessed greater
skills in accurately determining the clients nursing diagnosis. Nurses who employed clinical reasoning in the care of the client identified the client’s nursing diagnosis. Nurses who were educated on the nurs- ing process were able to more accurately assign a nursing diagnosis to the client. Finally, nurses with access to computer-generated care plans more accurately identified the client’s nursing diagnosis.
IMPLICATIONS The authors suggest that the identification of the factors that affect the prevalence and accuracy of nursing diagnoses documentation provides hospital management with determinants for quality im- provement in nursing diagnosis documentation.
Evidence-Based Practice What Factors Influence the Prevalence and Accuracy of Nursing Diagnoses in Clinical Practice? EVIDENCE-BASED PRACTICE
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ETIOLOGY (RELATED FACTORS AND RISK FACTORS) The etiology component of a nursing diagnosis identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. As shown in Table 12–1, the probable causes of Activity Intolerance include generalized weakness, sedentary lifestyle, and so on. Differentiating among possible causes in the nursing diagnosis is essential because each may require different nursing interventions. Table 12–2 provides examples of problems that have different etiolo- gies and therefore require different interventions.
Each diagnostic label approved by NANDA carries a definition that clarifies its meaning. For example, the definition of the diagnos- tic label Activity Intolerance is shown in Table 12–1.
DEFINING CHARACTERISTICS Defining characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms. For risk nursing diagnoses, no subjective and ob- jective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis.
The NANDA lists of defining characteristics are still being de- veloped and refined. In some cases, characteristics are listed sepa- rately according to whether they are subjective or objective in nature.
Differentiating Nursing Diagnoses from Medical Diagnoses A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses, by virtue of their education, experience, and ex- pertise, are licensed to treat. A medical diagnosis is made by a physician
Diagnosis and Definition Related Factors Defining Characteristics Activity Intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities
Bed rest or immobility Generalized weakness Imbalance between oxygen supply/demand Sedentary lifestyle
Verbal report of fatigue or weakness Abnormal heart rate or blood pressure response to activity Electrocardiographic changes reflecting arrhythmias or ischemia Exertional discomfort or dyspnea
From NANDA International Nursing Diagnoses: Definitions and Classification, 2015–2017 (p. 225), by T. H. Herdman and S. Kamitsuru (Eds.), 2014, Oxford, United Kingdom: Wiley-Blackwell. Adapted with permission.
TABLE 12–1 Components of a Nursing Diagnosis
and refers to a condition that only a physician can treat. Medical diag- noses refer to disease processes—specific pathophysiologic responses that are fairly uniform from one client to another. In contrast, nursing diagnoses describe the human response, a client’s physical, sociocul- tural, psychological, and spiritual responses to an illness or a health problem. See how these responses vary among individuals:
Seventy-year-old Mary Cain and 20-year-old Kristi Vidan both have rheumatoid arthritis. Their disease processes are much the same. X-ray studies show that in both clients, the extent of inflammation and the number of joints involved are similar, and both clients experience almost constant pain. Ms. Cain views her condition as part of the aging process and is responding with acceptance. Ms. Vidan, however, is respond- ing with anger and hostility because she views her disease as a threat to her personal identity, role performance, and self-esteem.
A client’s medical diagnosis remains the same for as long as the disease process is present, but nursing diagnoses change as the cli- ent’s responses change. Ms. Vidan’s response to her illness may change over time to become more similar to that of Ms. Cain.
Nurses have responsibilities related to both medical and nurs- ing diagnoses. Nursing diagnoses relate primarily to the nurse’s inde- pendent functions, that is, the areas of health care that are unique to nursing and separate and distinct from medical management. However, the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems.
A nurse may not be able to prescribe all of the care for a nurs- ing diagnosis, but the nurse can prescribe most of the interventions needed for prevention or resolution. For example, most clients with a nursing diagnosis of Pain have medical orders for analgesics, but many independent nursing interventions can also alleviate pain (e.g., guided imagery or teaching a client to “splint” an incision). With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatments, that is, dependent functions. See Chapter 13 for a discussion of independent and dependent nursing interventions.
Differentiating Nursing Diagnoses from Collaborative Problems A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interven- tions. Independent nursing interventions for a collaborative problem focus mainly on monitoring the client’s condition and preventing de- velopment of the potential complication. Definitive treatment of the condition requires both medical and nursing interventions.
Examples of Nursing Diagnoses with Different EtiologiesTABLE 12–2
Diagnostic Label (Problem)
Client
Etiology
Constipation Al Martinez Long-term laxative use
Jerry Wong Inactivity and insufficient fluid intake
Anxiety Tanya Brown Threat to physiological integrity: possible cancer diagnosis
Caitlin Shea Effects of aging (reduced hearing, vision, mobility)
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Collaborative problems are present when a particular disease or treatment is present; that is, each disease or treatment has specific complications that are always associated with it. For example, a state- ment of collaborative problems is “Potential complications of pneu- monia: atelectasis, respiratory failure, pleural effusion, pericarditis, and meningitis.”
Nursing diagnoses, by contrast, involve human responses, which vary greatly from one person to the next. Therefore, the same set of nursing diagnoses cannot be expected to occur with all persons who have a particular disease or condition; moreover, a single nurs- ing diagnosis may occur as a response to any number of diseases. For example, all postpartum clients have similar collaborative problems, such as “Potential complication of childbearing: postpartum hem- orrhage,” but not all new mothers have the same nursing diagnoses. Some might experience Impaired Parenting (delayed bonding), but most will not; some might have Deficient Knowledge, whereas others will not. Thus, the nurse uses nursing diagnoses rather than collabor- ative problems whenever possible, since nursing diagnoses are more individualized to a specific client and emphasize human responses to which the nurse can independently take action. Table 12–3 provides a comparison of nursing diagnoses, medical problems, and collab- orative problems.
THE DIAGNOSTIC PROCESS The diagnostic process uses the critical thinking skills of analysis and synthesis. In critical thinking, a person reviews data and considers ex- planations before forming an opinion. Analysis is the separation into components, that is, the breaking down of the whole into its parts
(deductive reasoning). Synthesis is the opposite, that is, the putting to- gether of parts into the whole (inductive reasoning). See Chapter 10 to review the concepts of deductive and inductive reasoning.
The diagnostic process is used continuously by most nurses. An experienced nurse may enter a client’s room and immediately observe significant data and draw conclusions about the client. As a result of attaining knowledge, skill, and expertise in the practice setting, the expert nurse may seem to perform these mental processes automati- cally. Novice nurses, however, need guidelines to understand and formulate nursing diagnoses. The diagnostic process has three steps:
• Analyzing data • Identifying health problems, risks, and strengths • Formulating diagnostic statements.
Analyzing Data In the diagnostic process, analyzing involves the following steps:
1. Compare data against standards (identify significant cues). 2. Cluster the cues (generate tentative hypotheses). 3. Identify gaps and inconsistencies.
For experienced nurses, these activities occur continuously rather than sequentially.
COMPARING DATA WITH STANDARDS Nurses draw on knowledge and experience to compare client data to standards and norms and identify significant and relevant cues. A standard or norm is a generally accepted measure, rule, model, or pattern. The nurse uses a wide range of standards, such as growth
Nursing Diagnoses Medical Diagnoses Collaborative Problems
Example Activity Intolerance related to decreased cardiac output
Myocardial infarction Potential complication of myocardial infarction: congestive heart failure
Description Describe human responses to disease process or health problem; consist of a one-, two-, or three-part statement, usually including problem and etiology
Describe disease and pathology; do not consider other human responses; usually consist of not more than three words
Involve human responses— mainly physiological complications of disease, tests, or treatments; consist of a two-part statement of situation/ pathophysiology and the potential complication
Orientation and responsibility for diagnosing
Oriented to the individual; nurses responsible for diagnosing
Oriented to pathology; physician responsible for diagnosing; diagnosis not within the scope of nursing practice
Oriented to pathophysiology; nurses responsible for diagnosing
Nursing focus Treat and prevent Implement medical orders for treatment and monitor status of condition
Prevent and monitor for onset or status of condition
Nursing actions Independent Dependent (primarily) Some independent actions, but primarily for monitoring and preventing
Duration Can change frequently Remains the same while disease is present
Present when disease or situation is present
Classification system Classification system is devel- oped and being used but is not universally accepted
Well-developed classification system accepted by the medical profession
No universally accepted classification system
TABLE 12–3 Comparison of Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems
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and development patterns, normal vital signs, and laboratory values. A cue is considered significant if it does any of the following:
• Points to negative or positive change in a client’s health status or pattern. For example, the client states: “I have recently experienced shortness of breath while climbing stairs” or “I have not smoked for three months.”
• Varies from norms of the client population. The client may con- sider a pattern—for example, eating very small meals and having little appetite—to be normal. This pattern, however, may not be healthy and may require further exploration.
• Indicates a developmental delay. To identify significant cues, the nurse must be aware of the normal patterns and changes that occur as the person grows and develops. For example, by age 9 months an infant is usually able to sit alone without support. The infant who has not accomplished this task needs further assessment for possible developmental delays.
Table 12–4 lists specific examples of client cues and norms to which they may be compared.
CLUSTERING CUES Data clustering or grouping of cues is a process of determining the re- latedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant. This is the beginning of synthesis.
The nurse may cluster data inductively (as in Table 12–5) by combining data from different assessment areas to form a pattern; or the nurse may begin with a framework, such as Gordon’s functional health patterns, and organize the subjective and objective data into the appropriate categories (see Box 11–4 and Table 11–4, pages 163 and 171). The latter is a deductive approach to data clustering (see Chapter 10 ).
Experienced nurses may cluster data as they collect and interpret it, as evidenced in remarks or thoughts such as “I’m getting a sense of . . .” or “This cue doesn’t fit the picture.” The novice nurse does not
Type of Cue Client Cues Standard/Norm Deviation from population norms Height is 158 cm (5 ft, 2 in.).
Woman with small frame. Weighs 109 kg (240 lb).
Height and weight tables indicate that the “ideal” weight for a woman 158 cm (5 ft, 2 in.) with a small frame is 49–53 kg (108–121 lb).
Developmental delay Child is 17 months old. Parents state child has not yet attempted to speak. Child laughs aloud and makes cooing sounds.
Children usually speak their first word by 10–12 months of age.
Changes in client’s usual health status States, “I’m just not hungry these days.” Ate only 15% of food on breakfast tray. Has lost 13 kg (30 lb) in past 3 months.
Client usually eats three balanced meals per day. Adults typically maintain stable weight.
Dysfunctional behavior Amy’s mother reports that Amy has not left her room for 2 days. Amy is age 16. Amy has stopped attending school and has withdrawn from social contact.
Adolescents usually like to be with their peers; social group very important. Functional behavior includes school attendance.
Changes in client’s usual behavior Mrs. Stuart reports that lately her husband angers easily. “Yesterday he even yelled at the dog.” “He just seems so tense.”
Mr. Stuart is usually relaxed and easygoing. He is friendly and kind to animals.
TABLE 12–4 Comparing Cues to Standards and Norms
have the knowledge base or the clinical experience that aids in rec- ognizing cues. Thus, the novice must take careful assessment notes, search data for abnormal cues, and use textbook resources for com- paring the client’s cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses.
Data clustering involves making inferences about the data. The nurse interprets the possible meaning of the cues, and labels the cue clusters with tentative diagnostic hypotheses. Data clustering or grouping for Margaret O’Brien is illustrated in Table 12–5, in which data are clustered according to standardized diagnostic labels.
IDENTIFYING GAPS AND INCONSISTENCIES IN DATA Skillful assessment minimizes gaps and inconsistencies in data. How- ever, data analysis should include a final check to ensure that data are complete and correct.
Inconsistencies are conflicting data. Possible sources of conflict- ing data include measurement error, expectations, and inconsistent or unreliable reports. For example, a nurse may learn from the nurs- ing history that the client reports not having seen a health care pro- vider in 15 years, yet during the physical health examination he states, “My doctor takes my blood pressure every year.” All inconsistencies must be clarified before a valid pattern can be established. See the Validating Data section in Chapter 11 .
Identifying Health Problems, Risks, and Strengths After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process (see Chapter 10 ).
DETERMINING PROBLEMS AND RISKS After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible di- agnoses. In addition, the nurse must determine whether the client’s
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Functional Health Pattern
Client Cue Clusters
Inferences (Tentative Identification of Problems)
Diagnostic Statements
Health perception/health management
No significant cues No problem No problem Strength: shows healthy lifestyle, understanding of and compliance with treatment regimens
Nutritional/metabolic (includes hydration)
“No appetite” since having “cold”; has not eaten today; last fluids at noon today Nauseated × 2 days
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite and nausea and increased metabolism (secondary to disease process) Strength: normal weight for height
Last fluids at noon today Oral temp 39.4°C (103°F) Skin hot and pale, cheeks flushed Mucous membranes dry Poor skin turgor Cues from elimination pattern: Decreased urinary frequency and amount × 2 days
Deficient Fluid Volume Deficient Fluid Volume related to intake insufficient to replace fluid loss secondary to fever, diaphoresis, anorexia
Elimination Decreased urinary frequency and amount × 2 days
Cues consist of elimination data but are actually symptoms of a fluid volume problem in the nutritional/metabolic functional health pattern
No elimination problem
Activity/exercise Difficulty sleeping because of cough “Can’t breathe lying down”
Disturbed Sleep Pattern Disturbed Sleep Pattern related to cough, pain, orthopnea, fever, and diaphoresis
States “I feel weak” Short of breath on exertion Cues from cognitive/perceptual pattern: Responsive but fatigued “I can think OK, just weak.” Cues from cardiovascular pattern: Radial pulses weak, regular Pulse rate 92 beats/min
Activity Intolerance Activity Intolerance related to general weakness, imbalance between oxygen supply/demand Strength: no musculoskeletal impairment, normal energy level is satisfactory, exercises regularly
Cognitive/perceptual Reports pain in chest, especially when coughing
Acute Pain Acute Pain (Chest) related to cough secondary to pneumonia
Responsive but fatigued “I can think OK, just weak.”
These are cognitive/perceptual data, but they reflect symptoms of problems in the activity/ exercise pattern
Strength: no cognitive or sensory deficits
Roles/relationships Husband out of town; will be back tomorrow afternoon Children with grandparents until husband returns
Interrupted Family Processes related to mother’s illness and temporary unavailability of father to provide child care
Risk for Interrupted Family Processes related to mother’s illness and temporary unavailability of father to provide child care Strength: in-laws available and willing to help
Self-perception/ self-concept
Expresses “concern” and “worry” over leaving daughter and son with their grandparents until husband returns
Cue is a symptom of a problem in the coping/stress pattern
No self-perception/self-concept problem
TABLE 12–5 Formulating Nursing Diagnoses for Margaret O’Brien
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DETERMINING STRENGTHS At this stage, the nurse and client also establish the client’s strengths, re- sources, and abilities to cope. Most people have a clearer perception of their problems or weaknesses than of their strengths and assets, which they often take for granted. By taking an inventory of strengths, the client can develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.
A client’s strength might be weight that is within the normal range for age and height, thus enabling the client to cope better with surgery. In another instance, a client’s strengths might be absence of allergies and being a nonsmoker.
A client’s strengths can be found in the nursing assessment record (health, home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor, for example), the health examination, and the client’s records. See Table 12–5 for the strengths identified for Margaret O’Brien.
Functional Health Pattern
Client Cue Clusters
Inferences (Tentative Identification of Problems)
Diagnostic Statements
Coping/stress Anxious: “I can’t breathe.” Facial muscles tense; trembling Expresses concerns about her nursing classes: “I’ll never get caught up.” Cues from role/relationship pattern: Husband out of town; will be back tomorrow afternoon Children with in-laws until hus- band returns Cues from self-perception/ self-concept patterns: Expresses “concern” and “worry” over leaving children with in-laws
Anxiety related to difficulty breath- ing, inability to attend nursing classes and to study, and child care
Anxiety related to difficulty breathing and concerns over work and parenting roles
Medication/history No significant cues No problem No problem
PHYSICAL ASSESSMENT
• Cardiovascular Radial pulses weak, regular Pulse rate 92 beats/min
Cues are symptoms only; symptoms of exercise/rest and oxygenation problems
No cardiovascular problem
• Oxygenation Skin hot, pale, and moist Respirations shallow; chest expansion, 3 cm Cough productive of small amounts of thick pale pink sputum Inspiratory crackles auscultated throughout right upper and lower lungs Diminished breath sounds on right side Mucous membranes pale, dry
Ineffective Airway Clearance related to disease process
Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to pain, fluid volume deficit, and fatigue
• Skin Old surgical scars, anterior neck, RLQ abdomen
No problem now Old problems; resolved
TABLE 12–5 Formulating Nursing Diagnoses for Margaret O’Brien—continued
problem is a nursing diagnosis, medical diagnosis, or collaborative problem. See Figure 12–2 • and Table 12–5.
Significant cues and data clusters for Margaret O’Brien that were extracted from Figure 11–5 on pages 168–169 and Box 11–4 on page 171 are shown in Table 12–5. In this example, the nurse and client identified eight tentative problems: Imbalanced Nutrition: Less Than Body Requirements, Deficient Fluid Volume, Disturbed Sleep Pattern, Activity Intolerance, Acute Pain (Chest), Interrupted Family Processes, Anxiety, and Ineffective Airway Clearance.
Note that some data may indicate a possible problem but when clustered with other data, the possible problem disappears. For ex- ample, the following data for Margaret O’Brien, “Decreased urinary frequency and amount × 2 days,” suggests a possible urinary elimina- tion problem. However, when these data are considered along with data associated with Deficient Fluid Volume, the nurse eliminates uri- nary elimination as a problem.
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Formulating Diagnostic Statements Most nursing diagnoses are written as two-part or three-part state- ments, but there are variations of these.
BASIC TWO-PART STATEMENTS The basic two-part statement includes the following:
1. Problem (P): statement of the client’s response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the
responses.
The two parts are joined by the words related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a re- lationship. Some examples of two-part nursing diagnoses are shown in Box 12–1.
For NANDA labels that contain the word Specify, the nurse must add words to indicate the problem more specifically. The format is still a two-part statement. For example, Noncompliance (Specify) would be Noncompliance (Diabetic Diet) related to denial of having disease. For
Figure 12–2 • Decision tree for differentiating among nursing diagnoses, collaborative problems, and medical diagnoses.
Identification of significant cue cluster
(problem)
Can the nurse take independent action to prevent or treat the problem?
yes
Are these the primary interventions needed to achieve the goal?
Are both medical and nursing orders needed to prevent or treat the problem?
no
yes no
Nursing diagnosis
yes no
Collaborative problem
Medical diagnosis
Problem Related to Etiology Constipation related to prolonged laxative use Anxiety related to threat to physiological integrity:
possible cancer diagnosis
BOX 12–1 Basic Two-Part Diagnostic Statement
ease in alphabetizing, many NANDA lists are arranged with qualify- ing words after the main word (e.g., Infection, Risk for). Avoid writ- ing diagnostic statements in that manner; instead, write them as they would be stated in normal conversation (e.g., Risk for Infection).
BASIC THREE-PART STATEMENTS The basic three-part nursing diagnosis statement is called the PES format and includes the following:
1. Problem (P): statement of the client’s response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the
response 3. Signs and symptoms (S): defining characteristics manifested by
the client.
Actual nursing diagnoses can be documented by using the three-part statement (see Box 12–2) because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis.
The PES format is especially recommended for beginning di- agnosticians because the signs and symptoms validate why the diag- nosis was chosen and make the problem statement more descriptive. The PES format can create very long problem statements, sometimes making the problem and etiology unclear. To minimize long prob- lem statements, the nurse can record the signs and symptoms in the nursing notes instead of on the care plan. Another possibility, recom- mended for students, is to list the signs and symptoms on the care plan below the nursing diagnosis, grouping the subjective (S) and
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following secondary to is often a pathophysiologic or disease process or a medical diagnosis, as in Risk for Impaired Skin In- tegrity related to decreased peripheral circulation secondary to diabetes.
5. Adding a second part to the general response or NANDA label to make it more precise. For example, the diagnosis Impaired Skin Integrity does not indicate the location of the problem. To make this label more specific, the nurse can add a descriptor as follows: Impaired Skin Integrity (Left Lateral Ankle) related to de- creased peripheral circulation.
COLLABORATIVE PROBLEMS Carpenito-Moyet (2013) has suggested that all collaborative (multi- disciplinary) problems begin with the diagnostic label Potential Com- plication (PC). Nurses should include in the diagnostic statement both the possible complication they are monitoring and the disease or treatment that is present to produce it. For example, if the client has a head injury and could develop increased intracranial pressure, the nurse should write the following:
Potential Complication of Head Injury: increased intracranial pressure
When monitoring for a group of complications associated with a dis- ease or pathology, the nurse states the disease and follows it with a list of the complications:
Potential Complication of Pregnancy-Induced Hypertension: seizures, fetal distress, pulmonary edema, hepatic/renal
failure, premature labor, CNS hemorrhage
In some situations, an etiology might be helpful in suggesting interventions. Nurses should write the etiology when (a) it clarifies the problem statement, (b) it can be concisely stated, and (c) it helps to suggest nursing actions. See the examples in Box 12–3.
EVALUATING THE QUALITY OF THE DIAGNOSTIC STATEMENT In addition to using the correct format, nurses must consider the content of their diagnostic statements. The statements should, for ex- ample, be accurate, concise, descriptive, and specific. The nurse must always validate the diagnostic statements with the client and compare the client’s signs and symptoms to the NANDA defining character- istics. For risk problems, the nurse compares the client’s risk factors to NANDA risk factors. After writing nursing diagnoses, the nurse checks them against the criteria in Table 12–6.
Avoiding Errors in Diagnostic Reasoning Some error is inherent in any human undertaking, and diagnosis is no exception. However, it is important for nurses to make nurs- ing diagnoses with a high level of accuracy. Nurses can avoid some common errors of reasoning by recognizing them and applying the
objective (O) data. The signs and symptoms are easily accessible, and the problem and etiology stand out clearly. For example:
Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested by
S— “I forget to take my pills.” “I can’t live without sugar in my food.” O— Weight 98 kg (215 lb) (gain of 4.5 kg [10 lb]) Blood pressure 190/100 mmHg
ONE-PART STATEMENTS Some diagnostic statements, such as health promotion diagnoses and syndrome nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be derived from the label itself. There- fore, an etiology may not be needed.
NANDA has specified that any health promotion diagnoses will be developed as one-part statements beginning with the words Readi- ness for Enhanced followed by the desired higher level of wellness (for example, Readiness for Enhanced Parenting). A syndrome diagno- sis is a diagnosis that is associated with a cluster of other diagnoses (Alfaro-LeFevre, 2014). Currently seven syndrome diagnoses are on the NANDA International list. Risk for Disuse Syndrome, for example, may be experienced by long-term bedridden clients. Clusters of diag- noses associated with this syndrome include Impaired Physical Mobil- ity, Risk for Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for Powerless- ness, Impaired Gas Exchange, and so on.
VARIATIONS OF BASIC FORMATS Variations of the basic one-, two-, and three-part statements include the following:
1. Writing unknown etiology when the defining characteristics are present but the nurse does not know the cause or contributing factors. One example is Noncompliance (Medication Regimen) re- lated to unknown etiology.
2. Using the phrase complex factors when there are too many eti- ologic factors or when they are too complex to state in a brief phrase. The actual causes of chronic low self-esteem, for instance, may be long term and complex, as in the following nursing diag- nosis: Chronic Low Self-Esteem related to complex factors.
3. Using the word possible to describe either the problem or the etiology. When the nurse believes more data are needed about the client’s problem or the etiology, the word possible is inserted. Examples are Possible Low Self-Esteem related to loss of job and rejection by family; Altered Thought Processes possibly related to unfamiliar surroundings.
4. Using secondary to to divide the etiology into two parts, thereby making the statement more descriptive and useful. The part
Problem Related to Etiology As Manifested by Signs and Symptoms
Situational Low Self-Esteem
related to (r/t) feelings of rejection by husband
as manifested by (a.m.b.)
hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback
BOX 12–2 Basic Three-Part Diagnostic Statement
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appropriate critical thinking skills. Error can occur at any point in the diagnostic process: data collection, data interpretation, and data clustering.
The following suggestions help to minimize diagnostic error:
• Verify. Hypothesize possible explanations of the data, but realize that all diagnoses are only tentative until they are verified. Begin and end the diagnostic process by talking with the client and fam- ily. When collecting data, ask them what their health problems are and what they believe the causes to be. At the end of the process, ask them to confirm the accuracy and relevance of your diagnoses.
• Build a good knowledge base and acquire clinical experience. Nurses must apply knowledge from many different areas to recog- nize significant cues and patterns and generate hypotheses about the data. To name only a few, principles from chemistry, anatomy, and pharmacology each help the nurse understand client data in a different way.
• Have a working knowledge of what is normal. Nurses need to know the population norms for vital signs, laboratory tests, speech development, breath sounds, and so on. In addition, nurses must determine what is usual for a particular person,
BOX 12–3 Collaborative Problems
Disease/Situation Complication Related to Etiology Potential complication of childbirth: hemorrhage related to uterine atony
retained placental fragments
bladder distention
Potential complication of diuretic therapy: arrhythmia related to low serum potassium
Guideline Correct Statement Incorrect or Ambiguous Statement
1. State in terms of a problem, not a need.
Deficient Fluid Volume (problem) related to fever
Fluid Replacement (need) related to fever
2. Word the statement so that it is legally advisable.
Impaired Skin Integrity related to immobility (legally acceptable)
Impaired Skin Integrity related to improper positioning (implies legal liability)
3. Use nonjudgmental statements. Spiritual Distress related to inability to attend church services secondary to immobility (nonjudgmental)
Spiritual Distress related to strict rules necessitating church attendance (judgmental)
4. Make sure that both elements of the statement do not say the same thing.
Risk for Impaired Skin Integrity related to immobility
Impaired Skin Integrity related to ulceration of sacral area (response and probable cause are the same)
5. Be sure that cause and effect are correctly stated (i.e., the etiology causes the problem or puts the client at risk for the problem).
Pain: Severe Headache related to avoidance of narcotics due to fear of addiction
Pain related to severe headache
6. Word the diagnosis specifically and precisely to provide direction for planning nursing intervention.
Impaired Oral Mucous Membrane related to decreased salivation secondary to radiation of neck (specific)
Impaired Oral Mucous Membrane related to noxious agent (vague)
7. Use nursing terminology rather than medical terminology to describe the client’s response.
Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs (nursing terminology)
Risk for Pneumonia (medical terminology)
8. Use nursing terminology rather than medical terminology to describe the probable cause of the client’s response.
Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs (nursing terminology)
Risk for Ineffective Airway Clearance related to emphysema (medical terminology)
TABLE 12–6 Guidelines for Writing a Nursing Diagnostic Statement
taking into account age, physical makeup, lifestyle, culture, and the person’s own perception of what his or her normal status is. For example, normal blood pressure for adults is in the range of 110/60 to 140/80 mmHg. However, a nurse might obtain a read- ing of 90/50 mmHg that is perfectly normal for a particular client. The nurse should compare actual findings to the client’s baseline when possible.
• Consult resources. Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources. The nurse should use a nursing diagnosis handbook to determine whether the client’s signs and symptoms truly fit the NANDA label chosen.
• Base diagnoses on patterns—that is, on behavior over time— rather than on an isolated incident. For example, even though Margaret O’Brien is concerned today about needing to leave her children with her in-laws, it is likely that this concern will be re- solved without intervention by the next day. Therefore, the admit- ting nurse should not diagnose Interrupted Family Processes but, rather, Risk for Interrupted Family Processes.
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• Improve critical thinking skills. These skills help the nurse to be aware of and avoid errors in thinking, such as overgeneral- izing, stereotyping, and making unwarranted assumptions. See Chapter 10 .
ONGOING DEVELOPMENT OF NURSING DIAGNOSES The first taxonomy of nursing diagnoses was alphabetical. This or- dering was considered unscientific by some, and a hierarchic struc- ture was sought. In 1982, NANDA accepted the “nine patterns of unitary man” (based on the nursing models of Sr. Callista Roy and Martha Rogers; see Chapter 3 ) as an organizing principle. In 1984, NANDA renamed the “patterns of unitary man” as “human re- sponse patterns” based more on the work of Marjorie Gordon (Kim, McFarland, & McLane, 1984), as listed in Box 12–4.
Having undergone refinements, revisions, and acceptance of new diagnoses, the taxonomy is now called Taxonomy II. Taxonomy II has three levels: domains, classes, and nursing diagnoses. The do- mains and classes are shown in Figure 12–3 •. The diagnoses are no longer grouped by Gordon’s patterns but coded according to seven axes: diagnostic concept, subject of diagnosis, judgment, location, age, time, and status of diagnosis. In addition, diagnoses are now listed alphabetically by concept, not by first word.
Review and refinement of diagnostic labels continue as new and modified labels are discussed at each biannual conference. Nurses
submit diagnoses to the Diagnostic Review Committee, which re- views and “stages” the diagnosis according to how well developed and supported it is. The NANDA board of directors gives final approval for incorporation of the diagnosis into the official list of labels. Diag- noses on the NANDA list are not finished products but are approved for clinical use and further study. Many on the list have been studied only minimally.
In 1997, NANDA changed the name of its official journal from Nursing Diagnosis to Nursing Diagnosis: The International Journal of Nursing Language and Classification, and it is now known as the Inter- national Journal of Nursing Terminologies and Classifications. The title emphasizes that nursing diagnosis is part of a larger, developing sys- tem of standardized nursing language. This system includes classifi- cations of nursing interventions (NIC) and nursing outcomes (NOC) that are being developed by other research groups and linked to the NANDA diagnostic labels. NIC and NOC are discussed in greater detail in Chapter 13 .
Research groups are examining what nurses do from these three different perspectives (diagnoses, interventions, and outcomes) to clarify and communicate the role nurses play in the health care system. A standardized language will also enable nurses to imple- ment a Nursing Minimum Data Set, which is needed for computer- ized client records.
LIFESPAN CONSIDERATIONS Diagnosing
CHILDREN Many developmental issues in pediatrics are not considered prob- lems or illnesses, yet can benefit from nursing intervention. When applied to children and families, nursing diagnoses may reflect a condition or state of health. For example, parents of a newborn infant may be excited to learn all they can about infant care and child growth and development. Assessment of the family system might lead the nurse to conclude that the family is ready and able, even eager, to take on the new roles and responsibilities of being parents. An appropriate diagnosis for such a family could be Readi- ness for Enhanced Family Processes, and nursing care could be directed to educating and providing encouragement and support to the parents.
OLDER ADULTS Older adults tend to have multiple problems with complex physical and psychosocial needs when they are ill. If the nurse has done a thorough and accurate assessment, nursing diagnoses can be se- lected to cover all problems and, at the same time, prioritize the spe- cial needs. For example, if a client is admitted with severe congestive heart failure, prompt attention will be focused on Decreased Car- diac Output and Excess Fluid Volume, with interventions selected to improve these areas quickly. As these conditions improve, then other nursing diagnoses, such as Activity Intolerance and Deficient Knowledge related to a new medication regimen, might require more attention. They are all part of the same medical problem of conges- tive heart failure, but each nursing diagnosis has specific expected outcomes and nursing interventions. The client’s strengths should be an essential consideration in all phases of the nursing process.
BOX 12–4 Human Response Patterns
1. Exchanging: mutual giving and receiving 2. Communicating: sending messages 3. Relating: establishing bonds 4. Valuing: assigning relative worth 5. Choosing: selection of alternatives 6. Moving: activity 7. Perceiving: reception of information 8. Knowing: meaning associated with information 9. Feeling: subjective awareness of information
Critical Thinking Checkpoint
A client has recently been diagnosed with lung cancer. Someone has written the nursing diagnosis of Anxiety on the care plan. 1. What data/defining characteristics would support this nursing
diagnosis? 2. Which related factors might exist in this situation? 3. Which other nursing diagnoses might you expect to find in this
case? 4. Another nursing diagnosis on the care plan reads “Lung cancer
related to smoking.” Is this diagnosis written in an acceptable format? If not, why not?
See Critical Thinking Possibilities on student resource website.
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Health Promotion
Domain
1 2 3 4 5 6
Class 1
Class 2
Class 3
Class 4
Class 5
Nutrition Elimination/ Exchange Activity/Rest
Perception/ Cognition
Self- Perception
Health Awareness
Health Management
Ingestion
Digestion
Absorption
Metabolism
Hydration
Urinary Function
Gastrointestinal Function
Integumentary Function
Pulmonary Function
Attention
Orientation
Sensation/ Perception
Cognition
CommunicationSelf-care
Self-Concept
Self-Esteem
Body Image
Sleep/Rest
Activity/ Exercise
Energy Balance
Cardiovascular- Pulmonary Responses
Role Relationship
Sexuality Coping/Stress
Tolerance Life
Principles Safety/
Protection Comfort
Caregiving Roles
Family Relationships
Role Performance
Sexual Identity
Sexual Function
Reproduction
Post-Trauma Responses
Coping Responses
Neuro- behavioral Stress
Infection
Physical Injury
Violence
Environmental Hazards
Defensive Processes
Thermoregulation
Physical Comfort
Environmental Comfort
Social Comfort
Growth/ Development
Growth
Development
Values
Beliefs
Value/Belief/ Action
Congruence
7 8 9 10 11 12 13
Figure 12–3 • Taxonomy II. From NANDA International Nursing Diagnoses: Definitions and Classification, 2015–2017 (pp. 66–78), by T. H. Herdman and S. Kamitsuru (Eds.), 2014, Oxford, United Kingdom: Wiley-Blackwell. Reprinted with permission.
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• The purpose of the NANDA International organization is to define, refine, and promote a taxonomy of nursing diagnostic terminology.
• A diagnosis is a statement or conclusion regarding the nature of a phenomenon.
• Professional standards of care hold that registered nurses are re- sponsible for making nursing diagnoses, even though others may contribute data or implement care.
• A nursing diagnosis is a clinical judgment about the client’s responses to actual and potential health problems or life processes.
• A nursing diagnosis provides the basis for selecting independent nursing interventions to achieve outcomes for which the nurse is accountable.
• Nursing diagnoses have a status of actual, health promotion, risk, and wellness.
• A nursing diagnosis has three components: the problem (and its definition), the etiology, and the defining characteristics. Each component serves a specific purpose.
• Nursing diagnoses differ from medical diagnoses and collaborative problems in orientation, duration, and nursing focus.
• A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions.
• The three phases of the diagnostic process are data analysis; iden- tification of the client’s health problems, health risks, and strengths; and formulation of diagnostic statements.
• In data analysis and processing, the nurse compares data against standards to identify significant cues, clusters the data, and identi- fies gaps and inconsistencies.
• Significant cues are those that (a) point to change in a client’s health status or pattern, (b) vary from norms of the client popula- tion, or (c) indicate a developmental delay.
• It is important to identify client strengths as well as problems. • The basic format for a nursing diagnostic statement is “Problem re-
lated to etiology.” However, there are several variations of this format. • The development of a taxonomy of nursing diagnosis labels is an
ongoing process. • The organizing principles for the NANDA Taxonomy II are the seven
axes: diagnostic concept, subject of diagnosis, judgment, loca- tion, age, time, and status of diagnosis.
• Work is progressing on a unified standardized nursing language that includes NANDA nursing diagnoses, a nursing interventions classification, and a nursing outcomes classification.
CHAPTER HIGHLIGHTS
Chapter 12 Review
1. The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? 1. Assess the client’s needs. 2. Delineate the client’s problems and strengths. 3. Determine which interventions are most likely to succeed. 4. Estimate the cost of several different approaches.
2. In the diagnostic statement “Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following? 1. Excess fluid volume 2. Decreased venous return 3. Edema 4. Unknown
3. Which of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness
course 2. Risk for Falls related to tendency to collapse when having
difficulty breathing 3. Impaired Communication related to stroke 4. Sleep Deprivation secondary to fatigue and a noisy
environment
4. One of the primary advantages of using a three-part diagnostic statement such as the problem–etiology–signs/symptoms (PES) format includes which of the following? 1. Decreases the cost of health care. 2. Improves communication between nurse and client. 3. Helps the nurse focus on health and wellness elements. 4. Standardizes organization of client data.
5. A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis 1. If both medical and nursing interventions are required to treat
the problem. 2. When independent nursing actions can be utilized to treat
the problem. 3. In cases where nursing interventions are the primary actions
required to treat the problem. 4. When no medical diagnosis (disease) can be determined.
6. In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? 1. A risk nursing diagnosis 2. A syndrome nursing diagnosis 3. A health promotion nursing diagnosis 4. An actual nursing diagnosis
TEST YOUR KNOWLEDGE
187
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7. Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1. The original taxonomy has proven to be adequate in scope. 2. The organizing framework of the taxonomy is based on the
work of Florence Nightingale. 3. More research is needed to validate and refine the diagnostic
labels. 4. New diagnostic labels are approved by means of a vote of
registered nurses.
8. Which of the following would indicate a significant cue when comparing data to standards? Select all that apply. 1. The client has moved partway toward a set goal (e.g., weight
loss). 2. The client’s vision is within normal range only when wearing
glasses. 3. A child is able to control bladder and bowels at age 18
months. 4. A recently widowed woman states she is “unable to cry.” 5. A 16-year-old high school student reports spending 6 hours
doing homework five nights per week. See Answers to Test Your Knowledge in Appendix A.
Suggested Reading Jarrin, O. F. (2010). Core elements of U.S. nurse practice acts
and incorporation of nursing diagnosis language. Interna- tional Journal of Nursing Terminologies and Classifications, 21, 166–177. According to this analysis of nurse practice acts through- out the United States, only 10 state nurse practice acts include the words nursing diagnosis. The major themes identified were nursing, care, nursing process, supervision, and delegation. Other themes included the execution of a medical regimen, health maintenance with prevention, and the teaching of nursing.
Related Research Guedes, N. G., Venicios De Oliveira Lopes, M.,
Leite De Araujo, T., Moreira, R. P., & Martins, L. C. G. (2011). Predictive factors of the nursing diagnosis sedentary lifestyle in people with high blood pressure. Public Health Nursing, 28, 193–200. doi:10.1111/ J.1525-1446.2011.00942.X
References Alfaro-LeFevre, R. A. (2014). Applying the nursing process:
The foundation for clinical reasoning (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Carpenito-Moyet, L. J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA Inter- national nursing diagnoses: Definitions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
Kim, M. J., McFarland, G. K., & McLane, A. M. (Eds.). (1984). Classification of nursing diagnoses: Proceedings of the fifth national conference. St. Louis, MO: Mosby.
Paans, W., Nieweg, R. M. B., van der Schans, C. P., & Sermeus, W. (2011). What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systemic literature review. Journal of Clinical Nursing, 20, 2386–2403. doi:10.1111/ j.1365-2702.2010.03573.x
Selected Bibliography Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis
handbook. St. Louis, MO: Elsevier. Carpenito-Moyet, L. J. (2013). Handbook of nursing
diagnosis (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Doenges, M. E., & Moorhouse, M. F. (2013). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (6th ed.). Philadelphia, PA: F.A. Davis.
Doenges, M. E., Moorhouse, M. F., & Geissler-Murr, A. C. (2010). Nursing diagnosis manual: Planning, individualizing, and documenting client care (3rd ed.). Philadelphia, PA: F.A. Davis.
Gordon, M. (1982). Historical perspective: The National Group for Classification of Nursing Diagnoses. In M. J. Kim & D. A. Moritz (Eds.). Classification of nursing diagnoses: Proceedings of the fourth national conference. New York, NY: McGraw-Hill.
Gordon, M. (2011). Manual of nursing diagnosis (12th ed.). Sudbury, MA: Jones & Bartlett.
Wilkinson, J. M. (2012). Nursing process and critical thinking (5th ed.). Upper Saddle River, NJ: Prentice Hall.
READINGS AND REFERENCES
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INTRODUCTION Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the client’s assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems (Figure 13–1 •). A nursing intervention is “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes” (Bulechek, Butcher, Dochterman, & Wagner, 2013, p. xv). The end product of the plan- ning phase is a client care plan.
Although planning is basically the nurse’s responsibility, in- put from the client and support persons is essential if a plan is to be effective. Nurses do not plan for the client, but encourage the client to participate actively to the extent possible. In a home set- ting, the client’s support people and caregivers are the ones who implement the plan of care; thus, its effectiveness depends largely on them.
TYPES OF PLANNING Planning begins with the first client contact and continues un- til the nurse–client relationship ends, usually when the client is discharged from the health care agency. All planning is multidis- ciplinary (involves all health care providers interacting with the cli- ent) and includes the client and family to the fullest extent possible in every step.
Initial Planning The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. This nurse has the benefit of seeing the client’s body language and can also gather some intuitive kinds of information that are not available solely from the written database. Planning should be initiated as soon as possible after the initial assessment.
Ongoing Planning All nurses who work with the client do ongoing planning. As nurses obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day. Using ongoing assessment data, the nurse carries out daily planning for the following purposes:
1. To determine whether the client’s health status has changed 2. To set priorities for the client’s care during the shift 3. To decide which problems to focus on during the shift 4. To coordinate the nurse’s activities so that more than one prob-
lem can be addressed at each client contact.
Discharge Planning Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive health care plan and should be addressed in each client’s care plan. Because the
collaborative care plans, 194 collaborative interventions, 201 concept map, 192 critical pathways, 194 dependent interventions, 201 discharge planning, 189 formal nursing care plan, 190
goals/desired outcomes, 197 independent interventions, 200 indicators, 197 individualized care plan, 190 informal nursing care plan, 190 multidisciplinary care plan, 194 nursing intervention, 189
Nursing Interventions Classification (NIC), 202
Nursing Outcomes Classification (NOC), 197
policies, 191 priority setting, 195 procedures, 191
protocols, 191 rationale, 192 standardized care plan, 190 standing order, 191
KEY TERMS
After completing this chapter, you will be able to: 1. Identify activities that occur in the planning process. 2. Compare and contrast initial planning, ongoing planning, and
discharge planning. 3. Explain how standards of care and predeveloped care plans
can be individualized and used in creating a comprehensive nursing care plan.
4. Identify essential guidelines for writing nursing care plans. 5. Identify factors that the nurse must consider when setting
priorities.
LEARNING OUTCOMES
13 Planning
6. Discuss the Nursing Outcomes Classification, including an ex- planation of how to use the outcomes and indicators in care planning.
7. State the purposes of establishing client goals/desired outcomes. 8. Identify guidelines for writing goals/desired outcomes. 9. Describe the process of selecting and choosing nursing
interventions. 10. Discuss the Nursing Interventions Classification, including an
explanation of how to use the interventions and activities in care planning.
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planning phase, the nurse must (a) decide which of the client’s prob- lems need individualized plans and which problems can be addressed by standardized plans and routine care, and (b) write individualized desired outcomes and nursing interventions for client problems that require nursing attention beyond preplanned, routine care.
The complete plan of care for a client is made up of several dif- ferent documents. Some documents describe the routine care needed to meet basic needs (e.g., bathing, nutrition), and others address the client’s nursing diagnoses and collaborative problems. There may also be documents that specify the nurse’s responsibilities in carrying out the medical plan of care (e.g., keeping the client from eating or drink- ing before surgery; scheduling a laboratory test). A complete plan of care integrates dependent and independent nursing functions into a meaningful whole and provides a central source of client informa- tion. Figure 13–2 • illustrates the various types of documents that may be included in a nursing care plan.
Standardized Approaches to Care Planning Most health care agencies have devised a variety of standardized plans for providing essential nursing care to specified groups of clients who have certain needs in common (e.g., all clients with pneumonia). Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to (a) ensure that minimally acceptable criteria are met and (b) promote efficient use of nurses’ time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit.
Standards of care describe nursing actions for clients with simi- lar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care. They define the interven- tions for which nurses are held accountable; they do not contain medical interventions. Standards of care are usually agency records and not part of the client’s care plan, but they may be referred to in the plan (e.g., a nurse might write “See unit standards of care for cardiac catheterization”). Standards of care may or may not be organized ac- cording to problems or nursing diagnoses. They are written from the perspective of the nurse’s responsibilities. Figure 13–3 • shows unit standards of care for the client with thrombophlebitis.
Standardized care plans are predeveloped guides for the nursing care of a client who has a need that arises frequently in the agency (e.g., a specific nursing diagnosis or all nursing diagnoses associated with a particular medical condition). They are written from the perspective of what care the client can expect. They should not be confused with standards of care. Although the two have some similarities, they have important differences. Figure 13–4 • shows a standardized care plan for Deficient Fluid Volume. Standardized care plans:
• Are kept with the client’s individualized care plan on the nursing unit. When the client is discharged, they become part of the per- manent medical record.
• Provide detailed interventions and contain additions or deletions from the standards of care of the agency.
• Typically are written in the nursing process format:
Problem → Goals/Desired Outcomes → Nursing Interventions → Evaluation
• Frequently include checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions.
average stay of clients in acute care hospitals has become shorter, people are sometimes discharged still needing care. Although many clients are discharged to other agencies (e.g., long-term care facili- ties), such care is increasingly being delivered in the home. Effective discharge planning begins at first client contact and involves com- prehensive and ongoing assessment to obtain information about the client’s ongoing needs. For details about discharge planning, see the Continuity of Care section in Chapter 7 .
DEVELOPING NURSING CARE PLANS The end product of the planning phase of the nursing process is a formal or informal plan of care. An informal nursing care plan is a strategy for action that exists in the nurse’s mind. For example, the nurse may think, “Mrs. Phan is very tired. I will need to reinforce her teaching after she is rested.” A formal nursing care plan is a written or computerized guide that organizes information about the client’s care. The most obvious benefit of a formal written care plan is that it provides for continuity of care.
A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction). An individualized care plan is tai- lored to meet the unique needs of a specific client—needs that are not addressed by the standardized plan. It is important for all caregivers to work toward the same outcomes and, if available, use approaches shown to be effective with a particular client. Nurses also use the for- mal care plan for direction about what needs to be documented in client progress notes and as a guide for delegating and assigning staff to care for clients. When nurses use the client’s nursing diagnoses to develop goals and nursing interventions, the result is a holistic, indi- vidualized plan of care that will meet the client’s unique needs.
Care plans include the actions nurses must take to address the client’s nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and updates it throughout the client’s stay in response to changes in the client’s condition and evaluations of goal achievement. During the
Figure 13–1 • Planning—the third phase of the nursing process. In this phase the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems.
Implementing
Evaluating
Assessing
Diagnosing
Planning • Prioritize problems/ diagnoses • Formulate goals/desired outcomes • Select nursing interventions • Write nursing interventions
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Figure 13–2 • Electronic health record containing client information and a summary of care. “Patient Summary View” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Like standards of care and standardized care plans, protocols are predeveloped to indicate the actions commonly required for a particular group of clients. For example, an agency may have a proto- col for admitting a client to the intensive care unit or for caring for a client receiving continuous epidural analgesia. Protocols may include both the primary care provider’s orders and nursing interventions. Depending on the agency, protocols may or may not be included in the client’s permanent record.
Policies and procedures are developed to govern the handling of frequently occurring situations. For example, a hospital may have a policy specifying the number of visitors a client may have. Some policies and procedures are similar to protocols and specify what is to be done, for example, in the case of cardiac arrest. If a policy cov- ers a situation pertinent to client care, it is usually noted on the care plan (e.g., “Make social service referral according to Policy Manual”).
Policies are institutional records and do not become a part of the care plan or permanent record.
A standing order is a written document about policies, rules, regulations, or orders regarding client care. Standing orders give nurses the authority to carry out specific actions under certain cir- cumstances, often when a primary care provider is not immediately available. In a hospital critical care unit, a common example is the administration of emergency antiarrhythmic medications when a client’s cardiac monitoring pattern changes. In a home care setting, a primary care provider may write a standing order for the nurse to obtain blood tests for a client who has been on a certain therapy for a prescribed amount of time.
Regardless of whether care plans are handwritten, computer- ized, or standardized, nursing care must be individualized to fit the unique needs of each client. In practice, a care plan usually consists
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sections that add assessment data preceding the problem/nursing diagnosis.
STUDENT CARE PLANS Because student care plans are a learning activity as well as a plan of care, they may be more lengthy and detailed than care plans used by working nurses. To help students learn to write care plans, educators may require that more of the plan be original work. They may also modify the plan by adding “Rationale” after the nursing interven- tions. A rationale is the evidence-based principle given as the reason for selecting a particular nursing intervention. Students may also be required to cite supporting literature for their stated rationale. For an example of a Nursing Care Plan, see pages 203–204.
Another method of organizing and representing care plan in- formation is to use a concept map. A concept map is a visual tool in which ideas or data are enclosed in circles or boxes of some shape, and relationships between these are indicated by connecting lines or arrows (Figure 13–5 •). Concept maps are creative endeavors. They can take many different forms and encompass various categories of data, according to the creator’s interpretation of the client or health condition. The concept map for Margaret O’Brien later in this chapter
of both preauthored and nurse-created sections. The nurse uses standardized care plans for predictable, commonly occurring prob- lems, and creates an individual plan for unusual problems or prob- lems needing special attention. For example, a standardized care plan for clients with a medical diagnosis of pneumonia would probably include a nursing diagnosis of Deficient Fluid Volume and direct the nurse to assess the client’s hydration status. On a respiratory or medical unit, this would be a common nursing diagnosis; therefore, Margaret O’Brien’s nurse was able to obtain a standardized plan direct- ing care commonly needed by clients with Deficient Fluid Volume (see Figure 13–4). However, the nursing diagnosis Risk for Inter- rupted Family Processes would not be common to all clients with pneumonia; it is specific to Margaret. Therefore, the goals and nursing interventions for that diagnosis would need to be created by the nurse.
Formats for Nursing Care Plans Although formats differ from agency to agency, the care plan is of- ten organized into four sections: (1) problem/nursing diagnoses, (2) goals/desired outcomes, (3) nursing interventions, and (4) eval- uation. Some agencies use a three-section plan in which evalua- tion is done with the goals or in the nurses’ notes; others have five
Figure 13–3 • Standards of care for the client with thrombophlebitis. From Nursing Process & Critical Thinking, 5th ed. (p. 351), by J. M. Wilkinson, 2012, Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
STANDARDS OF CARE: Client with Thrombophlebitis.
Goal: 1. To monitor for early signs and symptoms of compromised respiratory status. 2. To report any abnormal signs and/or symptoms promptly to the medical staff. 3. To initiate appropriate nursing actions when signs and/or symptoms of compromised respiratory status occur. 4. To institute protocol for emergency intervention should the client develop cardiopulmonary dysfunction.
SUPPORTIVE DATA: The purpose of these standards of care is to prevent, monitor, report, and record the client’s response to a diagnosis of thrombophlebitis. Thrombophlebitis places the client at risk for pulmonary embolism. The hemodynamic consequences of embolic obstruction to pulmonary blood flow involve increased pulmonary vascular resistance, increased right ventricular workload, decreased cardiac output, and development of shock and pulmonary arrest.
CLINICAL MANIFESTATIONS: Nursing assessments performed q3–4h should monitor for the following signs/symptoms:
• Dyspnea generally consistently present • Sudden substernal pain • Rapid/weak pulse • Syncope • Anxiety • Fever • Cough/hemoptysis • Accelerated respiratory rate • Pleuritic type chest pain • Cyanosis
PREVENTIVE NURSING MEASURES:
• Encourage increased fluid intake to prevent dehydration. • Maintain anticoagulant intravenous therapy as prescribed (See Protocol for Anticoagulant Administration). • Maintain prescribed bed rest. • Prevent venous stasis from improperly fitting elastic stockings; check q3–4h. • Encourage dorsiflexion exercises of the lower extremities while on bed rest.
INDIVIDUALIZED PLANS/ADDITIONAL NURSING/MEDICAL ORDERS
________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________
Initiated by: __________________________________________________________________________ Date: ____________________S. Ibarra, RN
Do not massage lower extremities. Intake and output q8h.
04-09-15
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Figure 13–4 • A standardized care plan for the nursing diagnosis of Deficient Fluid Volume.
Etiology
__Decreased oral intake
__Nausea
__Depression
__Fatigue, weakness
__Difficulty swallowing
__Other:___________
__Excess fluid loss
__Fever or increased metabolic rate
__Diaphoresis
__Vomiting
__Diarrhea
__Burns
__Other___________
Defining Characteristics
__Insufficient intake __Negative balance of
intake and output __Dry mucous
membranes __Poor skin turgor __Concentrated urine __Hypernatremia __Rapid, weak pulse __Falling B/P __Weight loss
Desired Outcomes
__Urinary output > 30 mL/hr
__Urine specific gravity 1.005 –1.025
__Serum Na+ within normal limits
__Mucous membranes moist
__Skin turgor elastic
__No weight loss
__8-hour intake =
________________
Other:
Nursing Interventions (Identify Frequency)
__Monitor intake and output q____h
__Weigh daily
__Monitor serum electrolyte levels
__Assess skin turgor and mucous membranes q_______
__Monitor temperature q_____
__Administer prescribed IV therapy (Monitor according to protocol for Intravenous Therapy)
__Offer 8 oz oral liquids q____h
Type_______________________
__Instruct client regarding amount, type, and schedule of fluid intake
__Assess understanding of type of fluid loss; teach accordingly
__Mouth care prn with___________
__Institute measures to reduce fever (e.g., lower room temperature, remove bed covers, offer cold liquids)
Other Nursing Orders:_______________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Plan initiated by:__________________________________Date_________________
Plan/outcomes evaluated___________________________Date_________________
Plan/outcomes evaluated___________________________Date_________________
Client:____________________________________________
X 1 or until normal
1000 mL D5 LR at 100 mL/hr
M. Medina RN 08-27-14
mouthwash
clear, cold 1
4 h
1
8 h
400 mL oral
Monitor urine specific gravity q-shift
Margaret O’Brien
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is another way of depicting her nursing care plan and includes unique boxes that enclose assessment, nursing diagnosis, desired outcomes, and interventions. The arrows represent the flow of the phases of the nursing process. (See the Concept Map on page 205.) Concept maps other than care plans are often used to depict complex relationships among ideas, processes, actions, and so on. Some are referred to as mind maps (see Chapter 10 ). Students are often asked to com- plete pathophysiology flow sheets or concept maps as a method of learning and demonstrating the linkages among disease processes, laboratory data, medications, signs and symptoms, risk factors, and other relevant data.
COMPUTERIZED CARE PLANS Computers are increasingly being used to create and store nursing care plans. The computer can generate both standardized and indi- vidualized care plans. Nurses access the client’s stored care plan from a centrally located terminal at the nurses’ station or from terminals in client rooms. For an individualized plan, the nurse chooses the appropriate diagnoses from a menu suggested by the computer. The computer then lists possible goals and nursing interventions for those diagnoses; the nurse chooses those appropriate for the client and types in any additional goals and interventions or nursing actions
Figure 13–5 • A sample pathophysiology concept map.
Increased fluids
Strep
Haemophilus influenza
Chlamydia
Legionella pneumophila
Influenza virus
Pneumocystis carinii
TB
CMV Atypical
mycobacteria
Mycoplasma
Staph aureus
Pseudomonas
Klebsiella
E coli
Pneumonia
Fungi Cough
Headache
General malaise
Confusion Crackles,
rales, decreased breath sounds
Sputum production
Fever
Chest PT
O2
Nutritional support
Antibiotics vaccines, antiviralsAnalgesics,
antipyretics
History & physical
exam Chest x-ray
Culture & sensitivity
Bronchoscopy
Pulse oximetryCBC
Arterial blood gases
Teaching, psychological
support
Manifestations
Types
Diagnosis
Treatment
Community acquired
Hospital acquired
Opportunistic
not listed on the menu. The nurse can read the plan on the computer screen or print out an updated working copy.
Multidisciplinary (Collaborative) Care Plans A multidisciplinary care plan is a standardized plan that outlines the care required for clients with common, predictable—usually medical— conditions. Such plans, also referred to as collaborative care plans and critical pathways, sequence the care that must be given on each day during the projected length of stay for the specific type of condition. Like the traditional nursing care plan, a multidisciplinary care plan can specify outcomes and nursing interventions to address client problems (including nursing diagnoses). However, it includes medical treatments to be performed by other health care providers as well.
The plan is usually organized with a column for each day, listing the interventions that should be carried out and the client outcomes that should be achieved on that day. There are as many columns on the multidisciplinary care plan as the preset number of days allowed for the client’s diagnosis-related group (DRG). For further informa- tion, see Chapter 6 . Multidisciplinary care plans do not include detailed nursing activities. They should be drawn from but do not replace standards of care and standardized care plans.
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teaching and discharge plans as addenda if they are lengthy and complex.
THE PLANNING PROCESS In the process of developing client care plans, the nurse engages in the following activities:
• Setting priorities • Establishing client goals/desired outcomes • Selecting nursing interventions and activities • Writing individualized nursing interventions on care plans.
Setting Priorities Priority setting is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Instead of rank-ordering diagnoses, nurses can group them as having high, medium, or low priority. Life-threatening problems, such as impaired respiratory or cardiac function, are designated as high priority. Health- threatening problems, such as acute illness and decreased coping ability, are as- signed medium priority because they may result in delayed de- velopment or cause destructive physical or emotional changes. A low-priority problem is one that arises from normal developmental needs or that requires only minimal nursing support.
Nurses frequently use Maslow’s hierarchy of needs when setting priorities (see Figure 16–3 on page 247). In Maslow’s hierarchy, physi- ological needs such as air, food, and water are basic to life and receive higher priority than the need for security or activity. Growth needs, such as self-esteem, are not perceived as “basic” in this framework. Thus, nursing diagnoses such as Ineffective Airway Clearance and Impaired Gas Exchange would take priority over nursing diagnoses such as Anxiety or Ineffective Coping.
It is not necessary to resolve all high-priority diagnoses before addressing others. The nurse may partially address a high-priority di- agnosis and then deal with a diagnosis of lesser priority. Furthermore, because the client may have several problems, the nurse often deals with more than one diagnosis at a time. Table 13–1 lists the priorities assigned to Margaret O’Brien’s nursing diagnoses, which were identi- fied in Chapter 12 .
Priorities change as the client’s responses, problems, and thera- pies change. The nurse must consider a variety of factors when as- signing priorities, including the following:
1. Client’s health values and beliefs. Values concerning health may be more important to the nurse than to the client. For example, a client may believe that being home for the children is more ur- gent than a health problem. When such a difference of opinion arises, the client and nurse should discuss it openly to resolve any conflict.
2. Client’s priorities. Involving the client in prioritizing and care planning enhances cooperation. Sometimes, however, the cli- ent’s perception of what is important conflicts with the nurse’s knowledge of potential problems or complications. For example, an older client may not regard turning and repositioning in bed as important, preferring to be undisturbed. The nurse, however, aware of the potential complications of prolonged bed rest (e.g., muscle weakness and pressure sores), needs to inform and work with the client to carry out these necessary interventions.
Guidelines for Writing Nursing Care Plans The nurse should use the following guidelines when writing nursing care plans:
1. Date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signa- ture demonstrates accountability to the client and to the nurs- ing profession, since the effectiveness of nursing actions can be evaluated.
2. Use category headings. “Nursing Diagnoses,” “Goals/Desired Outcomes,” “Nursing Interventions,” and “Evaluation” are the common headings. Include a date for the evaluation of each goal.
3. Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless agency policy dictates otherwise. For example, write “Turn and reposition q2h” rather than “Turn and reposition the client every two hours.” Or, write “Clean wound −c H2O2 bid” rather than “Clean the client’s wound with hydrogen peroxide twice a day, morning and evening.” See Table 15–4 on page 234 for a list of standard medical abbreviations.
4. Be specific. Because nurses are now working shifts of different lengths, with some working 12-hour shifts and some working 8-hour shifts, it is even more important to be specific about expected timing of an intervention. If the intervention reads “change incisional dressing q shift,” it could mean either twice in 24 hours, or three times in 24 hours, depending on the shift time. This miscommunication becomes even more serious when medications are ordered to be given “q shift.” Writing down spe- cific times during the 24-hour period will help clarify.
5. Refer to procedure books or other sources of information rather than including all the steps on a written plan. For example, write “See unit procedure book for tracheostomy care,” or attach a standard nursing plan about such procedures as radiation- implantation care and preoperative or postoperative care.
6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices, such as preferences about the times of care and the methods used, are included. This reinforces the client’s individuality and sense of control. For example, the written nursing intervention “Provide prune juice at breakfast rather than other juice” should indicate that the client was given a choice of beverages.
7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones. For example, carrying out the intervention “Provide active-assistance ROM (range-of-motion) exercises to affected limbs q2h” addresses the goal of preventing joint contractures and maintaining muscle strength and joint mobility.
8. Ensure that the plan contains ongoing assessment of the client (e.g., “Inspect incision q8h”).
9. Include collaborative and coordination activities in the plan. For example, the nurse may write interventions to ask a nutritionist or physical therapist about specific aspects of the client’s care.
10. Include plans for the client’s discharge and home care needs. The nurse begins discharge planning as soon as the client has been admitted. It is often necessary to consult and make arrangements with the community health nurse, social worker, and specific agen- cies that supply client information and needed equipment. Add
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Nursing Diagnosis Priority Rationale Ineffective Airway Clearance related to (1) viscous secretions secondary to Deficient Fluid Volume and (2) shallow chest expansion secondary to pain and fatigue
High priority Loss of respiratory functioning is a life-threatening problem. The nurse’s primary concern must be to promote Margaret’s oxygenation by addressing the etiologies of this problem.
Deficient Fluid Volume: intake insufficient to replace fluid loss related to fever and diaphoresis
High priority Severe Deficient Fluid Volume is life threatening. Although not that severe for Margaret, it is a high-priority problem because it is also a contributing factor for Ineffective Airway Clearance. Collaborative efforts to improve her hydration have already begun (intravenous fluids). The nurse must immediately and continuously assess and promote Margaret’s hydration.
Anxiety related to (1) difficulty breathing and (2) concerns over work and parenting roles
Medium priority Although Margaret is concerned about school and parenting roles, these are not a threat to life. Also, treatment of her high-priority problem, Ineffective Airway Clearance, will relieve one of the etiologies of this problem (dyspnea). Meanwhile, the nurse must provide symptomatic relief of Margaret’s anxiety during periods of dyspnea because extreme anxiety could further compromise her oxygenation by causing her to breathe ineffectively and increase the rate at which she uses oxygen.
Risk for Interrupted Family Processes related to mother’s illness and potential temporary unavailability of father to provide child care
Low priority Margaret’s children are currently being cared for by their grandparents until Margaret’s husband returns as planned, so this potential problem will not develop into an actual problem. No interventions are needed at present, except for continued assessment and reassurance.
Impaired Nutrition: Less Than Body Requirements related to decreased ap- petite, nausea, and increased metabolism secondary to disease process
Low priority This problem is not currently health threatening, but it could be if it were to persist. It will almost certainly resolve in a day or two as the medical problem is treated. If the medical problem does not resolve quickly, this will change to a medium priority.
Bathing/Hygiene Self-Care Deficit related to weakness secondary to ineffective airway clearance and sleep pattern disturbance
Low priority This problem is caused by the other higher priority problems; therefore, it will resolve as they resolve. Meanwhile, the nurse merely needs to assist Margaret with bathing and so on to support and conserve her energy until she is strong enough to resume her own care.
Sleep Pattern Disturbance related to cough, pain, orthopnea, fever, and diaphoresis
Low priority Lack of sleep is health threatening. At the moment (until night), the nurse does not need to address this problem. Sleep Pattern Disturbance does contribute to Margaret’s Ineffective Airway Clearance, but it is not the main cause. Therefore, measures to promote sleep will be low priority until evening. After the nurse has attended to Margaret’s oxygenation and hydration needs, this problem priority will change.
Acute Pain (Chest) related to cough secondary to pneumonia
Not on care plan The nurse did not write Pain as a problem on the care plan because Pain is to be addressed as the etiology of Sleep Pattern Disturbance and Ineffective Airway Clearance. The pain etiologies (cough and pneumonia) will be treated by medications (collabora- tive interventions). Independent nursing actions would address the problem rather than the etiology and would be the same as the nursing actions for Ineffective Airway Clearance.
TABLE 13–1 Assigning Priorities to Nursing Diagnoses for Margaret O’Brien
3. Resources available to the nurse and client. If finances, equip- ment, or personnel are scarce in a health care agency, then a problem may be given a lower priority than usual. Nurses in a home setting, for example, do not have the resources of a hos- pital. If the necessary resources are not available, the solution to that problem might need to be postponed, or the client may need a referral. Client resources, such as finances or coping ability, may also influence the setting of priorities. For example, a client who is unemployed may defer dental treatment; a client whose husband is terminally ill and dependent on her may feel unable to cope with nutritional guidance directed toward losing weight.
4. Urgency of the health problem. Regardless of the framework used, life-threatening situations require that the nurse assign them a high priority. For example, in Table 13–1, although
Margaret O’Brien is anxious about child care, her Ineffective Airway Clearance has higher priority. Situations that affect the integrity of the client, that is, those that could have a nega- tive or destructive effect on the client, also have high priority. Such health problems as drug abuse and radical alteration of self- concept due to amputation can be destructive both to the individual and to the family.
5. Medical treatment plan. The priorities for treating health prob- lems must be congruent with treatment by other health profes- sionals. For example, a high priority for the client might be to become ambulatory; however, if the primary care provider’s therapeutic regimen calls for extended bed rest, then ambula- tion must assume a lower priority in the nursing care plan. The nurse can provide or teach exercises to facilitate ambulation
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Writing the broad, general goal first may help students to think of the specific outcomes that are needed, but the broad goal is just a starting point for planning. It is the specific, observable outcomes that must be written on the care plan and used to evaluate client progress. Table 13–2 shows both broad goals and specific outcomes.
THE NURSING OUTCOMES CLASSIFICATION Standardized or common nursing language is required in all phases of the nursing process if nursing data are to be included in com- puterized databases that are analyzed and used in nursing prac- tice. Nurse leaders and researchers have been working since 1991 to develop a taxonomy, the Nursing Outcomes Classification (NOC), for describing client outcomes that respond to nursing in- terventions. In the taxonomy, over 385 outcomes belong to one of seven domains (e.g., physiological health or family health) and a class within the domain (e.g., nutrition under physiological health or family well-being under family health). Each NOC outcome is assigned a four-digit identifier, indicated in this text by square brackets, and a definition.
“A nursing-sensitive client outcome is an individual, family, or community state, behavior, or perception that is measured along a continuum in response to a nursing intervention(s)” (Moorhead, Johnson, Maas, & Swanson, 2013, p. 2). The NOC outcomes are broadly stated and conceptual. They are variable concepts, meaning that the client’s responses to interventions can be evaluated over time. This is different from a goal, which is either met or not met. To be measured, an outcome must be made more specific by identifying the indicators that apply to a particular client. It is important to note the nursing-sensitive outcome indicators assess the effectiveness of nursing interventions. Broadly written outcomes will have interven- tions from a variety of health care–related disciplines. Indicators are stated in neutral terms, and each outcome includes a five-point scale (a measure) that is used to rate the client’s status on each indicator. (See Appendix B on the student resource website.) When using the NOC taxonomy to write a desired outcome on a care plan, the nurse writes the label, the indicators that apply to the particular client, the NOC rating at initiation (initial client status), and the outcome target (lo- cation on the measuring scale that is desired for each indicator). For example, using the NOC outcome for the client diagnosed in Table 13–2, the individualized desired outcomes would read as follows:
Mobility Level: Indicators: Walking (independent with assistive device),
moves with ease NOC Rating at Initiation: 2 (substantially compromised)
Outcome Target Rating: 4 (mildly compromised)
later, provided the client’s health permits. The nursing diagnosis related to ambulation is not ignored; it is merely deferred.
Establishing Client Goals/ Desired Outcomes After establishing priorities, the nurse and client set goals for each nursing diagnosis (Figure 13–6 •). On a care plan, the goals/ desired outcomes describe, in terms of observable client re- sponses, what the nurse hopes to achieve by implementing the nursing interventions. The terms goal and desired outcome are used interchangeably in this text, except when discussing and using standardized language. Some references also use the terms expected outcome, predicted outcome, outcome criterion, and objective.
Some nursing literature differentiates the terms by defining goals as broad statements about the client’s status and desired outcomes as the more specific, observable criteria used to evaluate whether the goals have been met. For example:
Goal (broad): Improved nutritional status.
Desired outcome (specific): Gain 5 lb by April 25.
When goals are stated broadly, as in this example, the care plan must include both goals and desired outcomes. They are sometimes com- bined into one statement linked by the words “as evidenced by,” as follows:
Improved nutritional status as evidenced by weight gain of 5 lb by April 25.
Figure 13–6 • Nurse Medina and Margaret collaborate to set goals and outcome criteria and develop a care plan.
Nursing Diagnosis
Opposite Healthy Responses (Goals)
Desired Outcomes: The Client Will
Impaired Physical Mobility: inability to bear weight on left leg, related to inflammation of knee joint
Improved mobility Ability to bear weight on left leg
Ambulate with crutches by end of the week. Stand without assistance by end of the month.
Ineffective Airway Clearance related to poor cough effort, secondary to incision pain and fear of damaging sutures
Effective airway clearance
Have lungs clear to auscultation during entire postoperative period. Have no skin pallor or cyanosis by 12 hours postoperation. Demonstrate good cough effort within 24 hours after surgery.
TABLE 13–2 Deriving Desired Outcomes from Nursing Diagnoses
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Stated in traditional language, that goal would read: “Client will have improved mobility, as evidenced by ability to walk with assistive de- vice (walker) and move easily.”
PURPOSE OF GOALS/DESIRED OUTCOMES Although goals and outcomes are not necessarily the same concept, the terms are used by some people interchangeably. If referenced to NOC, goals are considered to be met or not met, while progress toward outcomes can be described along a continuum and in com- parison to previous status (Moorhead et al., 2013). Goals/desired out- comes serve the following purposes:
1. Provide direction for planning nursing interventions. Ideas for interventions come more easily if the desired outcomes state clearly and specifically what the nurse hopes to achieve.
2. Serve as criteria for evaluating client progress. Although de- veloped in the planning step of the nursing process, desired outcomes serve as the criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step (see Chapter 14 ).
3. Enable the client and nurse to determine when the problem has been resolved.
4. Help motivate the client and nurse by providing a sense of achievement. As goals are met, both client and nurse can see that their efforts have been worthwhile. This provides motivation to continue following the plan, especially when difficult lifestyle changes need to be made.
SHORT-TERM AND LONG-TERM GOALS Goals may be short term or long term. A short-term goal might be “Client will raise right arm to shoulder height by Friday.” In the same context, a long-term goal/outcome might be “Client will regain full use of right arm in 6 weeks.” Short-term goals are useful for clients who (a) require health care for a short time or (b) are frustrated by long-term goals that seem difficult to attain and who need the satis- faction of achieving a short-term goal. In an acute care setting, much of the nurse’s time is spent on the client’s immediate needs, so most goals are short term. However, clients in acute care settings also need long-term goals/outcomes to guide planning for their discharge to long-term agencies or home care, especially in a managed care en- vironment. Outcomes are often set for clients who live at home and have chronic health problems and for clients in nursing homes, ex- tended care facilities, and rehabilitation centers.
RELATIONSHIP OF GOALS/DESIRED OUTCOMES TO NURSING DIAGNOSES Goals and outcomes are derived from the client’s nursing diagnoses— primarily from the diagnostic label. The diagnostic label contains the unhealthy response; it states what should change. For example, if the nursing diagnosis is Risk for Deficient Fluid Volume related to diar- rhea and inadequate intake secondary to nausea, the essential goal statement might be:
The client will reestablish fluid balance, as evidenced by urinary and stool output in balance with fluid intake, normal skin turgor, and moist mucous membranes.
In this example, a general goal (fluid balance) is stated as the opposite of the problem (Deficient Fluid Volume) and then followed by a list of ob- servable desired outcomes. If achieved, the outcomes would be evidence that the problem, Deficient Fluid Volume, has been prevented.
For every nursing diagnosis, the nurse must write the desired outcome(s) that, when achieved, directly demonstrates resolution of the problem. When developing goals/desired outcomes, ask the fol- lowing questions:
1. What is the client’s problem? 2. What is the opposite, healthy response? 3. How will the client look or behave if the healthy response is
achieved? (What will I be able to see, hear, measure, palpate, smell, or otherwise observe with my senses?)
4. What must the client do and how well must the client do it to demonstrate problem resolution or to demonstrate the capabil- ity of resolving the problem?
COMPONENTS OF GOAL/DESIRED OUTCOME STATEMENTS Goal/desired outcome statements should have the following four components:
1. Subject. The subject, a noun, is the client, any part of the client, or some attribute of the client, such as the client’s pulse or urinary output. The subject is often omitted in goals; it is assumed that the subject is the client unless indicated otherwise.
2. Verb. The verb specifies an action the client is to perform, for ex- ample, what the client is to do, learn, or experience. Verbs that denote directly observable behaviors, such as administer, show, or walk, must be used. See Box 13–1 for some examples.
3. Conditions or modifiers. Conditions or modifiers may be added to the verb to explain the circumstances under which the behav- ior is to be performed. They explain what, where, when, or how. For example: Walks with the help of a cane (how). After attending two group diabetes classes, lists signs and
symptoms of diabetes (when). When at home, maintains weight at existing level (where). Discusses food pyramid and recommended daily servings
(what). Conditions need not be included if the criterion of performance clearly indicates what is expected.
4. Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These cri- teria may specify time or speed, accuracy, distance, and quality. To establish a time-achievement criterion, the nurse needs to ask “How long?” To establish an accuracy criterion, the nurse asks “How well?” Similarly, the nurse asks “How far?” and “What is
BOX 13–1 Examples of Action Verbs
Apply Drink Select Assemble Explain Share Breathe Help Sit Choose Identify Sleep Compare Inject State Define List Talk Demonstrate Move Transfer Describe Name Turn Differentiate Prepare Verbalize Discuss Report
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Subject Verb Conditions/Modifiers Criterion of Desired Performance Client drinks 2,500 mL of fluid daily (time)
Client administers correct insulin dose using aseptic technique (quality standard)
Client lists three hazards of smoking (accuracy indicated by “three hazards”)
Client recalls five symptoms of diabetes (accuracy indicated by “five symptoms”) before discharge (time)
Client walks the length of the hall without a cane by date of discharge (time)
Client’s ankle measures less than 25 cm (10 in.) in circumference in 48 hours (time)
Client performs leg ROM exercises as taught every 8 hours (time)
Client identifies foods high in salt from a prepared list before discharge (time)
Client states the purposes of his medications before discharge (time)
TABLE 13–3 Components of Goals/Desired Outcomes
the expected standard?” to establish distance and quality criteria, respectively. Examples are: Weighs 75 kg by April (time). Lists five out of six signs of diabetes (accuracy). Walks one block per day (distance and time). Administers insulin using aseptic technique (quality).
Table 13–3 illustrates the format that should be used to write outcomes. Table 13–4 lists desired outcomes that were developed for Margaret O’Brien.
GUIDELINES FOR WRITING GOALS/DESIRED OUTCOMES The following guidelines can help nurses write useful goals and de- sired outcomes:
1. Write goals and outcomes in terms of client responses, not nurs- ing activities. Beginning each goal statement with The client will may help focus the goal on client behaviors and responses. Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs followed by the word client. These verbs indicate what the nurse hopes to accomplish, not what the client will do. Correct: The client will drink 100 mL of water per hour (client
behavior). Incorrect: Maintain client hydration (nursing action).
2. Be sure that desired outcomes are realistic for the client’s capa- bilities, limitations, and designated time span, if it is indicated. Limitations refers to finances, equipment, family support, social services, physical and mental condition, and time. For example, the outcome “Measures insulin accurately” may be unrealistic for a client who has poor vision due to cataracts.
3. Ensure that the goals and desired outcomes are compatible with the therapies of other professionals. For example, the outcome “The client will increase the time spent out of bed by 15 minutes each day” is not compatible with a primary care provider’s pre- scribed therapy of bed rest.
4. Make sure that each goal is derived from only one nursing diag- nosis. For example, the goal “The client will increase the amount of nutrients ingested and show progress in the ability to feed self ” is derived from two nursing diagnoses: Imbalanced Nutrition: Less Than Body Requirements and Feeding Self-Care Deficit. Keeping the goal statement related to only one diagnosis facili- tates evaluation of care by ensuring that planned nursing inter- ventions are clearly related to the diagnosis.
5. Use observable, measurable terms for outcomes. Avoid words that are vague and require interpretation or judgment by the observer. For example, phrases such as increase daily exercise and improve knowledge of nutrition can mean different things to different people. If used in outcomes, these phrases can lead to disagreements about whether the outcome was met. These phrases may be suitable for a broad client goal but are not suf- ficiently clear and specific to guide the nurse when evaluating client responses.
6. Make sure the client considers the goals/desired outcomes im- portant and values them. Some outcomes, such as those for problems related to self-esteem, parenting, and communication, involve choices that are best made by the client or in collabora- tion with the client.
Some clients may know what they wish to accomplish with re- gard to their health problem; others may not know all the possibili- ties. The nurse must actively listen to the client to determine personal values, goals, and desired outcomes in relation to current health con- cerns. Clients are usually motivated and will expend the necessary energy to reach goals they consider important. See the Nursing Care Plan on pages 203–204 for desired outcomes for three of Margaret O’Brien’s nursing diagnoses.
Selecting Nursing Interventions and Activities Nursing interventions and activities are the actions that a nurse performs to achieve client goals. The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement.
When it is not possible to change the etiologic factors, the nurse chooses interventions to treat the signs and symptoms or the defining characteristics in NANDA International (Herdman & Kamitsuru, 2014) terminology. Examples of this situation would be Pain related to surgical incision and Anxiety related to unknown etiology.
Interventions for risk nursing diagnoses should focus on mea- sures to reduce the client’s risk factors, which are also found in the second clause. Correct identification of the etiology during the diag- nosing phase provides the framework for choosing successful nursing interventions. For example, the diagnostic label Activity Intolerance may have several etiologies: pain, weakness, sedentary lifestyle, anxi- ety, or cardiac arrhythmias. Interventions will vary according to the cause of the problem.
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Nursing Diagnosis* Goal Statements [NOC]/Desired Outcomes Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to fluid volume deficit, pain, and fatigue
Respiratory Status: Gas Exchange [0402], as evidenced by • Absence of pallor and cyanosis (skin and mucous membranes) • Use of correct breathing/coughing technique after instruction • Productive cough • Symmetric chest excursion of at least 4 cm (1.6 in.) Within 48–72 h: • Lungs clear to auscultation • Respirations 12–22/min, pulse less than 100 beats/min • Inhales normal volume of air on incentive spirometer
Deficient Fluid Volume: intake insufficient to replace fluid loss related to vomiting, fever, and diaphoresis
Fluid Balance [0601], as evidenced by • Urine output greater than 30 mL/h • Urine specific gravity 1.005–1.025 • Good skin turgor • Moist mucous membranes • Stating the need for oral fluid intake
Anxiety related to difficulty breathing and concerns about work and parenting roles
Anxiety Control [1402], as evidenced by • Listening to and following instructions for correct breathing and coughing
technique, even during periods of dyspnea • Verbalizing understanding of condition, diagnostic tests, and treatments
(by end of day) • Decrease in reports of fear and anxiety; none within 12 h • Voice steady, not shaky • Respiratory rate of 12–22/min • Freely expressing concerns and possible solutions about work and parenting roles
Risk for Interrupted Family Processes related to mother’s illness and temporary unavailability of father to provide child care
Family Coping [2600], as evidenced by • Report of satisfactory child care arrangements having been made • Client and husband communicating effectively and working together to solve
problems • Family members expressing feelings and providing mutual support
Imbalanced Nutrition: Less Than Body Requirements related to decreased appetite, nausea, and increased metabolism secondary to disease process
Nutritional Status: Nutrient Intake [1009], as evidenced by • Eating at least 85% of each meal • Maintaining present weight • Verbalizing importance of adequate nutrition • Verbalizing improved appetite
Bathing/Hygiene Self-Care Deficit related to activity intolerance secondary to airway clearance and sleep pattern disturbance
Self-Care: Activities of Daily Living [0300], as evidenced by • Ambulates to bathroom without dyspnea, fatigue, ineffective or shortness
of breath • Within 24 h, bathes with assistance in bed; within 48 h, bathes with
assistance at sink; within 72 h, bathes in shower without dyspnea • Reports satisfaction and comfort with hygiene needs
Disturbed Sleep Pattern related to cough, pain, orthopnea, and diaphoresis
Sleep [0004], as evidenced by • Observed sleeping at night rounds • Reports feeling rested • Does not experience orthopnea
*The nursing diagnoses are listed in priority order.
TABLE 13–4 Desired Outcomes for Margaret O’Brien
TYPES OF NURSING INTERVENTIONS Nursing interventions are identified and written during the plan- ning step of the nursing process; however, they are actually per- formed during the implementing step. Nursing interventions include both direct and indirect care, as well as nurse-initiated, physician-initiated, and other provider-initiated treatments. Direct care is an intervention performed by the nurse through interaction with the client. Indirect care is an intervention delegated by the nurse to another provider or performed away from but on behalf of
the client such as interdisciplinary collaboration or management of the care environment.
Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. They in- clude physical care, ongoing assessment, emotional support and com- fort, teaching, counseling, environmental management, and making referrals to other health care professionals. Recall from Chapter 12 that nursing diagnoses are client problems that can be treated primarily by independent nursing interventions. In performing an autonomous
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CRITERIA FOR CHOOSING NURSING INTERVENTIONS After considering the consequences of the alternative nursing inter- ventions, the nurse chooses one or more that are likely to be most effective. Although the nurse bases this decision on knowledge and experience, the client’s input is important.
The following criteria can help the nurse choose the best nursing interventions. The plan must be:
• Safe and appropriate for the individual’s age, health, and condition. • Achievable with the resources available. For example, a home care
nurse might wish to include an intervention for an older client to “Check blood glucose daily.” In order for that to occur, the client must have intact sight, cognition, and memory to carry this out independently, family who can assist with this task, or available and affordable daily visits from a home care nurse.
• Congruent with the client’s values, beliefs, and culture. • Congruent with other therapies (e.g., if the client is not permit-
ted food, the strategy of an evening snack must be deferred until health permits).
• Based on nursing knowledge and experience or knowledge from relevant sciences (i.e., based on a rationale). For examples of ra- tionales, refer to the Nursing Care Plan for Margaret O’Brien on pages 203–204.
• Within established standards of care as determined by state laws, professional organizations (e.g., American Nurses Association), accrediting organizations (e.g., The Joint Commission), and the policies of the institution. Many agencies have policies to guide the activities of health professionals and to safeguard clients. Rules for visiting hours and procedures to follow when a client has car- diac arrest are examples. If a policy does not benefit clients, nurses have a responsibility to bring this to the attention of the appropri- ate people and facilitate a modification of the policy.
Writing Individualized Nursing Interventions After choosing the appropriate nursing interventions, the nurse writes them on the care plan. See examples of nursing interventions for Margaret O’Brien in the accompanying Nursing Care Plan on pages 203–204.
Date nursing interventions on the care plan when they are writ- ten and review regularly at intervals that depend on the individual’s needs. In an intensive care unit, for example, the plan of care will be continually monitored and revised. In a community clinic, weekly or biweekly reviews may be indicated.
The format of written interventions is similar to that of out- comes: verb, conditions, and modifiers, plus a time element. The ac- tion verb starts the intervention and must be precise. For example, “Explain (to the client) the actions of insulin” is a more precise state- ment than “Teach (the client) about insulin.” “Measure and record an- kle circumference daily at 0900” is more precise than “Assess edema of left ankle daily.” Sometimes a modifier for the verb can make the nursing intervention more precise. For example, “Apply spiral ban- dage firmly to left lower leg” is more precise than “Apply spiral ban- dage to left leg.”
The time element answers when, how long, or how often the nursing action is to occur. Examples are “Assist client with tub bath
activity, the nurse determines that the client requires certain nursing interventions, either carries these out or delegates them to other nurs- ing personnel, and is accountable or answerable for the decision and the actions. An example of an independent action is planning and pro- viding special mouth care for a client after diagnosing Impaired Oral Mucous Membranes.
Dependent interventions are activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses. Primary care providers’ orders commonly direct the nurse to provide medications, intrave- nous therapy, diagnostic tests, treatments, diet, and activity. With the client, the nurse is responsible for assessing the need for, explaining, and administering the medical orders. Nursing interventions may be written for the purpose of individualizing the medical order based on the client’s status. For example, for a medical order of “Progressive ambulation, as tolerated,” a nurse might write the following:
1. Dangle for 5 min, 12 hours postop. 2. Stand at bedside 24 hours postop; observe for pallor, dizziness,
and weakness. 3. Check pulse before and after ambulating. Do not progress if
pulse is greater than 110.
Collaborative interventions are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers. Collaborative nursing activities reflect the overlapping responsibili- ties of, and collegial relationships among, health personnel. For ex- ample, the primary care provider might order physical therapy to teach the client crutch-walking. The nurse would be responsible for informing the physical therapy department and for coordinating the client’s care to include the physical therapy sessions. The nurse may assist with crutch-walking and collaborate with the physical therapist to evaluate the client’s progress.
The amount of time the nurse spends in an independent versus a collaborative or dependent role varies according to the clinical area, type of institution, and specific position of the nurse.
CONSIDERING THE CONSEQUENCES OF EACH INTERVENTION Usually several possible interventions can be identified for each nursing goal. The nurse’s task is to choose those that are most likely to achieve the desired client outcomes. The nurse begins by considering the risks and benefits of each intervention. An intervention may have more than one consequence. For example, “Provide accurate infor- mation” could result in the following client behaviors:
• Increased anxiety • Decreased anxiety • Wish to talk with the primary care provider • Cooperation • Relaxation.
Determining the consequences of each intervention requires nursing knowledge and experience. For example, the nurse’s experience may suggest that providing information the night before the client’s surgery may increase the client’s worry and tension, whereas maintain- ing the usual rituals before sleep is more effective. The nurse might then consider providing information several days before surgery.
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at 0700 daily” and “Administer analgesic 30 minutes prior to physical therapy.”
In some settings, the intervention (and other segments of the nursing care plan) is signed. The signature of the nurse prescrib- ing the intervention shows the nurse’s accountability and has legal significance.
RELATIONSHIP OF NURSING INTERVENTIONS TO PROBLEM STATUS Depending on the type of client problem, the nurse writes interven- tions for observation, prevention, treatment, and health promotion.
Observations include assessments made to determine whether a complication is developing, as well as observation of the client’s re- sponses to nursing and other therapies. The nurse should write ob- servations for both real problems and those for which the client is at risk. Some examples are “Auscultate lungs q8h,” “Observe for redness over sacrum q2h,” and “Record intake and output hourly.”
Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. They are needed mainly for po- tential nursing diagnoses and collaborative problems. Examples are “Turn, cough, and deep breathe q2h” (prevents respiratory complica- tions) and “Keep bed rails raised and bed in low position” (minimizes chances of clients falling out of bed or injuring themselves should they fall over the rails).
Treatments include teaching, referrals, physical care, and other care needed for an actual nursing diagnosis. Some interventions may accomplish either prevention or treatment functions, depending on the status of the problem. In the preceding examples, “Turn, cough, and deep breathe q2h” can also be intended to treat an existing respi- ratory problem.
Enhancement or promotion interventions are appropriate when the client has no health problems or when the nurse makes a health promotion nursing diagnosis. Such nursing interventions fo- cus on helping the client identify areas for improvement that will lead to a higher level of wellness and actualize the client’s overall health po- tential. Examples are “Discuss the importance of daily exercise” and “Explore infant stimulation techniques.”
Delegating Implementation Determining whether delegation is indicated is another activity that occurs during the planning phase of the nursing process. While choos- ing and writing nursing interventions on the client’s care plan, the nurse must also determine who should actually perform the activity. The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities” (p. 1). Cipriano (2010) states: “Delegation unburdens the RN from unneces- sary work others can do, while the RN retains accountability for care and outcomes.” The ability to delegate client care and assign tasks is a vital skill for registered nurses because many health care institutions use assistive personnel (e.g., licensed practical nurses and unlicensed nursing assistants). To delegate appropriately, the nurse must match the needs of the client and family with the skills and knowledge of the available caregivers. This requires knowing the background, experi- ence, knowledge, skills, and strengths of each person, and understand- ing which tasks are and are not within their legal scope of practice.
The nurse has several responsibilities in delegating. These in- clude appropriate delegation of duties (that is, giving people duties
within their scope of practice and abilities and under the right cir- cumstances) and adequate direction, communication, and supervi- sion of personnel to whom work is delegated or assigned. The RN can delegate certain tasks to an unlicensed person but cannot assign responsibility for total nursing care. The RN is responsible for see- ing that delegated tasks are carried out properly. Assistive personnel may perform tasks such as measuring intake and output, but the RN is still responsible for analyzing data, planning care, and evaluating outcomes. Because there are no universal standards for the training of unlicensed personnel, nurses often must assume responsibility for supplementing the training those staff members have received (see also Chapter 28 ).
THE NURSING INTERVENTIONS CLASSIFICATION In addition to the efforts of NANDA to standardize the language for describing problems that require nursing care and to create a taxonomy of standardized client outcome labels, nurse researchers also recognized the need for a standardized language to describe the interventions that nurses perform. A taxonomy of nursing in- terventions referred to as the Nursing Interventions Classifica- tion (NIC) taxonomy, developed by the Iowa Intervention Project, was first published in 1992 and has been updated every 4 years since then. This taxonomy consists of three levels: level 1, domains; level 2, classes; and level 3, interventions.
More than 542 interventions (level 3) have been developed. Sim- ilar to NANDA diagnoses, each broadly stated intervention includes a label (name), a definition, and a list of activities that outlines the key actions of nurses in carrying out the intervention. For example, the level 3 intervention Touch is one of several interventions devel- oped within the Behavioral domain and its class entitled Coping Assistance.
All NIC interventions have been linked to NANDA nursing diagnostic labels. The nurse can look up a client’s nursing diagno- sis to see which nursing interventions are suggested. However, each nursing diagnosis contains suggestions for several interventions, so nurses need to select the appropriate interventions based on their judgment and knowledge of the client. The nursing diagnostic label Disturbed Sleep Pattern has 10 NIC interventions listed for prob- lem resolution and 18 additional optional interventions. To assist the client in the promotion of sleep, the nurse may choose to massage around the painful area to promote comfort (Bulechek et al., 2013).
When planning and documenting care in an agency that uses the NIC taxonomy, the nurse chooses the broad intervention label (e.g., Touch). Not all activities suggested for the intervention would be needed for every client, so the nurse chooses the activities ap- propriate for the client and individualizes them to fit the supplies, equipment, and other resources available in the agency. When writing individualized nursing interventions on a care plan, the nurse should record customized activities rather than the broad intervention labels. In Domain 1, for example, the nurse is caring for the client’s physi- ological needs. The care provided should support physical function- ing. In regards to the client’s elimination, the interventions promote regular bowel and urinary elimination (Moorhead et al., 2013).
The NIC taxonomy provides many benefits to nurse practition- ers, nurse educators, nurse administrators, and the nursing profes- sion as a whole (Box 13–2).
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BOX 13–2 Benefits of Standardized Interventions
• Enhances communication among nurses and among nurses and nonnurses.
• Makes it possible for researchers to determine the effectiveness and cost of nursing treatments.
• Helps communicate the nature of nursing to the public. • Helps demonstrate the impact that nurses have on health care. • Makes it easier for nurses to select appropriate interventions by
reducing the need for memorization and recall. • Facilitates the teaching of clinical decision making.
• Contributes to the development and use of computerized clinical records.
• Assists in effective planning for staff and equipment needs. • Aids in development of a system of payment for nursing
services. • Promotes full and meaningful participation of nurses in the
multidisciplinary team.
From Nursing Process & Critical Thinking, 5th ed. (p. 253), by J. M. Wilkinson, 2012, Upper Saddle River, NJ: Prentice Hall. Adapted with permission.
LIFESPAN CONSIDERATIONS Nursing Care Plan
OLDER ADULTS When a client is in an extended care facility or a long-term care facility, interventions and medications often remain the same day after day. It is important to review the care plan on a regular basis, because changes in the condition of older adults may be subtle and go unnoticed. This applies to both changes of improvement or deterioration. Either one should receive attention so that appropri- ate revisions can be made in expected outcomes and interventions. Outcomes need to be realistic with consideration given to the cli- ent’s physical condition, emotional condition, support systems, and
mental status. Outcomes often have to be stated and expected to be completed in very small steps. For instance, clients who have had a cerebrovascular accident may spend weeks learning to brush their own teeth or dress themselves. When these small steps are successfully completed, it gives the client a sense of accomplish- ment and motivation to continue working toward increasing self- care. This particular example also demonstrates the need to work collaboratively with other departments, such as physical and occu- pational therapy, to develop the nursing care plan.
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/Indicators Nursing Interventions Rationale
Respiratory Status: Gas Exchange [0402], as evidenced by • Absence of pallor and cyanosis (skin
and mucous membranes) • Use of correct breathing/coughing
technique after instruction
Monitor respiratory status q4h: rate, depth, effort, skin color, mucous membranes, amount and color of sputum. Monitor results of blood gases, chest x-ray studies, and incentive spirometer volume as available. Monitor level of consciousness.
To identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidenced by pallor, cyanosis, lethargy, and drowsiness.
• Productive cough • Symmetric chest excursion of
at least 4 cm
Auscultate lungs q4h. Vital signs q4h (TPR, BP, pulse oximetry, pain).
Inadequate oxygenation and pain cause increased pulse rate. Respiratory rate may be decreased by narcotic analgesics. Shallow breathing further compromises oxygenation.
Within 48–72 hours: • Lungs clear to auscultation • Respirations 12–22/min; pulse, less
than 100 beats/min
Instruct in breathing and coughing techniques. Remind to perform, and assist q3h.
To enable client to cough up secretions. May need encouragement and support because of fatigue and pain.
• Inhales normal volume of air on incentive spirometer
Administer prescribed expectorant; schedule for maximum effectiveness. Maintain Fowler’s or semi-Fowler’s position. Administer prescribed analgesics. Notify primary care provider if pain not relieved.
Helps loosen secretions so they can be coughed up and expelled. Gravity allows for fuller lung expansion by decreasing pressure of abdomen on diaphragm. Controls pleuritic pain by blocking pain pathways and altering perception of pain, enabling client to increase thoracic expansion. Unrelieved pain may signal impending complication.
NURSING CARE PLAN Margaret O’Brien
Continued on page 204
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NURSING CARE PLAN Margaret O’Brien—continued
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/Indicators Nursing Interventions Rationale
Administer oxygen by nasal cannula as prescribed. Provide portable oxy- gen if client goes off unit (e.g., for x-ray examination).
Supplemental oxygen makes more oxygen available to the cells, even though less air is being moved by the client, thereby reducing the work of breathing.
Assist with postural drainage daily at 0930.
Gravity facilitates movement of secretions upward through the respiratory passage.
Administer prescribed antibiotic to main- tain constant blood level. Observe for rash and GI or other side effects.
Resolves infection by bacteriostatic or bactericidal effect, depending on type of an- tibiotic used. Constant level required to pre- vent pathogens from multiplying. Allergies to antibiotics are common.
Nursing Diagnosis: Deficient Fluid Volume: intake insufficient to replace fluid loss (see standardized care plan for Deficient Fluid Volume, Figure 13–4).
Nursing Diagnosis: Anxiety related to difficulty breathing and concern about school and parenting roles
Desired Outcomes*/Indicators Nursing Interventions Rationale Anxiety Control [1402], as evidenced by When client is dyspneic, stay with her;
reassure her you will stay. Presence of a competent caregiver reduces fear of being unable to breathe.
• Listening to and following instructions for correct breathing and coughing technique, even during periods of dyspnea
Remain calm; appear confident. Encourage slow, deep breathing.
Control of anxiety will help client to maintain effective breathing pattern.
• Verbalizing understanding of condition, diagnostic tests, and treatments (by end of day)
When client is dyspneic, give brief expla- nations of treatments and procedures.
Reassures client the nurse can help her. Focusing on breathing may help client feel in control and decrease anxiety.
• Decrease in reports of fear and anxiety • Voice steady, not shaky • Respiratory rate of 12–22/min
When acute episode is over, give detailed information about nature of condition, treatments, and tests.
Anxiety and pain interfere with learning. Knowing what to expect reduces anxiety.
• Freely expressing concerns and possible solutions about work and parenting roles
As client can tolerate, encourage to express and expand on her concerns about her child and her work. Explore alternatives as needed.
Awareness of source of anxiety enables client to gain control over it. Husband’s continued absence would constitute a defining characteristic for this nursing diagnosis.
Note whether husband returns as scheduled. If not, institute care plan for actual Interrupted Family Processes.
*The NOC # for desired outcomes is listed in brackets following the appropriate outcome.
Applying Critical Thinking 1. What assumptions does the nurse make when deciding that using a standardized care plan for Deficient Fluid Volume is
appropriate for this client? 2. Identify an outcome in the care plan and its nursing intervention that contribute to discharge care planning. What evidence
supports your choice? 3. Consider how the nurse shares the development of the care plan and outcomes with the client. 4. Not every intervention has a time frame or interval specified. It may be implied. Under what circumstances is this acceptable
practice? 5. In Table 13–1, Ineffective Airway Clearance is Margaret’s highest priority nursing diagnosis. Under what conditions might this
diagnosis be of only moderate priority in Margaret’s case? See Critical Thinking Possibilities on student resource website.
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CONCEPT MAP Ineffective Airway Clearance (Gas Exchange)
nursing intervention
Respiratory status: Gas Exchange aeb • Absent of pallor & cyanosis • Use of correct breathing/coughing technique after instruction • Productive cough • Symmetric chest excursion
• Lungs clear to auscultation • Respirations 12-22/min; pulse less than100 beats/min • Inhales normal volume air on incentive spirometer
Ineffective Airway Clearance r/t viscous secretions, & shallow chest expansion, secondary to deficient fluid volume, pain, & fatigue
MO 33 y.o. female Possible pneumonia
assess
generate nursing diagnosis
outcome
Within 24 hours
• Cold x 2 weeks • Dyspnea on exertion • Fever • Orthopnea • Occasional chills • Decreased oral intake x 2 days
• T: 103F P: 92 R: 22, shallow BP: 122/80 • Dry mucous membranes; skin hot, pale • Cheeks flushed • Decreased breath sounds • Inspiratory crackles RUL and RLL • Ineffective cough—small amount thick, pale pink sputum • Lethargic, c/o being weak, fatigued
nursing intervention
Auscultate breath sounds q4h
Monitor level of consciousness
Monitor results of blood gases, x-rays, & incentive spirometry
activity
activity
activity
activity activity
activity
activity
activity
activity
activity
activity
Instruct in breathing & coughing techniques. Remind & assist q3h
Administer expectorants
Administer analgesics
Administer antibiotics
Respiratory Monitoring
Administer O2 per NC
Assist with postural drainage @ 9:30 AM
Respiratory Monitoring
Monitor respiratory status q4h: rate, depth effort, skin color, mucous membranes, amount & color of sputum
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• Planning is the process of designing nursing activities required to prevent, reduce, or eliminate a client’s health problems.
• Planning involves the nurse, the client, support people, and other caregivers.
• Shorter acute care hospitalization stays necessitate careful dis- charge planning.
• Standardized care plans should be adapted and used with indi- vidualized plans to meet individual client needs.
• The nursing care plan provides direction for individualized care of the client.
• The planning process includes setting diagnostic priorities, estab- lishing client goals/desired outcomes, selecting nursing interven- tions and activities, and writing individualized nursing interventions on the care plan.
• Nursing diagnoses are assigned high, medium, and low priorities in consultation with the client, if health permits.
• Client goals/desired outcomes are used to plan nursing interven- tions that will achieve anticipated changes in the client.
• A taxonomy of nursing outcome statements, the Nursing Out- comes Classification (NOC), has been developed to describe mea- surable states, behaviors, or perceptions that respond to nursing
interventions. Each outcome has a definition, a measuring scale, and an indicator.
• Desired outcomes describe specific and measurable client re- sponses and help the nurse evaluate the effectiveness of the nurs- ing interventions.
• Client goals/desired outcomes are derived from the first clause of the nursing diagnosis.
• Nursing interventions are focused on the etiology or second clause of the nursing diagnosis.
• Independent nursing interventions are those the nurse is licensed to prescribe or delegate.
• Determining the consequences of each nursing strategy requires nursing knowledge and experience.
• A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy has been developed. These interventions have been linked to the NANDA nursing diag- nostic labels. Similar to NANDA diagnoses, each broadly stated intervention includes a label (name), a definition, and a list of ac- tivities that outlines the key actions of nurses in carrying out the intervention.
CHAPTER HIGHLIGHTS
Chapter 13 Review
1. After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1. Initial 2. Ongoing 3. Discharge 4. Strategic
2. The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care
3. The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The cli- ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection
4. The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical inci- sion. Which of the following represents a properly stated goal/ outcome? The client will 1. Turn in bed q2h. 2. Report the importance of applying lotion to skin daily. 3. Have intact skin during hospitalization. 4. Use a pressure-reducing mattress.
5. The care plan includes a nursing intervention “4/2/15 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None
6. Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes. 2. Write the care plan. 3. Set priorities. 4. Choose interventions.
7. The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed. 2. The nurse chooses from a list of interventions. 3. They are much shorter than nurse-authored care plans. 4. They have been approved by accrediting agencies.
8. Which of the following is likely to occur if a goal statement is poorly written? 1. There is no standard against which to compare outcomes. 2. The nursing diagnoses cannot be prioritized. 3. Only dependent nursing interventions can be used. 4. It is difficult to determine which nursing interventions can be
delegated.
TEST YOUR KNOWLEDGE
206
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10. Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be “doing,” not just “monitoring.”
See Answers to Test Your Knowledge in Appendix A.
9. When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse’s and the client’s values.
Suggested Reading Forward, C. (2012). Measuring the effectiveness of school
nursing interventions: A review of outcomes. British Journal of School Nursing, 7(10), 490–500.
This article provides clear indications of the importance of policy documents that measure outcomes in the delivery of nursing care. It is important for school nurses to examine the documents utilized to measure nursing intervention outcomes for children and adolescents. The study revealed that measuring outcomes has ensured that school nursing is meeting a purpose in the United Kingdom’s delivery of care.
Related Research Berben, L., Dobbels, F., Kugler, C., Russell, C., & Geest, S. D.
(2011). Interventions used by health care professionals to enhance medication adherence in transplant patients: A survey of current clinical practice. Progress in Transplan- tation, 21(4), 322–331. doi:2011394295
References American Nurses Association & National Council of State
Boards of Nursing. (2006). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_ statement_NCSBN-ANA.pdf
Bulechek, G. M., Butcher, H. K., Dochterman, J. C., & Wagner, C. M. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier.
Cipriano, P. (2010). Overview and summary: Delegation dilemmas: Standards and skills for practice. Online Journal of Issues in Nursing, 15(2). doi:10.3912/OJIN .Vol15No02ManOS
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA Inter- national Nursing Diagnoses: Definitions and Classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Wilkinson, J. M. (2012). Nursing process & critical thinking (5th ed.). Upper Saddle River, NJ: Prentice Hall Health.
Selected Bibliography Alfaro-LeFevre, R. A. (2014). Applying the nursing process:
The foundation for clinical reasoning (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Carpenito, L. J. (2008). Nursing diagnosis: Application to clinical practice (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Doenges, M. E., Moorhouse, M. F., & Murr, A. (2013). Nursing diagnosis manual: Planning, individualizing, and document- ing client care. Philadelphia, PA: F.A. Davis.
Wilkinson, J. M. (2014). Nursing diagnosis handbook (10th ed.). Upper Saddle River, NJ: Pearson.
READINGS AND REFERENCES
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INTRODUCTION The nursing process is action oriented, client centered, and outcome directed. After developing a plan of care based on the assessing and diagnosing phases, the nurse implements the interventions and eval- uates the desired outcomes. On the basis of this evaluation, the plan of care is either continued, modified, or terminated. As in all phases of the nursing process, clients and support persons are encouraged to participate as much as possible.
IMPLEMENTING In the nursing process, implementing is the action phase in which the nurse performs the nursing interventions. Using Nursing Inter- ventions Classification (NIC) terminology, implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing activities for the interventions that were devel- oped in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses.
The fifth standard of the American Nurses Association (ANA) Standards of Practice is implementation. Three of the implementa- tion substandards apply to all registered nurses: coordination of care, health teaching and health promotion, and consultation. The fourth substandard, prescriptive authority and treatment, applies only to ad- vanced practice nurses (ANA, 2010).
Relationship of Implementing to Other Nursing Process Phases The first three nursing process phases—assessing, diagnosing, and planning—provide the basis for the nursing actions performed during
the implementing step. In turn, the implementing phase provides the actual nursing activities and client responses that are examined in the fi- nal phase, the evaluating phase. Using data acquired during assessment, the nurse can individualize the care given in the implementing phase, tailoring the interventions to fit a specific client rather than applying them routinely to categories of clients (e.g., all clients with pneumonia).
While implementing nursing care, the nurse continues to reas- sess the client at every contact, gathering data about the client’s re- sponses to the nursing activities and about any new problems that may develop. A nursing activity on the client’s care plan for the NIC intervention Airway Management might read “Auscultate breath sounds q4h.” When performing this activity, the nurse is both carrying out the intervention (implementing) and performing an assessment. Some routine nursing activities are, themselves, assessments. For ex- ample, while bathing an older client, the nurse observes a reddened area on the client’s sacrum. Or, when emptying a urinary catheter bag, the nurse measures 200 mL of offensive smelling, brown urine.
Implementing Skills To implement the care plan successfully, nurses need cognitive, inter- personal, and technical skills. These skills are distinct from one an- other; in practice, however, nurses use them in various combinations and with different emphasis, depending on the activity. For instance, when inserting a urinary catheter, the nurse needs cognitive knowl- edge of the principles and steps of the procedure, interpersonal skills to inform and reassure the client, and technical skill in draping the client and manipulating the equipment.
The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, clinical reasoning, and creativity. They are crucial to safe, intelligent nursing care (see Chapter 10 ).
audit, 215 cognitive skills, 208 concurrent audit, 216 evaluating, 210 evaluation statement, 211
implementing, 208 interpersonal skills, 209 outcome evaluation, 214 process evaluation, 214
quality assurance (QA) program, 214
quality improvement (QI), 215 retrospective audit, 215 root cause analysis, 215
sentinel event, 215 structure evaluation, 214 technical skills, 209
KEY TERMS
After completing this chapter, you will be able to: 1. Explain how implementing relates to other phases of the
nursing process. 2. Describe three categories of skills used to implement nursing
interventions. 3. Discuss the five activities of the implementing phase. 4. Identify guidelines for implementing nursing interventions. 5. Explain how evaluating relates to other phases of the nursing
process.
LEARNING OUTCOMES
14 Implementing and Evaluating
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6. Describe five components of the evaluation process. 7. Describe the steps involved in reviewing and modifying the
client’s care plan. 8. Describe three components of quality evaluation: structure,
process, and outcomes. 9. Differentiate quality improvement from quality assurance.
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• Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain when moved).
• The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse who is not familiar with a particular model of traction equipment needs assistance the first time it is applied).
IMPLEMENTING THE NURSING INTERVENTIONS It is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the expected outcome is. For many nursing activities it is also im- portant to ensure the client’s privacy, for example, by closing doors, pulling curtains, or draping the client. The number and kind of di- rect nursing interventions are almost unlimited. Nurses also coordi- nate client care. This activity involves scheduling client contacts with other departments (e.g., laboratory and x-ray technicians, physical and respiratory therapists) and serving as a liaison among the mem- bers of the health care team.
When implementing interventions, nurses should follow these guidelines:
• Base nursing interventions on scientific knowledge, nursing re- search, and professional standards of care (evidence-based prac- tice) when these exist. The nurse must be aware of the scientific rationale, as well as possible side effects or complications, of all interventions. For example, a client has been taking an oral medi- cation after meals; however, this medication is not absorbed well in the presence of food. Therefore, the nurse will need to explain why this practice needs to be altered.
Interpersonal skills are all of the activities, verbal and non- verbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse’s ability to communicate with others. The nurse uses therapeutic com- munication to understand the client and in turn be understood. A nurse also needs to work effectively with others as a member of the health care team.
Interpersonal skills are necessary for all nursing activities: car- ing, comforting, advocating, referring, counseling, and supporting are just a few. Interpersonal skills include conveying knowledge, at- titudes, feelings, interest, and appreciation of the client’s cultural val- ues and lifestyle. Before nurses can be highly skilled in interpersonal relations, they must have self-awareness and sensitivity to others (see Chapters 25 and 39 ).
Technical skills are purposeful “hands-on” skills such as ma- nipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. These skills are also called tasks, proce- dures, or psychomotor skills. The term psychomotor refers to physi- cal actions that are controlled by the mind, not by reflexes.
Technical skills require knowledge and, frequently, manual dex- terity. The number of technical skills expected of a nurse has greatly increased in recent years because of the pervasive use of technology, especially in acute care hospitals.
Process of Implementing The process of implementing (Figure 14–1 •) normally includes the following:
• Reassessing the client • Determining the nurse’s need for assistance • Implementing the nursing interventions • Supervising the delegated care • Documenting nursing activities.
REASSESSING THE CLIENT Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even though an order is written on the care plan, the client’s condition may have changed. For example, a client has a nursing diagnosis of Disturbed Sleep Pattern related to anxiety and unfamiliar surroundings. Dur- ing rounds, the nurse discovers that the client is sleeping and therefore defers the back massage that had been planned as a relaxation strategy.
New data may indicate a need to change the priorities of care or the nursing activities. For example, a nurse begins to teach a client who has diabetes how to give himself insulin injections. Shortly after begin- ning the teaching, the nurse realizes that he is not concentrating on the lesson. Subsequent discussion reveals that he is worried about his eye- sight and fears he is going blind. Realizing that the client’s level of stress is interfering with his learning, the nurse ends the lesson and arranges for a primary care provider to examine the client’s eyes. The nurse also provides supportive communication to help alleviate the client’s stress.
DETERMINING THE NURSE’S NEED FOR ASSISTANCE When implementing some nursing interventions, the nurse may require assistance for one or more of the following reasons:
• The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating an unsteady obese client).
Figure 14–1 • Implementing—the fourth phase of the nursing pro- cess. In this phase the nurse implements the nursing interventions and documents the care provided.
Planning
Evaluating
Assessing
Diagnosing
Implementing • Reassessing the client • Determining the nurse’s need for assistance • Implementing the nursing interventions • Supervising the delegated care • Documenting nursing activities
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210 Unit 3 • The Nursing Process
degree of participation they desire. Some want total involvement in their care, whereas others prefer little involvement. The amount of desired involvement may be related to the severity of the illness; the client’s culture; or the client’s fear, understanding of the illness, and understanding of the intervention.
SUPERVISING DELEGATED CARE If care has been delegated to other health care personnel, the nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan. Other caregiv- ers may be required to communicate their activities to the nurse by documenting them on the client record, reporting verbally, or filling out a written form. The nurse validates and responds to any adverse findings or client responses. This may involve modifying the nursing care plan.
DOCUMENTING NURSING ACTIVITIES After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client re- sponses in the nursing progress notes. These are a part of the agency’s permanent record for the client. Nursing care must not be recorded in advance because the nurse may determine on reassessment of the client that the intervention should not or cannot be implemented. For example, a nurse is authorized to inject 10 mg of morphine sul- fate subcutaneously to a client, but the nurse finds that the client’s re- spiratory rate is 8 breaths per minute. This finding contraindicates the administration of morphine (a respiratory depressant). The nurse withholds the morphine and reports the client’s respiratory rate to the nurse in charge and/or primary care provider.
The nurse may record routine or recurring activities (e.g., mouth care) in the client record at the end of a shift. In the meantime, the nurse maintains a personal record of these interventions on a work- sheet. In some instances, it is important to record a nursing interven- tion immediately after it is implemented. This is particularly true of the administration of medications and treatments because recorded data about a client must be up to date, accurate, and available to other nurses and health care professionals. Immediate recording helps safeguard the client, for example, from receiving a duplicate dose of medication.
Nursing activities are communicated verbally as well as in writ- ing. When a client’s health is changing rapidly, the charge nurse and/ or the primary care provider may want to be kept up to date with ver- bal reports. Nurses also report client status at a change of shift and on a client’s discharge to another unit or health agency in person, via a voice recording, or in writing. For information on documenting and reporting, see Chapter 15 .
EVALUATING To evaluate is to judge or to appraise. Evaluating is the fifth phase of the nursing process. In this context, evaluating is a planned, ongo- ing, purposeful activity in which clients and health care profession- als determine (a) the client’s progress toward achievement of goals/ outcomes and (b) the effectiveness of the nursing care plan. Evalu- ation is an important aspect of the nursing process because conclu- sions drawn from the evaluation determine whether the nursing interventions should be terminated, continued, or changed. Evalua- tion is the sixth standard of the ANA Standards of Practice and states that “The registered nurse evaluates progress towards attainment of outcomes” (2010, p. 45).
• Clearly understand the interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and nursing plans of care. This requires knowledge of each intervention, its purpose in the client’s plan of care, any contraindications (e.g., allergies), and changes in the client’s condition that may affect the order.
• Adapt activities to the individual client. A client’s beliefs, values, age, health status, and environment are factors that can affect the success of a nursing action. For example, the nurse determines that a client chokes when swallowing pills. The nurse consults with the primary care provider to change the order to a liquid form of the medication. Or, the nurse recognizes that many Asian people pre- fer to drink hot water rather than ice water and, after confirming it with a specific client, supplies this at the bedside.
• Implement safe care. For example, when changing a sterile dress- ing, the nurse practices sterile technique to prevent infection; when giving a medication, the nurse administers the correct dos- age by the ordered route.
• Provide teaching, support, and comfort. See Chapter 27 for details on client teaching and Box 27–2 for examples of verbs used in writing learning outcomes. The nurse should always ex- plain the purpose of interventions, what the client will experience, and how the client can participate. The client must have sufficient knowledge to agree to the plan of care and to be able to assume re- sponsibility for as much self-care as desirable. These independent nursing activities enhance the effectiveness of nursing care plans (Figure 14–2 •).
• Be holistic. The nurse must always view the client as a whole and consider the client’s responses in that context. For example, when- ever possible, the nurse honors the client’s expressed preference that interventions be planned for times that fit with the client’s usual schedule of visitors, work, sleep, or eating.
• Respect the dignity of the client and enhance the client’s self- esteem. Providing privacy and encouraging clients to make their own decisions are ways of respecting dignity and enhancing self-esteem.
• Encourage clients to participate actively in implementing the nursing interventions. Active participation enhances the client’s sense of independence and control. However, clients vary in the
Figure 14–2 • Margaret agrees to practice deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake.
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about whether goals have been met. It is usually necessary to collect both objective and subjective data.
Some data may require interpretation. Examples of objective data requiring interpretation are the degree of tissue turgor of a de- hydrated client or the degree of restlessness of a client with pain. Ex- amples of subjective data needing interpretation include complaints of nausea or pain by the client. When interpreting subjective data, the nurse must rely on either (a) the client’s statements (e.g., “My pain is worse now than it was after breakfast”) or (b) objective indicators of the subjective data, even though these indicators may require further interpretation (e.g., decreased restlessness, decreased pulse and respi- ratory rates, and relaxed facial muscles as indicators of pain relief). Data must be recorded concisely and accurately to facilitate the next part of the evaluating process.
COMPARING DATA WITH DESIRED OUTCOMES If the first two parts of the evaluating process have been carried out effectively, it is relatively simple to determine whether a desired out- come has been met. Both the nurse and client play an active role in comparing the client’s actual responses with the desired outcomes. Did the client drink 3,000 mL of fluid in 24 hours? Did the client walk unassisted the specified distance per day? When determining whether a goal has been achieved, the nurse can draw one of three possible conclusions:
1. The goal was met; that is, the client response is the same as the desired outcome.
2. The goal was partially met; that is, either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained.
3. The goal was not met.
After determining whether or not a goal has been met, the nurse writes an evaluation statement (either on the care plan or in the nurse’s notes). An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that
Evaluation is continuous. Evaluation done while or immediately after implementing a nursing order enables the nurse to make on- the-spot modifications in an intervention. Evaluation performed at specified intervals (e.g., once a week for the home care client) shows the extent of progress toward achievement of goals/outcomes and en- ables the nurse to correct any deficiencies and modify the care plan as needed. Evaluation continues until the client achieves the health goals or is discharged from nursing care. Evaluation at discharge in- cludes the status of goal achievement and the client’s self-care abilities with regard to follow-up care. Most agencies have a special discharge record for this evaluation.
Through evaluating, nurses demonstrate responsibility and ac- countability for their actions, indicate interest in the results of the nursing activities, and demonstrate a desire not to perpetuate ineffec- tive actions but to adopt more effective ones.
Relationship of Evaluating to Other Nursing Process Phases Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must be accurate and complete so that the nurse can formulate appropriate nursing diagnoses and desired outcomes. The desired outcomes must be stated concretely in behav- ioral terms if they are to be useful for evaluating client responses. Fi- nally, without the implementing phase in which the plan is put into action, there would be nothing to evaluate.
The evaluating and assessing phases overlap. As previously stated, assessment is ongoing and continuous at every client contact. However, data are collected for different purposes at different points in the nursing process. During the assessment phase the nurse collects data for the purpose of making diagnoses. During the evaluation step the nurse collects data for the purpose of comparing it to preselected goals/outcomes and judging the effectiveness of the nursing care. The act of assessing is the same; the differences lie in (a) when the data are collected and (b) how the data are used.
Process of Evaluating Client Responses Before evaluation, the nurse identifies the desired outcomes (indica- tors) that will be used to measure client goal achievement. (This is done in the planning step.) Desired outcomes serve two purposes: They establish the kind of evaluative data that need to be collected and provide a standard against which the data are judged. For exam- ple, given the following expected outcomes, any nurse caring for the client would know what data to collect:
• Daily fluid intake will not be less than 2,500 mL. • Urinary output will balance with fluid intake. • Residual urine will be less than 100 mL.
The evaluation phase has five components (Figure 14–3 •):
• Collecting data related to the desired outcomes (NOC indicators) • Comparing the data with desired outcomes • Relating nursing activities to outcomes • Drawing conclusions about problem status • Continuing, modifying, or terminating the nursing care plan.
COLLECTING DATA Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse collects data so that conclusions can be drawn
Figure 14–3 • Evaluating—the final phase of the nursing process. In this phase the nurse determines the client’s progress toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or terminated.
Planning
Implementing
Assessing
Diagnosing Evaluating • Collecting data related to desired outcomes • Comparing data with desired outcomes • Relating nursing activities to outcomes • Drawing conclusions about problem status • Continuing, modifying, or terminating the nursing care plan
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• The potential problem stated in the nursing diagnosis is being prevented, but the risk factors are still present. In this case, the nurse keeps the problem on the care plan.
• The actual problem still exists even though some goals are be- ing met. For example, a desired outcome on a client’s care plan is “Will drink 3,000 mL of fluid daily.” Even though the data may show this outcome has been achieved, other data (dry oral mucous membranes) may indicate that the nursing diagnosis Deficient Fluid Volume is applicable. Therefore, the nursing interventions must be continued even though this one goal was met.
When goals have been partially met or when goals have not been met, two conclusions may be drawn:
• The care plan may need to be revised, since the problem is only partially resolved. The revisions may need to occur dur- ing the assessing, diagnosing, or planning phases, as well as implementing.
OR
• The care plan does not need revision, because the client merely needs more time to achieve the previously established goal(s). To make this decision, the nurse must assess why the goals are be- ing only partially achieved, including whether the evaluation was conducted too soon (Figure 14–4 •).
CONTINUING, MODIFYING, OR TERMINATING THE NURSING CARE PLAN After drawing conclusions about the status of the client’s problems, the nurse modifies the care plan as indicated. Depending on the agency, modifications may be made by drawing a line through por- tions of the care plan, marking portions using a highlighting pen, or indicating revisions as appropriate for electronic charting systems. The nurse may also write “Discontinued” (“dc’d”), “goal met,” or “prob- lem resolved” and the date.
Whether or not goals were met, a number of decisions need to be made about continuing, modifying, or terminating nursing care
the goal/desired outcome was met, partially met, or not met. The sup- porting data are the list of client responses that support the conclu- sion, for example:
Goal met: Oral intake 300 mL more than output; skin turgor resilient; mucous membranes moist.
See the Nursing Care Plan at the end of the chapter for evaluation statements for Margaret O’Brien. Data in the Evaluation Statements column on this table represent Margaret’s responses to care as ob- served by the night nurse on the morning after her admission to the unit. In practice, care plans usually do not have a column for evalua- tion statements; rather, these are recorded in the nurse’s notes. If NOC indicators are being used with the outcomes, scores on the scales after intervention would be compared with those measured at baseline to determine improvement.
RELATING NURSING ACTIVITIES TO OUTCOMES The third phase of the evaluating process is determining whether the nursing activities had any relation to the outcomes. It should never be assumed that a nursing activity was the cause of or the only factor in meeting, partially meeting, or not meeting a goal.
For example, a client was obese and needed to lose 14 kg (30 lb). When the nurse and client drew up a care plan, one goal was “Lose 1.4 kg (3 lb) in 4 weeks.” A nursing strategy in the care plan was “Explain how to plan and prepare a 1,200-calorie diet.” Four weeks later, the client weighed herself and had lost 1.8 kg (4 lb). The goal had been met—in fact, exceeded. It is easy to assume that the nurs- ing strategy was highly effective. However, it is important to collect more data before drawing that conclusion. On questioning the cli- ent, the nurse might find any of the following: (a) The client planned a 1,200-calorie diet and prepared and ate the food; (b) the client planned a 1,200-calorie diet but did not prepare the correct food; (c) the client did not understand how to plan a 1,200-calorie diet, so she did not bother with it.
If the first possibility is found to be true, the nurse can safely judge that the nursing strategy “Explain how to plan and prepare a 1,200-calorie diet” was effective in helping the client lose weight. However, if the nurse learns that either the second or third possibility actually happened, then it must be assumed that the nursing strategy did not affect the outcome. The next step for the nurse is to collect data about what the client actually did to lose weight. It is important to establish the relationship (or lack thereof) of the nursing actions to the client responses.
DRAWING CONCLUSIONS ABOUT PROBLEM STATUS The nurse uses the judgments about goal achievement to determine whether the care plan was effective in resolving, reducing, or pre- venting client problems. When goals have been met, the nurse can draw one of the following conclusions about the status of the client’s problem:
• The actual problem stated in the nursing diagnosis has been re- solved, or the potential problem is being prevented and the risk factors no longer exist. In these instances, the nurse documents that the goals have been met and discontinues the care for the problem.
Figure 14–4 • Upon assessment of respiratory excursion, Nurse Me- dina detects failure of the client to achieve maximum ventilation. She and Margaret reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.
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for each problem. See Table 14–1 for a checklist to use when review- ing a care plan. Although the checklist uses a closed-ended yes/no format, its only intent is to identify areas that require the nurse’s fur- ther examination.
Before making modifications, the nurse must determine the ef- fectiveness of the plan as a whole. This requires a review of the entire care plan and a critique of each step of the nursing process involved in its development.
ASSESSING An incomplete or incorrect database influences all subsequent steps of the nursing process and care plan. If data are incomplete, the nurse needs to reassess the client and record the new data. In some instances, new data may indicate the need for new nursing diagnoses, new goals/outcomes, and new nursing interventions.
DIAGNOSING If the database was incomplete, new diagnostic statements may be required. If the database was complete, the nurse needs to analyze whether the problems were identified correctly and whether the nursing diagnoses were relevant to that database. After making judgments about problem status, the nurse revises or adds new diagnoses as needed to reflect the most recent client data.
PLANNING: DESIRED OUTCOMES If a nursing diagnosis was inaccurate, obviously the goal/outcome statement will need revision. If the nursing diagnosis was appropriate, the nurse then checks if the goals were realistic and attainable. Unrealistic goals require correction. The nurse should also determine whether priorities have changed and whether the client still agrees with the priorities. For example, maybe the amount of time delineated for a specific amount of weight loss was too short and should be extended. Goals and outcomes must also be written for any new nursing diagnoses.
PLANNING: NURSING INTERVENTIONS The nurse investigates whether the nursing interventions were related to goal achievement and whether the best nursing interventions were selected. Even when diagnoses and goals/outcomes were appropriate, the nursing interventions selected may not have been the best ones to achieve the goal. New nursing interventions may reflect changes in the amount of nursing care the client needs, scheduling changes, or rearrangement of nursing activities to group similar activities or to permit longer rest or activity periods for the client. For example, for a client who wishes to stop smoking, there are many potential interventions. If medication was prescribed but the client is still smoking, possibly a behavioral intervention such as group counseling needs to be added. If new
Assessing Diagnosing Planning Implementing — Are data complete, accurate, and validated?
— Do new data require changes in the care plan?
— Are nursing diagnoses relevant and accurate?
— Are nursing diagnoses supported by the data?
— Has problem status changed (i.e., potential, actual, risk)?
— Are the diagnoses stated clearly and in correct format?
— Have any nursing diagnoses been resolved?
Desired Outcomes — Do new nursing diagnoses require new goals?
— Are goals realistic? — Was enough time allowed for goal achievement?
— Do the goals address all aspects of the problem?
— Does the client still concur with the goals?
— Have client priorities changed?
— Was client input obtained at each step of the nursing process?
— Were goals and nursing interventions acceptable to the client?
— Did the caregivers have the knowledge and skill to perform the interventions correctly?
— Were explanations given to the client prior to implementing?
Nursing Interventions
— Do nursing interventions need to be written for new nursing diagnoses or new goals?
— Do the nursing interventions seem to be related to the stated goals?
— Is there a rationale to justify each nursing order?
— Are the nursing interventions clear, specific, and detailed?
— Are new resources available?
— Do the nursing interventions address all aspects of the client’s goals?
— Were the nursing interventions actually carried out?
TABLE 14–1 Evaluation Checklist
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environmental and organizational characteristics that influence care, such as equipment and staffing.
Process evaluation focuses on how the care was given. It answers questions such as these: Is the care relevant to the cli- ent’s needs? Is the care appropriate, complete, and timely? Pro- cess standards focus on the manner in which the nurse uses the nursing process. Some examples of process criteria are “Checks client’s identification band before giving medication” and “Per- forms and records chest assessment, including auscultation, once per shift.”
Outcome evaluation focuses on demonstrable changes in the client’s health status as a result of nursing care. Outcome criteria are written in terms of client responses or health status, just as they are for evaluation within the nursing process. For example, “How many clients undergoing hip repairs develop pneumonia?” or “How many clients who have a colostomy experience an infection that delays discharge?”
QUALITY IMPROVEMENT Serious national efforts are currently under way to evaluate and improve the quality of health care based on internal assessment by health care providers and increasing awareness by the public that medical errors are not uncommon and can be lethal. In 2000 the Committee on Quality of Health Care in America of the Institute of Medicine (IOM) issued a landmark report, To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). The emphases of the report are increasing knowledge re- lated to medical errors and establishing systems for enhancing safe care. The IOM followed with another report in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, which delineated that care should be safe, effective, client centered, timely, efficient, and equitable. The entire reports are available at the National Academies Press website. Since the reports were issued, improved attention to these issues has come from a variety of sources.
CLINICAL ALERT!
Bad systems—not bad people—lead to most errors.
The Center for Quality Improvement and Patient Safety (CQuIPS) within the Agency for Healthcare Research and Quality
nursing diagnoses have been written, then new nursing interventions will also be necessary.
IMPLEMENTING Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. Before selecting new interventions, the nurse should check whether they were carried out. Other personnel may not have carried them out, either because the interventions were unclear or because they were unreasonable in terms of external constraints such as money, staff, time, and equipment.
After making the necessary modifications to the care plan, the nurse implements the modified plan and begins the nursing process cycle again. Refer to the Nursing Care Plan at the end of this chapter to see how the plan for Margaret O’Brien was modified after evalua- tion of goal achievement and review of the nursing process. A line has been drawn through portions the nurse wished to delete; additions to the care plan are shown in italics.
Evaluating the Quality of Nursing Care In addition to evaluating goal achievement for individual clients, nurses are also involved in evaluating and modifying the overall quality of care given to groups of clients. This is an essential part of professional accountability. In each of the processes described in the following sections, nurses and all other health care providers work together as an interprofessional team focused on improving client care. The activities both use and contribute to evidence-based practice.
QUALITY ASSURANCE A quality assurance (QA) program is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. Quality assurance frequently refers to evalu- ation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country.
Quality assurance requires evaluation of three components of care: structure, process, and outcome. Each type of evaluation re- quires different criteria and methods, and each has a different focus.
Structure evaluation focuses on the setting in which care is given. It answers this question: What effect does the setting have on the quality of care? Structural standards describe desirable
EVIDENCE-BASED PRACTICE
The objective of this continuous quality improvement study was to improve client safety in the postoperative population. Munoz, Lowery, and Smith (2012) conducted a study in a 671-bed teaching hospital. The target population of the study was general surgical, gy- necologic, ear, nose, and throat, and urologic surgical clients. Each client in the study had a diagnosis of diabetes mellitus. The nurse manager of the unit had observed a large number of clients with dia- betes experiencing low blood sugar levels in the postoperative pe- riod. This low blood sugar level is classified as a hypoglycemic event.
The researchers in the study sought to improve client safety by improving the client’s blood sugar control and decreasing the num- ber of low blood sugar events. They also wanted to identify the root
cause of the low blood sugar levels. The third outcome of the study was to improve interprofessional communication between nurses and physicians. The nurses and physicians on the unit participated in educational sessions regarding low blood sugar protocols. The protocols were established to increase the assessment of postsur- gical clients with diabetes mellitus. The implemented interventions and the strategies to improve communication yielded improved gly- cemic control and decreased frequency of low blood sugar events.
IMPLICATIONS This study provides evidence of how nurse-led quality improvement studies can improve client safety and the client’s health outcomes.
Evidence-Based Practice How Does a Continuous Quality Improvement Project Reduce Low Blood Sugar Levels in the Postoperative Surgical Client?
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system’s problems, such as duplication of services in a hospital. QI is also known as continuous quality improvement (CQI), total quality management (TQM), performance improvement (PI), or persistent quality improvement (PQI).
Quality improvement is one of the six competencies in the Qual- ity and Safety Education for Nurses (QSEN) project. In this context, QI is defined as: “Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continu- ously improve the quality and safety of health care systems” (Cronen- wett et al., 2007, p. 127). Johnson (2012) states:
To improve care, nurses must first know how well they are doing. Data reflecting the important elements of care is the only credible way of demonstrating the quality of care nurses provide. Thus, it is essential that nurses be taught a systematic process of defining problems, identifying potential causes of those problems, and methods for testing possible solutions to improve care. (p. 113)
As with all QSEN competencies, QI involves knowledge, skills, and attitudes important for every registered nurse to use in under- standing and improving variations in the outcomes of nursing care. A second QSEN competency related to QI is safety, in which the nurse “Minimize[s] risk of harm to patients and providers through both system effectiveness and individual performance” (Cronenwett et al., 2007, p. 128).
NURSING-SENSITIVE INDICATORS The National Qualify Forum (NQF) is a nonprofit organization fo- cused on improving health care. The NQF identified and endorsed national voluntary standards for nursing-sensitive care including evidence-based performance measures, a framework for measur- ing nursing-sensitive care, and related research recommendations. The Joint Commission tested and revised the measures and released a final set of 12 nursing-sensitive care measures in 2009 (The Joint Commission, 2009a). This work allows nurses to consistently gather data in a manner that can be used to evaluate the quality of nursing care. Examples of these measures are hospital-acquired pressure ulcer prevalence and client falls.
The National Database of Nursing Quality Indicators® (NDNQI®) is a proprietary database of the American Nurses Association. The database collects and evaluates unit-specific nurse-sensitive data from 1,899 hospitals in the United States. Some of the NDNQI indi- cators are the same as the NQF measures. NDNQI also surveys nurses annually regarding the practice environment and nurse satisfaction.
In addition to the lists of nursing-sensitive care indicators, NQF also publishes a list of serious reportable events (SREs), often referred to as “never events” since they should not occur if people act appropri- ately. Many states require health care facilities to report SREs and many insurance companies will not reimburse facilities for the care of clients who experience a never event. The 28 events are grouped into the cat- egories of surgical, product or device, client protection, care manage- ment, environmental, and criminal events. Nurses play a key role in protecting clients from these errors or accidents (Watson, 2010).
NURSING AUDIT An audit refers to the examination or review of records. A retrospective audit is the evaluation of a client’s record after
(2012) has as its mission to “improve[s] the quality and safety of all Americans through strategic partnerships. Specifically, CQuIPS:
1. Conducts and supports user-driven research on client safety and health care quality measurement, reporting, and improvement.
2. Develops and disseminates reports and information on health care quality measurement, reporting, and improvement.
3. Collaborates with stakeholders across the health care system to implement evidence-based practices, accelerating and amplify- ing improvements in quality and safety for clients.
4. Assesses our own practices to ensure continuous learning and improvement for the Center and its members.”
The Institute for Healthcare Improvement (IHI) is an indepen- dent not-for-profit organization that is helping to lead the improve- ment of health care throughout the world. Founded in 1991, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving client care, and helping health care systems put those ideas into action. Transforming Care at the Bedside, a collaboration program between the Robert Wood Johnson Foundation and the American Organization of Nurse Ex- ecutives and housed in the IHI, focuses on safe and reliable care, vitality and teamwork, client-centered care, and value-added care processes. In addition, the mission of The Joint Commission (2009b) is “To continuously improve health care for the public, in collabora- tion with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” The Joint Commission has put great em- phasis on the importance of what are called “sentinel events”:
• A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof ” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
• Such events are called “sentinel” because they signal the need for im- mediate investigation and response (The Joint Commission, 2009c).
The commission issues sentinel event alerts highlighting occur- rences common to a wide variety of agencies and health care environ- ments. For example, the “do-not-use” abbreviations, and look-alike/ sound-alike medications published in this text were originally senti- nel event alerts. The most common sentinel event for several years has been wrong-site surgery. More than 800 sentinel events are reported each year. Organizations must respond to their sentinel events by as- sessing the cause, identifying a plan for intervention, and evaluating the results of the plan. Often, assessment involves a root cause analy- sis. Root cause analysis is a process for identifying the factors that bring about deviations in practices that lead to the event. It focuses primarily on systems and processes, not individual performance. It begins with examination of the single event but with the purpose of determining which organizational improvements are needed to de- crease the likelihood of such events occurring again.
Unlike quality assurance, quality improvement (QI) follows client care rather than organizational structure, focuses on process rather than individuals, and uses a systematic approach with the intention of improving the quality of care rather than ensuring the quality of care. QI studies often focus on identifying and correcting a
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LIFESPAN CONSIDERATIONS Evaluating
Evaluation of goals, selected outcomes, and interventions needs to be continuous, with ongoing assessment and reassessment of the situation. Needs can change quickly and must be reprioritized when problems occur. Infants and young children are vulnerable to rapid change in their condition due to their small body size, disproportionate size of organs, and immaturity of body systems. Also, they may not be able to verbalize how they are feeling. Older adults may have conditions that impair communication, such as aphasia from a cerebrovascular accident, dementia, multiple scle- rosis, or other neurologic conditions. In such cases, the nurse needs to be even more astute in performing nonverbal assess- ments, being alert to potential problems, and detecting changes in the client’s condition. If evaluations are done often and thor- oughly, changes can be made quickly to intervene more effectively and improve outcomes. Constant assessment, communication, and interpersonal skills are as essential in the evaluation phase as they are during the initial assessment.
NURSING CARE PLAN For Margaret O’Brien Modified Following Implementation and Evaluation
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/ Indicators
Evaluation Statements
Nursing Interventions**
Explanation for Continuing or Modifying Nursing Interventions
Respiratory status: gas exchange [0402], as evidenced by
• Absence of pallor and cyanosis (skin and mucous membranes)
Partially met. Skin and mucous membranes not cyanotic, but still pale.
Monitor respiratory status q4h; rate, depth, effort, skin color, mucous membranes, amount and color of sputum.
Retain nursing interventions to continue to identify progress. Goal status indicates problem not resolved.
• Use of correct breathing/ coughing technique after instruction
Partially met. Uses correct technique when pain well controlled by narcotic analgesics.
Monitor results of blood gases, chest x-ray studies, pulse oximetry, and incentive spirometer volume as available.
• Productive cough Met. Cough productive of mod- erate amounts of thick, yellow, pink-tinged sputum.
Monitor level of consciousness.
• Symmetric chest excursion of at least 4 cm
Not met. Chest excursion 5 3 cm.
Auscultate lungs q4h.
• Lungs clear to auscultation within 48–72 h
Not met. Scattered inspiratory crackles auscultated throughout right anterior and posterior chest.
Vital signs q4h (TPR, BP, pulse oximetry, pain).
Does not need to be reinstructed as client demonstrates correct techniques. May still need support and encouragement because of fatigue and pain of breathing.
• Respirations 12–22/min, pulse, less than 100 beats/min
Partially met. Respirations 26/min, pulse 96 beats/min.
Instruct in breathing and coughing techniques. Remind to perform and assist q3h. Support and encourage. (8/27/14, JW)
discharge from an agency. Retrospective means “relating to past events.” A concurrent audit is the evaluation of a client’s health care while the client is still receiving care from the agency. These evalua- tions use interviewing, direct observation of nursing care, and review of clinical records to determine whether specific evaluative criteria have been met.
Another type of evaluation of care is the peer review. In a nurse peer review, nurses functioning in the same capacity, that is, peers, appraise the quality of care or practice performed by other equally qualified nurses. The peer review is based on preestablished stan- dards or criteria.
There are two types of peer reviews: individual and nursing au- dits. The individual peer review focuses on the performance of an in- dividual nurse. The nursing audit focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation.
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NURSING CARE PLAN For Margaret O’Brien Modified Following Implementation and Evaluation—continued
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/ Indicators
Evaluation Statements
Nursing Interventions**
Explanation for Continuing or Modifying Nursing Interventions
• Inhaling normal volume of air on incentive spirometer
Not met. Tidal volume only 350 mL (Evaluated 8/27/14, JW)
Administer prescribed expectorant; schedule for maximum effectiveness. Maintain Fowler’s or semi- Fowler’s position.
Administer prescribed analgesics. Notify primary care provider if pain not relieved.
As soon as client is hydrated and fever is controlled, she will probably be discharged to self-care at home.
Administer oxygen by nasal cannula as prescribed. Provide portable oxygen if client goes off unit (e.g., for x-ray examination).
Assist with postural drainage daily at 0930. On 8/27 teach to continue prn at home. (8/27/14, JW)
Administer prescribed antibiotic to maintain constant blood level. Observe for rash and GI or other side effects.
Anxiety control [1402], as evidenced by
• Listening to and following instructions for correct breathing and coughing technique, even during periods of dyspnea
Met. Performed coughing techniques as instructed during periods of dyspnea.
When client is dyspneic, stay with her; reassure her you will stay.
Remain calm, appear confident.
• Verbalizing understanding of condition, diagnostic tests, and treatments (by end of day)
Met. See nurse’s notes for 3–11 shift. Stated, “I know I need to try to breathe deeply even when it hurts.” Demonstrated correct use of incentive spirometer and stated understanding of the need to use it. Understands IV is for hydration and antibiotics. (Evaluated 8/27/14, JW)
Encourage slow, deep breathing.
When client is dyspneic, give brief explanations of treatments and procedures.
• Decrease in reports of fear and anxiety
Met. Stated, “I know I can get enough air, but it still hurts to breathe.”
• Voice steady, not shaky Met. Speaks in steady voice.
• Respiratory rate of 12–22/min Not met. Rate 26–36/min. When acute episode is over, give detailed information about nature of condition, treatments, and tests.
Detailed information has been given. Because client shows understanding, there is no need to repeat information.
Reassess whether client needs any information on condition, treatments, or tests. (8/27/14, JW).
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Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/ Indicators
Evaluation Statements
Nursing Interventions**
Explanation for Continuing or Modifying Nursing Interventions
• Freely expresses concerns and possible solutions about work and parenting roles
Partially met. Discussed only briefly on 3–11 shift. Not done on 11–7 shift because of client’s need to rest. (Evaluated 8/27/14, JW)
As client can tolerate, encourage to express and expand on her concerns about her child and her work. Explore alternatives as needed.
It is important that this assessment be made right away, so child care can be arranged if needed.
Note whether husband returns as scheduled. If he does not, institute care plan for actual Interrupted Family Process. (Do on 8/27, day shift) (8/27/14, JW)
*The NOC # for desired outcomes is listed in brackets following the appropriate outcome.
**In this care plan, a line has been drawn through portions the nurse wished to delete; additions to the care plan are shown in italics.
NURSING CARE PLAN For Margaret O’Brien Modified Following Implementation and Evaluation—continued
Applying Critical Thinking 1. From reviewing Margaret O’Brien’s nursing care plan, what general conclusions can you make about the desired outcomes for
Ineffective Airway Clearance and Anxiety? 2. Despite some of the outcomes being only partially met or not met, no new interventions were written for several outcomes. What
reasons might there be for this? 3. For the nursing diagnosis of Anxiety, most of the outcomes are fully met. Would you delete this diagnosis from the care plan at this
time? Why or why not? 4. Since the Evaluation Statements column is generally not used on written care plans, where would auditors or individuals
conducting quality assessments find these data? See Critical Thinking Possibilities on student resource website.
• Implementing is putting planned nursing interventions into action. • Successful implementing and evaluating depend in part on the
quality of the preceding phases of assessing, diagnosing, and planning.
• Reassessing occurs simultaneously with the implementing phase of the nursing process.
• Cognitive, interpersonal, and technical skills are used to implement nursing strategies.
• Before implementing an order, the nurse reassesses the client to be sure that the order is still appropriate.
• The nurse must determine whether assistance is needed to per- form a nursing intervention knowledgeably, safely, and comfortably for the client.
• The implementing phase terminates with the documentation of the nursing activities and client responses.
• After the care plan has been implemented, the nurse evaluates the client’s health status and the effectiveness of the care plan in achieving client goals.
• The desired outcomes formulated during the planning phase serve as criteria for evaluating client progress and improved health status.
• The desired outcomes determine the data that must be collected to evaluate the client’s health status.
• Reexamining the client care plan is a process of making decisions about problem status and critiquing each phase of the nursing process.
• Professional standards of care hold that nurses are responsible and accountable for implementing and evaluating the plan of care.
• Quality assurance evaluation includes consideration of the struc- tures, processes, and outcomes of nursing care.
• Quality improvement is a philosophy and process internal to the institution, and does not rely on inspections by an external agency.
CHAPTER HIGHLIGHTS
Chapter 14 Review
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7. The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? 1. Cognitive 2. Intellectual 3. Interpersonal 4. Psychomotor
8. Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. No interventions should be carried out without the nurse
having clear rationales. 2. Always follow the primary care provider’s orders exactly,
without variation. 3. Encourage all clients to be as dependent as desired and
allow the nurse to perform care for them. 4. When possible, give the client options in how interventions
will be implemented. 5. Each intervention should be accompanied by client
teaching. 9. Which of the following represents application of the
components of evaluating? 1. Goal achievement must be written as either completely met
or unmet. 2. Data related to expected outcomes must be collected. 3. If the outcome was achieved, conclude that the plan was
effective. 4. After determining that the outcome was not met, start over
with a new nursing care plan. 10. An element of quality improvement, rather than quality
assurance, is which of the following? 1. Focus is on individual outcomes. 2. Evaluates organizational structures. 3. Aims to confirm that quality exists. 4. Plans corrective actions for problems.
See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE 1. When initiating the implementation phase of the nursing process,
the nurse performs which of the following phases first? 1. Carrying out nursing interventions 2. Determining the need for assistance 3. Reassessing the client 4. Documenting interventions
2. Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. When the activity is routine (e.g., raising the bed rails) 2. When the activity occurs at regular intervals (e.g., turning the
client in bed) 3. When the activity is to be carried out immediately (e.g., a
stat medication) 4. It is never acceptable.
3. The primary purpose of the evaluation phase of the care planning process is to determine whether 1. Desired outcomes have been met. 2. Nursing activities were carried out. 3. Nursing activities were effective. 4. Client’s condition has changed.
4. The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. Delete the diagnosis since the problem has not occurred. 2. Keep the diagnosis since the risk factors are still present. 3. Modify the nursing diagnosis to Impaired Mobility. 4. Demote the nursing diagnosis to a lower priority.
5. If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Audit
6. Which of the following is true regarding the relationship of implementing to the other phases of the nursing process? 1. The findings from the assessing phase are reconfirmed in the
implementing phase. 2. After implementing, the nurse moves to the diagnosing
phase. 3. The nurse’s need for involvement of other health care team
members in implementing occurs during the planning phase. 4. Once all interventions have been completed, evaluating can
begin.
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Suggested Reading Hafner, J. M., Williams, S. C., Koss, R. G., Tschurtz, B. A.,
Schmaltz, S. P., & Loeb, J. M. (2011). The perceived impact of public reporting hospital performance data: Interviews with hospital staff. International Journal for Qual- ity Health Care, 23, 697–704. doi:10.1093/intqhc/mzr056 This qualitative study identified six themes related to publicly reported data on hospital performance. Hospital administrators, nurses, physicians, and front-line staff were interviewed. They identified that publicly reported data increased the involvement of the leadership to improve performance. Also, there was a heightened awareness of performance measurement in the health care facility lead- ing to reorganizational priorities. It also raised concerns about quality and how the consumer understood the performance report.
Related Research Montoya, I. D. (2010). Patient safety and quality improvement:
A policy assessment. Clinical Laboratory Science, 23(4), 212–218.
References Agency for Healthcare Research and Quality. (2012). Mission
statement: Center for Quality Improvement and Patient Safety. Rockville, MD: Author. Retrieved from http:// www.ahrq.gov/cpi/centers/cquips/index.html
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Bulechek, G. M., Butcher, H. K., Dochterman, J. C., & Wagner, C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier.
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006
Herdman, T. H., & Kamitsuru, S. (Eds.) (2014). NANDA Inter- national nursing diagnoses: Definitions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Author. Retrieved from http://www.nap.edu/ books/0309072808/html
Johnson, J. (2012). Quality improvement. In G. Sherwood & G. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to outcomes (pp. 113–132). Oxford, United Kingdom: Wiley Blackwell.
The Joint Commission. (2009a). Implementation guide for the NQF endorsed nursing-sensitive care measure set 2009. Oakbrook Terrace, IL: Author. Retrieved from http:// www.jointcommission.org/assets/1/6/NSC%20Manual.pdf
The Joint Commission. (2009b). Mission statement. Oakbrook Terrace, IL: Author. Retrieved from http://www .jointcommission.org/assets/1/18/Mission_Statement_ 8_09.pdf
The Joint Commission. (2009c). Sentinel event policy and procedures. Oakbrook Terrace, IL: Author. Retrieved from http://www.jointcommission.org/ Sentinel_Event_Policy_and_Procedures/
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. Retrieved from http://books.nap.edu/ books/0309068371/html/index.html
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Munoz, C., Lowry, C., & Smith, C. (2012). Continuous quality improvement: Hypoglycemia prevention in the postop- erative surgical population. MEDSURG Nursing, 21(5), 275–280.
Watson, D. S. (2010). Never events in health care. AORN Journal, 91, 378–382. doi:10.1016/j.aorn.2009.12.019
Selected Bibliography Alfaro-LeFevre, R. A. (2014). Applying the nursing process:
The foundation for clinical reasoning (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Berqquist-Beringer, S., Gajewski, B., Dunton, N., & Klaus, S. (2011). The reliability of the national database of Nursing Quality Indicators pressure ulcer indicator: A triangulation approach. Journal of Nursing Care Quality, 26(4), 292–301. doi:10.1097/NCQ.0b013e3182169452
Burston, S., Chaboyer, W., Wallis, M., & Stanfield, J. (2011). A discussion of approaches to transforming care: Contemporary strategies to improve patient safety. Journal of Advanced Nursing, 67(11), 2488–2495. doi:10.1111/j.1365-2648.2011.05706.x
Carpenito-Moyet, L. J. (2013). Nursing care plans and docu- mentation: Nursing diagnosis and collaborative problems (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Doenges, M. E., & Moorhouse, M. F. (2012). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning (6th ed.). Philadelphia, PA: F.A. Davis.
Johnson, H. L., & Kimsey, D. (2012). Patient safety: Break the silence. Association of Operating Room Nurses Journal, 95(5), 591–601. doi:10.1016/j.aorn.2012.03.002
Rivas, F. J. P., Garcia, J. M. S., Arenas, C. M., Lagos, M. B., & Lopez, M. G. (2012). Implementation and evaluation of the nursing process in primary health care. Inter- national Journal of Nursing Knowledge, 23(1), 18–28. doi:10.1111/j.2047-3095.2011.01199.x
Wilkinson, J. M. (2012). Nursing process & critical thinking (5th ed.). Upper Saddle River, NJ: Prentice Hall.
READINGS AND REFERENCES
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INTRODUCTION Effective communication among health professionals is vital to the quality of client care. Generally, health personnel communicate through discussion, reports, and records. A discussion is an in- formal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem. A report is oral, written, or computer-based communica- tion intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift.
A record, also called a chart or client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based. Although health care organizations use different systems and forms for documentation, all client records have simi- lar information. The process of making an entry on a client record is called recording, charting, or documenting.
Each health care organization has policies about recording and reporting client data, and each nurse is accountable for practicing according to these standards. Agencies also indicate which nursing assessments and interventions can be recorded by RNs and which can be charted by unlicensed personnel. In addition, The Joint Com- mission requires client record documentation to be timely, complete, accurate, confidential, and specific to the client. Health care reform
has been pivotal in the process of increasing the use of the electronic health record (EHR).
ETHICAL AND LEGAL CONSIDERATIONS The American Nurses Association Code of Ethics (2001) states that “. . . the nurse has a duty to maintain confidentiality of all patient information” (p. 12). The client’s record is also protected legally as a private record of the client’s care. Access to the record is restricted to health professionals involved in giving care to the client. The institution or agency is the rightful owner of the client’s record. This does not, however, exclude the client’s rights to the same records.
Changes in the laws regarding client privacy became effective on April 14, 2003. The new HIPAA regulations maintain the privacy and confidentiality of protected health information (PHI). HIPAA refers to the Health Insurance Portability and Accountability Act of 1996. PHI is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written com- munications (Hebda & Czar, 2013).
change-of-shift report, 237 chart, 221 charting, 221 charting by exception (CBE), 227 client record, 221 discussion, 221
documenting, 221 flow sheet, 226 focus charting, 226 handoff communication, 237 Kardex, 230 narrative charting, 223
PIE, 226 problem-oriented medical record
(POMR), 224 problem-oriented record
(POR), 224 progress note, 225
record, 221 recording, 221 report, 221 soap, 225 source-oriented record, 223 variance, 228
KEY TERMS
After completing this chapter, you will be able to: 1. List the measures used to maintain confidentiality and secu-
rity of computerized client records. 2. Discuss purposes for client records. 3. Compare and contrast different documentation methods:
source-oriented and problem-oriented medical records, PIE, focus charting, charting by exception, computerized records, and the case management model.
4. Explain how various forms in the client record (e.g., critical pathways care plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the
LEARNING OUTCOMES
15 Documenting and Reporting
nursing process (assessing, diagnosing, planning, imple- menting, and evaluating).
5. Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings.
6. Discuss guidelines for effective recording that meet legal and ethical standards.
7. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation.
8. Identify essential guidelines for reporting client data.
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Communication The record serves as the vehicle by which different health profession- als who interact with a client communicate with each other. This pre- vents fragmentation, repetition, and delays in client care.
Planning Client Care Each health professional uses data from the client’s record to plan care for that client. A primary care provider, for example, may order a specific antibiotic after establishing that the client’s temperature is steadily rising and that laboratory tests reveal the presence of a cer- tain microorganism. Nurses use baseline and ongoing data to evalu- ate the effectiveness of the nursing care plan.
Auditing Health Agencies An audit is a review of client records for quality assurance purposes (see Chapter 14 ). Accrediting agencies such as The Joint Com- mission may review client records to determine if a particular health agency is meeting its stated standards.
Research The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
Education Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
Reimbursement Documentation also helps a facility receive reimbursement from the federal government. For a facility to obtain payment through Medi- care, the client’s clinical record must contain the correct diagnosis- related group (DRG) codes and reveal that the appropriate care has been given.
Codable diagnoses, such as DRGs, are supported by accu- rate, thorough recording by nurses. This not only facilitates re- imbursement from the federal government, but also facilitates reimbursement from insurance companies and other third-party payers. If additional care, treatment, or length of stay becomes necessary for the client’s welfare, thorough charting will help jus- tify these needs.
Legal Documentation The client’s record is a legal document and is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, be- cause information the client gives to the primary care provider is confidential.
Health Care Analysis Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital ser- vices. Records can be used to establish the costs of various services
SAFETY ALERT!
Take safety measures before faxing confidential information. A fax cover sheet should contain instructions that the faxed material is to be given only to the named recipient. Consent is needed from the client to fax information. Make sure that personally identifiable information (e.g., client name, Social Security number) has been removed. Finally, check that the fax number is correct, check the number on the display of the machine after dialing, and check the number a third time before pressing the “send” button.
For purposes of education and research, most agencies allow student and graduate health professionals access to client records. The records are used in client conferences, clinics, rounds, client studies, and written papers. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health profes- sional to protect the client’s privacy by not using a name or any state- ments in the notations that would identify the client.
Ensuring Confidentiality of Computer Records Because of the increased use of EHRs (see Chapter 9 ), health care agencies have developed policies and procedures to ensure the privacy and confidentiality of client information stored in comput- ers. In addition, the Security Rule of HIPAA became mandatory in 2005. This rule governs the security of electronic PHI. The following are some suggestions for ensuring the confidentiality and security of computerized records:
1. A personal password is required to enter and sign off computer files. Do not share this password with anyone, including other health team members.
2. After logging on, never leave a computer terminal unattended. 3. Do not leave client information displayed on the monitor where
others may see it. 4. Shred all unneeded computer-generated worksheets. 5. Know the facility’s policy and procedure for correcting an entry
error. 6. Follow agency procedures for documenting sensitive material,
such as a diagnosis of AIDS. 7. Information technology (IT) personnel must install a firewall to
protect the server from unauthorized access.
PURPOSES OF CLIENT RECORDS Client records are kept for a number of purposes including communi- cation, planning client care, auditing health agencies, research, educa- tion, reimbursement, legal documentation, and health care analysis.
CLINICAL ALERT!
An accurate client health record provides details about the care a cli- ent has received and the client’s overall response to care. Accurate documentation provides the staff with a means for accountability and reflection on the delivery of client care (Prideaux, 2011). To enhance the accuracy in documenting care, Paans, Sermeus, Nieweg, and van der Schans (2010) identified the PES structure as a guideline for nurs- ing care. The letter P represents the client’s problem or diagnosis. The etiology or cause of the problem is represented by E, and S represents the signs and symptoms the nurse should be assessing. The use of this structure enhances nurses’ ability to exercise clinical reasoning.
SAFETY
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and to identify those services that cost the agency money and those that generate revenue.
DOCUMENTATION SYSTEMS A number of documentation systems are in current use: the source- oriented record; the problem-oriented medical record; the problems, interventions, evaluation (PIE) model; focus charting; charting by exception (CBE); computerized documentation; and case manage- ment. These documentation systems can be implemented using the traditional paper forms or with EHRs.
Source-Oriented Record The traditional client record is a source-oriented record. Each person or department makes notations in a separate section or sec- tions of the client’s chart. For example, the admissions department has an admission sheet; the primary care provider has a physician’s order form, a physician’s history sheet, and progress notes; nurses use the nurses’ notes; and other departments or personnel have their own records. In this type of record, information about a particular problem is distributed throughout the record. For example, if a client had left hemiplegia (paralysis of the left side of the body), data about this problem might be found in the physician’s history sheet, on the physician’s order form, in the nurses’ notes, in the physical therapist’s
record, and in the social service record. Table 15–1 lists the compo- nents of a source-oriented record.
Narrative charting is a traditional part of the source-oriented record (Figure 15–1 •). It consists of written notes that include rou- tine care, normal findings, and client problems. There is no right or wrong order to the information, although chronologic order is frequently used. Today, few institutions use only narrative chart- ing. Narrative recording is being replaced by other systems, such as charting by exception and focus charting. Many agencies combine narrative charting with another system. For example, an agency using a charting-by-exception system (discussed later) may use narrative charting when describing abnormal findings. When using narrative charting, it is important to organize the information in a clear, coher- ent manner. Using the nursing process as a framework is one way to do this. See Box 15–1.
Source-oriented records are convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information specific to one’s discipline. The disadvantage is that information about a particular client prob- lem is scattered throughout the chart, so it is difficult to find chrono- logic information on a client’s problems and progress. This can lead to decreased communication among the health team, an incomplete picture of the client’s care, and a lack of coordination of care (Chart smart, 2013).
Form Information
Admission (face) sheet Legal name, birth date, age, gender Social Security number
Address
Marital status; closest relatives or person to notify in case of emergency
Date, time, and admitting diagnosis
Food or drug allergies
Name of admitting (attending) primary care provider
Insurance information
Any assigned diagnosis-related group (DRG)
Initial nursing assessment Findings from the initial nursing history and physical health assessment Graphic record Body temperature, pulse rate, respiratory rate, blood pressure, daily weight, and special measurements
such as fluid intake and output and oxygen saturation Daily care record Activity, diet, bathing, and elimination records Special flow sheets Examples: fluid balance record, skin assessment Medication record Name, dosage, route, time, date of regularly administered medications
Name or initials of person administering the medication
Nurses’ notes Pertinent assessment of client Specific nursing care including teaching and client’s responses
Client’s complaints and how client is coping
Medical history and physical examination
Past and family medical history, present medical problems, differential or current diagnoses, findings of physical examination by the primary care provider
Physician’s order form Medical orders for medications, treatments, and so on Physician’s progress notes Medical observations, treatments, client progress, and so on Consultation records Reports by medical and clinical specialists Diagnostic reports Examples: laboratory reports, x-ray reports, CT scan reports Consultation reports Physical therapy, respiratory therapy Client discharge plan and referral summary
Started on admission and completed on discharge; includes nursing problems, general information, and referral data
TABLE 15–1 Components of the Source-Oriented Record
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Figure 15–1 • A narrative note in an EHR. “Narrative notes” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Situation: Client is postoperative day 2 after abdominal surgery. Questions to ask yourself:
• What assessment data are relevant? • What nursing interventions have I completed? • What is my evaluation of the result of the interventions and/or
what is the client’s response to the interventions?
EXAMPLE 1000 Diminished breath sounds in all lung fields with crackles in LLL. Not using incentive spirometer (IS). Stated he’s “not sure how to use it.” Temperature 99.6. Instructed how to use IS. Discussed the importance of deep breath- ing and coughing after surgery. Administered analgesic for c/o abdominal pain rating of 5/10. After pain relief (1/10), able to demonstrate correct use of IS. ––––– S. Martin, RN
1400 Using IS each hour. Lungs less diminished with fewer LLL crackles. Temp 99. ––––––––––––––––– S. Martin, RN
Example of Organizing Narrative ChartingBOX 15–1
Problem-Oriented Medical Record In the problem-oriented medical record (POMR), or problem- oriented record (POR), established by Lawrence Weed in the 1960s, the data are arranged according to the problems the client has rather than the source of the information. Members of the health care team contribute to the problem list, plan of care, and progress notes. Plans for each active or potential problem are drawn up, and progress notes are recorded for each problem.
The advantage of POMR is that (a) it encourages collaboration and (b) the problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem.
Its disadvantages are that (a) caregivers differ in their ability to use the required charting format, (b) it takes constant vigilance to maintain an up-to-date problem list, and (c) it is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.
The POMR has four basic components:
• Database • Problem list • Plan of care • Progress notes.
In addition, flow sheets and discharge notes are added to the record as needed.
DATABASE The database consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the primary care provider’s history, social and family data, and the results of the physical examination and baseline diagnostic tests. Data are constantly updated as the client’s health status changes.
PROBLEM LIST The problem list (Figure 15–2 •) is derived from the database. It is usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes. Problems are listed in the or- der in which they are identified, and the list is continually updated as new problems are identified and others resolved. All caregivers may contribute to the problem list, which includes the client’s physiologi- cal, psychological, social, cultural, spiritual, developmental, and envi- ronmental needs. Primary care providers write problems as medical diagnoses, surgical procedures, or symptoms; nurses write problems as nursing diagnoses.
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Figure 15–2 • An example of a problem list in the POMR in an EHR. In this record the nurse clicks on the problem to obtain more information. The lower screen allows the nurse or other health care provider to add problems to the problem list. “POMR” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
As the client’s condition changes or more data are obtained, it may be necessary to “redefine” problems. Figure 15–2 illustrates the client’s problem of Impaired Physical Mobility, which was confirmed by the nursing staff. The second problem, Functional Urinary In- continence, was identified by the medical staff. The lower portion of Figure 15–2 illustrates how problems are added to the client’s EHR. In this EHR Incontinence, Urinary is the option provided. Herd- man (2012) identifies the nursing diagnosis as Functional Urinary Incontinence.
PLAN OF CARE The initial list of orders or plan of care is made with reference to the active problems. Care plans are generated by the individual who lists the problems. Primary care providers write physician’s orders or medical care plans; nurses write nursing orders or nurs- ing care plans. The written plan in the record is listed under each problem in the progress notes and is not isolated as a separate list of orders.
PROGRESS NOTES A progress note in the POMR is a chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes. Progress notes are numbered to correspond to the problems on the problem list and may be lettered for the type of data. For example, the SOAP format is frequently used. SOAP is an acronym for subjective data, objective data, assessment, and planning.
S—Subjective data consist of information obtained from what the client says. It describes the client’s perceptions of and experience with the problem (see Chapter 11 ). When possible, the nurse
quotes the client’s words; otherwise, they are summarized. Sub- jective data are included only when it is important and relevant to the problem.
O—Objective data consist of information that is measured or ob- served by use of the senses (e.g., vital signs, laboratory and x-ray results).
A—Assessment is the interpretation or conclusions drawn about the subjective and objective data. During the initial assessment, the problem list is created from the database, so the “A” entry should be a statement of the problem. In all subsequent SOAP notes for that problem, the “A” should describe the client’s condition and level of progress rather than merely restating the diagnosis or problem.
P—The plan is the plan of care designed to resolve the stated problem. The initial plan is written by the person who enters the problem into the record. All subsequent plans, including revisions, are en- tered into the progress notes.
Over the years, the SOAP format has been modified. The acronyms SOAPIE and SOAPIER refer to formats that add interventions, evalu- ation, and revision:
I—Interventions refer to the specific interventions that have actually been performed by the caregiver.
E—Evaluation includes client responses to nursing interventions and medical treatments. This is primarily reassessment data.
R—Revision reflects care plan modifications suggested by the evalu- ation. Changes may be made in desired outcomes, interventions, or target dates.
Newer versions of this format eliminate the subjective and objective data and start with assessment, which combines the subjective and
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objective data. The acronym then becomes AP, APIE, or APIER. See Figure 15–3 • for an example of a SOAP note.
PIE The PIE documentation model groups information into three cate- gories. PIE is an acronym for problems, interventions, and evaluation of nursing care. This system consists of a client care assessment flow sheet and progress notes. The flow sheet uses specific assessment criteria in a particular format, such as human needs or functional health patterns. The time parameters for a flow sheet can vary from minutes to months. In a hospital intensive care unit, for example, a client’s blood pressure may be monitored by the minute, whereas in an ambulatory clinic a client’s blood glucose level may be recorded once a month.
After the assessment, the nurse establishes and records specific problems on the progress notes, often using NANDA diagnoses to word the problem. If there is no approved nursing diagnosis for a problem, the nurse develops a problem statement using NANDA International’s three-part format: client’s response, contributing or probable causes of the response, and characteristics manifested by the client (see Chapter 12 ). The problem statement is labeled “P” and referred to by number (e.g., P #5). The interventions employed to manage the problem are labeled “I” and numbered according to the problem (e.g., I #5). The evaluation of the effectiveness of the in- terventions is also labeled and numbered according to the problem (e.g., E #5).
The PIE system eliminates the traditional care plan and incor- porates an ongoing care plan into the progress notes. Therefore, the nurse does not have to create and update a separate plan. A disad- vantage is that the nurse must review all of the nursing notes before giving care to determine which problems are current and which in- terventions were effective.
Focus Charting Focus charting is intended to make the client and client concerns and strengths the focus of care. Three columns for recording are usu- ally used: date and time, focus, and progress notes. The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or a client strength. The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR. The data category reflects the assessment phase of the nurs- ing process and consists of observations of client status and behaviors, including data from flow sheets (e.g., vital signs, pupil reactivity). The nurse records both subjective and objective data in this section.
The action category reflects planning and implementation and includes immediate and future nursing actions. It may also include any changes to the plan of care. The response category reflects the evaluation phase of the nursing process and describes the client’s re- sponse to any nursing and medical care.
The focus charting system provides a holistic perspective of the client and the client’s needs. It also provides a nursing process frame- work for the progress notes (DAR). The three components do not need to be recorded in order and each note does not need to have all three categories. Flow sheets and checklists are frequently used on the client’s chart to record routine nursing tasks and assessment data.
Date/Hour Focus Progress Notes
2/11/15 0900
Pain D: Guarding abdominal incision. Facial grimacing. Rates pain at “8” on scale of 0–10.
A: Administered morphine sulfate 4 mg IV.
0930 R: Rates pain at “1.” States willing to ambulate.
Figure 15–3 • An example of a SOAP note in an EHR. “SOAP” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
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Charting by Exception Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are re- corded. CBE incorporates three key elements (Guido, 2010):
1. Flow sheets. Examples of flow sheets include graphic records of a vital sign sheet as shown in Figure 15–4 •, a head and face as- sessment in a daily nursing assessments record (Figure 15–5 •), and a Braden assessment of the skin (Figure 15–6 •).
2. Standards of nursing care. Documentation by reference to the agency’s printed standards of nursing practice eliminates much of the repetitive charting of routine care. An agency using CBE must develop its own specific standards of nursing practice that identify the minimum criteria for client care regardless of clinical area. Some units may also have unit-specific standards unique to their type of client. For example, “The nurse must ensure that the unconscious client has oral care at least q4h.” Documentation of care according to these specified standards involves only a check mark in the routine standards box on the graphic record. If all of the standards are not implemented, an asterisk on the flow sheet is made with reference to the nurses’ notes. All exceptions to the standards are fully described in nar- rative form on the nurses’ notes.
3. Bedside access to chart forms. In the CBE system, all flow sheets are kept at the client’s bedside to allow immediate recording and to eliminate the need to transcribe data from the nurse’s work- sheet to the permanent record.
The advantages to this system are that it eliminates lengthy, re- petitive notes and it makes client changes in condition more obvious. Inherent in CBE is the presumption that the nurse did assess the client
and determined what responses were normal and abnormal. Many nurses believe in the saying “not charted, not done” and subsequently may feel uncomfortable with the CBE documentation system. One suggestion is to write N/A on flow sheets where the items are not ap- plicable and to not leave blank spaces. This would then avoid the pos- sible misinterpretation that the assessment or intervention was not done by the nurse.
Computerized Documentation Electronic health records (EHRs) are used to manage the huge vol- ume of information required in contemporary health care. That is, the EHR can integrate all pertinent client information into one re- cord. Nurses use computers to store the client’s database, add new data, create and revise care plans, and document client progress ( Figure 15–7 •). Some institutions have a computer terminal at each client’s bedside, or nurses carry a small handheld terminal, enabling the nurse to document care immediately after it is given.
Multiple flow sheets are not needed in computerized record systems because information can be easily retrieved in a variety of formats. For example, the nurse can obtain results of a client’s blood test, a schedule of all clients on the unit who are to have surgery dur- ing the day, a suggested list of interventions for a nursing diagnosis, a graphic chart of a client’s vital signs, or a printout of all progress notes for a client. Many systems can generate a work list for the shift, with a list of all treatments, procedures, and medications needed by the client.
Computers make care planning and documentation relatively easy. To record nursing actions and client responses, the nurse either chooses from standardized lists of terms or types narrative informa- tion into the computer. Automated speech-recognition technology
Figure 15–4 • Table of vital signs and SpO2. “Vital signs and SpO2” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
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Figure 15–5 • Sample of a head and face assessment on a daily nursing CBE assessment form in an EHR. “Head and Face Assessment” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
now allows nurses to enter data by voice for conversion to written documentation. Again, according to HIPAA, if the spoken word is used to create PHI, the nurse must be alert and aware of others who might hear the dictation.
The computerization of clinical records has made it possible to transmit information from one care setting to another. The Nursing Minimum Data Set (NMDS) is an effort to establish uni- form definitions and categories (e.g., nursing diagnoses) for col- lecting, essential nursing data for inclusion in computer databases. Selected pros and cons of computer documentation are shown in Box 15–2.
Case Management The case management model emphasizes quality, cost-effective care delivered within an established length of stay. This model uses
a multidisciplinary approach to planning and documenting client care, using critical pathways. These forms identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day. See Figure 15–8 • and Chapter 6 for more information about criti- cal pathways.
Along with critical pathways, the case management model in- corporates graphics and flow sheets. Progress notes typically use some type of charting by exception. For example, if goals are met, no further charting is required. A goal that is not met is called a variance. A variance is a deviation from what was planned on the critical pathway—unexpected occurrences that affect the planned care or the client’s responses to care. When a variance oc- curs, the nurse writes a note documenting the unexpected event, the cause, and actions taken to correct the situation or justify the
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actions. See Table 15–2 for an example of how a variance might be documented.
The case management model promotes collaboration and team- work among caregivers, helps to decrease length of stay, and makes effi- cient use of time. Because care is goal focused, the quality may improve. However, critical pathways work best for clients with one or two di- agnoses and few individualized needs. Clients with multiple diagnoses (e.g., a client with a hip fracture, pneumonia, diabetes, and a pressure sore) or those with an unpredictable course of symptoms (e.g., a neu- rologic client with seizures) are difficult to document on a critical path.
DOCUMENTING NURSING ACTIVITIES The client record should describe the client’s ongoing status and reflect the full range of the nursing process. Regardless of the
Figure 15–6 • Sample of a Braden assessment form in an EHR. “Braden Assessment” from Cerner Electronic Health Record. Copyright © by Cerner Corporation. Used by permission of Cerner Corporation.
Figure 15–7 • A bedside computer.
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Figure 15–8 • Excerpt from a critical pathway documentation form.
CRITICAL PATHWAY: TOTAL HIP REPLACEMENT
DOS/Day 1
P ai
n M
an ag
em en
t R
es p
ira to
ry
Outcome: • Verbalizes comfort or tolerance of pain
Circle: V NV
Variance:
Key: V = Variance NV = No Variance Signature: Initials:
Signature: Initials:
Outcome: • Verbalizes comfort with pain control measures
Circle: V NV
Variance:
Outcomes: • Breath sounds clear to auscultation • Achieves 50% of volume goal on incentive spirometer
Circle: V NV
Variance:
Outcomes: • Breath sounds clear to auscultation • Achieves 100% of volume goal on incentive spirometer
Circle: V NV
Variance:
Days 2–3
PROS • Computer records can facilitate a focus on client outcomes. • Bedside terminals can synthesize information from monitoring
equipment. • Such systems allow nurses to use their time more efficiently. • The system links various sources of client information. • Client information, requests, and results are sent and received
quickly. • Links to monitors improve accuracy of documentation. • Bedside terminals eliminate the need to take notes on a
worksheet before recording. • Bedside terminals permit the nurse to check an order
immediately before administering a treatment or medication. • Information is legible. • The system incorporates and reinforces standards of care. • Standard terminology improves communication.
CONS • Client’s privacy may be infringed on if security measures are
not used. • Breakdowns make information temporarily unavailable. • The system is expensive. • Extended training periods may be required when a new or
updated system is installed.
Selected Pros and Cons of Computer DocumentationBOX 15–2
records system used in an agency, nurses document evidence of the nursing process on a variety of forms throughout the clinical record (Table 15–3).
Admission Nursing Assessment A comprehensive admission assessment, also referred to as an ini- tial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit. As discussed in Chapter 11 , these forms can be organized according to health patterns, body systems, functional abilities, health problems and risks, nursing model, or type of health care setting (e.g., labor and delivery, pediatrics, mental health). The nurse generally records ongoing assessments or reassessments on flow sheets or on nurs- ing progress notes.
Nursing Care Plans The Joint Commission requires that the clinical record include evi- dence of client assessments, nursing diagnoses and/or client needs, nursing interventions, client outcomes, and evidence of a current nursing care plan. Depending on the records system being used, the nursing care plan may be separate from the client’s chart, re- corded in progress notes and other forms in the client record, or incorporated into a multidisciplinary plan of care.
There are two types of nursing care plans: traditional and standardized. The traditional care plan is written for each client. The form varies from agency to agency according to the needs of the client and the department. Most forms have three columns: one for nursing diagnoses, a second for expected outcomes, and a third for nursing interventions. See Chapter 13 for additional information.
Standardized care plans were developed to save documentation time. These plans may be based on an institution’s standards of prac- tice, thereby helping to provide a high quality of nursing care. For further information, see Chapter 13 . Standardized plans must be individualized by the nurse in order to adequately address individual client needs.
Kardexes The Kardex is a widely used, concise method of organizing and re- cording data about a client, making information quickly accessible to all health professionals. The system consists of a series of cards kept in a portable index file or on computer-generated forms. The card for a particular client can be quickly accessed to reveal specific data.
A client has had a below-the-knee amputation. On the third postoperative day he has a temperature of 38.8°C (102°F). Lung sounds are clear and he is not coughing. The nurse notices redness and skin breakdown over the client’s sacrum. The critical pathway outcomes specified for day 3 are “Oral temperature 37.7°C (100°F)” and “Skin intact over bony prominences.” The nurse should chart the following variances:
Date/Time Variance Cause Action Taken/Plans
4/16/15 0900 Elevated temperature (38.9°C [102°F]) Possible sepsis 4/16—Blood cultures × 3 per order. Monitor temp q1h. Monitor I&O, hydration, and mental status.
4/16/15 1130 Impaired skin integrity: stage 1 redness, 5-cm (2-in.) circular area on sacrum
Client does not move about in bed unless reminded
4/16—Positioned on L side. Turn side-to-side q2h while awake. On every client contact, remind client to move about in bed. Apply Duoderm after bath.
TABLE 15–2 Example of Variance Documentation (Critical Pathway)
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Step* Documentation Forms
Assessment Initial assessment form, various flow sheets
Nursing diagnosis Nursing care plan, critical pathway, progress notes, problem list
Planning Nursing care plan, critical pathway
Implementing Progress notes, flow sheets
Evaluating Progress notes
*All steps are recorded on discharge/referral summaries.
Documentation for the Nursing ProcessTABLE 15–3
The Kardex may or may not become a part of the client’s permanent record. In some organizations it is a temporary worksheet written in pencil for ease in recording frequent changes in details of a client’s care. The information on Kardexes may be organized into sections, for example:
• Pertinent information about the client, such as name, room num- ber, age, admission date, primary care provider’s name, diagnosis, and type of surgery and date
• Allergies • List of medications, with the date of order and the times of admin-
istration for each • List of intravenous fluids, with dates of infusions • List of daily treatments and procedures, such as irrigations, dress-
ing changes, postural drainage, or measurement of vital signs • List of diagnostic procedures ordered, such as x-ray or laboratory
tests • Specific data on how the client’s physical needs are to be met,
such as type of diet, assistance needed with feeding, elimination devices, activity, hygienic needs, and safety precautions (e.g., one- person assist)
• A problem list, stated goals, and a list of nursing approaches to meet the goals and relieve the problems.
Although much of the information on the Kardex may be recorded by the nurse in charge or a delegate (e.g., the nursing unit clerk), any nurse who cares for the client plays a key role in initiating the record and keeping the data current. Whether the Kardex is a written pa- per or computerized, it is important to have a place on it to record dates and the initials of the person reviewing or revising it. It is a quick visual guide to ensure that information is current and updated on a regular basis.
Flow Sheets A flow sheet enables nurses to record nursing data quickly and con- cisely and provides an easy-to-read record of the client’s condition over time.
GRAPHIC RECORD This record typically indicates body temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel move- ments, appetite, and activity.
INTAKE AND OUTPUT RECORD All routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form. See Chapter 52 for more information.
MEDICATION ADMINISTRATION RECORD Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature. Some records also include a place to document the client’s allergies (see Chapter 35 ).
SKIN ASSESSMENT RECORD A skin or wound assessment is often recorded on a flow sheet such as the one shown earlier in Figure 15–6. This EHR specifically uti- lizes the Braden Assessment. EHRs may include categories related to stage of skin injury, drainage, odor, culture information, and treatments.
Progress Notes Progress notes made by nurses provide information about the progress a client is making toward achieving desired outcomes. Therefore, in addition to assessment and reassessment data, prog- ress notes include information about client problems and nursing interventions. The format used depends on the documentation system in place in the institution. Various kinds of nursing progress notes are discussed in the Documentation Systems section earlier in this chapter.
Nursing Discharge/Referral Summaries A discharge note and referral summary are completed when the cli- ent is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. See the discussion of discharge planning in Chapter 7 and the as- sessment parameters suggested when preparing clients to go home. Many institutions provide forms for these summaries. Some records combine the discharge plan, including instructions for care, and the final progress note. Many are designed with checklists to facilitate data recording.
If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be read- ily understood. For example, medications, treatments, and activities should be written in layman’s terms, and use of medical abbreviations (such as ad lib) should be avoided.
If a client is transferred within the facility or from a long-term facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area. It should include all components of the discharge instructions, but also describe the condition of the client before the transfer. Any teaching or client instruction that has been done should also be described and recorded.
If the client is being transferred to another institution or to a home setting where a visit by a home health nurse is required, the discharge note takes the form of a referral summary. Regardless of format, discharge and referral summaries usually include some or all of the following:
• Description of client’s physical, mental, and emotional status at discharge or transfer
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care facilities. Usually the nurse completes a nursing care summary at least once a week for clients requiring skilled care and every 2 weeks for those requiring intermediate care. Summaries should address the following:
• Specific problems noted in the care plan • Mental status • Activities of daily living • Hydration and nutrition status • Safety measures needed • Medications • Treatments • Preventive measures • Behavioral modification assessments, if pertinent (if client is
taking psychotropic medications or demonstrates behavioral problems).
See the Practice Guidelines for documentation in long-term care facilities.
HOME CARE DOCUMENTATION In 1985 the Health Care Financing Administration, a branch of the U.S. Department of Health and Human Services, mandated that home health care agencies standardize their documentation methods to meet requirements for Medicare and Medicaid and other third- party disbursements. Two records are required: (a) a home health certification and plan of treatment form and (b) a medical update and client information form. The nurse assigned to the home care client usually completes the forms, which must be signed by both the nurse and the attending primary care provider. See the Practice Guidelines for home health care documentation.
Some home health agencies provide nurses with laptop or hand- held computers to make records available in multiple locations. With the use of a modem, the nurse can add new client information to re- cords at the agency without traveling to the office.
GENERAL GUIDELINES FOR RECORDING Because the client’s record is a legal document and may be used to provide evidence in court, many factors are considered in recording. Health care personnel must not only maintain the confidentiality of the client’s record but also meet legal standards in the process of recording.
• Resolved health problems • Unresolved continuing health problems and continuing care
needs; may include a review-of-systems checklist that considers integumentary, respiratory, cardiovascular, neurologic, mus- culoskeletal, gastrointestinal, elimination, and reproductive problems
• Treatments that are to be continued (e.g., wound care, oxygen therapy)
• Current medications • Restrictions that relate to (a) activity such as lifting, stair climbing,
walking, driving, work; (b) diet; and (c) bathing such as sponge bath, tub, or shower
• Functional/self-care abilities in terms of vision, hearing, speech, mobility with or without aids, meal preparation and eating, pre- paring and administering medications, and so on
• Comfort level • Support networks including family, significant others, religious
adviser, community self-help groups, home care and other com- munity agencies available, and so on
• Client education provided in relation to disease process, activities and exercise, special diet, medications, specialized care or treat- ments, follow-up appointments, and so on
• Discharge destination (e.g., home, nursing home) and mode of discharge (e.g., walking, wheelchair, ambulance)
• Referral services (e.g., social worker, home health nurse).
LONG-TERM CARE DOCUMENTATION Long-term facilities usually provide two types of care: skilled or in- termediate. Clients needing skilled care require more extensive nurs- ing care and specialized nursing skills. In contrast, an intermediate care focus is needed for clients who usually have chronic illnesses and may only need assistance with activities of daily living (such as bath- ing and dressing).
Requirements for documentation in long-term care settings are based on professional standards, federal and state regulations, and the policies of the health care agency. Laws influencing the kind and frequency of documentation required are the Health Care Financ- ing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. The OBRA law, for example, requires that (a) a comprehensive assessment (the Minimum Data Set [MDS] for Resi- dent Assessment and Care Screening) be performed within 4 days of a client’s admission to a long-term care facility, (b) a formulated plan of care must be completed within 7 days of admission, and (c) the assessment and care screening process must be reviewed every 3 months.
Accurate completion of the MDS is required for reimbursement from Medicare and Medicaid. These requirements vary with the level of service provided and other factors. For example, Medicare pro- vides little reimbursement for services provided in long-term care facilities except for services that require skilled care such as chemo- therapy, tube feedings, ventilators, and so on. For such Medicare cli- ents, the nurse must provide daily documentation to verify the need for service and reimbursement.
Nurses need to familiarize themselves with regulations influenc- ing the kind and frequency of documentation required in long-term
LIFESPAN CONSIDERATIONS Long-Term Care
OLDER ADULTS Older adults in long-term care facilities tend to have chronic condi- tions and generally experience subtle small changes in their condi- tion. However, when problems do occur, such as a hip fracture, cardiovascular accident, or pneumonia, they are serious and require prompt attention. This points out the importance of keeping Kardexes and charting in long-term facilities current and up to date in the event that the client needs to be transferred for more skilled care and further treatment. A thorough transfer summary will facilitate communication and promote continuity of care in these situations.
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agency’s policies about the type of pen and ink used for recording. In regards to EHRs, changes are made in accordance with the software guidelines. It is important for the nurse to understand the policies and procedures of the health care institution regarding documentation.
Date and Time Document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (e.g., 9:00 am or 3:15 pm) or according to the 24-hour clock (military clock), which avoids confusion about whether a time was am or pm (Figure 15–9 •).
Timing Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition indicates; for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. As a rule, documenting should be done as soon as possible after an assessment or intervention. No recording should be done before providing nursing care.
Legibility All entries must be legible and easy to read to prevent interpreta- tion errors. Hand printing or easily understood handwriting is usually permissible. Follow the agency’s policies about handwritten recording.
Permanence All entries on the client’s record are made in dark ink so that the re- cord is permanent and changes can be identified. Dark ink repro- duces well on microfilm and in duplication processes. Follow the
PRACTICE GUIDELINES
Long-Term Care Documentation
• Complete the assessment and screening forms (MDS) and plan of care within the time period specified by regulatory bodies.
• Keep a record of any visits and of phone calls from family, friends, and others regarding the client.
• Write nursing summaries and progress notes that comply with the frequency and standards required by regulatory bodies.
• Review and revise the plan of care every 3 months or whenever the client’s health status changes.
• Document and report any change in the client’s condition to the primary care provider and the client’s family within 24 hours.
• Document all measures implemented in response to a change in the client’s condition.
• Make sure that progress notes address the client’s progress in relation to the goals or outcomes defined in the plan of care.
Figure 15–9 • The 24-hour clock.
PM
AM
2400
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300 12 1
2
3
4
5 6
7
8
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11 0100
0200
0300
0400
0500 0600
0700
0800
0900
1000
1100
PRACTICE GUIDELINES
Home Health Care Documentation
• Complete a comprehensive nursing assessment and develop a plan of care to meet Medicare and other third-party payer requirements. Some agencies use the certification and plan of treatment form as the client’s official plan of care.
• Write a progress note at each client visit, noting any changes in the client’s condition, nursing interventions performed (including education and instructional brochures and materials provided to the client and home caregiver), client responses to nursing care, and vital signs as indicated.
• Provide a monthly progress nursing summary to the attending primary care provider and to the reimburser to confirm the need to continue services.
• Keep a copy of the care plan in the client’s home and update it as the client’s condition changes.
• Report changes in the plan of care to the primary care provider and document that these were reported. Medicare and Medicaid will reimburse only for the skilled services provided that are reported to the primary care provider.
• Encourage the client or home caregiver to record data when appropriate.
• Write a discharge summary for the primary care provider to approve the discharge and to notify the reimbursers that services have been discontinued. Include all services provided, the client’s health status at discharge, outcomes achieved, and recommendations for further care.
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Abbreviation Term Abbreviation Term
Abd Abdomen MEDS Medications
ABO The main blood group system mL Milliliter
ac Before meals mod Moderate
ad lib As desired neg Negative
ADL Activities of daily living Ø None
Adm Admitted or admission # Number or pounds
am Morning NPO (NBM) Nothing by mouth
amb Ambulatory NS (N/S) Normal saline
amt Amount O2 Oxygen
approx Approximately OD Right eye or overdose
bid Twice daily OOB Out of bed
BM (bm) Bowel movement OS Left eye
BP Blood pressure p̄ After
BRP Bathroom privileges pc After meals
c̄ With PE (PX) Physical examination
C Celsius (centigrade) per By or through
CBC Complete blood count pm Afternoon
c/o Complains of po By mouth
DAT Diet as tolerated postop Postoperatively
Dc Discontinue preop Preoperatively
drsg Dressing prep Preparation
Dx Diagnosis prn When necessary
ECG (EKG) Electrocardiogram qid Four times a day
F Fahrenheit (R) Right
fld Fluid s̄ Without
GI Gastrointestinal stat At once, immediately
gtt Drop tid Three times a day
h (hr) Hour TO Telephone order
H2O Water TPR Temperature, pulse, respirations
I&O Intake and output VO Verbal order
IV Intravenous VS Vital signs
(L) Left WNL Within normal limits
LMP Last menstrual period WT Weight
*Institutions may elect to include some of these abbreviations on their “do-not-use” list. Check the agency’s policy.
TABLE 15–4 Commonly Used Abbreviations*
Accepted Terminology Abbreviations are used because they are short, convenient, and easy to use. People are often in a hurry and use abbreviations when text ing or text paging. Abbreviations are convenient; however, they are often ambiguous. This ambiguity places the client at risk for medical errors and significant harm, possibly even death (Galliers, Wilson, Randell, & Woodward, 2011). Ambiguity occurs when an abbreviation can stand for more than one term, leading to misinter- pretation. For example, a client was being treated for a viral infec- tion and died as a result of the use of the abbreviation HD for an order of “acyclovir unknown dose with HD.” HD was to represent hemodialysis, and the dosage (unknown) needed to be adjusted due
to the client’s renal impairment. The order was misunderstood and the dosage of acyclovir was not adjusted in consideration of the cli- ent’s renal impairment.
Therefore, it is important to use only commonly accepted abbre- viations, symbols, and terms that are specified by the agency. Many abbreviations are standard and used universally; others are used only in certain geographic areas. Many health care facilities supply an ap- proved list of abbreviations and symbols to prevent confusion. When in doubt about whether to use an abbreviation, write the term out in full until certain about the abbreviation. Table 15–4 lists some com- mon abbreviations (except those used for medications, which are de- scribed in Chapter 35 ).
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Do Not Use Potential Problem Use Instead
U, u (unit) Mistaken for “0” (zero), the number “4” (four), or cc
Write “unit”
IU (for International Unit) Mistaken for IV (intravenous) or the number 10 (ten)
Write “International Unit”
Q.D. QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day)
Mistaken for each other Period after the Q mistaken for “I” and “O” mistaken for “I”
Write “daily” and “every other day”
Trailing zero (X.0 mg)** Lack of leading zero (.X mg)
Decimal point is missed. Write X mg Write 0.Xmg
MS MSO4 and MGSO4
Can mean morphine sulfate or magnesium sulfate. Confused for one another
Write “morphine sulfate” or “magnesium sulfate”
*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.
**A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
From Facts About the Official “Do Not Use” List, by The Joint Commission, 2010. Retrieved from http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf. © The Joint Commission, 2010. Reprinted with permission.
TABLE 15–5 Official “Do Not Use” List*
In 2004, The Joint Commission developed National Patient Safety Goals (NPSGs) to reduce communication errors. These goals are required to be implemented by all organizations accred- ited by the commission. As a result, the accredited organizations must develop a do-not-use list of abbreviations, acronyms, and symbols. This list must include those banned by The Joint Com- mission (Table 15–5).
Correct Spelling Correct spelling is essential for accuracy in recording. If unsure how to spell a word, look it up in a dictionary or other resource book. Two decidedly different medications may have similar spellings; for ex- ample, Fosamax and Flomax.
CLINICAL ALERT!
Incorrect spelling gives a negative impression to the reader and, thereby, decreases the nurse’s credibility.
Signature Each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title; for example, “Susan J. Green, RN” or “SJ Green, RN.” Some agencies have a signature sheet and after signing this signature sheet, nurses can use their initials. With computerized charting, each nurse has his or her own code, which allows the documentation to be identified.
The following title abbreviations are often used, but nurses need to follow agency policy about how to sign their names:
RN registered nurse
LVN licensed vocational nurse
LPN licensed practical nurse
NA nursing assistant
NS nursing student
PCA patient care associate
SN student nurse
Accuracy The client’s name and identifying information should be stamped or written on each page of the clinical record. Before making an entry, check that the chart is the correct one. Do not identify charts by room number only; check the client’s name. Special care is needed when caring for clients with the same last name.
Notations on records must be accurate and correct. Accurate nota- tions consist of facts or observations rather than opinions or interpreta- tions. It is more accurate, for example, to write that the client “refused medication” (fact) than to write that the client “was uncooperative” (opinion); to write that a client “was crying” (observation) is preferable to noting that the client “was depressed” (interpretation). Similarly, when a client expresses worry about the diagnosis or problem, this should be quoted directly on the record: “Stated: ‘I’m worried about my leg.’” When describing something, avoid general words, such as large, good, or nor- mal, which can be interpreted differently. For example, chart specific data such as “2 cm × 3 cm bruise” rather than “large bruise.”
When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line (depending on agency policy). Do not erase, blot out, or use correction fluid. The original entry must remain visible. When using computerized charting, the nurse needs to be aware of the agency’s policy and process for correcting documentation mistakes. See Figure 15–10 • for an example.
Write on every line but never between lines. If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other per- son, and sign the notation.
CLINICAL ALERT!
Avoid writing the word error when a recording mistake has been made. Some believe that the word error is a “red flag” for juries and can lead to the assumption that a clinical error has caused a client injury.
Sequence Document events in the order in which they occur; for example, re- cord assessments, then the nursing interventions, and then the client’s responses. Update or delete problems as needed.
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example, write “Perspiring profusely. Respirations shallow, 28/min.” End each thought or sentence with a period.
Legal Prudence Accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a client. Documentation is usually viewed by juries and attorneys as the best evidence of what really happened to the client.
CLINICAL ALERT!
Complete charting, for example, by using the steps of the nursing process as a framework, is the best defense against malpractice.
For the best legal protection, the nurse should not only adhere to professional standards of nursing care but also follow agency policy and procedures for intervention and documentation in all situations—especially high-risk situations. For example:
1100—c/o of feeling dizzy. Raised top two side rails and in- structed to stay in bed and ring call bell if requiring assistance. 1130—found lying on floor beside the bed. Stated, “I climbed out of bed all by myself.” When asked about pain, replied, “I feel fine but a little dizzy.” Helped into bed. BP 100/60 P90 R24. Dr. RJ Naden notified. ____________________RS Woo RN
REPORTING The purpose of reporting is to communicate specific information to a person or group of people. A report, whether oral or written, should
Appropriateness Record only information that pertains to the client’s health problems and care. Any other personal information that the client conveys is inappropriate for the record. Recording irrelevant information may be considered an invasion of the client’s privacy and/or libelous. A client’s disclosure that she was addicted to heroin 15 years ago, for example, would not be recorded on the client’s medical record unless it had a direct bearing on the client’s health problem.
Completeness Not all data that a nurse obtains about a client can be recorded. How- ever, the information that is recorded needs to be complete and help- ful to the client and health care professionals.
Nurses’ notes need to reflect the nursing process. Record all as- sessments, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress toward goals, and communication with other members of the health team.
Care that is omitted because of the client’s condition or refusal of treatment must also be recorded. Document what was omitted, why it was omitted, and who was notified.
CLINICAL ALERT!
Do not assume that the person reading your charting will know that a common intervention (e.g., turning) has occurred because you believe it to be an “obvious” component of care.
Conciseness Recordings need to be brief as well as complete to save time in com- munication. The client’s name and the word client are omitted. For
Figure 15–10 • Correcting a charting error.
Date Time Progress Notes
9/12/2014 0800 Breath sounds diminished throughout all lung fields. C/O “shortness of breath”. N. Smith, RN.
PRACTICE GUIDELINES
Documentation
DO • Chart a change in a client’s condition and show that follow-up
actions were taken. • Read the nurses’ notes prior to care to determine if there has
been a change in the client’s condition. • Be timely. A late entry is better than no entry; however, the
longer the period of time between actual care and charting, the greater the suspicion.
• Use objective, specific, and factual descriptions. • Correct charting errors. • Chart all teaching. • Record the client’s actual words by putting quotes around
the words. • Chart the client’s response to interventions. • Review your notes—are they clear and do they reflect what you
want to say?
DON’T • Leave a blank space for a colleague to chart later. • Chart in advance of the event (e.g., procedure, medication). • Use vague terms (e.g., “appears to be comfortable,” “had a
good night”). • Chart for someone else. • Record “patient” or “client” because it is their chart. • Alter a record even if requested by a superior or a primary care
provider. • Record assumptions or words reflecting bias (e.g.,
“complainer,” “disagreeable”).
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be concise, including pertinent information but no extraneous detail. In addition to change-of-shift reports and telephone reports, report- ing can also include the sharing of information or ideas with col- leagues and other health professionals about some aspect of a client’s care. Examples include the care plan conference and nursing rounds.
Change-of-Shift Reports Incomplete handoff communication is associated with sentinel events that will result in adverse health care outcomes or death ( Criscitelli, 2013). As a result, a hospital is required to implement a standard- ized approach to “handoff” communication, which is defined as a process in which information about patient/client/resident care is communicated in a consistent manner including an opportunity to ask and respond to questions (Riesenberg, Leitzsch, & Cunningham, 2010, p. 24). The handoff of a client to another health care provider oc- curs at many levels in the health care setting. For example, the admis- sion of the client to the emergency department and then to intensive care or other hospital division requires a handoff from nurse to nurse, nurse to physician, physician to physician, and ultimately to other health care providers. It is important for each health care institution to develop and implement a standardized procedure for handoff in- cluding the communication of the client’s condition and health care needs (Berger, Sten, & Stockwell, 2012). Box 15–3 lists the elements of performance required for effective handoff communication.
BOX 15–3 Key Elements for Effective Handoff Communication
The communication should include the following: • Up-to-date information • Interactive communication allowing for questions between the
giver and receiver of client information • Method for verifying the information (e.g., repeat-back,
read-back techniques) • Minimal interruptions • Opportunity for receiver of information to review relevant client
data (e.g., previous care and treatment).
The handoff communication or change-of-shift report is given to all nurses on the next shift. Hill and Nyce (2010) identified three important features in an effective change-of-shift report. These are: “two way, face-to-face communication; written support tools; and content in handover which captures intention” (p. 44). Face-to- face communication allows the oncoming nurse the ability to ask questions and gain confidence to care for the client. The incoming and departing nurses establish priorities for the care of the client in the upcoming hours by reviewing checklists and the client’s medical record. Content of the handover, which captures intention, includes client problems and interventions to care for the client’s problems. The nurse must focus on the needs of the client and not become dis- tracted by irrelevant information (Box 15–4).
Change-of-shift reports may be written or given orally, ei- ther in a face-to-face exchange or by audiotape recording. The face-to-face report at the client’s bedside permits the nurse to in- troduce the oncoming nurse to the client and family. The oncom- ing nurse has the ability to ask questions during the report and address concerns. This allows clients to be involved in their care (Halm, 2013). Face-to-face report may also take place in a desig- nated room, nurses’ station, or at the client’s bedside. Written and tape-recorded reports are often briefer and less time consuming; however, verbal updates may be needed. A variety of handoff com- munication tools have been developed to facilitate consistency in communication. Examples include, but are not limited to, the “I PASS the BATON,” “I-SBAR,” “PACE,” or the “Five-P’s.” (Associa- tion of Operating Room Nurses, n.d.). Each tool is unique and spe- cific to the needs of the environment. Box 15–5 provides specifics for each mnemonic.
Many hospitals use the SBAR tool along with a verbal report for handoffs for change-of-shift reports (Wacogne & Diwakar, 2010). The tools may vary among institutions regarding the information to include in the report; however, all provide a printed standardized form for the nurse to use during a handoff. The Institute for Health- care Improvement (2013) states that “the SBAR allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing
BOX 15–4 Focusing on Relevant Information During a Change-of-Shift Report
• Follow a particular order (e.g., follow room numbers in a hospital).
• Provide basic identifying information for each client (e.g., name, room number, bed designation). Report information in the same order every time.
• For new clients, provide the reason for admission or medical diagnosis (or diagnoses), surgery (date), diagnostic tests, and therapies in past 24 hours.
• Include significant changes in client’s condition and present information in order (i.e., assessment, nursing diagnoses, interventions, outcomes, and evaluation). For example, “Mr. Ronald Oakes said he had an aching pain in his left calf at 1400 hours. Inspection revealed no other signs. Calf pain is related to altered blood circulation. Rest and elevation of his legs on a footstool for 30 minutes provided relief.”
• Provide exact information, such as “Ms. Jessie Jones received morphine 6 mg IV at 1500 hours,” not “Ms. Jessie Jones received some morphine during the evening.”
• Report clients’ need for special emotional support. For example, a client who has just learned that his biopsy results
revealed malignancy and who is now scheduled for a laryngec- tomy needs time to discuss his feelings before preoperative teaching is begun.
• Include current nurse-prescribed and primary care provider– prescribed orders.
• Clearly state priorities of care and care that is due after the shift begins. For example, in a 7 am report the nurse might say, “Mr. Li’s vital signs are due at 0730, and his IV bag will need to be replaced by 0800.” Give this information at the end of that client’s report, because memory is best for the first and last information given.
• Be concise. Don’t elaborate on background data or routine care (e.g., do not report “Vital signs at 0800 and 1150” when that is the unit standard). Do not report coming and going of visitors unless there is a problem or concern, or visitors are involved in teaching and care. Social support and visits are the norm.
• Incorporate a verification process (e.g., opportunity to ask and respond) to ensure that information is both received and understood.
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The nurse receiving a telephone report should document the date and time, the name of the person giving the information, and the subject of the information received, and sign the notation. For example:
6/6/14 1035 G Messina, laboratory technician, reported by telephone that Mrs. Sara Ames’s hematocrit is 39%. _______ ___________________________________ B. Ireland RN
The person receiving the information should repeat it back to the sender to ensure accuracy.
When giving a telephone report to a primary care provider, it is important that the nurse be concise and accurate. The SBAR com- munication tool is often used for telephone reports. Begin with name and relationship to the client (e.g., “This is Jana Gomez, RN; I’m call- ing about your client, Dorothy Mendes. I’m her nurse on the 7 pm to 7 am shift”).
Telephone reports usually include the client’s name and medi- cal diagnosis, changes in nursing assessment, vital signs related to baseline vital signs, significant laboratory data, and related nursing interventions. The nurse should have the client’s chart ready to give the primary care provider any further information.
After reporting, the nurse should document the date, time, and content of the call. For example:
1200—Admitted from ED. c/o burning upper right quadrant abdominal pain. Rates pain at 6/10. BP 115/80, P100, R15. Demerol 100 mg given IM per order. 1300—BP 100/40, P115, R30. Pain unchanged. Color pale and diaphoretic. Reported by telephone to Dr. Burns at 1305. _____________ TS Jones RN
Telephone Orders Primary care providers often order a therapy (e.g., a medication) for a client by telephone. Most agencies have specific policies about telephone orders. Many agencies allow only registered nurses to take telephone orders.
While the primary care provider gives the order, write the com- plete order down on the physician’s order form and read it back to the primary care provider to ensure accuracy. Question the primary care provider about any order that is ambiguous, unusual (e.g., an abnormally high dosage of a medication), or contraindicated by the client’s condition. Have the primary care provider verbally acknowl- edge the read-back of the verbal/telephone order. Then indicate on
teamwork and fostering a culture of patient safety” (para. 1). Box 15–6 provides a sample SBAR communication tool.
Telephone Reports Health professionals frequently report about a client by telephone. Nurses inform primary care providers about a change in a client’s condition; a radiologist reports the results of an x-ray study; a nurse may report to a nurse on another unit about a transferred client.
BOX 15–5 Sample Handoff Communication Tools
• I PASS the BATON: Introduction, Patient, Assessment, Situation, Safety Concerns, Background, Actions, Timing, Ownership, Next
• I-SBAR: Introduction, Situation, Background, Assessment, Recommendation
• PACE: Patient/Problem, Assessment/Actions, Continuing (treatments)/Changes, Evaluation
• Five-P’s: Patient, Plan, Purpose, Problem, Precautions, Physician (assigned to coordinate)
From “Hand-Off Communications,” by the Association of Operating Room Nurses, n.d. Retrieved from http://www.aorn.org/search.aspx?searchtext=aorn%20hand%20off%20toolkit.
BOX 15–6 Sample SBAR Communication Tool
S = Situation • State your name, unit, and client name. • Briefly state the problem.
B = Background • State client admission diagnosis and date of admission. • State pertinent medical history. • Provide brief summary of treatment to date. • Code status (if appropriate).
A = Assessment • Vital signs • Pain scale • Is there a change from prior assessments?
R = Recommendation • State what you would like to see done or specify that the
care provider needs to come and assess the client. • Ask if health care provider wants to order any tests or
medications. • Ask health care provider if she or he wants to be notified
for any reason. • Ask, if no improvement, when you should call again.
Evans, Grunawalt, McClish, Wood, and Friese (2012) conducted a study of shift-to-shift nursing reports. They hypothesized that re- porting in the client rooms rather than at the nurses’ station would improve client satisfaction and increase direct hours of client care. Through information gathered in the literature review, the nurses de- veloped criteria for the client report. They decided that communi- cation between nurses should be verbal and occur at the client’s bedside. Upon entering the client’s room they would conduct a joint environmental safety scan. For example, was the IV infusing properly and the bed in the low position? They also bundled their assign- ments based on location and client acuity. To measure outcomes,
the nurse leaders maintained log books of observations during the process of change. Also, a graduate student observed the six nurses in the study when shift reports were conducted.
IMPLICATIONS During the time of the study the team noted that in some instances adverse client outcomes were prevented. The nurses initiated rapid response teams due to a change in the client’s condition since the previous assessment. Thus, observation of the clients during report- ing decreased the time required to assess the client at the onset of the next shift yielding improved client care outcomes.
Evidence-Based Practice How Do Bedside Shift-to-Shift Nursing Reports Enhance Outcomes? EVIDENCE-BASED PRACTICE
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their values, opinions, and beliefs may seem different. Nurses need to accept and respect each person’s contributions, listening with an open mind to what others are saying even when there is disagreement.
Nursing Rounds Nursing rounds are procedures in which two or more nurses visit se- lected clients at each client’s bedside to:
• Obtain information that will help plan nursing care. • Provide clients the opportunity to discuss their care. • Evaluate the nursing care the client has received.
During rounds, the nurse assigned to the client provides a brief summary of the client’s nursing needs and the interventions being implemented. Nursing rounds offer advantages to both clients and nurses: Clients can participate in the discussions, and nurses can see the client and the equipment being used. To facilitate client partici- pation in nursing rounds, nurses need to use terms that the client can understand. Medical terminology excludes the client from the discussion.
the physician’s order form that it is a verbal order (VO) or telephone order (TO). See Box 15–7 for selected guidelines.
Once the order is written on the physician’s order form, the order must be countersigned by the primary care provider within a time period described by agency policy. Many acute care hospitals require that this be done within 24 hours.
Care Plan Conference A care plan conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client, such as inability to cope with an event or lack of progress toward goal attainment. The care plan conference allows each nurse an opportunity to offer an opinion about possible solutions to the problem. Other health pro- fessionals may be invited to attend the conference to offer their ex- pertise; for example, a social worker may discuss the family problems of a severely burned child, or a dietitian may discuss the dietary prob- lems of a client who has diabetes.
Care plan conferences are most effective when there is a climate of respect—that is, nonjudgmental acceptance of others even though
BOX 15–7 Guidelines for Telephone and Verbal Orders
1. Know the state nursing board’s position on who can give and accept verbal and phone orders.
2. Know the agency’s policy regarding phone orders (e.g., colleague listens on extension and cosigns order sheet).
3. Ask the prescriber to speak slowly and clearly. 4. Ask the prescriber to spell out the medication if you are not
familiar with it. 5. Question the drug, dosage, or changes if they seem in-
appropriate for this client. 6. Write the order down or enter into a computer on the
physician’s order form. 7. Read the order back to the prescriber. Use words instead of
abbreviations (i.e., “three times a day” instead of “tid”). 8. Have the prescriber verbally acknowledge the read-back
(i.e., “Yes, that is correct”).
9. Record date and time and indicate it was a telephone order (TO). Sign name and credentials.
10. When writing a dosage always put a number before a decimal (i.e., 0.3 mL) but never after a decimal (i.e., 6 mg).
11. Write out units (i.e., 15 units of insulin, not 15 u of insulin). 12. Transcribe the order. 13. Follow agency protocol about the prescriber’s protocol for
signing telephone orders (i.e., within 24 hours).
Other: • Never follow a voice-mail order. Call the prescriber for a client
order. Write it down and read it back for confirmation.
Critical Thinking Checkpoint
Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.
You read the following documentation entry by a previous nurse: 8— Client is a complainer. I listened to him for 15 minutes with
no success. BP 210/90 and 180/70. P 72, R 18. 12—Refused lunch. 2—Client fell out of bed.
1. What guidelines were not used in this documentation? 2. The nursing diagnosis for Mr. Anderson is Acute Pain. What
would you expect to document? 3. Sort the following pieces of data for Mr. Anderson into a SOAP
note: a. “I didn’t sleep last night” b. Positioned on side with pillows behind back
c. Continues to need narcotic medication to progress toward goal of pain relief
d. States pain is 8 out of 10 e. “I feel better” (after interventions) f. Last medicated 5 hours previously
g. Heating pad applied to lower back h. BP 210/90, P 72, R 18 i. Add to plan of care to offer analgesic around the clock q4h
versus prn j. 6/6/15 #1 Pain
k. “Sharp, stabbing pain in lower back that radiates to left leg” l. Medicated with ordered analgesic
4. Sort the pieces of data from Question 3 into a DAR note. See Critical Thinking Possibilities on student resource website.
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• Client records are legal documents that provide evidence of a cli- ent’s care.
• The nurse has a legal and ethical duty to maintain confidentiality of the client’s record; this includes special measures to protect client information stored in computers.
• Client records are kept for a number of purposes, including com- munication, planning client care, auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis.
• Examples of documentation systems include source oriented, problem oriented, PIE, focus charting, charting by exception, com- puterized documentation, and case management.
• In source-oriented clinical records, each health care professional group provides its own record. Recording is oriented around the source of the information.
• In problem-oriented clinical records, recording is organized around client problems.
• Computers make care planning and documentation relatively easy. The use of computer terminals at the bedside allows immediate documentation of nursing actions.
• The case management model emphasizes quality, cost-effective care delivered within an established length of stay.
• The Kardex is used to organize client data, making information quick to access for health professionals.
• Nursing progress notes provide information about the progress the client is making toward desired outcomes. The format for the prog- ress note depends on the documentation system at the facility.
• Long-term documentation varies depending on the level of care provided and requirements set by Medicare and Medicaid.
• Home health agencies must standardize their documentation methods to meet requirements for Medicare and Medicaid and other third-party disbursements.
• Legal guidelines for the process of recording in a client record in- clude documenting date and time, legible entries, using dark ink, using accepted terminology and spelling, accuracy, sequence, appropriateness, completeness, conciseness, and including an appropriate signature.
• The purpose of reporting is to communicate specific information for the goal of improving quality of care. Examples include change- of-shift reports, telephone reports, telephone orders, care plan conferences, and nursing rounds.
• A change-of-shift report and a telephone report are considered handoff communications. The Joint Commission requires hospitals to implement a standardized approach for “handing off” communi- cations, including an opportunity to ask and respond to questions.
CHAPTER HIGHLIGHTS
Chapter 15 Review
1. Which action by a nurse ensures confidentiality of a client’s com- puter record? 1. The nurse logs on to the client’s file and leaves the computer
to answer the client’s call light. 2. The nurse shares her computer password. 3. The nurse closes a client’s computer file and logs off. 4. The nurse leaves client computer worksheets at the com-
puter workstation. 2. The case management model using critical pathways would be
appropriate for a client with which diagnosis? 1. Myocardial infarction (heart attack) 2. Diabetes, hypertension 3. Myocardial infarction, diabetes, hypertension 4. Diabetes, hypertension, an infected foot ulcer, senile
dementia 3. After making a documentation error, which action should the
nurse take? 1. Use correcting liquid to cover the mistake and make a new
entry. 2. Draw a line through it and write error above the entry. 3. Draw a line through it and write mistaken entry above it. 4. Draw a line through the mistake and write mistaken entry
with initials above it. 4. Which charting entry would be the most defensible in court?
1. Client fell out of bed 2. Client drunk on admission 3. Large bruise on left thigh 4. Notified Dr. Jones of BP of 90/40
5. The client’s VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT. Interpret the commonly used abbreviations. 1. NKA: 2. BRP: 3. PRN: 4. DAT:
6. During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client’s blood pressure (BP) seems high. What is the next step? 1. Ask the client about past blood pressure ranges. 2. Review the graphic record on the client’s record. 3. Examine the medication record for antihypertensive
medications. 4. Review the progress notes included in the client’s record.
7. A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply. 1. Provides the medical diagnosis or reason for admission. 2. States the time the client last received pain medication. 3. Speaks loudly when giving report. 4. States priorities of care that are due shortly after the report. 5. Reports on number of visitors for each client.
8. Which charting entries are written correctly? Select all that apply. 1. MS 5 gr given IV for c/o abdominal pain 2. Lanoxin 0.25 mg given orally per Dr. Smith’s stat order 3. KCl 15 mL given orally for K+ level of 2.9 4. Regular insulin 10.0 u given SQ for capillary blood glucose
of 180 5. Ambien 5 mg given orally at bedtime per request
TEST YOUR KNOWLEDGE
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10. Which charting rule(s) will keep the nurse legally safe? Select all that apply. 1. Use military time. 2. Document worries or concerns expressed by the client. 3. Perform most of the charting at the end of the shift. 4. Record only information that pertains to the client’s health
problems. See Answers to Test Your Knowledge in Appendix A.
9. A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation? 1. Six round skin lesions partially healed, on the inner thighs
bilaterally 2. Several burned areas on both of the client’s inner thighs 3. Multiple lesions on inner thighs possibly related to elder
abuse 4. Several lesions on inner thighs similar to cigarette burns
Suggested Reading Mark, M. S. (2013, August). New tool aims to standardize
hand-offs in the ED, boosting safety and preventing communication errors. ED Management, pp. 85–89. The editor of ED Management reports that a group of emergency providers developed Safer Sign Out. This is a paper-based template to prompt clinicians to jointly review issues concerning clients with the oncoming emergency department staff.
Related Research Li, D., & Korniewicz, D. M. (2013). Determination of the effec-
tiveness of electronic health records to document pressure ulcers. Medsurg Nursing, 22(1), 18–25.
References American Nurses Association. (2001). Code of ethics for
nurses with interpretive statements. Washington, DC: Author.
Association of Operating Room Nurses. (n.d.). Hand-off com- munication tools overview. Retrieved from http://www.aorn .org/search.aspx?searchtext=aorn%20hand%20off% 20toolkit
Berger, J. T., Sten, M. B., & Stockwell, D. C. (2012). Patient handoffs: Delivering content efficiently and effectively is not enough. International Journal of Risk & Safety in Medicine, 24, 201–205. doi:10.3233/JRS-2012-0573
Chart smart. (3rd ed.). (2013). Philadelphia, PA: Lippincott Williams & Wilkins.
Criscitelli, T. (2013). Safe patient hand-off strategies. AORN Journal, 97, 582–585. doi:10.1016/j.aorn.2013.02.007
Evans, D., Grunawalt, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside shift-to-shift nursing report: Implementa- tion and outcomes. Medsurg Nursing, 21(5), 281–292.
Galliers, J., Wilson, S., Randell, R., & Woodward, P. (2011). Safe use of symbols in handover documentation for medical teams. Behavior & Information Technology, 30, 499–506. doi:10.1080/0144929X.2011.582147
Guido, G. W. (2010). Legal and ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall.
Halm, M. A. (2013). Nursing handoffs: Ensuring safe pas- sage for patients. American Journal of Critical Care, 22, 158–162. doi:10.4037/ajcc2013454
Hebda, T. L., & Czar, P. (2013). Handbook of informatics for nurses and healthcare professionals (5th ed.). Upper Saddle River, NJ: Prentice Hall.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA Inter- national nursing diagnoses: Definitions and classification, 2015–2017. O xford, United Kingdom: Wiley-Blackwell.
Hill, W., & Nyce, J. (2010). Human factors in clinical shift handover communication. Canadian Journal of Respiratory Therapy, 46(1), 44–51.
Institute for Healthcare Improvement. (2013). SBAR technique for communication: A situational briefing model. Retrieved from http://www.ihi.org/IHI/Topics/PatientSafety/ SafetyGeneral/Tools/SBARTechniquefor CommunicationASi tuationalBriefingModel.htm
The Joint Commission. (2010). Facts about the official “do not use” list. Retrieved from http://www.jointcommission.org/ assets/1/18/Do_Not_Use_List.pdf
Paans, W., Sermeus, W., Nieweg, R., & van der Schans, C. P. (2010). Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing, 66, 2481–2489. doi:10.1111/j.1365-2648.2010.05433.x
Prideaux, A. (2011). Issues in nursing documentation and record-keeping practice. British Journal of Nursing, 20, 1450–1454.
Riesenberg, L. A., Leitzsch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24–34. doi:10.1097/01.NAJ.0000370154.79857.09
Wacogne, I., & Diwakar, V. (2010). Handover and note- keeping: The SBAR approach. Clinical Risk, 16, 173–175. doi:10.1258/cr.2010.010043
Selected Bibliography Boucher, K., Griffiths, E., Sergent, D., Mahobatha, N., George, P.,
McKinley, D., & Marks, S. (2012). Documentation in the PICU setting: Is a checklist tool effective? Australian Journal of Advanced Nursing, 30(2), 5–12.
Edwards, C. (2012). Nursing leaders serving as a foundation for the electronic medical record. Journal of Trauma Nurs- ing, 19(2), 111–116. doi:10.1097/JTN.0b013e31825629db
Isherwood, J. D., Patel, M., Thomson, H., Metcalfe, M. S., Dennison, A., & Garcea, G. (2013). The positive effects of accurate documentation. British Journal of Healthcare Management, 19, 242–247.
Kerr, N. (2013). Creating a protective picture: A grounded theory of RN decision making when using a charting-by- exception documentation system. Medsurg Nursing, 22(2), 110–118.
McEwen, D., & Dumpel, H. (2013, June). Narrative docu- mentation, Part 2: Protecting your patients, practice, and license in the information age. National Nurse, pp. 20–31.
Plemmons, S., Lipton, B., Fong, Y., & Acosta, N. (2012). Mea- surable outcomes from standardized nursing documenta- tion in an electronic health record. ANIA-Caring, 27(2), 4–7.
Wang, N., Hailey, D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: A mixed method systemic review. Journal of Advanced Nursing, 67, 1858–1875. doi:10.1111/j.1365-2648.2011.05634.x
READINGS AND REFERENCES
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CLIENT: Benjamin AGE: 35 CURRENT MEDICAL DIAGNOSIS: Torn Anterior Cruciate Ligament (ACL) Left Knee STATUS: Presurgical Medical History: Benjamin is a well-nourished, well-developed man with no history of chronic illnesses. He has had the usual childhood diseases, and medical care has been limited to occasional sports-related trauma.
Personal and Social History: Benjamin is a married computer technician with three children ages 16, 6, and 2. He plays many sports including basketball, softball, and golf. He drives to work ap- proximately 20 miles each way. His job is primarily desk work with some standing, walking, lifting, and bending. He has a baccalaureate degree in business.
Questions American Nurses Association Standard of Practice #1 is Assessment: The registered nurse collects comprehensive data pertinent to the patient’s health and/or the situation. The nurse will care for many clients who do not have an acute illness. These clients may require health promotion, health maintenance, or wellness care. Others, like Benjamin, have health issues for which treatment is considered at least partially elective—meaning that it is not urgent and can probably be managed according to his preferred schedule. In assessing this client, the nurse focuses on gathering those data from all systems that provide information useful to the nurse and the health care team in planning his care and recovery. 1. As discussed in Chapter 11, the standard states that the nurse
“collects comprehensive data including but not limited to physi- cal, functional, psychosocial, emotional, cognitive sexual, cul- tural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while honoring the uniqueness of the person” (ANA, 2010, p. 32). How would you determine the best way to conduct Benja- min’s assessment that will provide the most useful findings?
American Nurses Association Standard of Practice #2 is Diagnosis: The registered nurse analyzes the assessment data to determine the diagnoses or issues. Competencies for this step of the nursing process as delineated in the standard include that the nurse validates the nursing diagnosis with the client and that both actual and potential problems are identified.
Another nurse has written the following NANDA International (Herdman, 2012) nursing diagnosis on Benjamin’s medical record: Risk for Impaired Parenting (defined as “Risk for inability of the
primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child”) related to physical illness, manifested by pain and postoperative immobility. 2. Describe the thinking process you would use to seek validation
that this diagnosis is appropriate. What data would you use? What questions would you ask, and of whom?
American Nurses Association Standard of Practice #4 is Planning: The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Planning may involve the use of standardized care plans that have desired outcomes and interventions already written for common medical diagnoses. The standardized care plan for repair of a torn ACL emphasizes mobility, pain control, and wound care. Planning also includes competencies related to documenting the plan of care using standardized language and terminology understood by every- one using the documentation. 3. How might you individualize and add to the care plan to address
the psychosocial needs identified for Benjamin that are related to his family and employment?
4. If you were caring for Benjamin on the evening of the day he had surgery, describe at least three different places in the medical record where you would document his care and what you might record there.
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International nursing diagnoses: Defini- tions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
3 Meeting the StandardsThe American Nurses Association Standards of Professional Nursing Practice consists of 6 Standards of Practice and 10 Standards of Professional Performance. The Standards of Practice are the compo-nents of the nursing process. The chapters in this unit of Fundamentals are Critical Thinking and Clini- cal Reasoning, Assessing, Diagnosing, Planning, Implementing and Evaluating, and Documenting and Reporting. They provide details about the steps of applying critical thinking to nursing practice and using a systematic approach in nursing care. Possibly no other structure is as universally applicable in organizing the nurse’s thinking and guiding the nurse’s actions.
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Health Beliefs and Practices
16 Health Promotion 244
17 Health, Wellness, and Illness 262
18 Culturally Responsive Nursing Care 276
19 Complementary and Alternative Healing Modalities 295
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INTRODUCTION Health promotion is an important component of nursing prac- tice. It is a way of thinking that revolves around a philosophy of wholeness, wellness, and well-being. In the past two decades, the public has become increasingly aware of and interested in health promotion. Many people are aware of the relationship between lifestyle and illness and are developing health-promoting habits, such as getting adequate exercise, rest, and relaxation; maintain- ing good nutrition; and controlling the use of tobacco, alcohol, and other drugs.
Assessing and planning health care of the individual client is enhanced when the nurse understands the concepts of indi- viduality, holism, homeostasis, and human needs. The beliefs and values of each person and the support he or she receives come in large part from the family and are reinforced by the community. The reverse is also true—the health of a community is affected by the beliefs, attitudes, and behaviors of the individuals in the community.
INDIVIDUAL HEALTH Dimensions of individuality include the person’s total character, self- identity, and perceptions. The person’s total character encompasses behaviors, emotional state, attitudes, values, motives, abilities, habits, and appearances. The person’s self-identity encompasses percep- tion of self as a separate and distinct entity alone and in interactions with others. The person’s perceptions encompass the way the person
interprets the environment or situation, directly affecting how he or she thinks, feels, and acts in any given situation.
Concept of Individuality To help clients attain, maintain, or regain an optimal level of health, nurses need to understand clients as individuals. Each individual is a unique being who is different from every other human being, with a different combination of genetics, life experiences, and environmen- tal interactions.
When providing care, nurses need to focus on the client within both a total care and an individualized care context. In the total care context, the nurse considers all the principles and areas that apply when taking care of any client of that age and condition. In the indi- vidualized care context, the nurse becomes acquainted with the cli- ent as an individual, using the total care principles that apply to this person at this time. For example, a nurse who is advising the mother of a preschooler understands that the child’s desire to explore his or her world is a developmental stage that all preschoolers experience. However, the preschooler diagnosed with attention deficit/hyperac- tivity disorder may have an increased risk of accidents and injuries when interacting with the environment, due to his or her impulsivity and poor self-control.
Concept of Holism Nurses are concerned with the individual as a whole, complete, or ho- listic person, not as an assembly of parts and processes. When applied
After completing this chapter, you will be able to: 1. Explain the relationship of individuality and holism to nursing
practice. 2. List four main characteristics of homeostatic mechanisms. 3. Identify theoretical frameworks used in individual health
promotion. 4. Describe the vision, mission, and goals of Healthy People
2020 to help improve the health of a community. 5. Differentiate health promotion from health protection or illness
prevention.
LEARNING OUTCOMES
16 Health Promotion
6. Identify various types and sites of health promotion programs. 7. Discuss the Health Promotion Model. 8. Explain the stages of health behavior change. 9. Discuss the nurse’s role in health promotion.
10. Describe components of health assessment that pertain to health promotion.
11. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion.
KEY TERMS
action stage, 252 boundary, 245 closed system, 245 compensatory, 245 contemplation stage, 252 disease prevention, 248 equilibrium, 245 feedback, 245
health promotion, 248 health promotion domain, 256 health protection, 248 health risk assessment
(HRA), 255 holism, 245 homeostasis, 245 input, 245
maintenance stage, 253 negative feedback, 245 open system, 245 output, 245 positive feedback, 245 precontemplation stage, 252 preparation stage, 252 primary prevention, 248
psychological homeostasis, 246 secondary prevention, 248 self-regulation, 245 system, 245 termination stage, 253 tertiary prevention, 248 throughput, 245
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that differentiates one system from another system or a system from its environment.
There are two general types of systems: closed and open. A closed system does not exchange energy, matter, or information with its environment; it receives no input from the environment and gives no output to the environment. An example of a closed system is a chemical reaction that takes place in a test tube. In reality, outside the laboratory, no closed systems exist. In an open system, energy, matter, and information move into and out of the system through the system’s boundary. All living systems, such as plants, animals, people, families, and communities, are open systems, because their survival depends on a continuous exchange of energy. They are, therefore, in a constant state of change.
An open system depends on the quality and quantity of its in- put, output, and feedback. Input consists of information, material, or energy that enters the system. After the input is absorbed by the system, it is processed in a way useful to the system. This transforma- tion is called throughput. For example, food is input to the digestive system; it is digested (throughput) so that it can be used by the body. Output from a system is energy, matter, or information given out by the system as a result of its processes. Output from the digestive sys- tem includes caloric energy, nutrients, urine, and feces.
Feedback is the mechanism by which some of the output of a system is returned to the system as input. Feedback enables a system to regulate itself by redirecting the output back into the system, thus forming a feedback loop (Figure 16–1 •). This input influences the behavior of the system and its future output. Negative feedback inhibits change; positive feedback stimulates change. Most bio- logic systems are controlled by negative feedback to bring the system back to stability. This type of feedback system senses and counter- acts any deviations from normal. The deviations may be greater or less than the normal level or range. For example, an increase in the production of parathyroid hormone is stimulated by a drop in blood calcium, but when additional parathyroid hormone raises the level of blood calcium, the hormone’s production is then inhibited (Figure 16–2 •). With hypoxia (shortage of oxygen), the concentra- tion of red blood cells increases and the heart rate becomes faster to transport the blood and available oxygen around the body ad- equately. People interact with the environment by adjusting them- selves to it or adjusting it to themselves. This premise directs the nurse to look at environmental factors influencing the system and to plan nursing interventions to help the client maintain homeostasis. For example, the individual who is experiencing severe anxiety may be taught a variety of stress management techniques.
in nursing, the concept of holism emphasizes that nurses must keep the whole person in mind and strive to understand how one area of concern relates to the whole person. The nurse must also consider the relationship of the individual to the external environment and to others. For example, in helping a man who is grieving over the death of his spouse, the nurse explores the impact of the loss on the whole person (i.e., on the man’s appetite, rest and sleep pattern, energy level, sense of well-being, mood, usual activities, family relationships, and relationships with others). Nursing interventions are directed toward restoring overall harmony, so they depend on the man’s sense of pur- pose and meaning of his life. For additional information about holis- tic practices, see Chapter 19 .
Concept of Homeostasis The concept of homeostasis was first introduced by Cannon (1939) to describe the relative constancy of the internal processes of the body, such as blood oxygen and carbon dioxide levels, blood pressure, body temperature, blood glucose, and fluid and electrolyte balance. To Cannon, the word homeostasis did not imply something stagnant, set, or immobile; it meant a condition that might vary but remained relatively constant. Cannon viewed the human being as separate from the external environment and constantly endeavor- ing to maintain physiological equilibrium, or balance, through adaptation to that environment. Homeostasis, then, is the tendency of the body to maintain a state of balance or equilibrium while con- tinually changing.
PHYSIOLOGICAL HOMEOSTASIS Physiological homeostasis means that the internal environment of the body is relatively stable and constant. All cells of the body require a relatively constant environment to function; thus the body’s inter- nal environment must be maintained within narrow limits. Homeo- static mechanisms have four main characteristics:
1. They are self-regulating. 2. They are compensatory. 3. They tend to be regulated by negative feedback systems. 4. They may require several feedback mechanisms to correct only
one physiological imbalance.
Self-regulation means that homeostatic mechanisms come into play automatically in the healthy person. However, if a person is ill, or if an organ such as a lung is injured, the homeostatic mech- anisms may not be able to respond to the stimulus as they would normally. Homeostatic mechanisms are compensatory (coun- terbalancing) because they tend to counteract conditions that are abnormal for the person. An example is a sudden drop in air tem- perature. The compensatory mechanisms are that the peripheral blood vessels constrict, thereby diverting most of the blood inter- nally, and increased muscular activity and shivering occur to cre- ate heat. Through these mechanisms the body temperature remains stable despite the cold.
Homeostasis occurs within the physiological system, a set of interacting identifiable parts or components. The fundamental com- ponents of a system are matter, energy, and communication. Without any one of these, a system does not exist. The individual is a human system with matter (the body), energy (chemical or thermal), and communication (e.g., the nervous system). The boundary of a sys- tem, such as the skin in the human system, is a real or imaginary line Figure 16–1 • An open system with a feedback mechanism.
Feedback
Input Throughput processes Output
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• A social environment that includes adults who are healthy role models. Children learn the customs and values of society from these individuals.
• A life experience that provides satisfactions. Throughout life, people encounter many frustrations. People deal with these better if enough satisfying experiences have occurred to counterbalance the frustrating ones.
Assessing the Health of Individuals A thorough assessment of an individual’s health status is basic to health promotion. Components of this assessment are the health his- tory and physical examination, physical fitness assessment, lifestyle assessment, health risk appraisal, health beliefs review, and life-stress review. Details about these assessments are discussed in Chapters 11 and 30 .
APPLYING THEORETICAL FRAMEWORKS A variety of theoretical frameworks provide the nurse with a holistic overview of health promotion for the individual and families across the life span. Two major theoretical frameworks that nurses use
PSYCHOLOGICAL HOMEOSTASIS The term psychological homeostasis refers to emotional or psychological balance or a state of mental well-being. It is main- tained by a variety of mechanisms. Each person has certain psycho- logical needs, such as the need for love, security, and self-esteem, which must be met to maintain psychological homeostasis. When one or more of these needs is not met or is threatened, certain cop- ing mechanisms are activated to protect the person and provide psy- chological homeostasis.
Psychological homeostasis is acquired or learned through the experience of living and interacting with others. In addition, soci- etal norms and culture influence behavior. Some prerequisites for a person to develop psychological homeostasis can be summarized as follows:
• A stable physical environment in which the person feels safe and secure. For example, the basic needs for food, shelter, and clothing must be met consistently from birth onward.
• A stable psychological environment from infancy onward, so that feelings of trust and love develop. Growing children and adoles- cents need kind but firm and consistent discipline, encourage- ment, and support to be their own unique selves.
Figure 16–2 • The homeostatic regulators of the body: autonomic nervous system, endocrine system, and specific organ systems.
Cranial nerves (parasympathetic)
Thoracic nerves (sympathetic)
Lumbar nerves (sympathetic)
Sacral nerves (parasympathetic)
Respiratory
Cardiovascular
Gastrointestinal
Renal
Pituitary gland
Thyroid gland
Pancreas
Adrenal glands
Parathyroid glands
Autonomic nervous system
Endocrine system
Organ systems
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KALISH’S HIERARCHY OF NEEDS Richard Kalish (1983) adapted Maslow’s hierarchy of needs into six levels rather than five. He suggests an additional category be- tween the physiological needs and the safety and security needs. This category, referred to as stimulation needs, includes sex, ac- tivity, exploration, manipulation, and novelty (see Figure 16–3). Kalish emphasizes that children need to explore and manipu- late their environments to achieve optimal growth and develop- ment. He notes that adults, too, often seek novel adventures or stimulating experiences before considering their safety or secu- rity needs.
CHARACTERISTICS OF BASIC NEEDS All people have the same basic needs; however, each person’s needs and reactions to those needs are influenced by the culture with which the person identifies. For example, professional achievement, inde- pendent functioning, and privacy may be important in one culture or subculture and unimportant in another.
• People meet their own needs relative to their own priorities. For example, a poor mother might give up her share of food so that her child might have sufficient food to live.
• Although basic needs generally must be met, some needs can be deferred. An example is the need for independence, which an ill person can defer until well.
• Failure to meet needs results in one or more homeostatic imbal- ances, which can eventually result in illness.
• A need can make itself felt by either external or internal stim- uli. An example is the need for food. A person may experi- ence hunger as a result of physiological processes (internal stimulation) or as a result of seeing a beautiful cake (external stimulation).
• A person who perceives a need can respond in several ways to meet it. The choice of response is largely a result of learned experi- ences, lifestyle, and the values of the culture. For example, many people’s food choices at mealtimes and snack times are based on past experiences, lifestyle, and culture.
• Needs are interrelated. Some needs cannot be met unless related needs are also met. The need for hydration can be influenced by the need for elimination of urine. Likewise, the need for security can be markedly altered if the need for oxygen is threatened by a respiratory obstruction.
Needs can be satisfied in healthy and unhealthy ways. Ways of meeting basic needs are considered healthy when they are not harmful to others or to self, conform to the individual’s sociocultural values, and are within the law. Conversely, un- healthy behavior may be harmful to others or to self, does not conform to the individual’s sociocultural values, or is not within the law. People who satisfy their basic needs appropriately are healthier, happier, and more effective than those whose needs are frustrated.
Knowledge of the theoretical bases of human needs assists nurses in responding therapeutically to a client’s behaviors and in understanding themselves and their own responses to needs. Hu- man needs serve as a framework for assessing behaviors, assigning priorities to desired outcomes, and planning nursing interventions.
in promoting the health of the individual are needs theories and developmental stage theories.
Needs Theories In needs theories, human needs are ranked on an ascending scale ac- cording to how essential the needs are for survival. Abraham Maslow (1970), perhaps the most renowned needs theorist, ranks human needs on five levels (Figure 16–3 •). The five levels in ascending or- der are as follows:
• Physiological needs. Needs such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance are crucial for survival.
• Safety and security needs. The need for safety has both physical and psychological aspects. The person needs to feel safe, both in the physical environment and in relationships.
• Love and belonging needs. The third level of needs includes giving and receiving affection, attaining a place in a group, and maintain- ing the feeling of belonging.
• Self-esteem needs. The individual needs both self-esteem (i.e., feelings of independence, competence, and self-respect) and es- teem from others (i.e., recognition, respect, and appreciation).
• Self-actualization. When the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential and realize one’s abilities and qualities.
Figure 16–3 • Maslow’s needs.
Self-Actualization Needs
Reaching Your Potential Independence
Creativity Self-Expression
Self-Esteem Needs
Responsibility Self-Respect Recognition
Sense of Accomplishment Sense of Competence
Love and Belonging Needs
Companionship Acceptance
Love and Affection Group Membership
Safety and Security Needs
Security for Self and Possessions Avoidance of Risks Avoidance of Harm Avoidance of Pain
Physiological Needs
Food Clothing Shelter Comfort
Self-Preservation
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areas, reflect public comments and the deliberation of work groups such as the Federal Interagency Workgroup on Healthy People 2020 and the Secretary’s Advisory Committee on National Health Promo- tion and Disease prevention objectives for 2020.
The foundation for Healthy People 2020 is the belief that indi- vidual health is closely linked to community health and the reverse. For example, community health is affected by the beliefs, attitudes, and behaviors of the individuals who live in the community. As a re- sult, partnerships are important to improve individual and commu- nity health. Businesses, local government, and civic, professional, and religious organizations can all participate. Examples include sponsor- ing a health fair, establishing fitness programs, beginning community recycling programs, and printing immunization schedules.
DEFINING HEALTH PROMOTION Considerable differences appear in the literature regarding the use of the terms health promotion, primary prevention, health protection, and illness prevention. Edelman and Mandle (2010) state that “preven- tion, in a narrow sense, means avoiding the development of disease in the future, and, in the broader sense, consists of all interventions to limit progression of a disease” (p. 14). The levels of prevention oc- cur at various points in the course of disease progression. Leavell and Clark (1965) defined three levels of prevention: primary, secondary, and tertiary. Five steps describe these levels: Primary prevention focuses on (a) health promotion and (b) protection against specific health problems (e.g., immunization against hepatitis B). The pur- pose of primary prevention is to decrease the risk or exposure of the individual or community to disease. Secondary prevention fo- cuses on (a) early identification of health problems and (b) prompt intervention to alleviate health problems. Its goal is to identify in- dividuals in an early stage of a disease process and to limit future disability. Tertiary prevention focuses on restoration and rehabili- tation with the goal of returning the individual to an optimal level of functioning. Table 16–1 provides examples of activities for each level of prevention. The three levels of prevention may overlap in prac- tice. For example, a client may have experienced a heart attack, and a goal of secondary prevention is to limit disability. The teaching (e.g., lifestyle changes) for the client’s rehabilitation will be similar to the health education activities used for primary prevention teaching.
Pender, Murdaugh, and Parsons (2011) consider health promo- tion to be different from disease prevention or health protection. They define health promotion as “behavior motivated by the de- sire to increase well-being and actualize human health potential,” and disease prevention or health protection as “behavior mo- tivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness” (p. 5). The individual’s underlying motivation for the behavior is the major difference. Box 16–2 provides an overview of the differences between health promotion and health protection.
The difficulty in separating the terms health promotion and dis- ease prevention/health protection lies in the fact that an activity may be carried out for numerous reasons. For example, a 40-year-old male may begin a program of walking 3 miles each day. If the goal of his program were to “decrease the risk of cardiovascular disease,” then the activity would be considered disease prevention or health protection. By contrast, if the motivation for his walking regimen were to “in- crease his overall health and feeling of well-being,” then the activity
For example, an adult with poor self-esteem would have difficulty accomplishing self-actualization. Therefore, nursing interventions would focus on increasing the client’s self-esteem.
Developmental Stage Theories Developmental stage theories categorize a person’s behaviors or tasks into approximate age ranges or in terms that describe the features of an age group. The age ranges of the stages do not take into account individual differences; however, the categories do describe charac- teristics associated with the majority of individuals at periods when distinctive developmental changes occur and with the specific tasks that must be accomplished. See Chapter 20 for further informa- tion about developmental stages.
Developmental stage theories allow nurses to describe typical behaviors of an individual within a certain age group, explain the sig- nificance of those behaviors, predict behaviors that might occur in a given situation, and provide a rationale to control behavioral mani- festations. Individuals can be compared with a representative group of people at the same point in time or compared at different points in time. The nurse’s knowledge of developmental stage theories can be used in parental and client education, counseling, and anticipatory guidance.
HEALTHY PEOPLE 2020 The vision of health promotion was initially expressed in 1979 with the surgeon general’s report Healthy People, which emphasized health promotion and disease prevention. Healthy People 2000 followed in 1990 and provided a framework for national health promotion, health protection, and preventive service strategy. Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2010) pre- sents the current vision, mission, and overarching goals (Box 16–1). Specific objectives and strategies were developed to achieve them. The Healthy People 2020 objectives, which are organized by topic
BOX 16–1 Healthy People 2020 Framework
Vision: A society in which all people live long, healthy lives. Mission: Healthy People 2020 strives to: • Identify nationwide health improvement priorities. • Increase public awareness and understanding of the
determinants of health, disease, and disability and the opportunities for progress.
• Provide measurable objectives and goals that are applicable at the national, state, and local levels.
• Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge.
• Identify critical research, evaluation, and data collection needs. Overarching Goals: • Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the
health of all groups. • Create social and physical environments that promote good
health for all. • Promote quality of life, health development, and healthy
behaviors across all life stages.
From Healthy People 2020, U.S. Department of Health and Human Services, 2010. Retrieved from http://www.healthypeople.gov/2020/default.aspx.
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Differences Between Health Promotion and Health ProtectionBOX 16–2
Health Promotion Health Protection Not disease oriented Illness or injury specific Motivated by personal, positive “approach” to wellness
Motivated by “avoidance” of illness
Seeks to expand positive Seeks to stop the potential for health occurrence of insults to health and well-being
From Health Promotion in Nursing Practice, 6th ed. (p. 5), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011. Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
TABLE 16–1 Levels of Prevention
Level and Description Examples Primary prevention: Generalized health promotion and specific protection against disease. It precedes disease or dysfunction and is applied to generally healthy individuals or groups.
• Health education about injury and poisoning prevention, standards of nutrition and of growth and development for each stage of life, exercise requirements, stress management, protection against occupational hazards, and so on
• Immunizations • Risk assessments for specific disease • Family planning services • Environmental sanitation and provision of adequate housing,
recreation, and work conditions
Secondary prevention: Emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Includes prevention of complications and disabilities.
• Screening surveys and procedures of any type (e.g., Denver Developmental Screening Test, hypertension screening)
• Encouraging regular medical and dental checkups • Teaching self-examination for breast and testicular cancer • Assessing the growth and development of children • Nursing assessments and care provided in home, hospital, or other
agency to prevent complications (e.g., maintaining skin integrity; turning, positioning, and exercising clients; ensuring adequate rest, food, and fluid intake; promoting fecal and urinary elimination; administering medical therapies such as medications; and so on)
Tertiary prevention: Begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Its focus is to help rehabilitate individuals and restore them to an optimum level of functioning within the constraints of the disability.
• Referring a client who has had a colostomy to a support group • Teaching a client who has diabetes to identify and prevent
complications • Referring a client with a spinal cord injury to a rehabilitation center to
receive training that will maximize use of remaining abilities
would be considered a health promotion behavior. It is most helpful to think of health promotion and health protection as being comple- mentary processes because both affect quality of health.
Health promotion can be offered to all clients regardless of their health and illness status or age. For example, weight-control measures can benefit both overweight clients without disease and clients with cardiac or joint disease. Age-specific health promotion activities are discussed in Chapters 21, 22, and 23 . See Lifespan Considerations for examples of health promotion topics.
SITES FOR HEALTH PROMOTION ACTIVITIES Health promotion programs exist in many settings. Programs and activities may be offered to individuals and families in the home or in the community setting and at schools, hospitals, or worksites. Some individuals may feel more comfortable having a nurse, diet counselor, or fitness expert come to their home for teaching and follow-up on individual needs. This type of program, however, is not cost effective
for most individuals. Many people prefer the group approach, find it more motivating, and enjoy the socializing and support. Most pro- grams offered in the community are group oriented.
Cities and towns frequently offer community programs. The type of program depends on the current concerns and the expertise of the sponsoring department or group. Program offerings may in- clude health promotion, specific protection, and screening for early detection of disease. The local health department may offer a town- wide immunization program because immunization provides one of the most cost-effective means of protecting infants and children. Other examples include the fire department distributing fire preven- tion information, or the police offering a bicycle safety program for children or a safe-driving campaign for young adults.
Hospitals began the emphasis on health promotion and pre- vention by focusing on the health of their employees. Because of the stress involved in caring for the sick and the various shifts that nurses and other health care workers must work, the lifestyles and health habits of health care employees were given priority.
Programs offered by health care organizations initially began with a specific focus on prevention. Examples include infection con- trol, fire prevention and fire drills, limiting exposure to x-rays, and the prevention of back injuries. Gradually, issues related to the health and lifestyle of the employee were addressed with programs on top- ics such as smoking cessation, exercise and fitness, stress reduction, and time management. Increasingly, hospitals have offered a variety of these programs and others (e.g., women’s health) to the community as well as to their employees. Such community activities enhance the public image of the hospital, increase the health of the surrounding population, and generate some additional income.
School health promotion programs may serve as a foundation for children of all ages to gain basic knowledge about personal hy- giene and issues in the health sciences. Because school is the focus
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LIFESPAN CONSIDERATIONS Health Promotion Topics
INFANTS Infant–parent attachment/bonding Breast-feeding Sleep patterns Playful activity to stimulate development Immunizations Safety promotion and injury control
CHILDREN Nutrition Dental checkups Rest and exercise Immunizations Safety promotion and injury control
ADOLESCENTS Communicating with the teen Hormonal changes Nutrition Exercise and rest Peer group influences Self-concept and body image
Sexuality Safety promotion and accident prevention
OLDER ADULTS Adequate sleep Appropriate use of alcohol Dental/oral health Drug management Exercise Foot health Health screening recommendations Hearing aid use Immunizations Medication instruction Mental health Nutrition Physical fitness Preventive health services Safety precautions Smoking cessation Weight control
of a child’s life for so many years, the school provides a cost-effective and convenient setting for health-focused programs. The school nurse may teach programs about basic nutrition, dental care, activity and play, drug and alcohol abuse, domestic violence, child abuse, and issues related to sexuality and pregnancy. Classroom teachers may in- clude health-related topics in their lesson plans, for example, the way the normal heart functions or the need for clean air and water in the environment.
Worksite programs for health promotion have developed out of the need for businesses to control the rising costs of health care and employee absenteeism. Many industries feel that both employ- ers and employees benefit from healthy lifestyles and behaviors. The convenience of the worksite setting makes these programs particu- larly attractive to many adults who would otherwise not be aware of them or motivated to attend them. Health promotion programs may be held in the company cafeteria so that employees can watch a film or attend a discussion group during their lunch break. Work- site programs may include programs that address air quality stan- dards for the office, classroom, or plant; programs aimed at specific populations, such as injury prevention for the machine worker or back-saver programs for the individual involved in heavy lifting; programs to screen for high blood pressure; or health enhance- ment programs, such as fitness information and relaxation tech- niques. Benefits to the worker may include an increased feeling of well-being, fitness, weight control, and decreased stress. Benefits to the employer may include an increase in employee motivation and productivity, an increase in employee morale, a decrease in absen- teeism, and a lower rate of employee turnover, all of which may de- crease business and health care costs.
Older adults who have retired often have more time for health promotion activities than they did before retirement. The nurse can inform older adults of available community resources such as walk- ing groups. Nurses can address the need for health protection and health promotion through teaching classes at retirement communi- ties and other community resource centers for older adults.
HEALTH PROMOTION MODEL The initial version of the Health Promotion Model (HPM) appeared in the nursing literature in the early 1980s and focused on health- promoting behaviors rather than health protection or illness preven- tion behaviors. The initial model has been replaced by the Health Promotion Model (Revised) as shown in Figure 16–4 •. The HPM is a competence- or approach-oriented model in which the motiva- tional source for behavior change is based on the individual’s subjec- tive value of the change—that is, how the client perceives the benefits of changing the given health behavior. The HPM does not include “fear” or “threat” as a motivating source for changing health behavior (Pender et al., 2011, p. 44). The assumptions of the HPM are stated in Box 16–3. The variables in the revised HPM and their interrelation- ships are described next.
Individual Characteristics and Experiences The importance of an individual’s unique personal factors or charac- teristics and experiences will depend on the target behavior for health promotion. There is flexibility in the HPM to select those charac- teristics that are relevant to the particular health behavior. Personal factors are categorized as biologic (e.g., age, strength, balance), psy- chological (e.g., self-esteem, self-motivation), and sociocultural (e.g., race, ethnicity, education, socioeconomic status). Some personal factors can influence health behaviors, whereas others, such as age, cannot be changed. Prior related behavior includes previous experi- ence, knowledge, and skill in health-promoting actions. Individu- als who made a habit of a previous health-promoting behavior and received a positive benefit as a result will probably engage in future health-promoting behaviors. In contrast, an individual with a history of barriers to achieving the behavior remembers the “hurdles,” which creates a negative effect. The nurse can assist by focusing on the posi- tive benefits of the behavior, teaching how to overcome the hurdles, and providing positive feedback for the client’s successes.
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practices such as performing breast self-exams and having regular mammograms or may even opt for extreme clinical measures such as a mastectomy. She may do this out of fear of finding a lump, or just feeling that with her family history, it is inevitable that she will have breast cancer. Nurses should recognize this and direct more sup- port and information to this group of women, reinforcing the idea that even with a strong family history, early detection and treatment are especially important and offer more hope for a cure. Helping to transform that fear into hope for early detection can make a differ- ence in health attitudes and behaviors. The new Healthy People 2020 objective to increase the proportion of women with a family history of breast or ovarian cancer who receive genetic counseling supports the need for early detection, support, and information.
Behavior-Specific Cognitions and Affect This set of variables is of major motivational significance for acquir- ing and maintaining health-promoting behaviors. Behavior-specific cognitions constitute a critical “core” for intervention because nursing interventions can modify them. They include the following:
• Perceived benefits of action. Anticipated benefits or outcomes (e.g., physical fitness, stress reduction) affect the person’s plan to participate in health-promoting behaviors and may facilitate continued practice. Prior positive experience with the behavior
Figure 16–4 • The Health Promotion Model (Revised).
Individual Characteristics
and Experiences
Behavior-Specific Cognitions and Affect
Behavioral Outcome
Personal factor;
biological psychological sociocultural
Prior related
behavior
Situational influences;
options demand characteristics
aesthetics
Interpersonal influences
(family, peers, providers); norms, support, models
Perceived benefits of action
Perceived barriers to action
Perceived self-efficacy
Activity-related affect
Immediate competing demands
(low control) and preferences
(high control)
Commitment to a
plan of action
Health-promoting behavior
BOX 16–3 Assumptions of the Health Promotion Model
• Individuals seek to create conditions of living through which they can express their unique human health potential.
• Individuals have the capacity for reflective self-awareness, including assessment of their own competencies.
• Individuals value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability.
• Individuals seek to actively regulate their own behavior. • Individuals in all their biopsychosocial complexity interact with
the environment, progressively transforming the environment and being transformed over time.
• Health professionals constitute a part of the interpersonal environment, which exerts influence on individuals throughout their life span.
• Self-initiated reconfiguration of person–environment interactive patterns is essential to behavior change.
From Health Promotion in Nursing Practice, 6th ed. (pp. 120–122), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011, Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
Nursing interventions usually focus on factors that can be modi- fied. It is just as important, however, to also focus on factors that can- not be changed, such as family history. For instance, if a woman has a strong family history of breast cancer, she may neglect self-care
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are behaviors over which an individual has a high level of control; however, this control depends on the individual’s ability to be self- regulating or to not “give in.” For example, a person who chooses a high-fat food over a low-fat food because it tastes better has “given in” to an urge based on a competing preference.
Behavioral Outcome Health-promoting behavior, the outcome of the Health Promotion Model, is directed toward attaining positive health outcomes for the client. Health-promoting behaviors should result in improved health, enhanced functional ability, and better quality of life at all stages of development (Pender et al., 2011, p. 50).
STAGES OF HEALTH BEHAVIOR CHANGE Health behavior change is a cyclic phenomenon in which people progress through several stages. In the first stage, the person does not think seriously about changing a behavior; by the time the per- son reaches the final stage, he or she is successfully maintaining the change in behavior. Several behavior change models have been pro- posed. The Transtheoretical Model (TTM), proposed by Prochaska, Redding, and Evers (2009), is discussed here. The stages are (a) precontemplation, (b) contemplation, (c) preparation, (d) action, (e) maintenance, and (f) termination. If the person does not succeed in changing behavior, relapse occurs.
Precontemplation Stage In the precontemplation stage, the person does not think about changing his or her behavior in the next 6 months. They may be uninformed or underinformed about the consequences of the risk behavior(s). The person who has tried changing previously and was unsuccessful may now see the behavior as his or her “fate” or believe that change is hopeless. Individuals in this stage tend to avoid read- ing, talking, or thinking about their high-risk behaviors (Prochaska et al., 2009, p. 100).
Contemplation Stage During the contemplation stage, the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future (e.g., next 6 months). The person, however, may not be ready to commit to action. Some people may stay in the contem- plative stage for months or years before taking action.
Preparation Stage The preparation stage occurs when the person intends to take action in the immediate future (e.g., within the next month). Some people in this stage may have already started making small behavioral changes, such as buying a self-help book. At this stage, the person makes the final specific plans to accomplish the change.
Action Stage The action stage occurs when the person actively implements be- havioral and cognitive strategies of the action plan to interrupt previ- ous health risk behaviors and adopt new ones. This stage requires the greatest commitment of time and energy.
or observations of others engaged in the behavior is a motiva- tional factor.
• Perceived barriers to action. A person’s perceptions about avail- able time, inconvenience, expense, and difficulty performing the activity may act as barriers (imagined or real). Perceived barriers to action affect health-promoting behaviors by decreasing the in- dividual’s commitment to a plan of action.
• Perceived self-efficacy. This concept refers to the conviction that a person can successfully carry out the behavior necessary to achieve a desired outcome, such as maintaining an exercise pro- gram to lose weight. Often people who have serious doubts about their capabilities decrease their efforts and give up, whereas those with a strong sense of efficacy exert greater effort to master prob- lems or challenges.
• Activity-related affect. The subjective feelings that occur before, during, and following an activity can influence whether a person will repeat the behavior again or maintain the behavior. What is the individual’s reaction to the thought of the behavior? Is it per- ceived as fun, enjoyable, or unpleasant? A behavior associated with a positive affect or emotional response is likely to be repeated, and behaviors associated with a negative affect are usually avoided.
• Interpersonal influences. Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of oth- ers. Family, peers, and health professionals are sources of interper- sonal influences that can influence a person’s health-promoting behaviors. Interpersonal influences include expectations of sig- nificant others, social support (e.g., emotional encouragement), and learning through observing others or modeling.
• Situational influences. Situational influences are direct and in- direct influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. An example of an in- dividual’s perception of available options can include easy access to healthy alternatives such as vending machines and restaurants that provide healthful menu options. Demand characteristics can directly affect healthy behaviors through policies such as a com- pany regulation that demands safety equipment to be worn or that establishes a “no smoking” environment. Individuals are more apt to perform health promotion behaviors if they are comfortable in the environment versus feeling alienated. Environments that are considered safe as well as interesting are also desirable aesthetic features that facilitate health promotion behaviors.
Commitment to a Plan of Action Commitment to a plan of action involves two processes: commit- ment and identifying specific strategies for carrying out and reinforc- ing the behavior. Strategies are important because commitment alone often results in “good intentions” and not actual performance of the behavior.
Immediate Competing Demands and Preferences Competing demands are those behaviors over which an individual has a low level of control. For example, an unexpected work or family responsibility may compete with a planned visit to the health club, and not responding to this responsibility may cause a more negative outcome than missing the exercise routine. Competing preferences
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practices. Knowing this, the church can often be the appropriate place to hold health fairs or even small group discussions on various health topics. It provides a stepping stone for providing information and sug- gesting resources for special needs—all done in a comfortable, non- threatening environment for individuals in that age group and culture.
It is just as critical to know where people get “misinformation.” Multiple mailings and TV infomercials have become a marketing ploy for advertising “miracle” vitamins, herbs, and food supplements. These are heavily directed toward older adults who may choose this route of purchasing items if they have transportation problems.
Health risk appraisals and wellness assessment programs explain to individuals the risk factors that are inherent in their lives in order to motivate them to reduce specific risks and develop positive health hab- its. Wellness assessment programs focus on more positive methods of enhancement, in contrast to the risk factor approach used in the health appraisal. A variety of tools are available to facilitate these assessments. Some of these tools are computer based and can therefore be offered to educational institutions and industries at a reasonable cost.
Lifestyle and behavior change programs require the participa- tion of the individual and are geared toward enhancing the quality of life and extending the life span. Individuals generally consider lifestyle changes after they learn of the need to change their health behavior and become aware of the potential benefits of the process. Many programs are available to the public, both on a group and in- dividual basis, some of which address stress management, nutrition awareness, weight control, smoking cessation, and exercise.
Environmental control programs have been developed in re- sponse to the continuing increase of contaminants of human ori- gin that have been introduced into our environment. The amounts of contaminants that are already present in the air, food, and water will affect the health of our descendants for several generations. The most common concerns of community groups are toxic and nuclear wastes, nuclear power plants, air and water pollution, and herbicide and pesticide use.
Health promotion activities, such as the variety of programs previously discussed, involve collaborative relationships with both clients and primary care providers. The role of the nurse is to work with people, not for them—that is, to act as a facilitator of the process of assessing, evaluating, and understanding health. The nurse may act as advocate, consultant, teacher, or coordinator of services. For ex- amples of the nurse’s role in health promotion, see Box 16–4.
Maintenance Stage During the maintenance stage, the person strives to prevent re- lapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealthy behaviors. It is estimated that mainte- nance lasts from 6 months to 5 years (Prochaska et al., 2009, p. 100). The relapse is usually to the precontemplation or contemplation stage.
Termination Stage The termination stage is the ultimate goal; it is the point at which the individual has complete confidence that the problem is no longer a temptation or threat. It is as if the person never acquired the habit in the first place or the new behavior has become automatic (Prochaska et al., 2009, p. 102). Experts debate whether some behaviors can be terminated versus requiring continual maintenance. For example, adults who automatically buckle their seat belts when getting in their vehicle may reach the termination stage. Other behaviors, such as smoking or overeating, may never reach the termination stage be- cause relapse temptations are too strong. The goal of maintenance may be more appropriate for those individuals.
These six stages are cyclical; people generally move through one stage before progressing to the next. However, at any point a person may relapse or recycle to any previous stage. In fact, the average suc- cessful self-changer recycles through the stages several times before making it to the top and exiting the cycle (Prochaska, Norcross, & DiClemente, 1994, pp. 47–48). The majority of individuals who re- lapse return to the contemplation stage. During this time they can think about what they learned and plan for the next action attempt.
THE NURSE’S ROLE IN HEALTH PROMOTION Individuals and communities who seek to increase their responsibility for personal health and self-care require health education. The trend toward health promotion has created the opportunity for nurses to strengthen the profession’s influence on health promotion, dissemi- nate information that promotes an educated public, and assist indi- viduals and communities to change long-standing health behaviors.
A variety of programs can be used for the promotion of health, including (a) information dissemination, (b) health risk appraisal and wellness assessment, (c) lifestyle and behavior change, and (d) envi- ronmental control programs.
Information dissemination is the most basic type of health pro- motion program. This method makes use of a variety of media to offer information to the public about the risk of particular lifestyle choices and personal behavior, as well as the benefits of changing that behavior and improving the quality of life. Billboards, posters, brochures, news- paper features, books, and health fairs all offer opportunities for the dis- semination of health promotion information. Alcohol and drug abuse, driving under the influence of alcohol, hypertension, and the need for immunizations are some of the topics frequently discussed. Informa- tion dissemination is a useful strategy for raising the level of knowledge and awareness of individuals and groups about health habits.
When planning information dissemination, it is important to consider factors such as cultural factors and different age groups. Knowing the best place and method to distribute information will in- crease the effectiveness. For example, older African Americans usually have strong ties to their churches for social support as well as religious
BOX 16–4 The Nurse’s Role in Health Promotion
• Model healthy lifestyle behaviors and attitudes. • Facilitate client involvement in the assessment, implementation,
and evaluation of health goals. • Teach clients self-care strategies to enhance fitness, improve
nutrition, manage stress, and enhance relationships. • Assist individuals, families, and communities to increase their
levels of health. • Educate clients to be effective health care consumers. • Assist clients, families, and communities to develop and
choose health-promoting options. • Guide clients’ development in effective problem solving and
decision making. • Reinforce clients’ personal and family health-promoting
behaviors. • Advocate in the community for changes that promote a
healthy environment.
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spiritual health assessment, social support systems review, health risk assessment, health beliefs review, and life-stress review.
Health History and Physical Examination The health history and physical examination discussed in Chapter 30 provide a means for detecting any existing prob- lems. The age of the individual must be considered when collecting data. For example, an environmental safety assessment and immu- nization history must be appropriate to the person’s age. A nutri- tional assessment is an important part of the health history. The nurse must consider both age and body build of the client when gathering information on dietary patterns. See Chapter 47 for more information about nutritional assessment.
Physical Fitness Assessment During an evaluation of physical fitness, the nurse assesses several components of the body’s physical functioning: muscle endurance, flexibility, body composition, and cardiorespiratory endurance. Spe- cific guidelines for obtaining measurements and the optimal values for men, women, and children can be found in physical fitness texts (Table 16–2). Older adults need to be monitored carefully for fatigue during strength and endurance tests.
In these roles, the nurse may work with individuals of all age groups and diverse family units or concentrate on a specific popula- tion, such as new parents, school-age children, or older adults. In any case, the nursing process is a basic tool for the nurse in a health promo- tion role. Although the process is the same, the nurse emphasizes teach- ing the client (who can be either an individual or a family unit) self-care responsibility. Adult clients decide the goals, determine the health pro- motion plans, and take responsibility for the success of the plans.
THE NURSING PROCESS AND HEALTH PROMOTION A thorough assessment of an individual’s health status is basic to health promotion. As nurses move toward greater autonomy in pro- viding client care, expanded assessment skills are essential to provide the meaningful data needed for health planning.
● ◯ ● NURSING MANAGEMENT Assessing Components of this assessment are the health history and physi- cal examination, physical fitness assessment, lifestyle assessment,
Sexually transmitted infections (STIs) are high and rising in Brit- ish Columbia, Canada, especially among people ages 15 to 24. Because youth participation in STI/HIV testing is a public health challenge, Shoveller, Knight, Davis, Gilbert, and Ogilvie (2012) con- ducted a study to examine youths’ perspectives on online services (e.g., online sexual health counseling through chat, forums, or e-mail; and referrals to other services). The authors recruited 38 males and 14 females between the ages of 15 and 24 to partici- pate in semistructured interviews. The interviews included questions about the youths’ previous experiences in using online services and their perspectives about online STI/HIV testing services and online counseling and education services. They were also asked to com- pare online services with face-to-face services. The results indicated that online services appealed to the youths’ needs for convenience, privacy, and easy access to testing and counseling. The researchers
also found that the youths had low tolerance for outdated technol- ogy. For example, they wanted to be able to e-mail the completed lab requisition to the lab instead of having to print the form.
IMPLICATIONS This study adds to the growing body of research about the applica- tion of online technology to health promotion, especially for the so- cially undesirable behavior of seeking STI/HIV testing. The findings of the study reflect that youths appear to be familiar with, receptive to, and have an affinity for online interventions. The authors point out that face-to-face interactions, however, have the benefit of being able to see body language and the ability to put conversation in con- text. Future research needs to investigate how the social face-to- face and the technologic aspects of online approaches can overlap, especially for sensitive matters like STIs in youths.
Evidence-Based Practice Can the Internet Be Used as an Effective Public Health Intervention? EVIDENCE-BASED PRACTICE
Test Age Desired Outcomes Undesired Outcomes Sit-ups 36–45 years Men: 42 or more 21 or less
Women: 39 or more 12 or less
46 years or older Men: 38 or more 18 or less
Women: 24 or more 11 or less
Trunk flexion Men: 11–15 in. Below –6 in.
Women: 12–16 in. Below –4 in.
Skinfolds Men: 21 mm Marked deviations
Women: 30 mm above or below desired ratings
Step test Men: recovery pulse rate 124 Men: recovery pulse rate 178
Women: recovery pulse rate 140 Women: recovery pulse rate 184
(95th percentile rankings) (10th percentile rankings) From Health Promotion in Nursing Practice, 6th ed. (pp. 94–98) by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011. Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
TABLE 16–2 Physical Fitness Values
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This assessment allows the nurse and client to discuss and evaluate the adequacy of the client’s support system together and, if necessary, plan options for enhancing the support system.
Health Risk Assessment A health risk assessment (HRA) is an assessment and educa- tional tool that indicates a client’s risk for disease or injury during the next 10 years by comparing the client’s risk with the mortality risk of the corresponding age, gender, and racial group. The client’s general health, lifestyle behaviors, and demographic data are compared to data from a large national sample. Individual risk reports are based on statistics for the population group that match the individual’s sur- veyed characteristics. The HRA includes a summary of the person’s health risks and lifestyle behaviors with educational suggestions on how to reduce the risk.
Many HRA instruments are available today in paper-and- pencil formats or as computerized forms. Recently, HRAs have be- gun to reflect a broader approach to health as companies use the HRA as a means to begin a health promotion and risk reduction program. Occupational health nurses can identify risk factors and subsequently plan interventions aimed at decreasing illness, absen- teeism, and disability.
HRAs are helpful for assessing individual and group health risks. They are not, however, substitutes for medical care and are not appro- priate for all individuals. For example, people with chronic illnesses such as cancer or heart disease may not obtain accurate risk assess- ments. Certain populations (e.g., very young, older adults, some so- ciocultural groups) may not be fully represented in the population databases and, therefore, the HRA may not project an accurate risk assessment.
Health Beliefs Review Clients’ health beliefs need to be clarified, particularly those beliefs that determine how they perceive control of their own health care status. Locus of control is a measurable concept that can be used to predict which people are most likely to change their behavior (see Chapter 17 ). Several instruments are available that assess a per- son’s health-belief measures. Assessment of clients’ health beliefs pro- vides the nurse with an indication of how much the clients believe they can influence or control health through personal behaviors. Sev- eral cultures have a strong belief in fate: “Whatever will be, will be.” If people hold this belief, they do not feel that they can do anything
SELF-CARE ALERT
Is exercise a negative term for you? Does it imply something that is boring, routine, and a “must-do”? Instead, think of “physical activity,” which can be a variety of things that increase your activity level (e.g., dancing, tennis, golf, walking the dog).
Lifestyle Assessment Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally as- sessed are physical activity, nutritional practices, stress management, and such habits as smoking, alcohol consumption, and drug use. Other categories may be included. Several tools are available to as- sess lifestyle. The goals of lifestyle assessment tools are to provide the following:
1. An opportunity for clients to assess the impact of their present lifestyle on their health
2. A basis for decisions related to desired behavior and lifestyle changes.
Spiritual Health Assessment Spiritual health is the ability to develop one’s inner nature to its fullest potential, including the ability to discover and articulate one’s basic purpose in life; to learn how to experience love, joy, peace, and ful- fillment; and to learn how to help ourselves and others achieve their fullest potential (Pender et al., 2011, p. 104). Spiritual beliefs can affect a person’s interpretation of events in his or her life and, therefore, an assessment of spiritual well-being is a part of evaluating the person’s overall health. See Chapter 41 for more information.
SELF-CARE ALERT
There are two physical arts that blend spirituality and health: t’ai chi and yoga. T’ai chi promotes muscle relaxation through movement. Yoga promotes mobility and flexibility.
Social Support Systems Review Understanding the social context in which a person lives and works is important in health promotion. Individuals and groups, through interpersonal relationships, can provide comfort, assistance, encour- agement, and information. Social support fosters successful coping and promotes satisfying and effective living.
Social support systems contribute to health by creating an en- vironment that encourages healthy behaviors, promotes self-esteem and wellness, and provides feedback that the person’s actions will lead to desirable outcomes. Examples of social support systems in- clude family, peer support groups (including computer-based sup- port groups), community-organized religious support systems (e.g., churches), and self-help groups (e.g., Mended Hearts, Weight Watch- ers). Culturally Responsive Care addresses aspects of social support within the context of culture.
The nurse can begin a social support system review by asking the client to do the following:
• List individuals who provide personal support. • Indicate the relationship of each person (e.g., family member, fel-
low worker or colleague, social acquaintance). • Identify which individuals have been a source of support for 5 or
more years.
Cultural Aspects of Social Support
It is important to understand how various subgroups of U.S. society may define social support. • In the African American community, the family and church
have been major providers of social support. • Hispanic/Latino Americans and Asian Americans view the
family as being a major social support system. • Asian Americans respect older adults and use shame and
harmony in giving and receiving support. • Native Americans live in social networks that foster mutual
assistance and support.
From Health Promotion in Nursing Practice, 6th ed. (p. 220), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011, Upper Saddle River, NJ: Prentice Hall.
PATIENT-CENTERED CARE Culturally Responsive Care
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• Level of physical fitness and nutritional status • Illnesses for which the client is at risk • Current positive health practices • Spirituality • Sources of life stress and ability to handle stress • Social support systems • Information needed to enhance health care practices • Client strengths.
Diagnosing Nursing diagnoses accepted by NANDA International have gener- ally focused on impaired or imbalanced health patterns or problems. Previously, NANDA included a wellness diagnosis. This diagnosis, however, was eliminated because it was already within the health promotion nursing diagnosis category (Herdman, 2012, p. 516). The definition of the NANDA health promotion domain is “the aware- ness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function” (Herdman & Kamitsuru, 2014, p. 66).
Health promotion diagnoses can be applied to any health state and do not require current levels of wellness. This readiness is sup- ported by the defining characteristics which now begin with the phrase “Expresses the desire to enhance” (Herdman & Kamitsuru, 2014, p. 5). When the nurse and client conclude that the client has positive function in a certain pattern area, such as adequate nutrition or effective coping, the nurse can use this information to help the cli- ent reach a higher level of functioning.
A health promotion diagnosis is preceded by the modifier “readiness for enhanced.” The following examples are included in the NANDA International (Herdman, 2012) taxonomy:
• Readiness for Enhanced Religiosity • Readiness for Enhanced Coping • Readiness for Enhanced Nutrition • Readiness for Enhanced Knowledge (Specify) • Readiness for Enhanced Relationship • Readiness for Enhanced Self-Concept • Readiness for Enhanced Self-Care • Readiness for Enhanced Health Management • Readiness for Enhanced Urinary Elimination.
to change the course of their disease. An example is doing diabetic teaching, which often requires many lifestyle changes in diet and ex- ercise and close control of glucose to prevent complications. If the person believes he or she has no control of the outcome, it is difficult to provide motivations to make the necessary changes. Being aware of these differences can provide a better indication of readiness and motivation on the part of the client to engage in healthy behaviors. See Lifespan Considerations for factors that might indicate a need for additional information or resources for older adults.
Life-Stress Review There is abundant literature about the impact of stress on mental and physical well-being. A variety of stress-related instruments can be found in the literature. For example, Holmes and Rahe (1967) de- veloped a Life-Change Index, a tool that assigns numerical values to life events. For example, life changes (e.g., death of a spouse, divorce, marital separation, pregnancy, etc.) have an impact score. The indi- vidual adds up all of the current life events and compares the total life-changes score to the likelihood of illness in the near future. Stud- ies have shown that a high score is associated with the increased pos- sibility of illness.
SELF-CARE ALERT
Nursing school is stressful. A few guidelines for dealing with the stress include good time management, setting priorities, establishing realistic expectations, and taking time to exercise and relax.
Validating Assessment Data Following the collection of assessment data, the nurse and client need to review, validate, and summarize the information. The nurse and the client carry this step out together. During this process, the nurse verbally reviews the current practices and attitudes of the client. This allows validation of the information by the client and may increase awareness of the need to change behavior. The nurse and client need to consider the following:
• Any existing health problems • The client’s perceived degree of control over health status • Key health beliefs
LIFESPAN CONSIDERATIONS Factors Affecting Health Promotion and Illness Prevention
CHILDREN Childhood obesity is becoming a serious health problem. Data show that 17% to 19% of 6- to 9-year-old children are obese and 20% to 30% of children ages 2 to 19 are either obese or at risk for obesity (Hopkins, DeCristofaro, & Elliott, 2011, p. 278). Obesity and be- ing overweight as children contribute to long-term health problems such as heart disease and diabetes mellitus.
Although specific causes of obesity and appropriate manage- ment to reduce weight will vary from child to child, healthy eating habits and adequate exercise patterns form the basis for healthy growth and prevention of overweight in children. It is the responsibil- ity of parents and caregivers to provide children with healthy food choices and an environment that makes eating a pleasure. It is the responsibility of children to decide how much and what foods to eat. Adults must be role models for their children, eating well and exercising regularly themselves.
OLDER ADULTS In older adults, health promotion and illness prevention are impor- tant, but often the focus is on learning to adapt to and live with in- creasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Factors to be aware of that might indicate a need for additional information or resources include these: • An increase in physical limitations • Presence of one or more chronic illnesses • Change in cognitive status • Difficulty in accessing health care services due to transportation
problems • Poor support system • Need for environmental modifications for safety and to maintain
independence • Attitude of hopelessness and depression, which decreases the
motivation to use resources or learn new information
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BOX 16–5 Example of an Individual Health Promotion/Prevention Plan
Designed for: James Moore Home Address: 714 George Home Telephone Number: 222-3333 Occupation (if employed): Building services supervisor Work Telephone Number: 445-6666 Cultural Identification: African American Birth Date: 3/14/59 Date of Initial Plan: 1/15/2015
Client strengths Satisfactory peer relationships, spiritual strength, adequate sleep pattern Major risk factors Elevated cholesterol, mild obesity, sedentary lifestyle, moderate life change, multiple daily
hassles, few reported uplifts Nursing diagnoses Deficient Diversional Activity (derived from assessment of functional health patterns)
Imbalanced Nutrition: More Than Body Requirements
Caregiver Role Strain (elderly mother) Medical diagnoses (if any) Mild hypertension Age-specific screening recommendations Blood pressure, cholesterol, fecal occult blood, malignant skin lesions, depression Desired behavioral and health outcomes Become a regular exerciser (33/week), lower my blood pressure, weigh 165 lb
Personal Health Goals (1 = Highest Priority)
Selected Behaviors to Accomplish Goals Stage of Change
Strategies/Interventions for Change
1. Achieve desired body weight Begin a progressive walking program
Planning Counterconditioning Reinforcement management Client contracting
Decrease caloric intake while maintaining good nutrition
Action (eating two fruits and two vegetables daily; using low-fat dairy products for past 2 months)
Stimulus control Cognitive restructuring
2. Decrease risk for hypertension- related disorders
Change from high- to low-sodium snacks
Contemplation Consciousness raising Learning facilitation
3. Learn to manage stress effectively
Attend relaxation classes and use home relaxation tapes
Contemplation Consciousness raising Self-reevaluation Simple relaxation therapy
4. Increase leisure-time activities Join a local bowling league Contemplation Support system enhancement From Health Promotion in Nursing Practice, 6th ed. (pp. 124–125), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011, Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.
Health promotion diagnoses provide a clear focus for planning inter- ventions without indicating that a problem exists. This type of diag- nosis does not need to include related factors in the diagnosis format because it is a wellness diagnosis (Wilkinson, 2014).
Planning Health promotion plans need to be developed according to the needs, desires, and priorities of the client. The client decides on health promotion goals, the activities or interventions to achieve those goals, the frequency and duration of the activities, and the method of evaluation. During the planning process the nurse acts as a resource person rather than as an adviser or counselor. The nurse provides information when asked, emphasizes the impor- tance of small steps to behavioral change, and reviews the client’s goals and plans to make sure they are realistic, measurable, and ac- ceptable to the client.
Steps in Planning Pender et al. (2011, pp. 120–130) outline several steps in the process of developing a joint health promotion/prevention plan (Box 16–5). These steps actively involve both the nurse and the client:
1. Review and summarize data from assessment. The nurse shares with the client a summary of the data collected from the various
assessments (e.g., physical health and fitness, nutrition, sources of stress, spirituality, health practices).
2. Reinforce strengths and competencies of the client. The nurse and the client come to consensus about areas in which the client is doing well and areas that need further development.
3. Identify health goals and related behavior-change options. The client selects two or three top priority personal health goals, pri- oritizes them, and reviews behavior-change options.
4. Identify behavioral or health outcomes. For each of the selected goals or areas in step 3, the nurse and client determine what spe- cific behavioral changes are needed to bring about the desired outcome. For example, to reduce the risk of cardiovascular dis- ease, the client may need to stop smoking, lose weight, and in- crease activity level.
5. Develop a behavior-change plan. A constructive program of change is based on client “ownership” of those behavior changes selected for implementation within everyday life (Pender et al., 2011, p. 128). Clients may need to be assisted in examining value-behavior inconsistencies and in selecting behavioral op- tions that are most appealing and that they are most willing to try. The client’s priorities will reflect personal values, activity preferences, and expectations for success.
6. Reiterate benefits of change. The positive benefits will prob- ably need to be reiterated by both the nurse and the client even
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though the client is committed to the change. The health-related and non–health-related benefits should be kept before the client as central motivating factors.
7. Address environmental and interpersonal facilitators and bar- riers to change. Environmental and interpersonal factors that support positive change should be used to reinforce the client’s efforts to change lifestyle. All people experience barriers, some of which can be anticipated and planned for, thereby making the change more likely to occur.
8. Determine a time frame for implementation. By developing a time frame, the appropriate knowledge and skills can be de- veloped before a new behavior is implemented. The time frame may be several weeks or months. Scheduling short-term goals and rewards can offer encouragement to achieve long-term ob- jectives. Clients may need help to be realistic and to deal with one behavior at a time.
9. Formalize commitment to behavior-change plan. Commitments to changing behaviors have usually been verbal. Increasingly, a formal, written behavioral contract is being used to motivate the client to follow through with selected actions (see Chapter 27 ). Motivation to follow through is provided by a positive reinforce- ment or reward stated in the contract. Contracting is based on the belief that all people have the potential for growth and the right of self-determination, even though their choices may be different from the norm.
Exploring Available Resources Another essential aspect of planning is identifying support resources available to the client. These may be community resources such as a fitness program at a local gymnasium, or educational programs such as stress management, breast self-examination, nutrition, smoking cessation, and health lectures.
Implementing Implementing is the “doing” part of behavior change. Self- responsibility is emphasized for implementing the plan. Depending on the client’s needs, the nursing interventions may include support- ing, counseling, facilitating, teaching, enhancing the behavior change, and modeling.
Providing and Facilitating Support A major nursing role is to support the client. A vital component of lifestyle change is ongoing support that focuses on the desired behavior change and is provided in a nonjudgmental manner. Support can be offered by the nurse on an individual basis or in a group setting. The nurse can also facilitate the development of support networks for the client, such as family members and friends.
Individual Counseling Sessions Counseling sessions may be routinely scheduled as part of the plan or may be provided if the client encounters difficulty in carrying out interventions or meets insurmountable barriers to change. In a counseling relationship, the nurse and client share ideas. In this sharing relationship, the nurse acts as a facilitator, promoting the client’s decision making with regard to the health promotion plan.
Telephone or Internet Counseling Regular telephone sessions or online computer interaction with the client may be provided to help answer questions, review goals and strategies, and reinforce progress. The client may find that scheduling a weekly interaction is helpful or may wish to initiate a call if a prob- lem occurs. The client is asked, “Is your plan working?” If the plan is not working, the nurse asks, “What would you like to do?” The client may wish to continue or may wish to change the plan to a more real- istic one. Telephone support is efficient for the busy client who may not have the time for in-person sessions.
“Participative Internet,” also known as social media, offers oppor- tunities for modifying health behavior. These technologies include Facebook, MySpace, Twitter, and blogs (Korda & Itani, 2013, p. 15). According to the Pew Internet and American Life Project (Fox, 2011), 80% of Internet users in 2010 looked for health information online, making it the third most popular online activity. Korda and Itani (2013) point out that online communications can provide easy, cost-effective access to large numbers of people across geographic distances. Studies that use social media for health promotion have been limited; however, as the interest and experience with social net- working increases, research is showing that online communications can encourage health behavior change (p. 16).
Group Support Group sessions provide an opportunity for participants to learn the experiences of others in changing behavior. Group contact gives indi- viduals a renewed commitment to their goals. Groups can be sched- uled at monthly or less frequent intervals for over a year.
Facilitating Social Support Social networks, such as family and friends, can facilitate or impede the efforts directed toward health promotion and prevention. The nurse’s role is to assist the client to assess, modify, and develop the so- cial support necessary to achieve the desired change. To provide the necessary support, families must communicate effectively, be aware of and support each other’s needs and goals, and provide help and as- sistance to one another to achieve those goals. The client may wish the nurse to meet with the family or significant others and help enlist their understanding and support.
Providing Health Education Health education programs on a variety of topics discussed earlier can be provided to groups, individuals, or communities. Group pro- grams need to be planned carefully before they are implemented. The decision to establish a health promotion program must be based on the health needs of the people; also, specific health promotion goals must be set. After the program is implemented, outcomes must be evaluated.
Enhancing Behavior Change Whether people will make and maintain changes to improve health or prevent disease depends on many interrelated factors. To help clients succeed in implementing behavior changes, the nurse needs to understand the stages of change and effective interventions that focus on progressing the individual through the stages of change. Figure 16–5 • provides suggested strategies to assist clients depend- ing on their stage of change. Nurses can use the stages of change to
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to have a philosophy and lifestyle that demonstrate good health habits.
Evaluating Evaluation takes place on an ongoing basis, both during the attain- ment of short-term goals and after the completion of long-term goals. Goals are written during the planning phase, and a date is determined for attaining the specific results or behaviors that are desired to pro- mote health or prevent illness. During evaluation, the client may de- cide to continue with the plan, reorder priorities, change strategies, or revise the health promotion-prevention contract. Evaluation of the plan is a collaborative effort between the nurse and the client.
recognize a client’s readiness to change and assist the client to the next stage of change.
Modeling Through observing a model, the client acquires ideas for behavior and coping strategies that can be used with specific problems. The client is not expected to mimic the sequence of actions or behavior patterns of the model. The nurse and client should mutually select models with whom the client can identify, since the cultural and ethnic backgrounds and age of the nurse and client often differ. Models should be people the client respects. Nurses should also serve as models of wellness. To model effectively, nurses need
Figure 16–5 • Strategies to promote behavioral change for each stage of change.
Assess confidence, importance & readiness for change.
Discuss positive & negative aspects of behavior to assist the person to consider changing.
Provide information in a caring, non- threatening manner.
Ask client if she or he would like information and about what.
Assist client to increase aware- ness of behavior by: -determining specific behavior(s) client wishes to change. -performing self- evaluation of present view of self versus future view of self without the behavior. -reflecting on the behavior (e.g., "Why do I want to smoke?") -examining the pros and cons of change.
Continue to discuss pros and cons of behavior change.
Provide support and guidance for the client to: -set a date to begin action. -tell family and friends of the intended change and advise them how they can be helpful. -create a plan of action. -make change a priority.
Remind client of past successes.
Continue to discuss benefits with client.
Continue positive reinforcement.
Encourage client to: -substitute healthy responses for problem behaviors (e.g., exercise, and relaxation). -modify environ- ment to reduce stimulus to a pro- blem behavior (e.g., remove ash- trays from home). -monitor behavior (e.g., food journal). -plan rewards.
Continue positive reinforcement of desired behavior.
Continue to remind client of previous successes.
Encourage client to know the danger signs, which are usually the result of overwhelming stress or insufficient coping skills.
Inform client of criteria for terminators (versus lifetime maintainers): -a new self-image. -no temptation in any situation. -solid confidence. -a healthier lifestyle.
precontemplation contemplation preparation action maintenance termination
strategies to promote behavioral change for each stage of change
Critical Thinking Checkpoint
Mr. W., a 50-year-old professional man, has pneumonia and is cur- rently being treated with antibiotics. He smokes two packs of ciga- rettes a day. Since this bout of pneumonia, he voices concern about his smoking and wonders if he should try to quit again. He states, “I’ve tried everything and nothing works. The longest I last is about one month.” He admits to being 30 pounds overweight and states that his wife and he have started walking for 30 minutes every evening. His wife has also started making low-fat meals. He is concerned that if he quits smoking he will gain more weight.
1. What information/knowledge is important for the nurse to remember when assisting a client to advance to the next stage of change?
2. Each contact between a nurse and a client is an opportunity for health promotion. Based on the knowledge or key concepts listed above, what question(s) would you ask Mr. W.?
3. Mr. W. is in which stage of change relating to his cigarette smoking? What strategies could you, the nurse, consider?
See Critical Thinking Possibilities on student resource website.
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• Nursing involves viewing the client as an individual and in a ho- listic way.
• Homeostasis is the tendency of the body to maintain a state of balance or equilibrium while constantly changing. Both physiologi- cal and psychological homeostasis are maintained by a variety of mechanisms.
• Maslow’s hierarchy of human needs consists of five categories: physiological (survival), safety and security, love and belonging, self-esteem, and self-actualization.
• All people have the same basic needs; however, each person’s needs and reactions to those needs are influenced by the culture with which the person identifies.
• Healthy People 2020 (USDHHS, 2010) presents objectives for promoting health and preventing illness of both individuals and communities.
• Health promotion is defined as client behavior directed toward de- veloping well-being and actualizing human health potential. Health protection is client behavior geared toward preventing illness, de- tecting it early, or maintaining function.
• The Health Promotion Model (Pender et al., 2011) is a competence- or approach-oriented model that depicts the multidimensional na- ture of individuals interacting with their interpersonal and physical environments as they pursue health. It includes major motivational variables that can be modified through nursing interventions.
• Prochaska et al. (2009) describe a six-stage model for health behavior change. The stages are precontemplation, contempla- tion, preparation, action, maintenance, and termination. An under- standing of these stages enables the nurse to provide appropriate nursing interventions.
• The nurse’s role in health promotion is to act as a facilitator of the process of assessing, evaluating, and understanding health. It is the opportunity for nurses to strengthen the profession’s influ- ence on health promotion, disseminate information that promotes an educated public, and assist individuals and communities to change long-standing adverse health behaviors.
• A complete and accurate assessment of an individual’s health status is basic to health promotion. Lifestyle assessment tools give clients the opportunity to assess the impact of their present lifestyle behav- iors on their health and to make decisions about specific lifestyle changes. Health risk appraisals provide the data that may influence the individual to adopt healthier life behaviors. Assessments or re- views of a client’s spiritual health, social support, health beliefs, and life stress are also important because they impact a person’s health.
• Health promotion plans need to be developed according to the needs, desires, and priorities of the client.
• The nurse acts as a resource person, provides ongoing support, and supplies additional information and education in a nonjudgmental manner to help individuals change their lifestyles or health behaviors.
• Organizing assessment data from individual and family assess- ments enables the nurse to make health promotion nursing diag- noses that identify client strengths, recognize self-care abilities, and enhance health promotion goals to help the client reach a higher level of functioning.
• As role models for their clients, nurses should have a philosophy and lifestyle that demonstrate good health habits.
• During the evaluation phase of the health promotion process, the nurse assists clients in determining whether they will continue with the plan, reorder priorities, or revise the plan.
CHAPTER HIGHLIGHTS
Chapter 16 Review
1. A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism? 1. Offer to come to the client’s home to provide needed
physical care. 2. Contact the client’s spiritual adviser. 3. Inquire how this will affect other aspects of the client’s life. 4. Provide the client with information about how to join a
support group. 2. A nurse is planning a workshop on health promotion for older
adults. Which topic will be included? 1. Prevention of falls 2. Cardiovascular risk factors 3. Adequate sleep 4. How to stop smoking
3. While hospitalized, a client is very worried about business activities. The client spends a great deal of time on the phone and with colleagues instead of resting. Which principle of need therapy applies to this client? 1. His higher level need cannot be met unless the lower level
physiological need is met. 2. His lower level physiological needs are being deferred while
higher needs are addressed. 3. The higher need takes precedence and the lower need no
longer must be met. 4. It is necessary for someone else to meet his higher level
needs so he can focus on the lower level needs.
4. Which statement by the client best represents the contemplation stage of the stages of behavior change? 1. “I currently do not need to exercise and do not intend to
start in the next six months.” 2. “I have tried several times to exercise 30 minutes three times
a week but am seriously thinking of trying again in the next month.”
3. “I currently do not exercise 30 minutes three times a week, but I am thinking about starting to do so within the next six months.”
4. “I have exercised 30 minutes three times a week regularly for more than six months.”
5. A client who is 46 pounds overweight tells you, “I was just born to be fat. I don’t have the willpower.” Although weight loss occurred while attending two previous programs that “ guaranteed” weight loss, the weight returned along with extra pounds after each program. According to the Health Promotion Model, the nurse is most likely to focus on which behavior- specific cognition and affect variable for this client? 1. Perceived barriers to action 2. Perceived self-efficacy 3. Interpersonal influences 4. Situational influences
TEST YOUR KNOWLEDGE
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9. A client is admitted for heart failure. The nurse assesses that the client’s blood pressure is below normal range and the api- cal pulse is 110 beats/min. The nurse knows that the increase in the client’s pulse illustrates which aspect of the client’s ho- meostatic mechanism? 1. Compensation 2. Decompensation 3. Self-regulation 4. Equilibrium
10. Using Maslow’s framework, which statement characterizes the highest level of need? 1. “Nurse, my pain is severe . . . is it time for my shot?” 2. “I felt welcomed when I first joined the group and I look
forward to the monthly meetings.” 3. “I’m very proud of receiving the Employee of the Month
award.” 4. “There have been home break-ins with burglary in our
neighborhood. We are thinking of moving.” See Answers to Test Your Knowledge in Appendix A.
6. Which of the following are overarching goals of Healthy People 2020? Select all that apply. 1. Raise the education and literacy level. 2. Increase quality and years of healthy life. 3. Eliminate health disparities. 4. Distribute health-related information. 5. Promote healthy behaviors.
7. The nurse who is assisting a client in the action stage of change would use which strategy? 1. Reinforce the importance of providing rewards for positive
behavior. 2. Ask the client if he or she would like information. 3. Guide the client to create a plan of action. 4. Remind the client of previous successes.
8. Which is the best response by the nurse if a client fails to follow the information or teaching provided? 1. Give up, because the client doesn’t want to change. 2. Develop a tough approach. 3. Reteach the information, because the nurse is the expert. 4. Reassess the client’s importance given to the behavior and
readiness to change it.
Suggested Readings Chou, W. S., Prestin, A., Lyons, C., & Wen, K. (2013). Web
2.0 for health promotion: Reviewing the current evidence. American Journal of Public Health, 103(1), e9–e18. doi:10.2105/AJPH.2012.301071. The authors provide a review of the literature on the use of the online environment for health promotion. Their findings highlight several key themes and suggest future directions for research and practice related to Web 2.0.
Smith, Y. G. (2013). How to love and care for yourself uncondi- tionally. American Nurse Today, 8(1), 30–33. The nurse author tells her story of how the stress in her life forced her to learn how to care for herself. Her story is a good reminder of what can happen to nurses who care for others at their own expense. She provides five essential self-care principles and practices and seven elements of a balanced life.
Related Research Brobeck, E., Bergh, H., Odencrants, S., & Hildingh, C.
(2011). Primary healthcare nurses’ experiences with motivational interviewing in health promotion practice. Journal of Clinical Nursing, 20(23–24), 3322–3330. doi:10.1111/j.1365-2702.2011.03874.x
Persson, R., Cleal, B., Bihal, T., Hansen, S. M., Jakobsen, M. O., Villadsen, E., & Andersen, L. L. (2013). Why do people with suboptimal health avoid health promotion at work? American Journal of Health Behavior, 37(1), 43–55. doi:10.5993/AJHB.37.1.5
References Cannon, W. B. (1939). The wisdom of the body (2nd ed.).
New York, NY: Norton. Edelman, C. L., & Mandle, C. L. (2010). Health promotion
throughout the lifespan (7th ed.). St. Louis, MO: Mosby. Fox, S. (2011). Health topics: 80% of users look for health
information online. Washington, DC: Pew Internet &
American Life Project. Retrieved from http://www .pewinternet.org/Reports/2011/HealthTopics.aspx
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA Inter- national nursing diagnoses: Definitions and classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
Holmes, T. H., & Rahe, T. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213–218. doi:10.1016/0022-3999(67)90010-4
Hopkins, K. F., DeCristofaro, C., & Elliott, L. (2011). How can primary care providers manage pediatric obesity in the real world? Journal of the Ameri- can Academy of Nurse Practitioners, 23, 278–288. doi:10.1111/j.1745-7599.2011.00614.x
Kalish, R. A. (1983). The psychology of human behavior (5th ed.). Monterey, CA: Brooks/Cole.
Korda, H., & Itani, Z. (2013). Harnessing social media for health promotion and behavior change. Health Promotion Practice, 14, 15–23. doi:10.1177/1524839911405850
Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in the community (3rd ed.). New York, NY: McGraw-Hill.
Maslow, A. H. (1970). Motivation and personality (2nd ed.). New York, NY: Harper & Row.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for good: A revolutionary six-stage program for overcoming bad habits and moving your life positively forward. New York, NY: Avon Books/HarperCollins.
Prochaska, J. O., Redding, C. A., & Evers, K. E. (2009). The transtheoretical model and stages of change. In K. Glanz, B. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 97–121). San Francisco, CA: Jossey-Bass.
Shoveller, J., Knight, R., Davis, W., Gilbert, M., & Ogilvie, G. (2012). Online sexual health services: Examining youth’s
perspectives. Canadian Public Health Association, 103(1), 14–18.
U.S. Department of Health and Human Services (USDHHS). (2010). Healthy people 2020. Retrieved from http://www .healthypeople.gov/2020/default.aspx
Wilkinson, J. M. (2014). Pearson nursing diagnosis handbook with NIC interventions and NOC outcomes (10th ed.). Upper Saddle River, NJ: Pearson.
Selected Bibliography Eliopoulos, C. (2010). Invitation to holistic health. A guide
to living a balanced life (2nd ed.). Sudbury, MA: Jones & Bartlett.
Hawks, J. H. (2012). The affordable care act: Emphasis on population health. Urologic Nursing, 32(5), 233–234.
Jadelhack, R. (2012). Health promotion in nursing and cost- effectiveness. Journal of Cultural Diversity, 19(2), 65–68.
Koh, H. K., & Tavenner, M. (2012). Connecting care through the clinic and community for a healthier America. American Journal of Public Health, 102, S305–S307. doi:10.2105/ AJPH.2012.300760
Maslow, A. H. (1968). Toward a psychology of being (2nd ed.). New York, NY: John Wiley & Sons.
Norman, C. D. (2012). Editorial: Social media and health promotion. Global Health Promotion, 19(4), 3–6. doi:10.1177/1757975912464593
Zeller, J. M., & Levin, P. F. (2013). Mindfulness interventions to reduce stress among nursing personnel: An occupational health perspective.Workplace Health & Safety, 61, 85–89; quiz, 90. doi:10.3928/21650799-20130116-67
READINGS AND REFERENCES
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17 Health, Wellness, and Illness
INTRODUCTION Nurses’ understanding of health and wellness largely determines the scope and nature of nursing practice. Clients’ health beliefs influence their health practices. Some people think of health and wellness (or well-being) as the same thing or, at the very least, as accompanying one another. However, health may not always accompany well-being: A person who has a terminal illness may have a sense of well-being; conversely, another person may lack a sense of well-being yet be in a state of good health. For many years, the concept of disease was the yardstick by which health was measured. In the late 19th cen- tury the “how” of disease (pathogenesis) was the major concern of health professionals. The 20th century focused on finding cures for diseases. Currently health care providers are increasing their empha- sis on promoting health and wellness in individuals, families, and communities.
CONCEPTS OF HEALTH, WELLNESS, AND WELL-BEING Health, wellness, and well-being have many definitions and interpre- tations. The nurse should be familiar with the most common aspects of the concepts and consider how they may be individualized with specific clients.
Health Traditionally health was defined in terms of the presence or absence of disease. Florence Nightingale (1860/1969) defined health as a state of being well and using every power the individual possesses to the fullest extent. The World Health Organization (WHO) (1948) takes a more holistic view of health. Its constitution defines health as “a state of complete physical, mental, and social well-being, and not merely
the absence of disease or infirmity.” This definition reflects concern for the individual as a total person functioning physically, psycholog- ically, and socially. Mental processes determine people’s relationship with their physical and social surroundings, their attitudes about life, and their interaction with others. It also places health in the context of environment. People’s lives, and therefore their health, are affected by everything they interact with—not only environmental influences such as climate and the availability of food, shelter, clean air, and wa- ter to drink, but also other people, including family, lovers, employ- ers, coworkers, friends, and associates.
Health has also been defined in terms of role and performance. Talcott Parsons (1951), an eminent American sociologist and creator of the concept “sick role,” conceptualized health as the ability to main- tain normal roles.
In 1953, the U.S. President’s Commission on Health Needs of the Nation made the following statement about health: “Health is not a condition; it is an adjustment. It is not a state but a process. The pro- cess adapts the individual not only to our physical but also our social environments” (p. 4). The American Nurses Association, in its social policy statement (2010), states, “Health and illness are human experi- ences. The presence of illness does not preclude health, nor does op- timal health preclude illness” (p. 6).
PERSONAL DEFINITIONS OF HEALTH Health is a highly individual perception. Consider the following ex- amples of individuals who would probably say they are healthy even though they have physical impairments that some would consider an illness:
• A 15-year-old with diabetes takes injectable insulin each morn- ing. He plays on the school soccer team and is editor of the high school newspaper.
LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Identify influences on clients’ definitions of health, wellness,
and well-being. 2. Describe five components of wellness. 3. Compare the various models of health outlined in this chapter. 4. Identify variables affecting health status, beliefs, and practices. 5. Describe factors affecting health care adherence.
KEY TERMS
acute illness, 271 adherence, 270 chronic illness, 271 disease, 271 etiology, 271
exacerbation, 271 health, 262 health behaviors, 266 health beliefs, 266 health status, 266
illness, 271 illness behavior, 272 lifestyle, 267 locus of control, 269 remission, 271
risk factors, 267 well-being, 264 wellness, 263
6. Differentiate illness from disease and acute illness from chronic illness.
7. Identify Parsons’ four aspects of the sick role. 8. Explain Suchman’s stages of illness. 9. Describe the effects of illness on individuals’ and family mem-
bers’ roles and functions.
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• Is health static or changing? • Are health and wellness the same? • Are disease and illness different? • Are there levels of health? • Are wellness, health, and illness separate entities or points along
a continuum? • Is health socially determined? • Do you rate your health and why?
Wellness and Well-Being Wellness is a state of well-being. Basic aspects of wellness include self-responsibility; an ultimate goal; a dynamic, growing process; daily decision making in the areas of nutrition, stress management, physical fitness, preventive health care, and emotional health; and, most importantly, the whole being of the individual.
Anspaugh, Hamrick, and Rosato (2011) propose seven com- ponents of wellness (Figure 17–2 •). To realize optimal health and wellness, people must deal with the factors within each component:
• Environmental. The ability to promote health measures that im- prove the standard of living and quality of life in the community. This includes influences such as food, water, and air.
• Social. The ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs.
• Emotional. The ability to manage stress and to express emotions appropriately. Emotional wellness involves the ability to recog- nize, accept, and express feelings and to accept one’s limitations.
• Physical. The ability to carry out daily tasks, achieve fitness (e.g., pul- monary, cardiovascular, gastrointestinal), maintain adequate nutri- tion and proper body fat, avoid abusing drugs and alcohol or using tobacco products, and generally practice positive lifestyle habits.
• Spiritual. The belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. It includes a person’s own morals, values, and ethics.
• Intellectual. The ability to learn and use information effectively for personal, family, and career development. Intellectual wellness involves striving for continued growth and learning to deal with new challenges effectively.
• Occupational. The ability to achieve a balance between work and leisure time. A person’s beliefs about education, employment, and home influence personal satisfaction and relationships with others.
The seven components overlap to some extent, and factors in one component often directly affect factors in another. For example, a per- son who learns to control daily stress levels from a physiological per- spective is also helping to maintain the emotional stamina needed to cope with a crisis. Wellness involves working on all aspects of the model.
“Well-being is a subjective perception of vitality and feeling well . . . can be described objectively, experienced, and measured . . . and can be plotted on a continuum” (Hood, 2010, p. 185). It is a com- ponent of health.
Nurses need to clarify their understanding of health, wellness, and well-being for the following reasons:
• Nurses’ definitions of health largely determine the scope and na- ture of nursing practice. For example, when health is defined nar- rowly as a physiological phenomenon, nurses confine themselves
• A 32-year-old is paralyzed from the waist down and needs a wheelchair for mobility. He is taking accounting at a nearby col- lege and uses a specially designed automobile for transportation.
• A 72-year-old takes antihypertensive medications to treat high blood pressure. She is a member of the neighborhood golf club, makes handicrafts for a local charity, and travels 2 months each year.
Many people define and describe health as the following:
• Being free from symptoms of disease and pain as much as possible • Being able to be active and to do what they want or must • Being in good spirits most of the time.
These characteristics indicate that health is not something that a person achieves suddenly at a specific time. It is an ongoing process— a way of life—through which a person develops and encourages every aspect of the body, mind, and feelings to interrelate harmoniously as much as possible (Figure 17–1 •).
Many factors affect individual definitions of health. Definitions vary according to an individual’s previous experiences, expectations of self, age, and sociocultural influences.
Nurses should be aware of their own personal definitions of health and appreciate that other people have their own individual definitions as well. A person’s definition of health influences behavior related to health and illness. By understanding clients’ perceptions of health and illness, nurses can provide more meaningful assistance to help them maintain, regain, or attain a state of health.
SELF-CARE ALERT
Nurses can ask the following questions to explore their personal defi- nition of health. In what way: • Is a person more than a biophysiological system? • Is health more than the absence of disease symptoms? • Is health the ability of an individual to perform work? • Is health the ability of an individual to adapt to the environment? • Is health a condition of a person’s actualization? • Is health a state or a process? • Is health the effective functioning of self-care activities?
Figure 17–1 • Satisfaction with work enhances a sense of well-being and contributes to wellness. George Doyle/Getty Images Inc.
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264 Unit 4 • Health Beliefs and Practices
Role Performance Model Health is defined in terms of an individual’s ability to fulfill societal roles, that is, to perform his or her work. People usually fulfill sev- eral roles (e.g., mother, daughter, friend), and certain individuals may consider nonwork roles the most important ones in their lives. Ac- cording to this model, people who can fulfill their roles are healthy even if they have clinical illness. For example, a man who works all day at his job as expected is healthy even though he is partially deaf. It is assumed in this model that sickness is the inability to perform one’s work role.
Adaptive Model In the adaptive model, health is a creative process; disease is a failure in adaptation, or maladaptation. The aim of treatment is to restore the ability of the person to adapt, that is, to cope. According to this model, extreme good health is flexible adaptation to the environment and interaction with the environment to maximum advantage. The famous Roy adaptation model of nursing (Roy, 2009) views the per- son as an adaptive system (see Chapter 3 ). The focus of this model is stability, although there is also an element of growth and change.
Eudaimonistic Model The eudaimonistic model incorporates a comprehensive view of health. Health is seen as a condition of actualization or realization of a person’s potential. Actualization is the apex of the fully developed personality, described by Abraham Maslow (see Chapter 16 ). In this model the highest aspiration of people is fulfillment and com- plete development, which is actualization. Illness, in this model, is a condition that prevents self-actualization.
Pender, Murdaugh, and Parsons (2011) include stabilizing and actualizing tendencies in their definition of health: “the realization of human potential through goal-directed behavior, competent self- care, and satisfying relationships with others while adapting to main- tain structural integrity and harmony with the social and physical environments” (p. 22).
Another model of this type is that of Margaret Newman (2008) who states that health is the expansion of consciousness. The basic assumptions of this model or theory are:
Health is an evolving unitary pattern of the whole, including patterns of disease. Consciousness is the informational capac- ity of the whole and is revealed in the evolving pattern. Pattern identifies the human–environmental process and is character- ized by meaning. (p. 6)
Agent–Host–Environment Model The agent–host–environment model of health and illness, also called the ecologic model, originated in the community health work of Leavell and Clark (1965) and has been expanded into a general the- ory of the multiple causes of disease. The model is used primarily in predicting illness rather than in promoting wellness, although identi- fication of risk factors that result from the interactions of agent, host, and environment are helpful in promoting and maintaining health. The model has three dynamic interactive elements (Figure 17–3 •):
1. Agent. Any environmental factor or stressor (biologic, chemical, mechanical, physical, or psychosocial) that by its presence or ab- sence (e.g., lack of essential nutrients) can lead to illness or disease.
to assisting clients to regain normal physiological functioning. When health is defined more broadly, the scope of nursing prac- tice enlarges correspondingly.
• People’s health beliefs influence their health practices. A nurse’s health values and practices may differ from those of a client. Nurses need to ensure that a plan of care developed for an in- dividual relates to the client’s concept of health rather than the nurse’s belief system. Otherwise the client may fail to respond to the health care regimen.
MODELS OF HEALTH AND WELLNESS Because health is such a complex concept, various researchers have developed models or paradigms to explain health and in some in- stances its relationship to illness or injury. Models can be helpful in assisting health professionals to meet the health and wellness needs of individuals.
Models of health include the clinical model, the role perfor- mance model, the adaptive model, the eudaimonistic model, the agent–host–environment model, and health–illness continua.
Clinical Model The narrowest interpretation of health occurs in the clinical model. People are viewed as physiological systems with related functions, and health is identified by the absence of signs and symptoms of disease or injury. It is considered the state of not being “sick.” In this model, the opposite of health is disease or injury.
Many medical practitioners have used the clinical model in their focus on the relief of signs and symptoms of disease and elimination of malfunction and pain. When these signs and symptoms are no longer present, the medical practitioner considers the individual’s health restored.
Figure 17–2 • The seven components of wellness. “The Seven Components of Wellness” from Wellness: Concepts and Applications by David Anspaugh, Michael Hamrick and Frank Rosato. Copyright ©2010 by McGraw-Hill Education. Used by permission of McGraw-Hill Education.
Environmental
Occupational
Intellectual
SpiritualPhysical
Emotional
Social
Wellness
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From a high level of health a person’s condition can move through good health, normal health, poor health, and extremely poor health, eventually to death. People move back and forth within this contin- uum day by day. There is no distinct boundary across which people move from health to illness or from illness back to health. How people perceive themselves and how others see them in terms of health and illness will also affect their placement on the continuum. The ranges in which people can be thought of as healthy or ill are considerable.
DUNN’S HIGH-LEVEL WELLNESS GRID Dunn (1959) described a health grid in which a health axis and an environmental axis intersect. The grid demonstrates the inter- action of the environment with the illness–wellness continuum ( Figure 17–4 •). The health axis extends from peak wellness to death, and the environmental axis extends from very favorable to very unfavorable. The intersection of the two axes forms four quad- rants of health and wellness:
1. High-level wellness in a favorable environment. An example is a person who implements healthy lifestyle behaviors and has the biopsychosocial, spiritual, and economic resources to support this lifestyle.
2. Emergent high-level wellness in an unfavorable environment. An example is a woman who has the knowledge to implement healthy lifestyle practices but does not implement adequate self- care practices because of family responsibilities, job demands, or other factors.
3. Protected poor health in a favorable environment. An example is an ill person (e.g., one with multiple fractures or severe hyperten- sion) whose needs are met by the health care system and who has access to appropriate medications, diet, and health care instruction.
4. Poor health in an unfavorable environment. An example is a young child who is starving in a drought-stricken country.
2. Host. Person(s) who may or may not be at risk of acquiring a dis- ease. Family history, age, and lifestyle habits influence the host’s reaction.
3. Environment. All factors external to the host that may or may not predispose the person to the development of disease. Physical environment includes climate, living conditions, sound (noise) levels, and economic level. Social environment includes interac- tions with others and life events, such as the death of a spouse.
Because each of the agent–host–environment factors constantly interacts with the others, health is an ever-changing state. When the variables are in balance, health is maintained; when the variables are not in balance, disease occurs.
Health–Illness Continua Health–illness continua (grids or graduated scales) can be used to measure a person’s perceived level of wellness. Health and illness or disease can be viewed as the opposite ends of a health continuum.
Figure 17–3 • The agent–host–environment triangle.
Agent
Environment
Host
Very favorable environment
Very unfavorable environment
Protected poor health (in favorable environment, i.e., through social and cultural institutions)
High-level wellness (in favorable environment)
Poor health (in unfavorable environment)
Emergent high-level wellness (in unfavorable environment)
Death Peak wellnessHealth Axis
Environm ental
A xis
Figure 17–4 • Dunn’s health grid: its axes and quadrants. From “High-Level Wellness for Man and Society,” by H. L. Dunn, 1959, American Journal of Public Health, 49, p. 788. Reprinted with permission of American Public Health Association.
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266 Unit 4 • Health Beliefs and Practices
Family wellness enhances wellness in individuals. In a well fam- ily that offers trust, love, and support, the individual does not have to expend energy to meet basic needs and can move positively on the wellness continuum. By providing effective sanitation and safe water, disposing of sewage safely, and preserving beauty and wildlife, the com- munity enhances both family and individual wellness. Environmental wellness is related to the premise that humans must be at peace with and guard the environment. Societal wellness is significant because the sta- tus of the larger, social group affects the status of smaller groups. Dunn believes that social wellness must be considered on a worldwide basis.
ILLNESS–WELLNESS CONTINUUM The illness–wellness continuum developed by Anspaugh, Hamrick, and Rosato (2011) ranges from optimal health to premature death (Figure 17–5 •). The model illustrates arrows pointing in opposite directions and joined at a neutral point. Movement to the right of the neutral point indicates increasing levels of health and wellness for an individual. This is achieved through health knowledge, disease pre- vention, health promotion, and positive attitude. In contrast, move- ment to the left of the neutral point indicates progressively decreasing levels of health. Some people believe that a health continuum is overly simplistic and linear when the real concepts are more complex than the diagram suggests.
VARIABLES INFLUENCING HEALTH STATUS, BELIEFS, AND PRACTICES Many variables influence a person’s health status, beliefs, and behav- iors or practices. These factors may or may not be under conscious control. People can usually control their health behaviors and can choose healthy or unhealthy activities. In contrast, people have little or no choice over their genetic makeup, age, sex, culture, and some- times their geographic environments. Box 17–1 differentiates health status, beliefs, and behaviors or practices.
Figure 17–5 • Illness–wellness continua. “Illness-Wellness Continua” from Wellness: Concepts and Applications by David Anspaugh, Michael Hamrick and Frank Rosato. Copyright ©2010 by McGraw-Hill Education. Used by permission of McGraw-Hill Education.
Optimal health
Neutral power
Average health
Above- average health
Below- average health
WellnessIllness
No discernible
illness
Premature death
Disability Positive attitude
Disease prevention Health promotion
Traditional medicine Health knowledge
Disease signs
BOX 17–1 Health Status, Beliefs, and Behaviors
• Health status. State of health of an individual at a given time. A report of health status may include anxiety, depres- sion, or acute illness and thus describe the individual’s prob- lem in general. Health status can also describe such specifics as pulse rate and body temperature.
• Health beliefs. Concepts about health that an individual believes are true. Such beliefs may or may not be founded on fact. Some of these are influenced by culture, such as the “hot–cold” system of some Hispanic Americans. In this system, health is viewed as a balance of hot and cold qualities within a person. Citrus fruits and some fowl are considered cold foods, and meats and bread are hot foods. In this context, hot and cold do not denote temperature or spiciness but innate qualities of the food. For example, a fe- ver is said to be caused by an excess of hot foods. Another example of a culturally related health belief is the belief that health and illness are closely associated with the amount and quality of blood in the body. For example, some South- ern Americans say that “high blood,” meaning too much blood in the body, causes headaches and dizziness. For ad- ditional information about cultural views of health and illness, see Chapter 18 .
• Health behaviors. The actions people take to understand their health state, maintain an optimal state of health, prevent illness and injury, and reach their maximum physical and mental potential. Behaviors such as eating wisely, exercising, paying attention to signs of illness, following treatment advice, avoiding known health hazards such as smoking, taking time for rest and relaxation, and managing one’s time effectively are all examples.
Health behavior is intended to prevent illness or disease or to provide for early detection of disease. Nurses preparing a plan of care with an individual need to consider the person’s health beliefs before they suggest a change in health behaviors.
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urinary frequency and diarrhea. A person worried about the outcome of surgery or about the behavior of a teenager may chain-smoke. Pro- longed emotional distress may increase susceptibility to organic dis- ease or precipitate it. Emotional distress may influence the immune system through central nervous system and endocrine alterations. Alterations in the immune system are related to the incidence of in- fections, cancer, and autoimmune diseases.
Increasing attention is being given to the mind’s ability to di- rect the body’s functioning. Relaxation, meditation, and biofeedback techniques are gaining wider recognition by individuals and health care professionals. For example, women often use relaxation tech- niques to decrease pain during childbirth. Other people may learn biofeedback skills to reduce hypertension.
Emotional reactions also occur in response to body conditions. For example, a person diagnosed with a terminal illness may expe- rience fear and depression. Self-concept is how a person feels about self (self-esteem) and perceives the physical self (body image), needs, roles, and abilities. Self-concept affects how people view and handle situations. Such attitudes can affect health practices, responses to stress and illness, and the times when treatment is sought. An ex- ample is a woman with anorexia who deprives herself of needed nutrients because she believes she is too fat even though she is well below an acceptable weight level. Self-concept is discussed in detail in Chapter 39 . Self-perceptions are also associated with a per- son’s definition of health. For example, a 75-year-old man who feels he should be able to move large objects just as he did when he was younger may need to examine and redefine his concept of health in view of his age and abilities.
COGNITIVE DIMENSION Cognitive or intellectual factors influencing health include lifestyle choices and spiritual and religious beliefs.
Lifestyle refers to a person’s general way of living, including liv- ing conditions and individual patterns of behavior that are influenced by sociocultural factors and personal characteristics. In brief, lifestyle is often considered to be the behaviors and activities over which people have control. Lifestyle choices may have positive or negative effects on health. Practices that have potentially negative effects on health are often referred to as risk factors. For example, overeat- ing, getting insufficient exercise, and being overweight are closely re- lated to the incidence of heart disease, arteriosclerosis, diabetes, and hypertension. Excessive use of tobacco is clearly implicated in lung cancer, emphysema, and cardiovascular diseases. See Box 17–2 for examples of healthy lifestyle choices.
Internal Variables Internal variables include biologic, psychological, and cognitive di- mensions. They are often described as nonmodifiable variables be- cause, for the most part, they cannot be changed. However, when internal variables are linked to health problems, the nurse must be even more diligent about working with the client to influence ex- ternal variables (such as exercise and diet) that may assist in health promotion and prevention of illness. Regular health exams and ap- propriate screening for early detection of health problems become even more important.
BIOLOGIC DIMENSION Genetic makeup, sex, age, and developmental level all significantly influence a person’s health.
Genetic makeup influences biologic characteristics, innate tem- perament, activity level, and intellectual potential. It has been related to susceptibility to specific disease, such as diabetes and breast can- cer. For example, people of African heritage have a higher incidence of sickle cell disorder and hypertension than the general population but may be less susceptible to malaria. Genetic predisposition for health or illness is enhanced when parents are from the same ethnic genetic pool. Nurses are expected to incorporate knowledge of ge- netics and genomics (how genetics interacts with the environment and other personal factors in influencing health) in their care and teaching of clients (Calzone et al., 2012). See Chapter 11 for in- formation on including items regarding genetic background when taking a client history.
Sex influences the distribution of disease. Certain acquired and genetic diseases are more common in one sex than in the other. Dis- orders more common among females include osteoporosis and auto- immune disease such as rheumatoid arthritis. Those more common among males are stomach ulcers, abdominal hernias, and respiratory diseases.
Age is also a significant factor. The distribution of disease var- ies with age. For example, arteriosclerotic heart disease is common in middle-aged males but occurs infrequently in younger people; such communicable diseases as whooping cough and measles are com- mon in children but rare in older adults, who often have acquired immunity to them.
Developmental level has a major impact on health status. Con- sider these examples:
• Infants lack physiological and psychological maturity so their de- fenses against disease are lower during the first years of life.
• Toddlers who are learning to walk are more prone to falls and in- jury than are older children.
• Adolescents who strive to conform to peers are more prone to risk-taking behavior and subsequent injury than adults are.
• Declining physical and sensory-perceptual abilities limit the ability of older adults to respond to environmental hazards and stressors.
PSYCHOLOGICAL DIMENSION Psychological (emotional) factors influencing health include mind– body interactions and self-concept.
Mind–body interactions can affect health status positively or neg- atively. Emotional responses to stress affect body function. For exam- ple, a student who is extremely anxious before a test may experience
BOX 17–2 Examples of Healthy Lifestyle Choices
• Regular exercise • Weight control • Avoidance of saturated fats • Avoidance of excessive alcohol • Abstaining from use of tobacco products • Seat belt use • Bike helmet use • Immunization updates • Regular dental checkups • Regular health maintenance visits for screening examinations
or tests
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STANDARDS OF LIVING An individual’s standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the ability to seek health care advice and follow health regimens vary among high-income and low-income groups.
Low-income families must prioritize use of their finances, often choosing food and housing over health care. They may have difficulty obtaining time off from work and transportation to health care fa- cilities. Because their present problems are so great and all efforts are exerted toward survival, they may lack an orientation toward actions that help prevent illness.
The environmental conditions of impoverished areas have a bearing on overall health. Slum neighborhoods are overcrowded and in a state of deterioration. Sanitation services tend to be inad- equate, streets strewn with garbage, and pests are common. Fires and violence may be frequent. Recreational facilities are limited, forcing children to play in streets and alleys.
Occupational roles also predispose people to certain illnesses. For instance, some industrial workers may be exposed to carcino- genic agents. High-pressure social or occupational roles predispose to stress-related diseases. Such roles may also encourage overeating or social use of drugs or excessive alcohol.
FAMILY AND CULTURAL BELIEFS The family passes on patterns of daily living and lifestyles to offspring. For example, a man who was abused as a child may physically abuse his own children. Physical or emotional abuse may cause long-term health problems. Emotional health depends on a social environment that is free of excessive tension and does not isolate the person from others. A climate of open communication, sharing, and love fosters the fulfillment of the person’s optimum potential.
Culture and social interactions also influence how a person per- ceives, experiences, and copes with health and illness. Each culture has ideas about health, and these are often transmitted from parents to children. People of certain cultures may perceive home remedies or tribal health customs as superior to and more dependable than the health care practices of North American society. For example, a person of Asian origin may prefer to use herbal remedies and acu- puncture to treat pain rather than analgesic medications. Cultural rules, values, and beliefs give people a sense of being stable and able to predict outcomes. The challenging of old beliefs and values by second-generation cultural groups may give rise to conflict, instabil- ity, and insecurity, in turn contributing to illness. Heritage and cul- tural influences on health are discussed in detail in Chapter 18 .
SOCIAL SUPPORT NETWORKS Having a support network (family, friends, or a confidant) and job satisfaction helps people avoid illness. Support persons also help the individual confirm that illness exists. People with inadequate support networks sometimes allow themselves to become increasingly ill be- fore confirming the illness and seeking therapy. Support people also provide the motivation for an ill person to become well again.
HEALTH BELIEF MODELS Several theories or models of health beliefs and behaviors have been developed to help determine whether an individual is likely to par- ticipate in disease prevention and health promotion activities. These models can be useful tools in developing programs for helping people
Spiritual and religious beliefs can significantly affect health be- havior. For example, Jehovah’s Witnesses oppose blood transfusions; some fundamentalists believe that a serious illness is a punishment from God; some religious groups are strict vegetarians; and religious Jews perform circumcision on the eighth day of a male baby’s life. The influence of spirituality and religion is discussed further in Chapter 41 .
SELF-CARE ALERT
Knowledge of health behaviors does not always translate into action. The nurse should be self-reflective and consider both the personal and professional advantages of examining and minimizing one’s own barriers to ways of becoming a positive role model.
External Variables External variables affecting health include the physical environment, standards of living, family and cultural beliefs, and social support networks.
ENVIRONMENT People are becoming increasingly aware of their environment and how it affects their health and level of wellness. Geographic loca- tion determines climate, and climate affects health. For instance, malaria and malaria-related conditions occur more frequently in tropical rather than temperate climates. Pollution of the water, air, and soil affects the health of cells. Pollution can occur naturally (e.g., lightning-caused fires produce smoke, which pollutes the air). Some man-made substances in the environment, such as asbestos, are con- sidered carcinogenic (i.e., they cause cancer). Tobacco is “hazardous to one’s health,” with rates of cancer higher among both smokers themselves, and those who live or work near people who smoke in their environment.
An environmental hazard is radiation. The improper or exces- sive use of medical x-rays, for example, can harm many of the body’s organs. Another common source of radiation is the sun’s ultraviolet rays. Light-skinned people are more susceptible to the harmful ef- fects of the sun than are dark-skinned people. Ozone molecules in the atmosphere absorb most of the harmful sun radiation but the manu- facture of certain products releases chemicals that damage the ozone layer, increasing the amount of harmful rays that reach the earth’s sur- face. International legislation limiting the production of these chemi- cals can lessen damage to the ozone layer.
The main component of acid rain is sulfur dioxide, produced by ore smelters and related industries. The other components are nitro- gen oxides. These emissions, brought down by the air when it rains, are thought to damage forests, lakes, and rivers.
An environmental hazard that is receiving more attention is an increase in the “greenhouse effect.” The glass roof of a greenhouse permits the sun’s radiation to penetrate, but the resulting heat does not escape back through the glass. Carbon dioxide in the earth’s at- mosphere acts like the glass roof of a greenhouse, and as carbon di- oxide levels increase due to industrial and automobile emissions, the surface temperature of the earth may also be increasing.
Other sources of environmental contamination are pesticides and chemicals used to control weeds and plant diseases. These con- taminants can be found in some animals and plants that are subse- quently ingested by people. In excessive levels, they are harmful to health.
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to a specific individual. For example, a person who perceives that many individuals in the community have AIDS may not necessar- ily perceive a personal threat of the disease; if the person is a drug addict or a homosexual, however, the perceived threat of illness is likely to increase because the susceptibility is combined with seriousness.
MODIFYING FACTORS Factors that modify a person’s perceptions include the following:
• Demographic variables. Demographic variables include age, sex, race, and ethnicity. An infant, for example, does not perceive the importance of a healthy diet; an adolescent may perceive peer ap- proval as more important than family approval and as a conse- quence may participate in hazardous activities or adopt unhealthy eating and sleeping patterns.
• Sociopsychological variables. Social pressure or influence from peers or other reference groups (e.g., self-help or vocational groups) may encourage preventive health behaviors even when individual motivation is low. Expectations of others may motivate people, for example, not to drive an automobile after drinking alcohol.
• Structural variables. Knowledge about the target disease and prior contact with it are structural variables that are presumed to influence preventive behavior.
• Cues to action. Cues can be either internal or external. Internal cues include feelings of fatigue, uncomfortable symptoms, or thoughts about the condition of an ill person who is close.
LIKELIHOOD OF ACTION The likelihood of a person taking recommended preventive health action depends on the perceived benefits of the action minus the per- ceived barriers to the action:
• Perceived benefits of the action. Examples include that in order to prevent lung cancer one refrains from smoking, and to maintain weight, one eats nutritious foods and avoids snacking.
• Perceived barriers to action. Examples include cost, inconve- nience, unpleasantness, and lifestyle changes.
Nurses play a major role in helping clients implement healthy behaviors. They help clients monitor health, they supply anticipatory guidance, and they impart knowledge about health. Nurses can also reduce barriers to action (e.g., by minimizing inconvenience or dis- comfort) and can support positive actions.
Pender et al. (2011) have modified this health belief model to develop a health promotion model. According to Pender, the health belief model explains health-protecting or preventive behaviors but does not emphasize health-promoting behaviors. See the discussion of Pender’s Health Promotion Model in Chapter 16 .
In addition to applying these models, the nurse uses other re- sources to evaluate options in planning interventions to maximize wellness. Two very useful documents developed by federal agencies are the Guide to Community Preventive Services from the Centers for Disease Control and Prevention and the 2012 Guide to Clini- cal Preventive Services from the U.S. Preventive Services Task Force (USPSTF). The electronic Preventive Services Selector (ePSS) al- lows users to download the USPSTF recommendations to mobile or tablet devices, receive notifications of updates, and search and browse recommendations online. Users can search the ePSS for
with healthier lifestyles and more positive attitudes toward preventive health measures (see also Chapter 16 ).
Health Locus of Control Model Locus of control is a concept from social learning theory that nurses can use to determine whether clients are likely to take action regarding health, that is, whether clients believe that their health status is under their own or others’ control. People who believe that they have a major influence on their own health status—that health is largely self-determined—are called internals. People who exercise in- ternal control are more likely than others to take the initiative on their own health care, be more knowledgeable about their health, make and keep appointments with primary care providers, maintain diets, and give up smoking. By contrast, people who believe their health is largely controlled by outside forces (e.g., chance or powerful others) are referred to as externals.
Research has shown that locus of control plays a role in cli- ents’ choices about health behaviors and in their health experiences. A high external health locus of control has been related to a better quality of life in clients with cancer (Allart, Soubeyran, & Cousson- Gélie, 2013), whereas individuals who had heart attacks who returned to work had stronger internal locus of control beliefs than those who did not return to work (Bergvik, Sørlie, & Wynn, 2012).
Locus of control is a measurable concept that can be used to predict which people are most likely to change their behavior. Many measurement instruments are available to assess locus of control. One widely used example is the Multidimensional Health Locus of Control (MHLC) Scale (Wallston, Wallston, & DeVellis, 1978), most recently expanded to Form C (Wallston, Stein, & Smith, 1994). Public domain versions and scoring instructions for these scales are avail- able on the Vanderbilt University School of Nursing website.
Rosenstock and Becker’s Health Belief Models Rosenstock and Becker’s health belief model (Rosenstock, Strecher, & Becker, 1988) is based on the assumption that health-related action depends on the simultaneous occurrence of three factors: (1) suf- ficient motivation to make health issues be viewed as important, (2) belief that one is vulnerable to a serious health problem or its consequences, and (3) belief that following a particular health rec- ommendation would be beneficial. The model includes individual perceptions, modifying factors, and variables likely to affect initiat- ing action.
INDIVIDUAL PERCEPTIONS Individual perceptions include the following:
• Perceived susceptibility. A family history of a certain disorder, such as diabetes or heart disease, may make the individual feel at increased risk. Awareness of personal high-risk lifestyle behaviors also increases perceived susceptibility.
• Perceived seriousness. In the perception of the individual, does the illness cause death or have serious consequences? For ex- ample, concern about the spread of acquired immunodeficiency syndrome (AIDS) reflects the general public’s perception of the seriousness of this illness.
• Perceived threat. Perceived susceptibility and perceived serious- ness combine to determine the total perceived threat of an illness
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recommendations by age, sex, and pregnancy status. A major em- phasis in both documents is providing evidence-based recommen- dations for practices and policies aimed at improving health. Both documents are updated as the data become available and can be re- trieved from their respective websites.
HEALTH CARE ADHERENCE Adherence is the extent to which an individual’s behavior (for exam- ple, taking medications, following diets, or making lifestyle changes) coincides with medical or health advice. Degree of adherence may range from disregarding every aspect of the recommendations to fol- lowing the total therapeutic plan. There are many reasons why some people adhere and others do not (Box 17–3).
To enhance adherence, nurses need to ensure that the client is able to perform the activities, understands the necessary instructions, is a willing participant in establishing goals of therapy, and values the planned outcomes of behavior changes. Examples of questions to be
In this study, Poorolajal, Cheraghi, Hazavehei, and Rezapur Shahkolai (2013) used a health belief model questionnaire to examine the knowl- edge, beliefs, and practices of 580 mothers who had at least one child under age 5. Injuries were more common in boys than in girls and at home than away from home. Overall, the mothers’ knowledge about ways to prevent injury to their children was low, although it was higher among those mothers whose children had actually expe- rienced injury. Perceived severity, perceived barriers, cues to action, and self-efficacy most predicted mothers’ use of prevention strate- gies. Higher levels of knowledge, perceived benefits, cues to action, and self-efficacy correlated with more prevention, whereas perceived susceptibility, severity, and barriers correlated with less prevention.
IMPLICATIONS The findings from this research support the concept that preven- tion can be effective in limiting injury among young children. This is especially true since the majority of injuries occurred in the home with the mother present. Use of the health belief model in this study provided a standardized way of viewing the variables and comparing the findings with those from similar studies in other parts of the world. Nurses have a significant role in design- ing interventions that can address the barriers to effective injury prevention in this population. Assisting mothers with anticipating possible risks and taking action to minimize them is an appropriate nursing role.
Evidence-Based Practice Which Components of the Health Belief Model Most Correlate with Mothers’ Injury Prevention Practices? EVIDENCE-BASED PRACTICE
ASSESSMENT INTERVIEW Determining the Risk for Medication Nonadherence • Are you having side effects from any of your medications? • Do you think your medications are helping? • Do you have “tools” to remind you to take your medication?
Examples could be an alarm or environmental cues (e.g., 6:00 news).
• Is there someone at home who helps you with your medications?
• How many times per day are your medications prescribed?
• How many pills do you take every day? • Are there any special storage requirements for your
medications? • How much do your medication requirements interfere with your
lifestyle? • How well are you able to follow special dosing requirements? • How many doses of your medications have you missed during
the past 3 days?
BOX 17–3 Factors Influencing Adherence
• Client motivation to become well • Degree of lifestyle change necessary • Perceived severity of the health care problem • Value placed on reducing the threat of illness • Ability to understand and perform specific behaviors • Degree of inconvenience of the illness itself or of the regimens • Beliefs that the prescribed therapy or regimen will or will
not help • Complexity, side effects, and duration of the proposed therapy • Cultural heritage, beliefs, or practices that support or conflict
with the regimen • Degree of satisfaction and quality and type of relationship with
the health care providers • Overall cost of therapy
included in assessment of medication adherence are found in the As- sessment Interview.
When a nurse identifies nonadherence, it is important to take the following steps:
• Establish why the client is not following the regimen. Depending on the reason, the nurse can provide information, correct mis- conceptions, attempt to decrease expense, or suggest counseling if psychological problems are interfering with adherence. It is also essential for the nurse to reevaluate the suitability of the health ad- vice provided. In situations where the client’s cultural beliefs or age conflict with planned therapies, the nurse needs to consider ways to repattern and restructure care that will preserve and accommo- date the client’s practices. See the Providing Culturally Responsive Care section in Chapter 18 .
• Demonstrate caring. Show sincere concern about the client’s problems and decisions and at the same time accept the client’s right to a course of action. For example, a nurse might tell a client who is not taking his heart medication, “I can appreciate how you feel about this, but I am very concerned about your heart.”
• Encourage healthy behaviors through positive reinforcement. If the man who is not taking his heart medication is walking every day, the nurse might say, “You are really doing well with your walking.”
• Use aids to reinforce teaching. For instance, the nurse can leave pamphlets for the client to read later or make a “pill calendar,” a paper with the date and number of pills to be taken.
• Establish a therapeutic relationship of freedom, mutual under- standing, and mutual responsibility with the client and support persons. By providing knowledge, skills, and information, the nurse gives clients control over their health and establishes a co- operative relationship, which results in greater adherence.
Aspects influencing clients of varying ages are found in Lifespan Considerations.
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of all causal factors that act together to bring about the particular dis- ease. For example, the tubercle bacillus is designated as the biologic agent of tuberculosis. However, other etiologic factors, such as age, nutritional status, and even occupation, are involved in the develop- ment of tuberculosis and influence the course of infection. There are many diseases for which the specific cause is unknown (e.g., multiple sclerosis). Nurses have traditionally taken a holistic view of people and base their practice on the multiple-causation theory of health problems.
There are many ways to classify illness and disease; one of the most common is as acute or chronic. Acute illness is typically char- acterized by symptoms of relatively short duration. The symptoms often appear abruptly and subside quickly and, depending on the cause, may or may not require intervention by health care profession- als. Some acute illnesses are serious (for example, appendicitis may require surgical intervention), but many acute illnesses, such as colds, subside without medical intervention or with the help of over-the- counter medications. Following an acute illness, most people return to their normal level of wellness.
A chronic illness is one that lasts for an extended period, usu- ally 6 months or longer, and often for the person’s life. Chronic ill- nesses usually have a slow onset and often have periods of remission, when the symptoms disappear, and exacerbation, when the symp- toms reappear.
Examples of chronic illnesses are arthritis, heart and lung dis- eases, and diabetes mellitus. Nurses are involved in caring for chroni- cally ill individuals of all ages in all types of settings—homes, nursing
CLINICAL ALERT!
Chronic illness often requires complicated treatment regimens for lengthy periods that may include significant adverse reactions and be very costly. Thus, clients with chronic illnesses may be at increased risk for treatment nonadherence.
ILLNESS AND DISEASE Illness is a highly personal state in which the person’s physical, emotional, intellectual, social, developmental, or spiritual func- tioning is thought to be diminished. It is not synonymous with dis- ease and may or may not be related to disease. An individual could have a disease and not feel ill. Similarly a person can feel ill, that is, feel uncomfortable, and yet have no discernible disease. Illness is highly subjective; only the individual person can say he or she is ill.
Disease can be described as an alteration in body functions resulting in a reduction of capacities or a shortening of the normal life span. Traditionally, intervention by primary care providers has the goal of eliminating or ameliorating disease processes. Primitive people thought “forces” or spirits caused disease. Later this belief was replaced by the single-causation theory. Today multiple factors are considered to interact in causing disease and determining an indi- vidual’s response to treatment.
The causation of a disease or condition is called its etiology. A description of the etiology of a disease includes the identification
LIFESPAN CONSIDERATIONS Medication Nonadherence
CHILDREN Microbial resistance to antibiotics has increased significantly in re- cent years, making it critical that antibiotics given to children are necessary, administered correctly by parents in the home, and taken as prescribed. Providers, parents, and children must work together in order to increase the adherence rate in taking antibiotics.
Adherence is influenced by: • Attitudes toward medications. Some parents may think that when
their child is feeling better, the medication is no longer necessary. • Past experience. Children may remember a bad experience
with taking a medication and resist parents’ efforts to give them an antibiotic.
• Cost of medication. Generic drugs are less costly than brand- name drugs, and can be equally effective.
• Cultural issues. Providers must work with families who have language or cultural differences to make sure they under- stand the family’s needs and communicate the provider’s recommendations.
• Number of doses necessary. Adherence improves if fewer doses per day are required and if the antibiotic can be taken over fewer days.
• Taste and palatability. Pharmaceutical companies continue to develop liquid medication that will be more acceptable to young children.
ADOLESCENTS Several causes of nonadherence are specific to teenagers. It is im- portant for the nurse to consider these when working with adoles- cents, because they: • Less often consider the consequences of their actions.
• Are in the early stages of demonstrating effective problem solving.
• Assert independence by rejecting adult values. • Conform to their peers and don’t like being “different.” • Focus on self-concept and body image. • Live in the “here and now.” • May regress developmentally at times of stress or illness. • May be unable to distinguish benefits from disadvantages.
OLDER ADULTS Issues that influence adherence in older adults include the following: • Long-term lifestyle choices • Limited or fixed income • Availability of home and community-based services to maximize
independence • Available, acceptable, and cost-effective alternative/
complementary therapies • Housing and home modifications needed to accommodate
physical aspects of aging • Affordable and accessible transportation • Beliefs about the value of preventive nursing and medical care • Availability of mental health services • Caregiving needs that overburden some family and informal
caregivers • Forgetfulness • Dementia • Feeling that they have lived their life and it is time for life to end
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homes, hospitals, clinics, and other institutions. Care needs to be focused on promoting the highest level possible of independence, sense of control, and wellness. Clients often need to modify their ac- tivities of daily living, social relationships, and perception of self and body image. In addition, many must learn how to live with increasing physical limitations and discomfort.
Illness Behaviors When people become ill, they behave in certain ways that sociolo- gists refer to as illness behavior. Illness behavior, a coping mecha- nism, involves ways individuals describe, monitor, and interpret their symptoms, take remedial actions, and use the health care system. How people behave when they are ill is highly individualized and affected by many variables, such as age, sex, occupation, socioeco- nomic status, religion, ethnic origin, psychological stability, person- ality, education, and modes of coping.
Parsons (1979) described four aspects of the sick role.
Rights: 1. Clients are not held responsible for their condition. Even if the
illness was partially caused by an individual’s behavior (e.g., lung cancer from smoking), the individual is not capable of reversing the condition on his or her own.
2. Clients are excused from certain social roles and tasks. For ex- ample, an ill parent would not be expected to prepare meals for the family.
Obligations: 3. Clients are obliged to try to get well as quickly as possible. The
ill person should follow legitimate advice regarding a specialized diet or activity restrictions that could help with recovery.
4. Clients or their families are obliged to seek competent help. For example, the ill person should contact the primary care pro- vider rather than relying solely on his or her own ideas of how to recover.
Suchman (1979) described five stages of illness: symptom expe- riences, assumption of the sick role, medical care contact, dependent client role, and recovery or rehabilitation. Not all clients progress through each stage. For example, the client who experiences a sudden heart attack is taken to the emergency department and immediately enters stages 3 and 4, medical care contact and dependent client role. Other clients may progress through only the first two stages and then recover. Details of Suchman’s five stages follow.
STAGE 1: SYMPTOM EXPERIENCES At this stage the person comes to believe something is wrong. Either someone significant mentions that the person looks unwell, or the person experiences some symptoms such as pain, rash, cough, fever, or bleeding. Stage 1 has three aspects:
• The physical experience of symptoms • The cognitive aspect (the interpretation of the symptoms in terms
that have some meaning to the person) • The emotional response (e.g., fear or anxiety).
During this stage, the unwell person usually consults others about the symptoms or feelings, validating with support people that the symp- toms are real. At this stage the sick person may try home remedies. If self-management is ineffective, the individual enters the next stage.
Figure 17–6 • In assuming the sick role for simple illnesses such as a cold, individuals are expected to rest and treat themselves with common remedies. Matt Meadows/Photolibrary/Getty Images.
STAGE 2: ASSUMPTION OF THE SICK ROLE The individual now accepts the sick role and seeks confirmation from family and friends. Often people continue with self-treatment and delay contact with health care professionals as long as possible. Dur- ing this stage people may be excused from normal duties and role ex- pectations (Figure 17–6 •). Emotional responses such as withdrawal, anxiety, fear, and depression are not uncommon depending on the severity of the illness, perceived degree of disability, and anticipated duration of the illness. When symptoms of illness persist or increase, the person is motivated to seek professional help.
STAGE 3: MEDICAL CARE CONTACT Sick people seek the advice of a health professional either on their own initiative or at the urging of significant others. When people seek pro- fessional advice, they are really asking for three types of information:
• Validation of real illness • Explanation of the symptoms in understandable terms • Reassurance that they will be all right or prediction of what the
outcome will be.
The health professional may determine that the client does not have an illness or that an illness is present and may even be life threat- ening. The client may accept or deny the diagnosis. If the diagnosis is accepted, the client usually follows the prescribed treatment plan. If the diagnosis is not accepted, the client may seek the advice of other health care professionals or quasi-practitioners who will provide a diagnosis that fits the client’s perceptions.
STAGE 4: DEPENDENT CLIENT ROLE After accepting the illness and seeking treatment, the client be- comes dependent on the professional for help. People vary greatly in the degree of ease with which they can give up their independence, particularly in relation to life and death. Role obligations—such as those of wage earner, parent, student, sports team member, or choir member—complicate the decision to give up independence.
Most people accept their dependence on the primary care pro- vider, although they retain varying degrees of control over their own lives. For example, some people request precise information about their disease, their treatment, and the cost of treatment, and may
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a disturbance in self-concept: loss of body parts and function, pain, disfigurement, dependence on others, unemployment, financial problems, inability to participate in social functions, strained rela- tionships with others, and spiritual distress. Nurses need to help cli- ents express their thoughts and feelings, and to provide care that helps the client effectively cope with change.
Ill individuals are also vulnerable to loss of autonomy, the state of being independent and self-directed without outside control. Fam- ily interactions may change so that clients are no longer involved in making family decisions or even decisions about their own health care. Nurses need to support clients’ right to self-determination and autonomy as much as possible by providing them with sufficient in- formation to participate in decision-making processes and to main- tain a feeling of being in control.
Illness also often necessitates a change in lifestyle. In addition to participating in treatments and taking medications, the ill person may need to change diet, activity and exercise, and rest and sleep patterns.
Nurses can help clients adjust their lifestyles by these means:
• Provide explanations about necessary adjustments. • Make arrangements wherever possible to accommodate the cli-
ent’s lifestyle. • Encourage other health professionals to become aware of the
person’s lifestyle practices and to support healthy aspects of that lifestyle.
• Reinforce desirable changes in practices with a view to making them a permanent part of the client’s lifestyle.
IMPACT ON THE FAMILY A person’s illness affects not only the person who is ill but also the family or significant others. The kind of effect and its extent depend chiefly on three factors: (1) the member of the family who is ill, (2) the seriousness and length of the illness, and (3) the cultural and social customs the family follows.
The changes that can occur in the family include the following:
• Role changes • Task reassignments and increased demands on time • Increased stress due to anxiety about the outcome of the illness for
the client and conflict about unaccustomed responsibilities • Financial problems • Loneliness as a result of separation and pending loss • Change in social customs.
See Chapter 24 for further information about the effects of illness on the family.
delay the decision to accept treatment until they have all this infor- mation. Others prefer that the primary care provider proceed with treatment and do not request additional information.
For some clients, illness may meet dependence needs that have never been met and thus provide satisfaction. Other people have minimal dependence needs and do everything possible to return to independent functioning. A few may even try to maintain indepen- dence to the detriment of their recovery.
STAGE 5: RECOVERY OR REHABILITATION During this stage the client is expected to relinquish the dependent role and resume former roles and responsibilities. For people with acute illness, the time as an ill person is generally short and recov- ery is usually rapid. Thus most find it relatively easy to return to their former lifestyles. People who have long-term illnesses and must ad- just their lifestyles may find recovery more difficult. For clients with a permanent disability, this final stage may require therapy to learn how to make major adjustments in functioning.
Effects of Illness Illness brings about changes in both the involved individual and in the family. The changes vary depending on the nature, severity, and duration of the illness, attitudes associated with the illness by the cli- ent and others, the financial demands, the lifestyle changes incurred, adjustments to usual roles, and so on.
IMPACT ON THE CLIENT Ill clients may experience behavioral and emotional changes, changes in self-concept and body image, and lifestyle changes. Behavioral and emotional changes associated with short-term illness are generally mild and short lived. The individual, for example, may become irri- table and lack the energy or desire to interact in the usual fashion with family members or friends. More acute responses are likely with severe, life-threatening, chronic, or disabling illness. Anxiety, fear, anger, with- drawal, denial, a sense of hopelessness, and feelings of powerlessness are all common responses to severe or disabling illness. For example, a client experiencing a heart attack fears for his life and the financial burden it may place on his family. Another client informed about a diagnosis of cancer or AIDS or crippling neurologic disease may, over time, experience episodes of denial, anger, fear, and hopelessness.
Certain illnesses can also change the client’s body image or physical appearance, especially if there is severe scarring or loss of a limb or sense organ. The client’s self-esteem and self-concept may also be affected. Many factors can play a part in low self-esteem and
Critical Thinking Checkpoint
Jerry and Joe have both suffered heart attacks. Jerry, upon advice from his primary care provider, started exercising, changed his di- etary intake, entered stress reduction classes, and returned to work 6 weeks after his heart attack. He has a positive outlook, is doing well, and talks about being “well.” Joe also changed his dietary habits and started exercising. However, Joe has been unable to quit smok- ing even though he wants to and has been advised to do so. Joe is frequently despondent, is very fearful of having another heart attack, has not yet returned to work, and frequently talks about being “ill.” 1. How does Jerry’s psychological dimension of health status differ
from Joe’s?
2. Both Jerry and Joe have heart disease. Jerry considers himself “well,” whereas Joe considers himself “ill.” Explain this phenom- enon based on the health locus of control model.
3. What external factors may have influenced Jerry’s decision to implement positive health behaviors?
4. What factors may have prevented Joe from developing the same positive outlook and actions that Jerry was able to take in regard to his illness?
5. What nursing interventions would be most beneficial to Joe concerning his smoking problem?
See Critical Thinking Possibilities on student resource website.
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CHAPTER HIGHLIGHTS
Chapter 17 Review
• Nurses need to clarify their understanding of health because their definitions of health largely determine the scope and nature of nursing practice. Likewise, people’s health beliefs influence their health practices.
• The perspective from which health is viewed has changed; instead of absence of disease, health has come to mean a high level of wellness or the fulfillment of one’s maximum potential for physical, psychosocial, and spiritual functioning.
• Most people describe health as freedom from symptoms of dis- ease, the ability to be active, and a state of being in good spirits.
• Nurses should be aware of their own personal definitions of health and appreciate that other people have their own individual defini- tions as well. By understanding clients’ perceptions of health and illness, nurses can provide more meaningful assistance to help them maintain, regain, or attain a state of health.
• Wellness is an active, seven-dimensional process of becom- ing aware of and making choices toward a higher level of well- being. The seven dimensions of wellness are the physical, social, emotional, intellectual, spiritual, occupational, and environmental dimensions.
• Well-being is a subjective perception of vitality and feeling well that can be described, experienced, and measured.
• Various models have been developed to explain health: clini- cal, role performance, adaptive, and eudaimonistic models, and Leavell and Clark’s agent–host–environment model, Dunn’s high- level wellness grid, and the illness–wellness continuum.
• The health status of a person is affected by many internal and external variables over which the person has varying degrees of control.
• Internal variables include biologic, psychological, and cognitive di- mensions. The biologic dimension includes genetic makeup, gen- der, age, and developmental level. The psychological dimension includes mind–body interactions and self-concept. The cognitive di- mension includes lifestyle choices and spiritual and religious beliefs.
• External variables influencing health are physical environment, standards of living, family and cultural beliefs, and social support networks.
• Health belief and behavior models have been developed to help determine whether an individual is likely to participate in disease prevention and health promotion activities. Examples of these are the locus of control model and Rosenstock and Becker’s health belief model.
• A decision to implement health behaviors or to take action to im- prove health depends on such factors as the client’s motivation to become well, perceived severity of the health problem, perceived benefits of preventive or therapeutic actions, inconvenience and unpleasantness involved, degree of lifestyle change necessary, cultural ramifications, and cost.
• Nurses can enhance health care adherence by identifying the rea- sons for nonadherence if it occurs, demonstrating caring, using positive reinforcement to encourage healthy behaviors, using aids to reinforce teaching, and establishing a therapeutic relationship of freedom, mutual understanding, and mutual responsibility with the client and support persons.
• Illness is usually associated with disease but may occur indepen- dently of it. Illness is a highly personal state in which the person feels unhealthy or ill. Disease alters body functions and results in a reduction of capacities or a shortened life span.
• Various theorists have described stages and aspects of illness. Parsons describes four aspects of the sick role. Suchman outlines five stages of illness: symptom experiences, assumption of the sick role, medical care contact, dependent client role, and recov- ery or rehabilitation.
• An individual’s usual pattern of behavior changes with illness and hospitalization, which disrupt a person’s privacy, autonomy, life- style, roles, and finances.
• Nurses need to be aware that the illness of one member of a family affects all other members.
1. Which one of the following is an example of the emotional component of wellness? 1. The client chooses healthy foods. 2. A new father decides to take parenting classes. 3. A client expresses frustration with her partner’s substance
abuse. 4. A widow with no family decides to join a bowling league.
2. Which individual appears to have “taken on” the sick role? 1. A client who is obese states, “I deserve to have a heart
attack.” 2. A mother is ill and says, “I won’t be able to make your lunch
today.” 3. A man with low back pain misses several physical therapy
appointments. 4. An older adult states, “My horoscope says I will be well
again.”
3. Because a client recently diagnosed with diabetes mellitus is confident that blood sugar control can be improved with diet and exercise alone, and recently checked out a video on the management of diabetes at the HMO education center, the client’s actions are most representative of which model? 1. Health belief model 2. Clinical model 3. Role performance model 4. Agent–host–environment model
4. Because a client with human immunodeficiency virus (HIV) is scheduled to begin several medications to manage the infection, the nurse will need to provide client education. Which client characteristics are most likely to predict adherence with the treatment program? Select all that apply. 1. Educational level 2. A trusting relationship with the health care provider 3. An expectation that the medications will be helpful 4. Being able to take the medications twice daily instead of
four times daily 5. Sex
TEST YOUR KNOWLEDGE
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8. A client recently diagnosed with a chronic illness asks for help in understanding the term chronic. It would be correct for the nurse to say which of the following? 1. Symptoms are always less severe than with an acute illness. 2. Chronic illnesses are considered incurable. 3. Signs and symptoms of chronic illnesses tend to be stable
for many years. 4. Chronic illnesses have no effective treatments.
9. Although not every client progresses in order through each stage, what is the usual sequence in Suchman’s stages of illness? 1. The client makes contact with medical care. 2. The client goes into rehabilitation/recovery. 3. Signs and symptoms appear. 4. The client takes on the dependent role. 5. The client takes on the sick role.
10. A married mother of three small children has frequent immobi- lizing headaches of unknown cause. The nurse anticipates that the woman may have which of the following possible reactions? Select all that apply. 1. She feels guilty when unable to perform her usual activities. 2. She is angry and acting out. 3. She shifts some responsibilities to the spouse. 4. She takes on a job to help pay for the medical expenses. 5. She has fewer social interactions with her friends.
See Answers to Test Your Knowledge in Appendix A.
5. Which one of the following might be the BEST way to measure adherence to a prescribed medication regime? 1. Direct observation of medication administration 2. Evidence of illness complications or exacerbations 3. Monitoring laboratory values of elements influenced by the
medication 4. Questioning the client about his or her medication routine
6. Which of the following is least likely to influence a client’s personal definition of health/wellness? 1. The client’s ability to perform his or her usual activities 2. The cultural traditions the client uses in everyday life 3. The availability and accessibility of health care services
appropriate for the client’s health condition 4. The medical diagnostic terminology used to describe the
client’s signs and symptoms 7. Which of the following is an internal variable affecting health
status, beliefs, or practices? 1. Living situation 2. Socioeconomic status 3. Family structure 4. Genetics
Suggested Reading Edlin, G., & Golanty, E. (2014). Health and wellness (11th ed.).
Burlington, MA: Jones & Bartlett. As stated in its preface, the purpose of this book is to provide the reader with information about how to maintain physical, mental, and spiritual wellness. It contains a variety of exercises and activities to assist the reader in reflecting on his or her own health and making positive changes.
Related Research Rabinovitch, M., Cassidy, C., Schmitz, N., Joober, R., & Malla, A.
(2013). The influence of perceived social support on medi- cation adherence in first-episode psychosis. Canadian Journal of Psychiatry, 58(1), 59–65.
Reitzel, L. R., Lahoti, S., Li, Y., Cao, Y., Wetter, D. W., Waters, A. J., & Irvin Vidrine, J. I. (2013). Neighborhood vigilance, health locus of control, and smoking abstinence. American Journal of Health Behavior, 37, 334–341. doi:10.5993/AJHB.37.3.6
References Allart, P., Soubeyran, P., & Cousson-Gélie, F. (2013). Are
psychosocial factors associated with quality of life in patients with haematological cancer? A critical review of the literature. Psycho-Oncology, 22, 241–249. doi:10.1002/ pon.3026
American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Author.
Anspaugh, D. J., Hamrick, M., & Rosato, F. D. (2011). Well- ness: Concepts and applications (8th ed.). New York, NY: McGraw-Hill.
Bergvik, S., Sørlie, T., & Wynn, R. (2012). Coronary patients who returned to work had stronger internal locus of control beliefs than those who did not return to work. British Journal of Health Psychology, 17, 596–608. doi:10.1111/j.2044-8287.2011.02058.x
Calzone, K. A., Jenkins, J., Yates, J., Cusack, G., Wallen, G. R., Liewehr, D. J., . . . McBride, C. (2012). Survey of nursing integration of genomics into nursing prac- tice. Journal of Nursing Scholarship, 44, 428–436. doi:10.1111/j.1547-5069.2012.01475.x
Dunn, H. L. (1959). High-level wellness for man and soci- ety. American Journal of Public Health, 49, 786–792. doi:10.2105/AJPH.49.6.786
Hood, L. J. (2010). Leddy & Pepper’s conceptual bases of professional nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Leavell, H. R., & Clark, E. G. (1965). Preventive medicine for the doctor in his community (3rd ed.). New York, NY: McGraw-Hill.
Newman, M. A. (2008). Transforming presence: The difference that nursing makes. Philadelphia, PA: F.A. Davis.
Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover Books. (Original work published 1860)
Parsons, T. (1951). The social system. Glencoe, IL: Free Press. Parsons, T. (1979). Definitions of health and illness in the light
of American values and social structure. In E. G. Jaco (Ed.), Patients, physicians, and illness (3rd ed.). New York, NY: Free Press.
Pender, N. J., Murdaugh, C. L., & Parsons, M. J. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Poorolajal, J., Cheraghi, P., Hazavehei, S. M. M., & Rezapur Shahkolai, F. (2013). Factors associated with mothers’ beliefs and practices concerning injury prevention in under five-year children, based on health belief model. Journal of Research in Health Sciences, 13(1), 63–68.
President’s Commission on Health Needs of the Nation. (1953). Building Americans’ health (Vol. 2). Washington, DC: U.S. Government Printing Office.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 12, 175–183.
Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
Suchman, E. A. (1979). Stages of illness and medical care. In E. G. Jaco (Ed.), Patients, physicians, and illness (3rd ed.). New York, NY: Free Press.
Wallston, K. A., Stein, M. J., & Smith, C. A. (1994). Form C of the MHLC scales: A condition-specific measure of locus of control. Journal of Personality Assessment, 63, 534–553. doi:10.1207/s15327752jpa6303_10
Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978, Spring). Development of the Multidimensional Locus of Control (MHLC) scales. Health Education Monographs, 6, 160–170.
World Health Organization. (1948). Preamble to the constitution of the World Health Organization as adopted by the Interna- tional Health Conference. New York, 19–22 June 1946;
signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
Selected Bibliography Abbasi, K. (2012). The Olympics and the National Health
Service: A definition of health. Journal of the Royal Society of Medicine, 105(8), 321. doi:10.1258/ jrsm.2012.12k057
Agency for Healthcare Research and Quality, U.S. Public Health Service. (2012). Guide to clinical preventive services, 2012. Rockville, MD: Author. Retrieved from http://www .ahrq.gov/professionals/clinicians-providers/guidelines- recommendations/guide/index.html
Community Guide Branch, National Center for Health Market- ing (NCHM), Centers for Disease Control and Prevention. (2013). The guide to community preventive services. Re- trieved from http://www.thecommunityguide.org/index.html
Cramm, J. M. M., & Nieboer, A. P. (2013). The importance of neighborhood social cohesion and social capital for the well being of older adults in the community. Gerontologist, 53(1), 142–152. doi:10.1093/geront/gns052
Henly, S. J., Wyman, J. F., & Findorff, M. J. (2011). Health and illness over time. Nursing Research, 60, S5–S14. doi:10.1097/NNR.0b013e318216dfd3
Raingruber, B. (2014). Contemporary health promotion in nurs- ing practice. Burlington, MA: Jones & Bartlett.
Snedker, K. A., & Hooven, C. (2013). Neighborhood percep- tions and emotional well-being in young adulthood. Journal of Child & Adolescent Psychiatric Nursing, 26(1), 62–73. doi:10.1111/jcap.12016
Viswanathan, M., Golin, C., Jones, C., Ashok, M., Blalock, S., Wines, R., . . . Lohr, K. (2012). Interventions to improve adherence to self-administered medications for chronic diseases in the United States: A systematic review. Annals of Internal Medicine, 157, 785–795.
Vonarx, N. (2011). Haitian vodou as a health care system: Be- tween magic, religion, and medicine. Alternative Therapies in Health & Medicine, 17(5), 44–51.
Wight, R. G., LeBlanc, A. J., & Badgett, M. V. L. (2013). Same- sex legal marriage and psychological well-being: Findings from the California Health Interview Survey. American Journal of Public Health, 103, 339-346. doi:10.2105/ AJPH.2012.301113
READINGS AND REFERENCES
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18 Culturally Responsive Nursing Care
INTRODUCTION Nursing care is holistic and encompasses the client’s perspectives on health, which are greatly influenced by the client’s culture. Each person is born into a culture influenced by the place of birth and the family of origin. A child learns the family’s customs and beliefs, which shape his or her worldview. An individual’s culture is dynamic and shifts over the course of a lifetime, influenced by many other factors, such as communities, schools, migration patterns, career choices, and religion. Similarly, a nurse’s worldview is influenced by the culture of the nursing profession and the culture of the organization that he or she represents. Therefore, every nurse–client interaction is a cultural encounter. A nurse cannot assume sameness of values, even if the client appears to resemble the nurse in outward appearance. It is the nurse’s responsibility to recognize the client’s cultural perspectives.
Culturally responsive care is care that is centered on the cli- ent’s cultural point of view and integrates the client’s values and beliefs into the plan of care. To deliver such care, the nurse must first develop self-awareness of his or her own culture, attitudes, and beliefs, and examine the biases and assumptions he or she holds about different cultures. Next, the nurse needs to gain the necessary knowledge and skills to create an environment where trust can be developed with the client. This knowledge must include an understanding of health dis- parities as well as the historical and current portrayals of racial and ethnic groups in society. Additionally, cultural knowledge can help the nurse to better understand different perspectives, while recogniz- ing that cultural generalizations may not hold true at the individual
level. Cultural assessment skills are essential in understanding the client’s viewpoint more fully, and learning what the client values as important. The nurse must partner with the client in a caring and respectful relationship that honors the client’s differences and per- spectives. In culturally responsive care, the nurse must respond to the client’s needs, not vice versa. Only through self-awareness, deliberate cultural assessment, and incorporation of the client’s culture into the plan of care can a nurse optimally care for a client.
CULTURAL CONCEPTS Culture is complex, with multiple definitions, and the term is often used interchangeably with other terms such as race, ethnicity, and nationality.
• Culture is the “thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or so- cial groups” (U.S. Department of Health and Human Services [USDHHS], Office of Minority Health [OMH], 2005). It has been described as the learned and shared patterns of information that a group uses to generate meaning among its members. These pat- terns include nonverbal language and material goods. Within macro-cultures (national, ethnic, or racial groups) are micro- cultures (gender, age, or religious beliefs) in which members share belief in certain rules, roles, behaviors, and values. Macro- and micro-cultures combine to shape the individual’s worldview and influence interaction with others.
LEARNING OUTCOMES
After completing this chapter, you will be able to: 1. Describe concepts related to culture such as race, ethnicity,
and acculturation. 2. Examine factors that contribute to health disparities among
racial and ethnic groups. 3. Describe the role of federal agencies and initiatives regarding
the provision of culturally responsive health care. 4. Describe cultural models of care, such as cultural competency. 5. Describe health views from culturally diverse perspectives.
KEY TERMS
acculturation, 279 assimilation, 279 biomedical health belief, 282 cultural broker, 284 cultural competence, 280 culturally responsive care, 276 culture, 276 discrimination, 278 diversity, 277
ethnicity, 277 ethnocentrism, 278 folk medicine, 282 generalizations, 278 health disparities, 278 health equity, 278 heritage, 277 heritage consistent, 288 heritage inconsistent, 288
holistic health belief, 282 interpreter, 284 magico-religious health belief, 282 multicultural, 277 nationality, 277 prejudice, 278 race, 277 racism, 278 religion, 277
scientific health belief, 282 stereotyping, 278 subculture, 277 traditional, 280 transcultural nursing, 280 translator, 284
6. Differentiate culturally influenced approaches to healing and treatment.
7. Describe ways culture influences communication patterns and how to provide linguistically appropriate care.
8. Create self-awareness of your own culture, beliefs, biases, and assumptions.
9. Identify methods of cultural assessment. 10. Create a culturally responsive nursing care plan.
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Although, it is now recognized that there is no scientific merit to the concept of race, race remains an important social construct, whereby social meanings are attached to perceived physical differ- ences, resulting in inequality among racial groups.
• Ethnicity is a term often interchangeably used with race. Ethnic- ity may be viewed as a relationship among individuals who be- lieve that they have distinctive characteristics that make them a group (Guibernau & Rex, 2010). Ethnicity is not a fixed concept. Much like culture, ethnicity may shift over time. Migration, inter- marriage, and intermating patterns show that people move into another ethnic group, and become participants in that ethnicity, sharing the language, religion, values, beliefs, and customs. His- panics, for instance, represent multiple geographic areas and mul- tiple races, and share a common language. Ethnic groups are often self-defined, and labeling can become problematic.
• Nationality is sometimes used interchangeably with ethnicity or citizenship. It generally refers to the sovereign state or coun- try where an individual has membership, which may be through birth, through inheritance (parents), or through naturalization. It is also possible to be a member of a nation where no such country is officially recognized, for instance, Kurds, Basques, and Native Americans. A person may also be multinational, holding citizen- ship in two or more countries. Ethnic groups may have territo- ries to which they have national affiliation. This was particularly evident in Eastern Europe where group tensions led to divisions of multiethnic states along territorial lines. For instance, Czecho- slovakia is now two countries: the Czech Republic and Slovakia. Yugoslavia is now six countries: Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, Serbia, and Slovenia.
• Religion may be considered a system of beliefs, practices, and ethical values about divine or superhuman power worshipped as the creator(s) and ruler(s) of the universe. The practice of religion is revealed in numerous denominations, organizations, sects, and cults. Ethnicity and religion are related, and one’s religion is often determined by one’s ethnic group. Religion gives a person a frame of reference and a perspective with which to organize informa- tion. Religious teachings about health help to present a meaning- ful philosophy and system of practices within a system of social
• A subculture is usually composed of people who have a distinct identity and yet are related to a larger cultural group. A subcul- tural group generally shares ethnic origin or physical characteris- tics with the larger cultural group. Examples of cultural subgroups include occupational groups (e.g., nurses), societal groups (e.g., feminists), and ethnic groups (e.g., Cajuns, who are descendants of French Acadians—17th-century settlers in Canadian Nova Scotia, New Brunswick, and Prince Edward Island).
• Multicultural is used to describe a person who has multiple pat- terns of identification or crosses several cultures, lifestyles, and sets of values. For example, a man whose father is Cherokee and whose mother is European may honor his Cherokee heritage (things passed down from previous generations) while also being influenced by his mother’s cultural values. Another example exists in large areas of Canada where both British and French influences are strong. The term is often used interchangeably with bicultural, biracial, multiracial, and multiethnic.
• Diversity refers to the fact or state of being different. Many fac- tors account for diversity: sex, age, culture, ethnicity, socioeco- nomic status, educational attainment, religious affiliation, and so on. Diversity, therefore, occurs not only between cultural groups but also within a cultural group.
• Race is a term with many definitions, often used interchangeably with the terms ethnicity and culture. The Office of Management and Budget (OMB) (1997), which determines federal standards for reporting race, states that racial categories “should not be in- terpreted as being primarily biological or genetic in reference. Race and ethnicity may be thought of in terms of social and cul- tural characteristics as well as ancestry” (p. 36,881). The American Anthropological Association (AAA) (1998) statement on race de- fines it as an idea created by western Europeans following explora- tion across the world to account for differences among people and justify colonization, conquest, enslavement, and social hierarchy among humans. It has been used to refer to groupings of people according to common origin or background and associated with perceived biologic markers. Ideas about race are culturally and socially transmitted and form the basis of racism, racial classifica- tion, and often complex racial identities.
The Human Genome Project has discovered that humans are 99.9% genetically alike, and that the genetic variations related to geographic ancestry do not correlate with the socially constructed racial classifications; that is, there are no genetically discrete races. In fact, there is greater genetic variability within the racial categories than among them (Figure 18–1 •). The official U.S. classification of race has varied throughout history. The 2010 U.S. Census racial classifications are White, Black/African American/Negro, American Indian or Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, Other Pacific Islander, and Some Other Race. It does not classify Hispanic as a race. In addition to the question about race, respondents are asked if they are of Hispanic, Latino, or Spanish origin. For example, of the 50 million respondents to the 2010 U.S. Census who indicated they were Hispanic or Latino, 53% indicated their race as White; less than 3% as Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native; 36.7% Some Other Race, and 6% Two or More Races (Humes, Jones, & Ramirez, 2011).
Figure 18–1 • Although differing in outward appearance, humans are biologically more similar to each other than they are different. franckreporter/Getty Images.
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groups and quality is improving over time while access and dispari- ties are not. The following health disparities are a few examples from the document.
Quality of care: • Adults ages 65 and over received worse care than adults ages 18 to
44 for 39% of measures. • Blacks received worse care than Whites for 41% of measures. • Asians, American Indians, and Alaska Natives (AI/ANs) received
worse care than Whites for about 30% of measures. • Hispanics received worse care than non-Hispanic Whites for 39%
of measures. • Poor people received worse care than high-income people for
47% of measures.
Access to care: • Blacks had worse access to care than Whites for 32% of measures. • Asians had worse access to care than Whites for 17% of measures. • AI/ANs had worse access to care than Whites for 62% of measures. • Hispanics had worse access to care than non-Hispanic Whites for
63% of measures. • Poor people had worse access to care than high-income people for
89% of measures.
The causes of health disparities are multiple and overlapping. Many of the underlying risk factors result from interrelated elements that affect individuals across their life span. These factors can be cat- egorized under four categories of “determinants of health” (National Partnership for Action to End Health Disparities, 2011):
• Social determinants of health—examples include gender, socio- economic status, employment status, educational attainment, food security status, availability of housing and transportation, racism, and health system access and quality
• Behavioral determinants of health—examples include patterns of overweight and obesity; exercise norms; and use of illicit drugs, tobacco, or alcohol
• Environmental determinants of health—examples include lead exposure, asthma triggers, workplace safety factors, unsafe or pol- luted living conditions
• Biological and genetic determinants of health—examples include family history of heart disease and inherited conditions such as hemophilia and cystic fibrosis
Until the passage of the Civil Rights Act in 1964, the United States had a legalized system of discrimination and segregation policies and laws. Rooted in a history of slavery, the health disparities between racial groups have existed for hundreds of years. It is clear from the evidence on health disparities that passage of the Civil Rights Act has not eliminated such disparities. Disparities between racial and ethnic groups exist even within the same socioeconomic status. The efforts to address disparities are aimed at achieving health equity—the highest possible standard of health for all people, especially those at greatest risk for poor health (Braveman, 2014). Only through train- ing can providers begin to recognize and change the discriminatory practices that perpetuate health disparities. The efforts described in the following list are evidence of increased emphasis on providing culturally appropriate health care:
• The National Partnership for Action to End Health Disparities (NPA) was established to mobilize a nationwide, comprehensive,
controls having specific values, norms, and ethics. Illness is some- times seen as punishment for the violation of religious codes and morals. See Chapter 41 for more information on spirituality.
• Ethnocentrism is the belief in the superiority of one’s own cul- ture and lifestyle. Other viewpoints are not only considered dif- ferent, but also wrong or of lesser importance. A related concept is xenophobia—the fear or dislike of people different from one’s self.
• Prejudice is a preconceived notion or judgment that is not based on sufficient knowledge; it may be favorable or unfavorable. Un- favorable prejudice may lead to stereotyping and discriminatory behavior toward groups of people. There are many types of preju- dice, including racial prejudice.
• Racism refers to assumptions held about racial groups. Assump- tions include the belief that races are biologically discrete and exclusive groups that are inherently unequal and ranked hierar- chically. Cultural behaviors are viewed as inherited and exclusive to each group and form the basis of judging persons based on their racial classification. Institutional racism or institutional dis- crimination is the denial of opportunities and equal rights based on race. Examples include standards for assessing credit risks that disadvantage African Americans and Hispanics who may lack conventional credit references, higher insurance costs in low- income areas, school testing that favors White middle-class children because of the types of questions included, and hiring practices that require experience at jobs not historically open to members of subordinate groups (Schaefer, 2013). In a system that advantages Whites over other races, the advantages are often re- ferred to as “White privilege.”
• Discrimination refers to the negative treatment of individuals or groups on the basis of their race, ethnicity, gender, or other group membership. It occurs when rights and opportunities are denied for arbitrary or prejudicial reasons.
• Generalizations are statements about common cultural pat- terns. Generalizations may not hold true at the individual level, and should serve only as openings for individuals to better under- stand each other. Unfortunately, generalizations are often inter- preted as statements describing every individual in a group, which leads to stereotyping.
• Stereotyping refers to making the assumption that an indi- vidual reflects all characteristics associated with being a member of a group. For instance, a nurse may assume that a Latino client speaks limited English and comes from a large family. Rather than asking the client, the nurse immediately calls for an interpreter, speaks loudly and very slowly to the client, and tells the client that the visitor policy allows for only two visitors as a time, and that they cannot bring all of their siblings to the hospital. Stereotyp- ing serves as a barrier to communication and understanding, and propagates discriminatory behavior.
HEALTH DISPARITIES Health disparities are the differences in care experienced by one population compared with another population. Although everyone should receive high-quality health care, the National Healthcare Dis- parities Report, 2011 (USDHHS Agency for Healthcare Research and Quality [AHRQ], 2012) shows that in the United States, some people receive inferior care compared to others. The 2012 report demon- strates that health care quality and access are substandard for some
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scholarships provided by the NURSE Corps scholarship and loan repayment programs.
DEMOGRAPHICS Statistics about the ethnicity of the population can be complicated to interpret. The U.S. Census Bureau (Humes et al., 2011) revealed that in 2010, 97% of U.S. residents identified themselves as belong- ing to a single race. Of the total claiming a single race, 74% identify themselves as White, 13% as Black or African American, 5% as Asian/ Pacific Islander, 1% as American Indian or Alaska Native, and 6% as some other race. Those who indicated they were of Hispanic or Latino origin (which is considered an ethnicity, not a race by the U.S. Census Bureau) were 16.3% of the total American population. Cen- sus Bureau projections (2012) are that by 2060, Hispanics/Latinos of any race will increase by 70 million to represent 31% of the total, while White non-Hispanics will decrease from 63% to 43% of the total.
Nurses are predominantly White and in percentage dispropor- tionate to the demographic profile of the United States. Until recently, most statistics came from the National Sample Survey of Registered Nurses (NSSRN), but the last of those surveys was conducted in 2008 (USDHHS Health Resources and Service Administration Bureau of Health Professions, 2010). However, exact data varies according to the method used to collect it. For example, the NSSRN estimated that 5.4% of RNs in 2008 were Black, whereas the U.S. Census bureau surveys re- ported that 12% of RNs were Black in 2010 (U.S. Department of Labor, Bureau of Labor Statistics, 2011) and 11.5% were Black in 2012 (U.S. Department of Labor, Bureau of Labor Statistics, 2013). Similarly, the percentage of Hispanic and Asian RNs was reported to be almost half as many in the NSSRN survey when compared to the more recent cen- sus data. Given that the nurse workforce demographics do not reflect national demographics, it is essential that nurses be committed to re- ducing health care disparities by providing culturally responsive care.
IMMIGRATION According to the U.S. Census Bureau (2011), the foreign-born popu- lation in the United States numbered 40 million in 2010, which corre- sponds to 12.9% of the total U.S. population. Of these, 53% were born in Latin America (Central and South America), 28% in Asia, 12% in Europe, and the remaining 7% in other regions of the world. The larg- est numbers were born in Mexico (11.7 million), China (2.2 million), and India (1.8 million).
As immigrants become participants in the dominant culture, they may continue to identify as members of the culture from which they originate. People immigrating to the United States from any country will be associated with their native countries for many years, if not for all of their lives. The involuntary process of acculturation occurs when people incorporate traits from another culture. The members of the nondominant cultural group are often forced to adopt the new culture to survive. Acculturation can also be defined as the changes of one’s cultural patterns to those of the host society. Assimilation is the process by which an individual develops a new cultural identity. Assimilation means becoming like the members of the dominant culture. The process of assimilation encompasses vari- ous aspects, such as behavioral, marital, identification, and civic. The underlying assumption is that the person from a given cultural group loses his or her original cultural identity to acquire the new one. In fact, because this is a conscious effort, it is not always possible, and the
community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity. The mission of the NPA is to increase the effectiveness of programs that target the elimination of health disparities through the coordi- nation of partners, leaders, and stakeholders committed to action.
• The NPA released the National Stakeholder Strategy for Achieving Health Equity in 2011, a common set of goals and objectives for public and private sector initiatives and partnerships to help racial and ethnic minorities and other underserved groups reach their full health potential.
• The USDHHS 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities was written to operationalize the national strat- egy and the Affordable Care Act.
• The Office of Minority Health, established in 1986, was reau- thorized in 2010 “to improve and protect the health of racial and ethnic minority populations through the development of health policies and programs that will eliminate health disparities” (USDHHS OMH, 2011). In collaboration with other organiza- tions, it developed the National Standards for Culturally and Lin- guistically Appropriate Services in Health Care (CLAS), which were enhanced in 2012. “The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to provide effective, equitable, understandable, and respectful quality care and services that are responsive to di- verse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs” (USDHHS OMH, 2012). Culture and language have a considerable impact on how clients access and respond to health care services.
• The Centers for Disease Control and Prevention (CDC) (2012) also has an Office of Minority Health and Health Equity that “aims to accelerate CDC’s health impact in the U.S. population and to eliminate health disparities for vulnerable populations as defined by race/ethnicity, socio-economic status, geography, gender, age, disability status, risk status related to sex and gender, and among other populations identified as at-risk for health disparities.”
• The mission of the National Center on Minority Health and Health Disparities (NCMHD, n.d.), within the National Institutes of Health (NIH), is also to improve minority health and eliminate health disparities. It plans, reviews, coordinates, evaluates, trans- lates, and disseminates all minority health and health disparities research and activities of the National Institutes of Health.
• The nursing profession plays a major role in a CDC program ti- tled Racial and Ethnic Approaches to Community Health Across the United States (REACH U.S.). REACH U.S. strives to eliminate racial and ethnic disparities (inequalities) in infant mortality; in screening and management of breast and cervical cancer, cardio- vascular diseases, diabetes, hepatitis, tuberculosis, asthma, and HIV infections/AIDS; and in infant mortality and child and adult immunizations. This program has achieved significant results, which are profiled on the agency website.
• One of the major goals of Healthy People is to eliminate health dis- parities by gender, race or ethnicity, education, income, disability, geographic location, and sexual orientation (details of Healthy People 2020 are discussed in Chapter 16 ). To achieve these goals, the Health Resources and Services Administration (HRSA) aims to increase the number of underrepresented racial and eth- nic groups entering the nursing profession through grants and
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American Association of Colleges of Nursing Competencies In 2008, the American Association of Colleges of Nursing (AACN) published end-of-program cultural competencies for baccalaureate nursing education. These five competencies should be used to guide nursing practice:
1. Apply knowledge of social and cultural factors that affect nurs- ing and health care across multiple contexts.
2. Use relevant data sources and best evidence in providing cultur- ally competent care.
3. Promote achievement of safe and quality outcomes of care for diverse populations.
4. Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities.
5. Participate in continuous cultural competency development.
Cultural Competence According to Campinha-Bacote (2011), cultural competence is “the ongoing process in which the health care professional continu- ously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, commu- nity).” Cultural competence has five constructs:
• Cultural desire: the motivation to “want to” engage in the process of becoming culturally aware, culturally knowledgeable, cultur- ally skillful, and seeking cultural encounters
• Cultural awareness: self-examination of one’s own prejudices and biases toward other cultures, and an in-depth exploration of one’s own cultural/ethnic background
• Cultural knowledge: obtaining a sound educational foundation concerning the various worldviews of different cultures
• Cultural skills: the ability to collect culturally relevant data re- garding the client’s health in a culturally sensitive manner
• Cultural encounters: engaging in face-to-face cultural interac- tions with persons from diverse backgrounds, and learning to modify one’s existing beliefs and prevent possible stereotyping.
HEALTH Traditions Model Another model for providing culturally responsive care is to view health holistically, as a complex, interrelated, threefold phenom- enon, that is, as the balance of all aspects of the person—the body, mind, and spirit. The HEALTH traditions model (Spector, 2013) is predicated on the concept of holistic health and describes what people do from a traditional perspective to maintain, protect, and restore health. In this context, the term traditional refers to those customs, beliefs, or practices that have existed for many generations without changing.
• The body includes all physical aspects, such as genetic inheritance, body chemistry, gender, age, nutrition, and physical condition.
• The mind includes cognitive processes, such as thoughts, memo- ries, and knowledge of such emotional processes as feelings, de- fenses, and self-esteem.
• The spirit includes both positive and negative learned spiritual practices and teachings, dreams, symbols, stories, protecting forces, and metaphysical or native forces.
process may cause severe stress and anxiety. Assimilation can also be described as a process of inclusion through which a person gradually ceases to conform to standards of life that differ from the dominant group standards and, at the same time, a process through which the person learns to conform to the dominant group standards.
The concepts of assimilation and acculturation are complex and sensitive. The dominant society may expect that all immigrants are in the process of becoming acculturated and assimilated and that the worldview that we have as nurses is commonly shared by our clients. Because we live in a society with many cultures, however, many varia- tions of health beliefs and practices exist.
CULTURAL MODELS OF NURSING CARE “The responsibility of supporting cultural competence is shared among individual nurses, employers, educators, professional asso- ciations, regulatory bodies, unions, accreditation organizations, gov- ernment and the public” (Canadian Nurses Association, 2010, p. 2). Culturally responsive care takes into account the context in which the client lives as well as the situations in which the client’s health prob- lems arise. Culturally responsive care is essential and nurses must be able to assess and interpret a given client’s health beliefs, practices, and cultural needs. Countless conflicts in the health care delivery arenas result from cultural misunderstandings. Although many of these misunderstandings are related to universal situations such as verbal and nonverbal language misunderstandings, the conventions of courtesy, sequencing of interactions, phasing of interactions, and objectivity, many cultural misunderstandings are unique to the de- livery of nursing and health care. Culturally responsive care alters the perspective of nursing care delivery because it enables the nurse to understand, from a cultural perspective, the manifestations of the client’s health care beliefs and practices. Several cultural models are used to guide nursing care of the client.
The term transcultural nursing has been promulgated by nurse Madeleine Leininger since the 1950s. Transcultural nursing fo- cuses on providing care within the differences and similarities of the beliefs, values, and patterns of cultures (Leininger & McFarland, 2010). Leininger created the theory of culture care diversity and universality.
LIFESPAN CONSIDERATIONS International Adoption
CHILDREN International adoption of children by families in the United States is increasing. These children present many challenges, and the care given by pediatric health providers can strongly influence the suc- cess with which they are assimilated into their new families. Under- standing and assessing adopted children’s potential issues early and intervening appropriately can lead to stronger family bonds. Children who arrive in the United States should be evaluated within 10 to 14 days for the following: • Immunization history (blood titers may be appropriate) • Infectious disease, parasites, general health (CBC, thyroid,
liver function, and other blood work) • Tuberculosis exposure (PPD) • Developmental history and status, including speech,
language, motor, and social development • Vision and hearing • Dental health.
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These aspects are in constant flux and change over time, yet each is completely related to the others and also related to the context of the person. The context includes the person’s family, culture, work, com- munity, history, and environment.
The HEALTH traditions model, shown in Table 18–1, consists of nine interrelated facets, represented by the following:
1. Traditional methods of maintaining HEALTH—physical, men- tal, and spiritual—may include following a proper diet and wear- ing proper clothing, concentrating and using the mind, and practicing one’s religion.
2. Traditional methods of protecting HEALTH—physical, mental, and spiritual—may include wearing protective objects, such as amulets, avoiding people who may cause trouble, and placing religious objects in the home.
3. Traditional methods of restoring HEALTH—physical, mental, and spiritual—may include the use of herbal remedies, exorcism, and healing rituals.
SYMBOLIC EXAMPLES Figure 18–2 • depicts symbolic, HEALTH-related images that may be used by people of different heritages to maintain, protect, or re- store physical, mental, or spiritual HEALTH.
1. Thousand-year-old eggs represent traditional foods that may be eaten daily to maintain physical HEALTH (China).
2. The enjoyment of nature, the natural environment, may be a universal way of maintaining mental HEALTH.
3. The Islamic prayer represents a way of maintaining spiritual HEALTH (East Jerusalem).
4. Red string may be worn to protect physical HEALTH (Tomb of Rachel in Bethlehem, Israel).
5. The eye represents the plethora of eye-related objects that may be worn or hung in the home to protect the mental HEALTH of people by shielding them from the envy and bad wishes of oth- ers (Cuba).
Physical Mental Spiritual
MAINTAIN HEALTH Proper clothing Proper diet Exercise/rest
Concentration Social and family support systems Hobbies
Religious worship Prayer Meditation
PROTECT HEALTH Special foods and food combination Symbolic clothing
Avoid certain people who can cause illness Family activities
Religious customs Superstitions Wearing amulets and other symbolic objects to prevent the “evil eye” or defray other sources of harm
RESTORE HEALTH Homeopathic remedies Liniments Herbal teas Special foods Massage Acupuncture/moxibustion
Relaxation Exorcism Curanderos and other traditional healers Nerve teas
Religious rituals, special prayers Meditation Traditional healings Exorcism
From Cultural Diversity in Health and Illness, 8th ed. (p. 93), by R. E. Spector, 2013, Upper Saddle River, NJ: Pearson Education. Reprinted with permission.
The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and Personal Methods of Maintaining Health, Protecting Health, and Restoring HealthTABLE 18–1
Figure 18–2 • Symbols of the HEALTH traditions model and themes.
6. The thunderbird may be worn for spiritual protection and good luck (Hopi Nation).
7. The herbal remedy represents aromatic plants that may be used by people from all ethnocultural traditional backgrounds as one method of restoring physical HEALTH (Africa).
8. Tiger balm represents substances that are used in massage ther- apy as a way of restoring mental HEALTH (Singapore).
9. Rosary beads symbolize prayer and meditation methods used in the spiritual restoration of HEALTH (Italy).
There are an infinite number of examples one could present, and many of these symbols are used across many cultures. A major as- pect of conducting the heritage assessment of a client is to deter- mine what items are used by a specific person and its meaning to the person.
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childbirth is seen as a “cold” condition. To reduce a fever, conven- tional scientific thought recommends cooling the body. The primary care provider may order liquids for the client and cool compresses to be applied to the forehead, the axillae, or the groin. In contrast, many cultures believe that the best way to treat a fever is to increase elimina- tion of toxins through sweat baths. Clients from these cultures may want to cover up with several blankets, take hot baths, and drink hot beverages.
The nurse must keep in mind that a treatment strategy that is consistent with the client’s beliefs may have a better chance of being successful. For example, the Latino client who avoids “hot” foods when experiencing a stomach disturbance may be eating foods consistent with the bland diet that is normally prescribed by pri- mary care providers. Even when a practice is different from what would be prescribed, the nurse should consider whether any harm is resulting from the practice, and take caution to not judge different as wrong.
Sociocultural forces, such as politics, economics, geography, re- ligion, and the predominant health care system, influence the client’s health status and health care behavior. For example, someone who has limited access to scientific health care may turn to folk medicine or folk healing. Folk medicine is defined as those beliefs and prac- tices relating to illness prevention and healing that derive from cul- tural traditions rather than from modern medicine’s scientific base. Many individuals have special teas or “cures” (such as chicken soup) used by older family members to prevent or treat colds, fevers, in- digestion, and other common health problems. Why do individuals use traditional healing methods? Folk medicine is thought to be more humanistic than biomedical health care. The consultation and treat- ment take place in the community of the recipient, frequently in the home of the healer. It may be less expensive than scientific or biomed- ical care. The healer often prepares the treatments, for example, herbs to be ingested, poultices to be applied, or charms or amulets to be worn. A frequent component of treatment is some ritual practice on the part of the healer or the client to cause healing to occur. Because folk healing is more culturally based than conventional medicine as practiced in the United States, it is often more comfortable and less frightening for the client.
PROVIDING CULTURALLY RESPONSIVE CARE The nurse must gain cultural knowledge regarding people’s various worldviews in order to provide care to a client. The nurse must then use this knowledge by acquiring the awareness, attitudes, and skills to care for diverse populations. Although nurses cannot possibly learn every cultural perspective, they can, at minimum, become familiar with the cultures within the communities that they serve, and be re- ceptive to differing viewpoints. The cultural perspectives in the fol- lowing sections serve as examples, and should not serve as the nurse’s only cultural knowledge base.
Health Beliefs and Practices Three commonly held views of health beliefs include magico- religious, scientific, and holistic. In the magico-religious health belief view, health and illness are controlled by supernatural forces. The client may believe that illness is the result of “being bad” or op- posing the creator(s)’ will. Getting well is also viewed as dependent on the will of the creator(s). The client may make statements such as “If it is God’s will, I will recover” or “What did I do wrong to be pun- ished with cancer?” Some cultures believe that magic can cause ill- ness. Some people view illness as possession by an evil spirit. Others believe a sorcerer or witch may have placed a spell or hex on the cli- ent. Although these beliefs are not supported by empirical evidence, clients who hold these beliefs may in fact become ill as a result. Such illnesses may require magical treatments in addition to scientific treatments. For example, a man who experiences headaches after be- ing told that a spell has been placed on him may recover only if the spell is removed by the culture’s healer, and he may, in fact, not need a scientific intervention.
The scientific or biomedical health belief is based on the belief that life is controlled by physical and biochemical processes that can be manipulated by humans. The client with this view will be- lieve that illness is caused by germs, viruses, bacteria, or a breakdown of the body. This client will expect a pill, treatment, or surgery to cure health problems.
The holistic health belief holds that the forces of nature must be maintained in balance or harmony. Human life is one aspect of nature that must be in harmony with the rest of nature. When the natural balance or harmony is disturbed, illness results. The medicine wheel (Figure 18–3 •) is an ancient symbol used by Native Americans of North and South America to express many concepts. For health and wellness, the medicine wheel teaches the four aspects of the individual’s nature: the physical, the mental, the emotional, and the spiritual. The four dimensions must be in bal- ance to be healthy. The medicine wheel can also be used to express the individual’s relationship with the environment as a dimension of wellness.
The concept of yin and yang (in the Chinese culture) and the hot–cold theory of illness in many cultures (such as Middle Eastern, Spanish, and Asian) are examples of holistic health beliefs. When a Chinese client has a yin illness or a “cold” illness such as cancer, the treatment may include a yang or “hot” food (e.g., hot tea).
What is considered hot or cold varies considerably across cul- tures. In many cultures, the mother who has just delivered a baby is offered warm or hot foods and kept warm with blankets because
Figure 18–3 • A medicine wheel in Arizona. Nick Hanna/Alamy.
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members. The woman is expected to maintain the home and raise the children.
Cultural family values may also dictate the extent of the family’s involvement in the hospitalized client’s care. In some cultures, only the nuclear and the extended family will want to visit for long peri- ods and participate in care. In other cultures, the entire community may want to visit and participate in the client’s care. The nurse should evaluate the positive benefits of family participation in the client’s care and adapt visiting policies as appropriate. The nurse must also recognize that family roles often shift during hospitalization.
Cultures that value the needs of the extended family as much as those of the individual may believe that personal and family informa- tion must stay within the family. Some cultural groups are very reluc- tant to disclose family information to outsiders, including health care professionals. This attitude can present difficulties for health care professionals who require knowledge of family interaction patterns to help clients with emotional problems.
Naming systems in many cultures differ from those in North America. In some cultures (e.g., Japanese and Vietnamese), the family name comes first and the given name second. One or two names may be added between the family and given names. Other nomenclature may be used to delineate gender, child, or adult status. For example, in traditional Japanese culture, adults address other adults by their surname followed by san, meaning Mr., Mrs., or Miss. An example is Maurakami san. The children are referred to by their first names fol- lowed by kun for boys and chan for girls. Sikhs and Hindus tradition- ally have three names. Sikhs have a personal name, then the title Singh for men and Kaur for women, and lastly the family name. Hindus have a personal name, a complimentary name, and then a family name. Names by marriage also vary. In Central America, a woman who marries retains her father’s name and takes her husband’s. For example, if Louisa Viccario marries Carlos Gonzales, she becomes Louisa Viccario de Gonzales. The connecting de means “belonging to.” Their son is Pedro Gonzales Viccario. Nurses need to become fa- miliar with appropriate ways to address clients, and ask clients about their preferences.
Communication Style Communication and culture are closely interconnected. Through communication, the culture is transmitted from one generation to the next, and knowledge about the culture is transmitted within the group and to those outside the group. Communicating effectively with clients of various ethnic and cultural backgrounds is critical to providing culturally competent nursing care. Cultural variations are seen in both verbal and nonverbal communication.
CLAS standards under the category of Communication and Language Assistance require health care agencies to:
• Offer language assistance to individuals who have limited En- glish proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
• Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
• Ensure the competence of individuals providing language assis- tance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
It is important for the nurse to obtain information about folk or family healing practices that may have been used before or while the client used conventional medical treatment. Often clients are re- luctant to disclose the use of home remedies to health care profes- sionals for fear of being laughed at or rebuked. However, a study on complementary and alternative medicine (CAM) use among adults in 2007 indicated that 38% of adults in the United States had used some form of CAM therapy during the previous 12 months, includ- ing most commonly natural products, deep breathing, meditation, massage, and yoga (Barnes, Bloom, & Nahin, 2008). The increased use of traditional, alternative, and complementary healing practices in the United States represents an opportunity for nurses to inform clients about what the nursing profession offers in this regard (see Chapter 19 ).
CLINICAL ALERT!
Treatments once considered to be folk treatments, including acupunc- ture, therapeutic touch, and massage, are now being investigated for their therapeutic effect. The National Center for Complementary and Alternative Medicine at the National Institutes of Health provides up- to-date information on this line of research.
Family Patterns The family is considered the basic unit of society; however, the con- cept of family is complex and influenced by personal and social values. There is no agreed-on definition of family and there is great diversity in family types and structures (see Chapter 24 ). Cultural values greatly influence communication patterns within the fam- ily group, the norm for family size, and the roles of specific family members. In some families, the man is considered the provider and decision maker. The woman may need to consult her husband be- fore making decisions about her medical treatment or the treatment of her children. Some families are matriarchal; that is, the mother or grandmother is viewed as the leader of the family and is usually the decision maker. The nurse needs to identify who has the “authority” to make decisions in a client’s family. If the decision maker is someone other than the client, the nurse needs to obtain the client’s permission and then include that person in health care discussions.
The value placed on children and older adults within a society is culturally derived. In some cultures, children are not disciplined by spanking or other forms of physical punishment. Rather, chil- dren are allowed to interact with their environment while caregivers provide subtle direction to prevent harm or injury. In other cultures, older adults are considered the holders of the culture’s wisdom and are therefore highly respected. Responsibility for caring for older relatives is determined by cultural practices. In many cultures, older relatives who cannot live independently live with a married son or daughter and family.
Cultural gender-role behavior may also affect nurse–client in- teractions. In some countries, men dominate and women have little status. Men from these countries may not accept instruction from a female nurse or primary care provider, but will be receptive to the same instruction given by a male nurse or primary care provider. Some cultures have a prevailing concept of machismo, or male su- periority. The positive aspects of machismo require that the adult man provide for and protect his family, including extended family
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that the interpreted message has the potential of eliciting the same response in the listener as the original message. The clinical encoun- ter is a highly interactive process in which the nurse uses language to understand, evaluate, and provide teaching. The interpreter must also serve as a cultural broker and engage both provider and client effectively and efficiently in accessing the nuances and hidden socio- cultural assumptions embedded in each other’s language (Interna- tional Medical Interpreters Association, 2007). Health care facilities accredited by The Joint Commission are required to have qualified and competent interpreters available for clients who require them. The interpreter may be on-site, available by telephone, or through videoconferencing. Studies have shown that fewer errors occur when professional (trained) interpreters are used with LEP clients (Flores, Abreu, Barone, Bachur, & Lin, 2012). The first U.S. standards for certification of medical interpreters were implemented in 2010 by the National Board of Certification for Medical Interpreters. Many institutions that are located in culturally diverse communities have interpreters available on staff or maintain a list of employees who are fluent in other languages. Embassies, consulates, ethnic churches (e.g., Russian Orthodox, Greek Orthodox), ethnic clubs (e.g., Polish American Club, Italian American Club), or telephone companies may also be able to provide interpreters. However, asking a family member or other nonprofessional to interpret can create difficulties. Cultural rules often dictate who can discuss what with whom. Guide- lines for using an interpreter are listed in the Practice Guidelines.
Nurses and other health care providers must remember that cli- ents for whom English is a second language may lose command of their English when they are in stressful situations. Clients who have used English comfortably for years in social and business commu- nication may forget and revert back to their primary language when they are ill or distressed. It is important for the nurse to assure the client that this is normal and to promote behaviors to facilitate verbal communication.
• Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area (USDHHS OMH, 2012).
VERBAL COMMUNICATION The most obvious cultural difference is in verbal communication: vo- cabulary, grammatical structure, voice qualities, intonation, rhythm, speed, pronunciation, and silence. In North America, the dominant language is English; however, immigrant groups who speak English still encounter language differences because English words can have different meanings in different English-speaking cultures. For ex- ample, in the United States, a boot is a type of footwear that comes to the ankle or higher; in England, a boot can also be the trunk of a car. Spanish is spoken by people throughout the world. It is the second most commonly spoken language in the United States. Nevertheless, each cultural group that speaks Spanish may speak with different ac- cents and dialects, using different vocabulary, rules of grammar, and pronunciation, so that often two Spanish-speaking people of differ- ent cultures may not completely understand each other.
Initiating verbal communication may be influenced by cultural values. The busy nurse may want to complete nursing admission as- sessments quickly. The client, however, may be offended when the nurse immediately asks personal questions. In some cultures, social courtesies should be established before business or personal topics are discussed. Discussing general topics can convey that the nurse is interested and has time for the client. This enables the nurse to de- velop a rapport with the client before progressing to discussion that is more personal.
Verbal communication becomes even more difficult when an in- teraction involves people who speak different languages. Both clients and health professionals experience frustration when they are unable to communicate verbally with each other. Techniques for therapeutic communication with individuals who have limited English are listed in the accompanying Practice Guidelines.
For the client whose language is not the same as that of the health care provider, an intermediary may be necessary. A translator con- verts written material (such as client education pamphlets) from one language into another. Interpretation moves beyond translation. An interpreter is able to transform the message expressed in a spoken or signed source language into its equivalent in a target language, so
PRACTICE GUIDELINES
Verbal Communication with Clients Who Have Limited English Proficiency (LEP)
• Avoid slang words, medical terminology, and abbreviations. • Augment spoken conversation with congruent gestures or
pictures to increase the client’s understanding. • Speak slowly, in a respectful manner, and at a normal volume.
Speaking loudly does not help the client understand and may be offensive.
• Frequently validate the client’s understanding of what is being communicated. Do not automatically interpret a client’s smiling and nodding to mean that the client understands; the client may only be trying to please the nurse and not understand what is being said.
• Use print resources that have been designed especially for clients with LEP.
PRACTICE GUIDELINES
Using an Interpreter
• Avoid asking a member of the client’s family, especially a child or spouse, to act as interpreter. The client, not wishing family members to know about his or her problem, may not provide complete or accurate information. A child who is used as interpreter may be exposed to language and concepts they are not developmentally ready for.
• Be aware of gender and age differences; it is preferable to use an interpreter of the same gender as the client to avoid embarrassment and faulty translation of sexual matters.
• Choose an interpreter who is politically or socially compatible with the client. For example, a Bosnian Serb may not be the best interpreter for a Muslim, even if he speaks the language.
• Address the questions to the client, not to the interpreter. • Ask the interpreter to interpret as closely as possible the
words used by the nurse. • Speak slowly and distinctly. Do not use metaphors, for
example, “Does it swell like a grapefruit?” or “Is the pain stabbing like a knife?”
• Observe the facial expressions and body language that the client assumes when listening and talking to the interpreter.
• Become aware of the individual expressions and colloquial words used in specific regions and acknowledge them when using interpreting services.
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the family. To provide safe and effective care, nurses who work with specific cultural groups should learn more about cultural behavior and communication patterns within these cultures.
Nonverbal communication can include the use of silence, touch, eye movement, facial expressions, and body posture (Figure 18–4 •). Some cultures are quite comfortable with long periods of silence, whereas others consider it appropriate to speak before the other person has finished talking. Many people value silence and view it as essential to understanding a person’s needs or use silence to preserve privacy. Some cultures view silence as a sign of respect, whereas to other people silence may indicate agreement.
Touching involves learned behaviors that can have both positive and negative meanings. In the American culture, a firm handshake is a recognized form of greeting that conveys character and strength. In some European cultures, greetings may include a kiss on one or both cheeks. In some societies, touch is considered magical and because of
SELF-CARE ALERT
Bilingual nurses may provide nursing care in any language they speak. Nurses who speak a second language may be asked to interpret for others. However, nursing schools and health care institutions may prohibit nurses or nursing students from interpreting for other health care providers unless they have received specialized training and are approved as language assistants or medical interpreters. Check the institution’s policy before agreeing to interpret for institutional staff and primary care providers.
NONVERBAL COMMUNICATION To communicate effectively with culturally diverse clients, the nurse needs to be aware of two aspects of nonverbal communication behav- iors: what nonverbal behaviors mean to the client and what specific nonverbal behaviors mean in the client’s culture. Before assigning meaning to nonverbal behavior, the nurse must consider the possibil- ity that the behavior may have a different meaning for the client and
Figure 18–4 • Nonverbal gestures may have different meanings for different cultures and age groups. A, Christine Schneider/Cusp/Cusp; B, Stockbyte/Getty Images; C, Dag Sundberg/The Image Bank/Getty Images; D, Steve Gordon/Dorling Kindersley Limited; F, Stockbyte/Getty Images; G, Jeff Greenberg/PhotoEdit.
A B C
D E F
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the client. The client may physically withdraw or back away if the nurse is perceived as being too close. The nurse will need to explain to the client why there is a need to be close. To assess the lungs with a stethoscope, for example, the nurse needs to move into the client’s in- timate space. The nurse should first explain the procedure and, when possible, await permission to continue.
Clients who reside in long-term care facilities, or who are hos- pitalized for an extended time, may want to personalize their space. They may want to arrange their room differently or con- trol the placement of objects on their bedside cabinet. The nurse should be responsive to clients’ needs to have some control over their space. When there are no medical contraindications, clients should be permitted and encouraged to have objects of personal sig- nificance. Having personal and cultural items in one’s environment can increase self-esteem by promoting not only one’s individuality but also one’s cultural identity. Of course, the nurse should caution the client about the risk for loss or damage of personal items in the health care setting.
Time Orientation Time orientation refers to an individual’s focus on the past, the pres- ent, or the future. Most cultures include all three time orientations, but one orientation is more likely to dominate. The European- American focus on time tends to be directed to the future, empha- sizing time and schedules. European Americans often plan for next week, their vacation, or their retirement. Other cultures may have a different concept of time. For example, the Navajo Indians are pres- ent and past oriented, and do not have a word for “late.” A Navajo mother may view her child’s development differently from European Americans, and might not measure her child’s milestones such as toi- leting and walking by the same targeted schedule as other cultures. African Americans are often generalized as present oriented as well, with a focus on current health status, rather than the anticipation of what may happen in the future. Socioeconomic status may also influ- ence time orientation. The middle class is generally future oriented; however, lower socioeconomic classes are generally present oriented because of the focus on daily survival, which may not allow for the luxury of being able to plan for the future.
The culture of nursing and health care values punctuality and is future oriented. Appointments are scheduled, and treatments are pre- scribed with time parameters (e.g., changing a dressing once a day). Medication orders include how often a medicine is to be taken and when (e.g., digoxin 0.25 mg, once a day, in the morning). Nurses need to be aware of the meaning of time for clients. When caring for clients who are “present oriented,” it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments. For example, instead of telling the client to take digoxin every day at 10:00 am, the nurse might tell the client to take it every day in the morning or every day af- ter getting out of bed. The nurse may also consider telling the client that even if the client feels well they may still need to take the medication.
Nutritional Patterns Most cultures have staple foods that are plentiful or readily accessible in the environment. For example, the staple food of Asians is usu- ally rice; and of Europeans it may be wheat or pasta. Even clients who have been in the United States for several generations often continue to eat the foods of their cultural homeland.
the belief that the soul can leave the body on physical contact, casual touching is forbidden. In some Asian cultures only certain older peo- ple are permitted to touch the head of others, and children are never patted on the head. Nurses should therefore touch a client’s head only with permission. Cultures dictate what forms of touch are appropri- ate for individuals of the same and opposite gender. In many cultures, for example, a kiss is not appropriate for a public greeting between individuals of the opposite sex, even those who are family members; however, a kiss on the cheek is acceptable as a greeting among indi- viduals of the same sex. The nurse should watch interaction among clients and families for cues to the appropriate degree of touch in that culture. The nurse can also assess the client’s response to touch when providing nursing care, for example, by noting the client’s reaction to the physical examination or the bath. The nurse should also inquire about clients’ preferences, and inform clients before touching them, and whenever possible proceed after obtaining permission. For ex- ample, “I would like to check your pulse, and I will need to hold your wrist. Is that okay?”
Facial expression can also vary among cultures. In some cul- tures, individuals are more likely to smile readily and use facial ex- pressions to communicate feelings, whereas in others, individuals may use fewer facial expressions and may be less open in their re- sponse, especially to strangers. Facial expressions can also convey a meaning opposite to what is felt or understood.
Eye movement during communication has cultural founda- tions. In many Western cultures, direct eye contact is regarded as important and generally shows that the other is attentive and listen- ing. It is assumed to convey self-confidence, openness, interest, and honesty. Lack of eye contact may be interpreted as secretiveness, shy- ness, guilt, lack of interest, or even a sign of mental illness. However, other cultures may view direct eye contact as impolite or an invasion of privacy. In the Hmong culture, for example, continuous direct eye contact is considered rude, but intermittent eye contact is acceptable. The nurse must consider the cultural context to avoid misinterpret- ing avoidance of eye contact.
Body posture and hand gestures are also culturally learned. For example, the V sign means victory in some cultures, but it is an of- fensive gesture in other cultures. Giving someone a thumbs up may mean “right” or “great job” in the United States, but is an obscene ges- ture in many Middle Eastern countries, equivalent to a raised middle finger in the United States. Tapping the index finger on one’s temple may mean someone is intelligent in the United States but “crazy” in The Netherlands.
Space Orientation Space is a relative concept that includes the individual, the body, the surrounding environment, and objects within that environment. The relationship between the individual’s own body and objects and indi- viduals within that space is learned and is influenced by culture. For example, in nomadic societies, space is not owned; it is occupied tem- porarily until the tribe moves on. In many Western societies people tend to be more territorial, as reflected in phrases such as “This is my space” or “Get out of my space.” Spatial distances may be defined as the intimate zone, the personal zone, and the social and public zones. The size of these areas may vary with the specific culture. Nurses move through all three zones as they provide care for clients. The nurse needs to be aware of the client’s response to movement toward
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Developing Self-Awareness In learning how to provide culturally responsive care, the nurse must first understand his or her own culture, beliefs, and assumptions. Many models have been documented in the literature to deepen this self-exploration. Campinha-Bacote (2007) offers the ASKED mne- monic model to develop cultural consciousness: Awareness, Skill, Knowledge, Encounters, Desire. Using this model, nurses reflect on questions which focus on how well prepared they are to acknowledge their own biases, their openness to embracing differences in people, and their willingness to learn appropriate means of communicating and caring for diverse populations.
Other self-identity questions may include the following ( Tochluk, 2010):
• When did you first realize you were a member of your race/ ethnicity? What did it mean to you at that time?
• How did your culture/race/ethnicity play a role in your childhood and/or adolescence?
• What important events changed your relationship to race/ethnicity? What happened?
• What significant people/relationships shaped the way you experi- ence being a member of your race/ethnicity?
• How do you understand what it means to be a member of your race/ethnicity at this time in your life?
Health-related questions may include:
• How does your ethnic/racial group view health and illness? • What are the common healing practices in your ethnic/racial
group? • What are examples of your family’s traditional health and illness
beliefs and practices? • Do they value stoic behavior in relation to pain, or is it permissible
to state that you are in pain? Are the rights of the individual valued over and above the rights of the family?
• What is your view on health? How does it compare to your family’s view of health?
• What beliefs do you hold about health care providers?
Conveying Cultural Sensitivity The process of cultural assessment is important. How and when ques- tions are asked requires sensitivity and clinical judgment. The tim- ing and phrasing of questions need to be adapted to the individual. Timing is important in introducing questions. Sensitivity is needed in phrasing questions. Trust must be established before clients can be expected to volunteer and share sensitive information. The nurse therefore needs to spend time with clients and convey a genuine de- sire to understand their values and beliefs.
Before conducting a cultural assessment, determine what lan- guage the client speaks and the client’s degree of fluency in the English language. It is also important to learn about the client’s communi- cation patterns and space orientation. This is accomplished by ob- serving both verbal and nonverbal communication. For example, does the client do the speaking or defer to another? What nonverbal communication behaviors does the client exhibit (e.g., touching, eye contact)? What significance do these behaviors have for the nurse– client interaction? What is the client’s proximity to other people and objects within the environment? How does the client react to the
The way food is prepared and served is also related to cultural practices. For example, in the United States a traditional food served for the Thanksgiving holiday is stuffed turkey; however, in different regions of the country the contents of the stuffing may vary. In South- ern states, the stuffing may be made of cornbread; in New England, of seasoned bread and chestnuts.
The way in which staple foods are prepared also varies. For ex- ample, some Asian cultures prefer steamed rice; others prefer boiled rice. Southern Asians from India prepare unleavened bread from wheat flour rather than the leavened bread of European Americans.
Food-related cultural behaviors can include whether to breast- feed or bottle-feed infants, and when to introduce solid foods to them. Food can also be considered part of the remedy for illness. Foods clas- sified as “hot” foods or foods that are hot in temperature may be used to treat illnesses that are classified as “cold” illnesses. For example, corn- meal (a “hot” food) may be used to treat arthritis (a “cold” illness). Each cultural group defines what it considers to be hot and cold entities.
Religious practice associated with specific cultures also affects diet. Some Roman Catholics avoid meat on certain days, such as Ash Wednesday and Good Friday, and some Protestant faiths prohibit meat, tea, coffee, or alcohol. Both Orthodox Judaism and Islam pro- hibit the ingestion of pork or pork products. Orthodox Jews observe kosher customs, eating certain foods only if they have been inspected by a rabbi and prepared according to certain dietary laws. For exam- ple, the eating of milk products and meat products at the same meal is prohibited. Some Buddhists, Hindus, and Sikhs are strict vegetarians. The nurse must be sensitive to such religious dietary practices.
Box 18–1 lists texts authored by nurses that may be helpful in developing cultural knowledge.
● ◯ ● NURSING MANAGEMENT All phases of the nursing process are affected by the client’s and the nurse’s cultural values, beliefs, and behaviors. As the client’s culture and the nurse’s culture come together in the nurse–client relationship, a unique cultural environment is created that can improve or impair the client’s outcome. Self-awareness of personal biases can enable nurses to develop modifying behaviors or (if they are unable to do so) to remove themselves from situations where care may be compro- mised. Nurses can become more aware of their own culture through values clarification (see Chapter 5 ). The nurse must also consider the cultural values dominant in the health care setting because those, too, may influence the client’s outcome.
BOX 18–1 Selected Nurse-Authored Texts
Andrews, J. D., & Boyle, J. S. (2011). Transcultural concepts in nursing care (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Giger, J. N., & Davidhizar, R. E. (2012). Transcultural nursing: Assessment & intervention (6th ed.). St. Louis, MO: Mosby Elsevier.
Kersey-Matusiak, G. (2013). Delivering culturally competent nursing care. New York, NY: Springer.
Purnell, L. D. (2012). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis.
Sagar, P. (2012). Transcultural nursing theory and models: Application in nursing education, practice, and administration. New York, NY: Springer.
Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson.
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Assessing In creating a plan of care that is culturally responsive, many assess- ment tools are available. The tools are a way of interviewing and fa- cilitating communication with clients and their families, and may be used in any setting. The LEARN model and the 4 C’s are quick assess- ment tools to better understand the client’s perspective. LEARN is a commonly used tool (Berlin & Fowkes, 1983):
Listen actively with empathy to the client’s perception of the problem. Explain what you think you heard/ask for clarification. Acknowledge the importance of what is said and what it means. Recommend inclusive strategies. Negotiate the plan of care by collaborating with the client and
others.
The 4 C’s of Culture were developed by Slavin, Galanti, and Kuo (as cited in Galanti, 2012).
1. What do you call your problem? (Remember to ask “What do you think is wrong?” or “What is concerning/worrying you?” to get at the client’s perception of the problem. You should not liter- ally ask, “What do you call your problem?”)
2. What do you think caused your problem? (This gets at the client’s beliefs regarding the source of the problem.)
3. How do you cope with your condition? (You may want to phrase this as “What have you done to try to make it better? Who else have you been to for treatment?”)
4. What are your concerns regarding the condition and/or rec- ommended treatment? (This should address questions such as “How serious do you think this is?” “What potential complica- tions do you fear?” “How does it interfere with your life, or your ability to function?” “Do you know anyone else who has tried the treatment I’ve recommended? What was their experience with it?”)
The Heritage Assessment Interview depicts the questions to ask when conducting a heritage assessment. It is designed to enhance the process in order to determine if clients are identifying with their tra- ditional cultural heritage (heritage consistent) or if they have ac- culturated into the dominant culture of the modern society in which they reside (heritage inconsistent). The tool may be used in any setting and is used to facilitate conversation and help in the planning of cultural care. Once a conversation begins and the person describes aspects of cultural heritage, it becomes possible to develop an under- standing of the person’s unique health and illness beliefs, practices,
nurse’s movement toward the client? What cultural objects within the environment have importance for health promotion or health maintenance?
It is vital for nurses to be culturally sensitive and to convey this sensitivity to clients, support people, and other health care personnel. Some ways to do so follow:
• Always address clients, support people, and other health care personnel by their last names (e.g., Mrs. Aylia, Dr. Rush) until they give you permission to use other names. In some cultures, the more formal style of address is a sign of respect, whereas the informal use of first names may be considered disrespectful. It is important to ask people how they wish to be addressed.
• When meeting a person for the first time, introduce yourself by your full name, and then explain your role (e.g., “My name is Ali- cia Bernett and I am a nursing student at Nightingale School of Nursing”). This helps establish a relationship and provides an op- portunity for clients, others, and nurses to learn the pronuncia- tion of one another’s names and their roles.
• Be authentic with people, and be honest about your knowledge about their culture. When you do not understand a person’s ac- tions, politely and respectfully seek information.
• Use language that is culturally sensitive; for example, say “gay,” “les- bian,” or “bisexual” rather than “homosexual”; do not use “man” or “mankind” when referring to a woman. Ask how the person self- identifies his or her race/ethnicity. A person may have a preferred term, such as Latino rather than Hispanic. Make note of the cli- ent’s preferences and use language preferred by the client.
• Find out what the client thinks about his or her health problems, illness, and treatments. Assess whether this information is congru- ent with the dominant health care culture. If the beliefs and prac- tices are incongruent, determine the impact on the client’s health.
• Always ask about anything you do not understand to avoid mak- ing assumptions about the client.
• Show respect for the client’s values, beliefs, and practices, even if they differ from your own or from those of the dominant culture. If you do not agree with them, it is important to respect the client’s right to hold these beliefs.
• Show respect for the client’s support people. In some cultures, men in the family make decisions affecting the client, whereas in other cultures women make the decisions.
• Make a concerted effort to obtain the client’s trust, but do not be surprised if it develops slowly or not at all. A cultural assessment may take time and may need to extend over several meetings.
In a descriptive, quantitative study by Starr and Wallace (2011), us- ing a theoretical framework derived from Leininger’s Culture Care model, both nurses and clients assessed dimensions of nurses’ cul- tural competence including communication, decision-making, and interpersonal styles. Sixty-nine clients completed the Interpersonal Processes of Care and 71 nurses completed the Cultural Compe- tence Assessment instruments. Clients were treated in home health, hospice, or public health departments in rural and medically under- served regions. Clients perceived their nursing care to contain key components of cultural competence. They rated nurses’ communi- cation, decision-making, and interpersonal styles very high. Nurses rated themselves as having moderate to high cultural competence.
Consistencies were noted between the clients’ and nurses’ percep- tions of cultural competence.
IMPLICATIONS It is easier to believe that our communication and care planning efforts are effective than it is to find research that confirms this. Studies such as this one used data from both nurses and clients to examine the same concepts: How well do nurses communicate with diverse clients and consider the cultural needs of their clients? To strengthen these findings, the study needs to be replicated broadly, with clients who have many different characteristics and in diverse geographical settings.
Evidence-Based Practice Do Nurses and Clients Have Similar Perspectives About the Nurses’ Cultural Competence? EVIDENCE-BASED PRACTICE
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Figure 18–5 • Celebrations of the passage to adulthood are often based on culture or religion; for example, the Jewish bar mitzvah at age 13 and the Mexican quinceañera or “sweet fifteen.” ( Top) Gordon Swanson/Shutterstock; (Bottom) Erin Patrice O’Brien/Taxi/Getty Images.
and cultural needs. For example, you may discover that the indi- vidual participates in ethnic cultural events and social groups, such as religious festivals or national holidays, sometimes with singing, dancing, and costumes (Figure 18–5 •). Or that the client’s child- hood development occurred in the person’s country of origin or in an immigrant community in the United States. For example, the person was raised in a specific ethnic neighborhood, such as an Italian, Af- rican American, Hispanic, or Jewish one, in a given part of a city and was exposed only to the culture, language, foods, and customs of that particular group. There are infinite examples of cultural influences on the client’s health.
Diagnosing The nursing diagnoses developed by NANDA International are fo- cused on nursing care provided in the United States and are based on European-centric cultural beliefs. It is essential to expand the under- standing of the nursing practice to include cultural beliefs of other cul- tures. Nurses must provide appropriate care to clients of any culture. This is accomplished through developing cultural sensitivity and con- sidering how a client’s culture influences his or her responses to health conditions, much as the nurse considers how a client’s age or gender influences a nursing diagnosis, plan, and delivery of nursing care.
Planning Cultural competence in nursing involves delivering care that inte- grates the mind, the body, the spirit, and the cultural values of the individual. The AACN (2008) defines cultural competence as the attitudes, knowledge, and skills necessary for providing quality care to diverse populations. Becoming culturally competent is an ongo- ing process in which an individual or organization develops along a continuum until diversity is accepted as a norm and the nurse has acquired greater understanding and capacity in a diverse environ- ment. Several steps are involved in the process that leads to the devel- opment of cultural competency. The knowledge and skills necessary to incorporate cultural care into standard nursing require the acqui- sition of a broad base of knowledge about different cultures and so- cial structures (Box 18–2). It is an ongoing process and the skills and knowledge base grow over time. As one’s knowledge base grows, the ability to convey cultural sensitivity also grows.
The following are examples of the necessary steps:
1. Become aware of one’s own cultural heritage. 2. Become aware of the client’s heritage and health traditions as de-
scribed by the client. 3. Become aware of adaptations the client made to live in another
culture. During this part of the interview, a nurse can also iden- tify the client’s preferences in health practices, diet, hygiene, and so on.
4. Form a nursing plan with the client that incorporates his or her cultural beliefs regarding the maintenance, protection, and res- toration of health. In this way, cultural values, practices, and be- liefs can be incorporated with the necessary nursing care.
As a component of the planning phase of the nursing process, the nurse “develops an individualized plan in partnership with the per- son, family and others considering the person’s characteristics or situ- ation, including but not limited to, values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, cul- ture and environment and available technology” (American Nurses Association [ANA], 2010, p. 36).
Implementing The implementation of cultural nursing care includes (a) cultural preservation and maintenance and (b) cultural accommodation and negotiation. Cultural preservation may involve the use of cultural health care practices, such as giving herbal tea, chicken soup, or “hot” foods to the ill client. The tasks of accommodating a client’s viewpoint and negotiating appropriate care require expert communication skills, such as responding empathetically, validating information, and effectively summarizing content. Negotiation is a collaborative
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ASSESSMENT INTERVIEW Heritage Assessment Tool This set of questions is to be used to describe a given client’s—or your own—ethnic, cultural, and religious background. In perform- ing a heritage assessment it is helpful to determine how deeply a given person identifies with his or her traditional heritage. This tool is most useful in setting the stage for assessing and understanding a person’s traditional health and illness beliefs and practices and in helping to determine the community resources that will be appropri- ate to target for support when necessary. The greater the number of positive responses, the greater the degree to which the person may identify with his or her traditional heritage. The one exception to positive answers is the question about whether a person’s name was changed.
1. Where was your mother born? 2. Where was your father born? 3. Where were your grandparents born?
a. Your mother’s mother? b. Your mother’s father? c. Your father’s mother? d. Your father’s father?
4. How many brothers and sisters do you have? 5. What setting did you grow up in? Urban Rural 6. What country did your parents grow up in?
Father Mother
7. How old were you when you came to the United States?
8. How old were your parents when they came to the United States? Mother Father
9. When you were growing up, who lived with you?
10. Have you maintained contact with a. Aunts, uncles, cousins? (1) Yes (2) No b. Brothers and sisters? (1) Yes (2) No c. Parents? (1) Yes (2) No d. Your own children? (1) Yes (2) No
11. Did most of your aunts, uncles, cousins live near your home? 1. Yes 2. No
12. Approximately how often did you visit family members who lived outside of your home? 1. Daily 2. Weekly 3. Monthly 4. Once a year or less 5. Never
13. Was your original family name changed? 1. Yes 2. No
14. What is your religious preference? 1. Catholic 2. Jewish 3. Protestant Denomination 4. Other 5. None
15. Is your spouse the same religion as you? 1. Yes 2. No
16. Is your spouse the same ethnic background as you? 1. Yes 2. No
17. What kind of school did you go to? 1. Public 2. Private 3. Parochial
18. As an adult, do you live in a neighborhood where the neighbors are the same religion and ethnic background as yourself? 1. Yes 2. No
19. Do you belong to a religious institution? 1. Yes 2. No
20. Would you describe yourself as an active member? 1. Yes 2. No
21. How often do you attend your religious institution? 1. More than once a week 2. Weekly 3. Monthly 4. Special holidays only 5. Never
22. Do you practice your religion in your home? 1. Yes 2. No (if yes, please specify) 3. Praying 4. Bible reading 5. Diet 6. Celebrating religious holidays
23. Do you prepare foods special to your ethnic background? 1. Yes 2. No
24. Do you participate in ethnic activities? 1. Yes 2. No (if yes, please specify) 3. Singing 4. Holiday celebrations 5. Dancing 6. Festivals 7. Costumes 8. Other
25. Are your friends from the same religious background as you? 1. Yes 2. No
26. Are your friends from the same ethnic background as you? 1. Yes 2. No
27. What is your native language? 28. Do you speak this language?
1. Prefer 2. Occasionally 3. Rarely
29. Do you read your native language? 1. Yes 2. No
From Cultural Diversity in Health & Illness, 8th ed. (pp. 376–378), by R. E. Spector, 2013, Upper Saddle River, NJ: Pearson Education.
process. It acknowledges that the nurse–client relationship is recip- rocal and that different views exist of health, illness, and treatment. The nurse attempts to bridge the gap between the nurse’s scientific and the client’s cultural perspectives. During the negotiation process, the client’s views are explored and acknowledged. Relevant scientific
information is then provided. If the client’s views reveal that certain behaviors would not affect the client’s condition adversely, then they are incorporated into the care plan. If the client’s views can lead to harmful behavior or outcomes, then an attempt is made to educate the client on the scientific view.
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Providing culturally responsive care can be challenging. It requires discovery of the meaning of the client’s behavior, flexibility, creativ- ity, and knowledge to adapt nursing interventions. An effort must be made to learn from each experience. This knowledge will improve the delivery of culture-specific care to future clients. The accompanying box offers suggestions for providing such care to clients and families.
Evaluating In evaluating nursing care that incorporates the client’s cultural per- spectives, the actual client outcomes are compared with the goals and expected outcomes established following comprehensive as- sessment that includes cultural sensitivity. However, if the outcomes are not achieved, the nurse should be especially careful to consider whether the client’s belief system has been adequately included as an influencing factor.
Nurses should determine precisely how a client is managing an illness, what practices could be harmful, and which practices can be safely combined. For example, reducing dosages of an antihyperten- sive medication or replacing insulin therapy with herbal measures may be detrimental. Some herbal remedies are synergistic with mod- ern medicines and others are antagonistic; therefore, it is necessary to fully inform the client about the possible outcomes. Consider these examples of potential conflicts between cultural beliefs or practices and the dominant American health care system:
• Native American women may value large body size and may be resistant to weight control.
• The decision to circumcise male infants, often made based on cultural and family beliefs, can occasionally conflict with medical advice.
• Hispanic/Latino or Asian clients may be unable to obtain hospice care if family members do not permit the client to be informed of the diagnosis or prognosis.
• Members of the Jehovah’s Witness faith do not accept blood trans- fusions even in life-threatening situations.
• Orthodox Sikhs do not cut their hair. This can conflict with the need to shave the hair for medical procedures.
When a client chooses to follow only cultural practices and de- clines all prescribed medical or nursing interventions, the nurse and client must adjust the client goals. Monitoring the client’s condition to identify changes in health and to recognize impending crises before they become irreversible may be all that is realistically achievable. At a time of crisis, the opportunity may arise to renegotiate care.
The ANA (2010) standard related to health teaching and health promotion includes a competency requiring the nurse to imple- ment the use of methods appropriate to the client and the situation. This includes consideration of client “values, beliefs, health prac- tices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status” (p. 36).
BOX 18–2 Selected Cultural Health-Related Practices
Note that these practices may or may not be applicable to the client you are caring for; they are generalizations. Caution must be exer- cised to not convert a generalization into a stereotype.
ASIAN • Coining and cupping are traditional medical practices. This
should not be misinterpreted as abuse. • Fevers may be treated by wrapping the ill person in warm
blankets and having him or her drink warm liquids. • Hot liquids, such as tea, may be preferred. Ice water should be
provided upon request only. • Have rich tradition of herbal remedies. Health care providers
should be sure to discuss the use of home or herbal remedies to avoid potential drug interactions.
• May use traditional Chinese medicine. Compliance with traditional treatment may be very different from expected compliance with modern medicines. Care must be taken to fully explain instructions, such as taking antibiotics for entire course, even after symptoms have disappeared.
AFRICAN AMERICAN • Menstruation may be viewed as the body’s way of clearing dirty
and excess blood. Too little flow may be viewed as “bad blood”
staying in the body; too much flow may be viewed as weaken- ing the body. May influence views of birth control.
• Have rich tradition of herbal remedies. Health care providers should be sure to discuss the use of home or herbal remedies to avoid potential drug interactions.
• May avoid dairy products due to high incidence of lactose intolerance. Check for family history.
• Focus on present time may interfere with use of preventive medicine and follow-up care.
HISPANIC • Certain foods or medications upset hot–cold body balance. Try
offering alternative foods or liquids for medications. Provide ice water upon request only, or ask client whether he or she would like ice water.
• Postpartum rest is valued. • Sponge baths may be preferred after giving birth. • Family members may want to spend as much time with the
client as possible and provide nontechnical care. • Strong beliefs in fate and external control over events may lead
to less adherence to medical regimens.
FAMILIES • Identify your personal assumptions, biases, attitudes,
prejudices, and stereotypes. Include cultural assessment of the client and family as part of your overall assessment.
• Learn the rituals, customs, and practices of the major cultural groups with whom you come into contact, recognizing that these generalizations may not hold true at the individual level. Learn to appreciate the richness of diversity and consider it an asset rather than a hindrance in your practice.
• Don’t make assumptions about beliefs or practices. • Ask about the client’s use of cultural or alternative approaches
to healing. • Recognize that it is the client’s (or family’s) right to make
their own health care choices. Explain in detail the client’s condition and the treatment plan if the client is willing for you to do this.
• Convey respect and cooperate with traditional helpers and caregivers.
PATIENT-CENTERED CARE Culturally Responsive Care
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Critical Thinking Checkpoint
Rachel was born to a Jewish couple and lists her religion as Jewish. Her father died when she was 10 years old and her mother remarried 3 years later. Rachel was legally adopted by her Italian stepfather, who was a devout Catholic. Although the family participated in Catholic– Italian traditions, Rachel’s mother taught her many Jewish traditions as well, so that her heritage would be preserved. Rachel is now 58 years old, practices traditions from both her Jewish and Italian up- bringing, and is dying of cancer. You are the nurse caring for Rachel during her final days.
1. Differentiate between Rachel’s culture and ethnicity. 2. How might Rachel’s multicultural background affect you as her
nurse or in working with her family? 3. How might Rachel’s culture affect her approach to death and the
care of her body following her death? 4. Of what benefit would a cultural assessment be to Rachel or her
family since she is dying? 5. How could nurses’ culture or religion influence their care of
clients who are racially or culturally different? See Critical Thinking Possibilities on student resource website.
• Culturally responsive care requires the nurse to develop self- awareness and gain the attitudes, knowledge, and skills to incor- porate each client’s cultural perspectives into the plan of care.
• People may live within their traditional heritage or they may em- brace both their original ethnocultural traditional heritage(s) and the modern culture of the United States.
• The National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) should be understood by nurses and applied to their professional practice.
• Healthy People 2020 calls for nursing to contribute to eliminating health disparities by gender, race or ethnicity, education, income, disability, geographic location, and sexual orientation.
• Racial and Ethnic Approaches to Community Health Across the United States (REACH U.S.) is an initiative that strives to eliminate
racial and ethnic disparities in infant mortality, deficits in breast and cervical cancer screening/management, cardiovascular diseases, diabetes, HIV infections/AIDS, and child and adult immunizations.
• Through acculturation, most groups in the United States modify some of their traditional cultural characteristics.
• Personal characteristics also modify an individual’s cultural values, beliefs, and practices.
• Health beliefs and practices, family patterns, communication style, space and time orientation, and nutritional patterns may influence the relationship between the nurse and the client who have differ- ent cultural backgrounds.
• When assessing a client, the nurse considers the client’s cultural values, beliefs, and practices related to health and health care.
CHAPTER HIGHLIGHTS
Chapter 18 Review
1. The major factor contributing to the increased emphasis on the need for proficiency in cultural nursing practice in the United States is which of the following? 1. An increasing birth rate 2. Increased access to health care services 3. Demographic changes 4. A decreasing rate of immigration
2. Which behavior is an initial step in culturally responsive nursing practice? 1. Help the client recognize the need to adapt health practices
to fit commonly accepted practices. 2. Discuss the meaning of the medical regimen with the client. 3. Inform the client that lack of adherence to the medical
regimen may be detrimental. 4. Ask a cultural broker to explain the relevance of the
intervention.
3. In initiating care for a client from a different culture than the nurse, which of the following would be an appropriate statement? 1. “Since, in your culture, people don’t drink ice water, I will
bring you hot tea.” 2. “Do you have any books I could read about people of your
culture?” 3. “Please let me know if I do anything that is not acceptable in
your culture.” 4. “You will need to set aside your usual customs and practices
while you are in the hospital.” 4. Which behavior is most representative of a culturally competent
nurse? 1. Helps clients of Native American heritage identify ways to
relate more to their culture. 2. Helps parents of Latino heritage recognize that their children
need to speak English. 3. Interprets and validates beliefs of a client with African
American heritage. 4. Asks a nurse of Japanese heritage to teach others dosage
calculations since Asians are good at math.
TEST YOUR KNOWLEDGE
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8. Which of the following factors are most likely to be influenced by culture as opposed to personal characteristics? Select all that apply. 1. Value of older people in society 2. Gender roles 3. Nonverbal gestures 4. Skill with technology 5. Intelligence 6. Diet
9. What is the most productive method of gathering assessment data regarding heritage? 1. Physical exam 2. Medical history 3. Blood analysis 4. Traditional beliefs and practices checklist
10. A client who speaks limited English requires instructions for a test. No one at your agency speaks the person’s language. What is the nurse’s best approach? 1. Provide the instructions in writing. 2. Locate a professional interpreter. 3. Ask a family member to translate on the phone. 4. Document that the required instruction is not possible.
See Answers to Test Your Knowledge in Appendix A.
5. An outcome of achieving national cultural health goals would be which of the following? 1. All cultures receive the same health care. 2. All people have the same life expectancy. 3. All U.S. residents have access to the same quality of health
care. 4. All cultures are fully assimilated into the dominant society.
6. Which nursing action primarily supports restoring HEALTH using traditional methods? 1. Herbal teas 2. Prayer 3. Wearing symbolic objects 4. Exercise
7. A client with strong preferences for folk healing methods would prefer which of the following to treat a sinus infection? 1. Hospitalization 2. Steam humidifier 3. Antibiotic therapy 4. “Watch and wait”
Suggested Reading McConnell, J., & Reams, P. (2012). Climate change: Trans-
forming a biased atmosphere. Nursing Management, 43(8), 36–40. doi:10.1097/01.NUMA.0000416405.37861.86 This article describes the work of a nurse manager in addressing the inappropriate treatment of an Afghani nurse by the other members of the staff. It demonstrates how the use of the literature during an in-service plus activi- ties to allow the nurses some self-reflection could provide an atmosphere open to improving working relationships. Consequences for violations of the “zero tolerance” policy were also included.
Related Research Ingram, R. (2012). Using Campinha-Bacote’s process of
cultural competence model to examine the relation- ship between health literacy and cultural compe- tence. Journal of Advanced Nursing, 68, 695–704. doi:10.1111/j.1365-2648.2011.05822.x
Weech-Maldonado, R., Elliott, M., Pradhan, R., Schiller, C., Hall, A., & Hays, R. (2012). Can hospital cultural com- petency reduce disparities in patient experiences with care? Medical Care, 50S, 48–55. doi:10.1097/ MLR.0b013e3182610ad1
References American Anthropological Association. (1998). Statement
on “race.” Retrieved from http://www.aaanet.org/stmts/ racepp.htm
American Association of Colleges of Nursing. (2008). Cultural competency in baccalaureate nursing education. Washington, DC: Author. Retrieved from http://www.aacn .nche.edu/education/pdf/competency.pdf
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
Barnes, P. M., Bloom, B., & Nahin, R. (2008). Complementary and alternative medicine use among adults and children: United States, 2007 (National Health Statistics Report No. 12). Retrieved from http://nccam.nih.gov/news/ camstats/NHIS.htm
Berlin, E. A., & Fowkes, W. C. (1983). A teaching frame- work for cross-cultural health care. Western Journal of Medicine,139, 934–938.
Braveman, P. (2014). What are health disparities and health equity: We need to be clear. Public Health Reports,129(Suppl. 2), 5–8.
Campinha-Bacote, J. (2007). The process of cultural compe- tence in the delivery of healthcare services: The journey
continues (5th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates.
Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural com- petence. Online Journal of Issues in Nursing, 16(2), Manu- script 5. doi:10.3912/OJIN.Vol16No02Man05
Canadian Nurses Association. (2010). Position statement: Promoting cultural competence in nursing. Retrieved from http://www2.cna-aiic.ca/CNA/documents/pdf/publications/ PS114_Cultural_Competence_2010_e.pdf
Centers for Disease Control and Prevention (CDC). (2012). Office of Minority Health & Health Equity: Mission. Retrieved from http://www.cdc.gov/minorityhealth/OMHHE.html
Flores, G., Abreu, M., Barone, C. P., Bachur, R., & Lin, H. (2012). Errors of medical interpretation and their po- tential clinical consequences: A comparison of profes- sional versus ad hoc versus no interpreters. Annals of Emergency Medicine, 60, 545–553. doi:10.1016/j. annemergmed.2012.01.025
Galanti, G. (2012). Cultural sensitivity: A pocket guide for health care professionals (2nd ed.). Oakbrook Terrace, IL: The Joint Commission Resources.
Guibernau, M., & Rex, J. (2010). The ethnicity reader: Nation- alism, multiculturalism and migration (2nd ed.). Malden, MA: Polity.
Humes, K. R., Jones, N. A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin: 2010. Washington, DC: U.S. Census Bureau. Retrieved from http://www.census.gov/ prod/cen2010/briefs/c2010br-02.pdf
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National Partnership for Action to End Health Disparities. (2011). National stakeholder strategy for achieving health equity. Rockville, MD: U.S. Department of Health & Human Services, Office of Minority Health. Retrieved from http://minorityhealth.hhs.gov/npa/templates/content .aspx?lvl=1&lvlid=33&ID=286
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and Budget concerning changes to the standards for the classification of federal data on race and ethnicity. Federal Register, 62, 36874–36946.
Schaefer, R. T. (2013). Race and ethnicity in the United States (7th ed.). Upper Saddle River, NJ: Pearson Education.
Spector, R. E. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Spector, R. E. (2013). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Pearson Education.
Starr, S. S., & Wallace, D. C. (2011). Client perceptions of cul- tural competence of community-based nurses. Journal of Community Health Nursing, 28(2), 57–69. doi:10.1080/ 07370016.2011.564057
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U.S. Department of Health and Human Services. (2011). HHS action plan to reduce racial and ethnic health dispari- ties: A nation free of disparities in health and health care. Washington, D.C.: U.S. Department of Health and Human Services. Retrieved from http://minorityhealth.hhs.gov/npa/ templates/content.aspx?lvl=1&lvlid=33&ID=285
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2012). National healthcare disparities report, 2011 (AHRQ Publication No. 12-0006). Rockville, MD: Author. Retrieved from http://www.ahrq.gov/qual/qrdr11.htm
U.S. Department of Health and Human Services, Health Resources and Service Administration Bureau of Health Pro- fessions. (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Retrieved from http://bhpr.hrsa.gov/healthworkforce/ rnsurveys/rnsurveyfinal.pdf
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READINGS AND REFERENCES
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U.S. Department of Health and Human Services, Office of Minority Health (OMH). (2012). National standards for cul- turally and linguistically appropriate services in health care. Washington, DC: U.S. Department of Health and Human Services. Retrieved from https://www.thinkculturalhealth .hhs.gov/Content/clas.asp
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Auerbach, D. I., Staiger, D. O., Muench, U., & Buerhaus, P. I. (2012). The nursing workforce: A comparison of three national surveys. Nursing Economics, 30, 253–260.
Bucher, R. D. (2010). Diversity consciousness: Opening our minds to people, cultures, and opportunities (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
Burgoon, J. K., Guerrero, L. K., & Floyd, K. (2010). Nonver- bal communication. Upper Saddle River, NJ: Pearson Education.
Campinha-Bacote, J. ( 2011). Coming to know cultural com- petence: An evolutionary process. International Journal for Human Caring, 15(3), 42–48.
Expert Panel on Cultural Competence Education for Students in Medicine and Public Health (2012). Cultural competence education for students in medicine and public health: Report of an expert panel. Washington, DC: Association of American Medical Colleges and Association of Schools of Public Health.
Hall, J. M., & Fields, B. (2012), Race and microaggression in nursing knowledge development. Advances in Nursing Science, 35(1), 25–38.
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA Inter- national Nursing Diagnoses: Definitions and Classification, 2015–2017. Oxford, United Kingdom: Wiley-Blackwell.
Hicks, D. (2012). Cultural competence and the Hispanic popu- lation. MEDSURG Nursing, 21, 314–315.
Kaiser Permanente National Diversity Council. (2009). A pro- vider’s handbook on culturally competent care: Women’s health. Retrieved from https://www2.massgeneral.org/ disparitiessolutions/z_files/Kaiser%20CC%20handbook .pdf
Kersey-Matusiak, G. (2012). Culturally competent care: Are we there yet? Nursing Management, 43(4), 34–40. doi:10.1097/01.NUMA.0000413093.39091.c6
Millender, E. (2012). Acculturation stress among the Maya in the United States. Journal of Cultural Diversity, 19(2), 58–64.
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U.S. Department of Health and Human Services, Advisory Committee on Minority Health. (2009). Ensuring that health care reform will meet the health care needs of minority communities and eliminate health disparities: A statement of principles and recommendations. Retrieved from http:// minorityhealth.hhs.gov/Assets/pdf/Checked/1/ACMH_ HealthCareAccessReport.pdf
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INTRODUCTION Western medicine is an approach to health that focuses on the use of science in the diagnosis and treatment of health problems. This is in contrast to Eastern medicine, which places greater emphasis on prevention and natural healing. The differences between Western and Eastern medicine are not about geographic location since both Eastern and Western health practitioners exist in almost every part of the world. Most of nursing education in the United States, Canada, Europe, and Australia has been under the umbrella of Western medi- cine. Thus, nurses from these parts of the world are familiar and comfortable with biomedical beliefs, theories, practices, strengths, and limitations. In this chapter the terms conventional medicine, biomedicine, and allopathic medicine are used to describe West- ern medical practices. Fewer nurses have studied Eastern medicine and as a result may lack information or even harbor misinformation about these healing practices.
The term complementary and alternative medicine (CAM) includes as many as 1,800 other therapies practiced all over the world. Many of these have been handed down over thousands of years, both orally and as written records. They are based on the Eastern medical
systems of ancient people, including Egyptians, Chinese, Asian Indi- ans, Greeks, and Native Americans. Other therapies, such as bioelec- tromagnetics and chiropractic, evolved in the United States during the past two centuries. Still others, such as some of the mind–body approaches, are on the frontier of scientific knowledge and under- standing. The CAM therapies described in this chapter are only some of the many used by clients. Nurses must learn about the ones being used by the clients in their specific practice settings.
Complementary medicine refers to the use of CAM together with conventional medicine. Most use of CAM by Americans is complementary. Alternative medicine refers to use of CAM in place of conventional medicine. Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness. It is also called integrated medicine.
The public interest in complementary and alternative therapies is extensive and growing. One has only to look at the proliferation of popular health books, health food stores, and clinics offering heal- ing therapies to realize this. In 1998, the National Institutes of Health established the National Center for Complementary and Alternative
acupressure, 301 acupuncture, 301 allopathic medicine, 295 alternative medicine, 295 animal-assisted therapy, 306 aromatherapy, 299 Ayurveda, 297 balance, 296 bioelectromagnetics, 306 biofeedback, 304 biomedicine, 295 chiropractic, 300
complementary medicine, 295 conventional medicine, 295 curanderismo, 298 detoxification, 306 Eastern medicine, 295 energy, 296 faith, 304 guided imagery, 303 hand-mediated biofield
therapies, 301 herbal medicine, 298 holism, 296
homeopathy, 299 horticultural therapy, 306 humanist, 296 hypnotherapy, 303 imagery, 303 integrative medicine, 295 massage therapy, 301 meditation, 303 music therapy, 305 naturopathic medicine, 300 pilates, 304 prayer, 304
qi, 297 qi gong, 304 reflexology, 301 spirituality, 296 t’ai chi, 304 traditional Chinese medicine
(TCM), 297 Western medicine, 295 yoga, 302
KEY TERMS
After completing this chapter, you will be able to: 1. Describe the basic concepts of alternative practices. 2. Give examples of healing environments. 3. Describe the basic principles of health care practices such
as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.
4. Explain how herbs are similar to many prescription drugs. 5. Discuss the principles of naturopathic medicine. 6. Identify the role of manual healing methods in health and
illness.
LEARNING OUTCOMES
19 Complementary and Alternative Healing Modalities
7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qi gong, and t’ai chi have in common.
8. Identify types of detoxification therapies. 9. Discuss uses of animals, prayer, and humor as treatment
modalities. 10. Teach clients the uses of and safety precautions regarding
complementary and alternative therapies.
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each component have to be balanced, equilibrium is needed among the components. Physical aspects include optimal functioning of all body systems. Emotional aspects include the ability to feel and ex- press the entire range of human emotions. Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. Spiritual aspects involve moral values, a meaningful purpose in life, and a feeling of connect- edness to others and a divine source. Environmental aspects include physical, biologic, economic, social, and political conditions. Being in balance is a learned skill and one that must be practiced regularly to engage in the process of healthful living. This concept of balance appears throughout the various alternative therapies.
Spirituality Spiritual healing techniques and spiritually based health care sys- tems are among the most ancient healing practices. Spirit is the live- liness, richness, and beauty of one’s life. It is who we are and how we are in the world. Spirituality includes the drive to become all that one can be, and is bound to intuition, creativity, and motivation (see Chapter 41 ). It is the dimension that involves relationship with oneself, with others, and with a higher power. Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death.
Energy The concept of energy has been recognized in most cultures for cen- turies. Energy is viewed as the force that integrates the body, mind, and spirit; it is that which connects everything.
Chinese Taoist scholars believed that energy was the basic building material of the universe. Albert Einstein and other physi- cists proved that matter and energy are the same and that energy is not only the raw material of the cosmos but the glue that holds it together. Modern scientists now look at the universe in terms of forces of tiny particles of matter. Their experimental findings are similar to the intuitive observation of China’s ancient scholars. Everything in the world—animate and inanimate—is made of en- ergy. People are beings of energy, living in a universe composed of energy.
Two terms common in various healing practices and related to energy and balance are grounding and centering. Grounding, as its name suggests, relates to one’s connection with the ground and, in a broader sense, to one’s whole contact with reality. Being grounded suggests stability, security, independence, having a solid founda- tion, and living in the present rather than escaping into dreams. Centering refers to the process of bringing oneself to the center or middle. When people are centered, they are fully connected to the part of their bodies where all their energies meet. Centering is the process of focusing one’s mind on the center of energy, allowing one to operate intuitively, with awareness, and to channel energy throughout the body.
Healing Environments Nursing has always focused on creating healing environments for those who have been entrusted to their care. Healing environ- ments are created when nurses empower clients by providing the knowledge, skills, and support that allow them to tap into their
Medicine to provide research, educational grants, and dissemination of information to the public. In March 2000, President Clinton or- dered the establishment of the White House Commission on Com- plementary and Alternative Medicine Policy, which has the mission of making legislative and administrative recommendations for the integration of conventional and alternative medicine.
CLINICAL ALERT!
What constitutes traditional, alternative, complementary, or holistic to one person may be considered mainstream to another. Do not as- sume anything about the client’s belief system—be sure to assess and be open minded.
BASIC CONCEPTS Several concepts are common to most alternative practices. These are holism, humanism, balance, spirituality, energy, and healing environments.
Holism Although they represent diverse approaches, alternative therapies share certain attributes. They are based on the paradigm of whole systems and the belief that people are more than physical bodies with fixable and replaceable parts. Combined mental, emotional, spiritual, relationship, and environmental components, referred to as holism, are considered to play crucial and equal roles in a person’s state of health. Interventions are individualized within the entire context of the person’s life.
Nurses have engaged in natural and traditional healing interac- tions since the finest traditions of Florence Nightingale. The modern nurse draws on biomedical and caring-healing models by utilizing technology and focusing on caring relationships and healing pro- cesses. Nurses, by virtue of their education and relationships with cli- ents, help clients assert their right to choose their own healing journey and the quality of their life and death experiences (Fontaine, 2011).
The American Nurses Association (ANA) recognizes holistic nursing as a specialty practice. The vision statement of the American Holistic Nurses Association (AHNA) (2012) is “. . . a world in which nursing nurtures wholeness and inspires peace and healing” and has a purpose to “promote the education of nurses, other health care pro- fessionals, and the public, in all aspects of holistic caring and healing.”
Humanism The humanist perspective includes propositions such as the follow- ing: The mind and body are indivisible, people have the power to solve their own problems, people are responsible for the patterns of their lives, and well-being is a combination of personal satisfaction and contributions to the larger community. Nursing is in a unique posi- tion to take a leadership role in integrating alternative healing methods into Western health care systems. Nurses have historically used their hands, heart, and head in natural and traditional healing interactions.
Balance In terms of optimal wellness, the concept of balance consists of finding a desirable point between two opposite forces rather than being purely in one state or another. Balance has mental, physical, emotional, spiritual, and environmental components. Not only does
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Although the information may be new to us, many of these traditions are hundreds or even thousands of years old and have long been part of the medical mainstream in other cultures (see also Chapter 18 ). The nurse should inquire about healing modalities the client may have used previously (see Assessment Interview).
Systematized Health Care Practices A number of health care practices have been systematized through- out the centuries and throughout the world. These typically include an entire set of values, attitudes, and beliefs that generate a philosophy of life, not simply a group of remedies. Definitions and summaries of research in these practices can be found on the National Center for Complementary and Alternative Medicine (NCCAM) website. NCCAM is a part of the U.S. Department of Health and Human Services’ National Institutes of Health.
AYURVEDA The Indian system of medicine, Ayurveda, is at least 2,500 years old. Illness is viewed as a state of imbalance among the body’s sys- tems. Ayurveda is a Sanskrit word that means “science of life” or “sciences of life span” (Synovitz & Larson, 2013). Ayurveda empha- sizes the interdependence of the health of the individual and the quality of societal life. Mentally healthy people have good memory, comprehension, intelligence, and reasoning ability. Emotionally healthy people experience evenly balanced emotional states and a sense of well-being or happiness. Physically healthy people have abundant energy with proper functioning of the senses, diges- tion, and elimination. From a spiritual perspective, healthy people have a sense of aliveness and richness of life, are developing in the direction of their full potential, and are in good relationships with themselves, other people, and the larger cosmos. Environ- mentally healthy individuals have minimal economic, social, and political stress.
Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized diet and exercise program depending on dosha (body) type and the nature of the underlying dosha imbalance. Herbal preparations are added to the diet for preventive or regen- erative purposes as well as for the treatment of specific disorders. Yoga, breathing exercises, and meditative techniques are also pre- scribed by the practitioner. This ancient system has adapted to modern science and technology, including biomedical science and quantum physics.
TRADITIONAL CHINESE MEDICINE Traditional Chinese medicine (TCM) has developed over 3,000 years and is based on the premise that the body’s vital energy or qi (pronounced chee) circulates through pathways or meridians and can be accessed and manipulated through specific anatomic points along the surface of the body. Disease is described as an imbalance
inner wisdom and make healthy decisions for themselves. Healing environments are a synthesis of the medical-curing approach and the nursing-healing approach. Nurses need a healthy balance be- tween technology and compassion. Nurses create healing environ- ments when they take the time to be with clients in deeply caring ways. It is when they stop, become still, and enter the other’s subjec- tive world that they are able to be wholly present for that person (Fontaine, 2011).
Nurses must also create their own healing environments. Work- ing with people can be draining work. Nurses need to learn how to restore their energy and replenish themselves. Nurses might compare their ability to care for others to a well of fresh, healing water. If the well is never dipped into, the water becomes stagnant and brackish. If the water is constantly drawn out and given away, with no source of replenishment, the well will soon run dry. What happens to nurses who do not sincerely care for others or take the time to replenish themselves? It soon becomes obvious by their behavior that they are stagnant or depleted; they are less patient, less tolerant, more irritable, and unhappy. Their state of “burnout” contaminates all aspects of their professional and personal lives.
SELF-CARE ALERT
Self-Healing Methods for Nurses
• Poor posture robs your body of energy. You may spend many hours of your day walking incorrectly or slumped in a chair, which interrupts the flow of energy and oxygen through your body. Take a moment to sit up or stand straight. Imagine that a cord is at- tached to the top of your head, pulling it gently toward the sky. This image helps readjust your posture.
• Do the following to boost your energy: Take your shoes off; sit on the floor with your legs stretched out in front of you and your palms facing down at your sides. Point your toes as hard as you can and hold for 5 seconds, then dorsiflex your feet as hard as you can and hold for 5 seconds. Repeat 10 times.
• Sit comfortably and close your eyes. Simply notice your breathing without trying to change it. Pay attention to your in-breath and your out-breath. Now imagine that the breath is pouring into your heart with each inhalation and blowing out of your heart with each exhalation. Just feel the breath flowing in and out of your heart. Imagine the breath is pure love. Perform this breath awareness for 5 to 10 minutes. Now let your attention return to your environ- ment, slowly open your eyes, get up, and move on. Think about the feeling throughout the day.
HEALING MODALITIES Ethnocentrism, the assumption that one’s own cultural or ethnic group is superior to others, has often prevented Western health care practitioners from learning new ways to promote health and pre- vent chronic illness. With consumer demand for a broader range of options, we must open our minds to the idea that other cultures and countries have valid ways of preventing and curing diseases.
ASSESSMENT INTERVIEW Complementary and Alternative Therapies • Tell me about your use of teas, herbs, vitamins, or other natural
products to improve your health or treat diseases. • What traditional or folk remedies are used in your family?
• Do you meditate, pray, or use relaxation techniques, music, or yoga for healing purposes?
• What alternative therapies have you used (acupuncture, touch therapies, magnets, hypnosis, etc.)?
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Botanical Healing Botanical (plant) healings are used by 80% of the world’s population. These include herbs, aromatherapy, homeopathy, and naturopathy (Figure 19–1 •).
HERBAL MEDICINE Before pharmaceutical companies existed, there was herbal medicine. In many parts of the world, treating illness with herbs is still the only medicine available. Even though only a tiny fraction of plants have been studied for medicinal benefits, conventional primary care providers use plant-derived products regularly. Many prescription drugs sold in the United States are derived from plants. Examples of herbal remedies that have been synthesized into mod- ern drugs are reserpine from the Indian snakeroot plant, digoxin from foxglove, quinine from Peruvian bark, aspirin from willow tree bark, morphine from opium poppy, cocaine from coca leaves, atropine from deadly nightshade, and paclitaxel (Taxol) found in Pacific yew bark.
Not all plant life is beneficial. Most plant-related poisonings are due to accidental consumption of toxic ornamental plants such as jade, holly, and poinsettia. The vast majority of herbal medicines pre sent no danger if taken appropriately. Some can, however, cause serious side effects if taken in excess or, for some, if taken over a pro- longed period of time. Herbs can also interact with drugs, and cau- tion should be used when combining herbs with prescription and over-the-counter (OTC) medications. Pregnant and breast-feeding women should be cautioned not to take herbs internally except for mild herb teas.
Although herbs can be quite effective, it is important to caution people about becoming overdependent on them. If they have a life- threatening illness such as asthma, experience chest pain, or notice symptoms that persist for longer than a few days, they should seek medical attention. For example, although it may be healthy to take echinacea if a person feels a cold coming on, any serious ailment should be diagnosed by a health care practitioner before undertak- ing an herbal cure. Conventional medicine is best used in crisis situa- tions, and herbs are best used in noncrisis situations.
or interruption in the flow of qi. In TCM the mind, body, spirit, and emotions are never separated. Thus, the heart is not just a blood pump; it also influences one’s capacity for joy, one’s sense of purpose in life, and one’s connectedness with others. The kidneys filter fluids, but they also manage one’s capacity for fear, one’s will and motiva- tion, and one’s faith in life. The lungs breathe in air and breathe out waste products, but they also regulate one’s capacity to grieve, as well as one’s acknowledgment of self and others. The liver cleanses the body, and it also influences one’s feeling of anger as well as that of vision and creativity. The stomach has a part in digestion of food and influences one’s ability to be thoughtful, kind, and nurturing as well. These are just a few of the mind–body connections that TCM prac- titioners recognize.
Practitioners of TCM are trained to use a variety of ancient and modern therapeutic methods, including acupuncture, acupressure, herbal medicine, massage, heat therapy, qi gong, t’ai chi, and nutri- tional lifestyle counseling.
NATIVE AMERICAN HEALING Spirituality and medicine are inseparable in Native American heal- ing. Medicine women and men see themselves as channels through which the Great Power helps others achieve well-being in mind, body, and spirit. The only healer is the One who created all things. Medicine people consider that they have certain knowledge to put things together to help the sick person heal and that knowledge has to be dispensed in a certain way, often through ritual or cer- emony. The healer enters into the healing relationship with love and compassion. The two individuals experience a joining or merging as this process unfolds. This merger symbolizes the cementing to- gether of people and the Divine Spirit. Healers use medicine objects to assist them and ceremonial treatments such as the sweat lodge (a ceremonial sauna), singing, dancing, and vision quests (which usually involve periods of fasting and solitude). Other treatments include smudging (brushing the smoke of burned herbs on the per- son’s skin), drumming and chanting, healing touch, acupressure, and herbs.
Health is viewed as a balance or harmony of mind and body. The goal is to be in harmony with all things, which means first being in harmony with oneself. It is believed that most illness begins in the head and people must get rid of ideas that predispose illness. If the mind is negative, the body will be drained, making it more vulner- able. When people open up to the universe, learn what is good for them, and find ways to be happier, they can begin to work toward a longer and healthier life.
CURANDERISMO Curanderismo (pronounced koo-rahn-dare-ees-mo) is a cultural healing tradition found in Latin America and among many Latinos in the United States. Although it is a traditional healing system, it may utilize Western biomedical beliefs, treatment, and practices. Healers are called curanderos (men) and curanderas (women). They may specialize as herbalists, midwives, counselors, spine and joint work- ers, and massage therapists. They also utilize religious rituals, cleans- ing rites, and prayers in their healing practices. Particularly when other treatment modalities may be expensive or difficult to access, clients may turn to more traditional healers such as those who prac- tice curanderismo (Torres, 2011).
Figure 19–1 • Aromatherapy, homeopathy, and other botanical therapies may be used alone or in combination. Will & Deni McIntyre/Getty Images.
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Herb Traditional Uses Selected Warnings
Echinacea May boost immune system, enhance wound healing.
May reduce the effectiveness of immunosuppressants.
Feverfew Prevents migraine headaches, arthritis; stimulates digestion.
May increase the anticoagulant effects of aspirin and anticoagulant medications.
Garlic Reduces high blood pressure and cholesterol; antibiotic/antifungal; anticlotting.
May increase the anticoagulant effects of aspirin and anticoagulant medications.
Ginger For digestion; relieves motion sickness, dizziness, and nausea.
May increase the anticoagulant effects of aspirin and anticoagulant medications.
Ginkgo May improve memory function, relieve stress, treat dizziness.
May increase the anticoagulant effects of aspirin and anticoagulant medications.
Ginseng Stimulates mental activity; enhances immune system, appetite.
May interact with caffeine and cause irritability. May decrease the effectiveness of glaucoma medications.
Milk thistle Enhances flow in gallbladder, liver, spleen, and stomach.
Reduces the effectiveness of oral contraceptives.
Saw palmetto Treats prostate hypertrophy; anti-inflammatory. May give false low prostate-specific antigen (PSA) levels, thereby delaying diagnosis of prostate cancer.
St. John’s wort Acts as antidepressant, anti-inflammatory; is antiviral.
May potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.
Valerian Sedative, tranquilizer; lowers blood pressure; helps menstrual cramps.
May increase the sedative effects of antianxiety medication.
*Some preparations may vary in efficacy and toxicity depending on the age of the client. Use extra caution with young children and older adults.
PRACTICE GUIDELINES
Uses, Cautions, and Contraindications for Popular Herbal Preparations*
Nurses must be open to exploring and discussing their clients’ uses of and questions regarding herbal medicine. This clinical screen- ing allows for evaluation of herbal intake against known and poten- tial adverse interactions with prescriptions and OTC medications. See the Practice Guidelines for some cautions and contraindications. In addition to the uses of herbs described in the Practice Guidelines, herbs may also be used in aromatherapy and homeopathy. These are only some of the examples of uses of medicinal herbs. When working with a client who is using herbal therapies, the nurse needs to learn as much as possible about the herbs so as to promote their positive effects and minimize any potential adverse effects.
AROMATHERAPY Aromatherapy is the therapeutic use of essential oils of plants in which the odor or fragrance plays an important part. It is an offshoot of herbal medicine with the basis of action being the same as that of modern pharmacology. The chemicals found in the essential oils are absorbed into the body, resulting in physiological or psychological benefit. Essential oils are extracted from plants and are massaged into the skin, inhaled, placed in baths, used as compresses, or mixed into ointments. Different oils may calm, stimulate, improve sleep, change eating habits, or boost the immune system.
Essential oils, other than lavender or tea tree oil, are quite po- tent and can irritate the skin, so they should be diluted with a carrier oil before being used on the skin. Carrier oils such as sunflower oil,
grapeseed oil, and soy oil contain vitamins, proteins, and minerals that provide added nutrients to the body. Essential oils should not be ingested, because even modest amounts can be fatal. Pregnant women and persons with epilepsy should consult a knowledgeable health care practitioner or qualified aromatherapist prior to the use of essential oils. Some oils can trigger bronchial spasms, so persons with asthma should consult their primary health care provider before using oils. Table 19–1 describes oils that may be useful at home.
HOMEOPATHY Homeopathy is a self-healing system, assisted by small doses of reme- dies or medicines, which is useful in a variety of acute and chronic disor- ders. It was developed by Samuel Hahnemann, a German physician and chemist. He proposed the use of the law of similars, which claims that a natural substance that produces a given symptom in a healthy person cures it in a sick person. If taken in large amounts, these natural com- pounds will produce symptoms of disease. In the doses used by homeo- paths, however, these remedies stimulate a person’s self-healing capacity.
Natural healing compounds are prepared through a process of serial dilution and are taken orally. The compound is first dissolved in a water–alcohol mixture called the “mother tincture.” One drop of the tincture is then mixed with 10 drops of water–alcohol, and this process is repeated hundreds or thousands of times depending on the potency being prepared. The remedies are diluted beyond the point at which any molecules of the substance can theoretically still
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substances such as enzymes and fish oils for the purpose of prevent- ing or treating illness. Supplements are not considered medications. The Dietary Supplement Health and Education Act of 1994 requires that the companies selling these products determine their safety; however, the companies are not required to publicize this informa- tion or to inform the FDA of reports of adverse reactions.
Three major concerns are related to clients’ use of nutritional supplements: efficacy, consistency, and safety. Often, research con- ducted to determine the effectiveness of supplements has been flawed in design or produced conflicting results. Nurses should assist clients in gathering reliable information about supplements such as information available from the National Institutes of Health’s Office of Dietary Supplements website. Supplements are manufactured by many different companies and often contain a variety of substances in varying amounts. The specific amount of a substance needed to produce the desired effect may not be known and there is no guaran- tee that each dose (pill, capsule, tablet, or liquid) contains a consistent amount of the substance. There are no legal definitions of the words standardized, certified, or verified for supplements.
As mentioned in the discussion of herbs, not all supplements are harmless. Some supplements cause adverse effects such as diarrhea or high blood pressure; yet others become dangerous when taken in combination with certain medications (see earlier Practice Guide- lines). Another safety concern with supplements is that they may be contaminated with dangerous substances such as mold, bacteria, pesti- cides, and metals (Rolfes, Pinna, & Whitney, 2012). Nurses must assess clients for use of dietary supplements, and nurses’ care planning should include teaching about the known benefits and risks of supplements.
Manual Healing Methods Some manual healing methods come from ancient times; some were developed in the latter half of the 20th century. These healing prac- tices include chiropractic, massage, acupuncture, acupressure, reflex- ology, and hand-mediated biofield therapies.
CHIROPRACTIC Chiropractic focuses on the relationship between the body’s structure—mainly the spine—and its functioning. Although prac- titioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body’s natural ability to heal itself.
be found in the solution. The homeopathic belief is that the more the substance is diluted, the more potent it becomes. No matter how many times a substance is diluted, a smaller but complete essence of the substance remains. Advances in quantum physics have led some scientists to suggest that electromagnetic energy in the remedies in- teracts with the body on some level. Researchers in physical chemis- try have proposed the memory of water theory in which the structure of the water–alcohol solutions is altered during the process of dilu- tion and retains its new structure even after the substance is no longer present. It seems likely that remedies work through a bioenergetic or subatomic mechanism that we are not as yet capable of understand- ing. Homeopathic remedies are regulated by the U.S. Food and Drug Administration (FDA). However, the FDA does not evaluate the remedies for safety or effectiveness (NCCAM, 2012).
NATUROPATHY Naturopathic medicine is not only a system of medicine but also a way of life with emphasis on client responsibility, education, health maintenance, and disease prevention. It may be the model health system of the future with the movement toward healthy lifestyles, healthy diets, and preventive health care.
The education of naturopathic practitioners is extensive and similar to that for conventional medical education. Four years of medical school follow a college degree in a biologic science. Natu- ropathic medicine holds the same view of human physiology, body functions, and disease processes as conventional medicine. Naturo- pathic practitioners do not provide emergency care nor do they per- form major surgery. They rarely prescribe drugs and they treat clients in private practice and outpatient clinics, not in hospitals.
The goal of treatment is the restoration of health and normal body function, rather than the application of a particular therapy. Virtually every CAM therapy is utilized. Naturopaths mix and match different approaches, customizing treatment for each person. The least invasive intervention to support the body’s natural healing processes is a primary consideration. These interventions include dietetics, therapeutic nutrition, herbs, physical therapy, spinal ma- nipulation, acupuncture, lifestyle counseling, stress management, exercise therapy, homeopathy, and hydrotherapy.
Nutritional Therapy Nutritional therapy consists of the consumption of specific types of diets (see Chapter 47 ) or supplements, including vitamins, min- erals, amino acids, herbs and other botanicals, and miscellaneous
TABLE 19–1 Oils That May Be Useful to Have at Home
Oil Use Chamomile Soothes muscle aches, sprains, swollen joints; GI antispasmodic; rub on abdomen for colic, indigestion, gas; decreases
anxiety, stress-related headaches; decreases insomnia; can be used with children.
Eucalyptus Feels cool to skin and warm to muscles; decreases fever; relieves pain; anti-inflammatory; antiseptic, antiviral, and expectorant to respiratory system in steam inhalation; boosts immune system.
Ginger Helps ward off colds; calms upset stomach, decreases nausea; soothes sprains, muscle spasms.
Jasmine Uplifting and stimulating, antidepressant; massage abdomen and lower back for menstrual cramps.
Lavender Calming, sedative for insomnia; massage around temples for headache; inhale to speed recovery from colds, flu; massage chest to decrease congestion; heals burns.
Tea tree Antifungal, good for athlete’s foot; soothes insect bites, stings, cuts, wounds; in bath for yeast infection; drops on handkerchief for coughs, congestion.
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ACUPUNCTURE, ACUPRESSURE, AND REFLEXOLOGY Acupuncture and acupressure are techniques in which pressure or stimulation is applied to specific points on the body, known as acu- puncture points, to relieve pain, cure certain illnesses, and promote wellness. Acupuncture uses needles (Figure 19–3 •), whereas acu- pressure uses finger pressure. Reflexology is a form of acupressure most commonly performed on the feet but the hands or ears may also be manipulated. Figure 19–4 • shows the foot reflex areas.
Acupuncture, acupressure, and reflexology are treatments rooted in the traditional Eastern philosophy that qi, or life energy, flows through the body along pathways known as meridians. As vital energy flows through the meridians, it forms tiny whirlpools close to the skin’s surface at places called acupuncture points. These points function somewhat like gates to moderate the flow of qi.
When the flow of energy becomes blocked or congested, people experience discomfort or pain on a physical level, may feel frustrated or irritable on an emotional level, and may experience a sense of vul- nerability or lack of purpose in life on a spiritual level. The goal of care in wellness acupuncture is to recognize and manage the disrup- tion before illness or disease occurs. Practitioners bring balance to the body’s energies, which promotes optimal health and well-being, and facilitates people’s own healing capacity.
Examples of research on the effectiveness of acupuncture include the following:
• A systematic review, including 17 randomized clinical trials with 1,806 participants, found that acupuncture was not better at treating irritable bowel syndrome than sham (“pretend”) acupuncture, but was superior to certain medication treatments (Manheimer et al., 2012).
• A systematic review, including three studies and 204 participants, found that acupuncture was more effective at treating cancer pain than medication after the first 10 days of treatment (Paley, Johnson, Tashani, & Bagnall, 2011).
HAND-MEDIATED BIOFIELD THERAPIES The three most prominent hand-mediated biofield therapies, using the hands to alter the biofield, or energy field, are therapeutic
Figure 19–2 • Massaging the back. Celia Peterson/Getty Images.
Figure 19–3 • Acupuncture involves the insertion of thin, sterile needles. Michelle Del Guercio/Getty Images.
Three primary clinical goals guide chiropractic intervention. The first clinical goal is to reduce or eliminate pain. The second goal is to correct the spinal dysfunction, thereby restoring biomechanical bal- ance to reestablish shock absorption, leverage, and range of motion. In addition, muscles and ligaments are strengthened by spinal rehabilita- tive exercises to increase resistance to further injury. The third clinical goal is preventive maintenance to ensure the problem does not recur.
As holistic practitioners, chiropractors work with many facets of clients’ lifestyles. Exercise programs are designed, rehabilitation measures are planned, correct posture and lifting techniques are ex- plained, and activities of daily living are assessed and improved.
MASSAGE Massage therapy, the scientific manipulation of the soft tissues of the body, is a healing art, an act of physical caring, and a way of communicating without words. It is believed that massage aids the ability of the body to heal itself and is aimed at achieving or increas- ing health and well-being. In the United States massage is considered an alternative or complementary treatment, whereas in many areas of the world it is an integral part of health systems.
Strong, sustained touch in massage can have an even greater ef- fect than other forms of touch. A skilled massage therapist not only stretches and loosens muscle and connective tissue, but also greatly improves blood flow and the movement of lymph fluid throughout the body (Figure 19–2 •). Massage speeds the removal of metabolic waste products resulting from exercise or inactivity, allowing more oxygen and nutrients to reach the cells and tissues. The release of muscular tension also helps to unblock and balance the overall flow of life energy throughout the body.
On the physical level, massage relieves muscle tension, reduces muscle spasms, improves joint flexibility and range of motion, im- proves posture, lowers blood pressure, slows heart rate, promotes deeper and easier breathing, and improves the health of the skin. On the mental level, massage induces a relaxed state of alertness, reduces mental stress, and increases the capacity for clearer thinking. On the emotional level, massage satisfies the need for caring and nurturing touch, increases feelings of well-being, decreases mild depression, en- hances self-image, reduces levels of anxiety, and increases awareness of the mind–body connection (Fontaine, 2011). For back massage techniques, see Skill 46–1 in Chapter 46 .
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Mind–Body Therapies In mind–body therapies, individuals focus on realigning or creating balance in mental processes to bring about healing. These therapies include yoga, meditation, hypnotherapy, guided imagery, biofeed- back, qi gong, t’ai chi, and Pilates.
YOGA Yoga has been practiced for thousands of years in India, where it is a way of life that includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment. It is a method for life that can complement and enhance any system of
touch (TT), healing touch, and Reiki. All three approaches could be simply defined as the use of the hands on or near the body with the in- tention to help or to heal. The goals are to accelerate the person’s own healing process and to facilitate healing at all levels of body, mind, emotions, and spirit. All three are forms of treatment and are not de- signed to diagnose physical conditions, nor are they meant to replace conventional surgery, medicine, or drugs in treating organic disease.
Trained nurses can use TT, healing touch, and Reiki in almost any clinical setting, including hospitals, nursing homes, home health care, hospice, and private practice. These therapies are helpful for people with a variety of medical and nursing diagnoses.
Figure 19–4 • Foot reflex areas.
SinusSinus Brain
Side of neck
Eyes/ears
7th cervical
Throat/neck/thyroid
Lungs
Shoulder
HeartLiver
Gallbladder
Right Sole
Diaphragm/solar plexus
Stomach
Kidneys
Spine
Descending colon
Small intestine
Bladder
Sacrum/coccyx
Sigmoid colon
Sciatic Left Sole
Ascending colon
Ileocecal valve and appendix
Hardwick, Pulido, and Adelson (2012) hypothesized that addition of healing touch (HT) to standard pharmacologic intervention would reduce pain, anxiety, and opioid consumption, and improve ambula- tion distance, knee flexion, and satisfaction with quality of care in cli- ents undergoing bilateral total knee arthroplasty. More than 300,000 such surgeries are performed each year in the United States. In this study, 41 clients were prospectively randomized to an HTT group or a standard treatment (ST) group. HT was administered once daily between two daily physical therapy sessions. Pain was assessed using a visual analog scale. Anxiety was measured using the State- Trait Anxiety Inventory (STAI). Opioid analgesic consumption was converted into dose equivalents. Satisfaction was assessed at the 1-month postoperative visit.
The HT practitioner used light touch to implement the HT tech- niques. Each HT session lasted approximately 30 minutes. The first session was administered immediately after surgery in the postan- esthesia care unit. The following sessions were administered once daily, on the nursing unit, between the two daily physical therapy sessions, approximately 2 hours after pain medication was given.
Data showed that pain was lower in the HT group than in the ST group, but was not statistically significant. Within the HT group,
pain after the HT treatment was significantly diminished compared with pre-HT pain except on the first postoperative day. Anxiety was lower in the HT group, but reached statistical significance only on postoperative day 2. The total opioid dose was similar in both groups. Twenty percent more in the ST group reported over- all pain as moderate/severe. There were no differences between groups in terms of their ability to move or ambulate. One month after surgery, 95% of the HT group, compared with 87% of the ST group, felt that their pain was adequately controlled during the hospital stay.
IMPLICATIONS The limitations of this study include the challenge found in most pain research, that the measurement of pain is subjective. It is possible that just the additional attention given clients during HT could have influenced their ratings. Also, this was not a very large study and it may not be possible to generalize the findings to a larger and broader population. The HT nurses required training, which may not be practical for all settings. However, the use of a nursing interven- tion that has a positive impact and no adverse side effects is always worthy of consideration.
Evidence-Based Practice Can Healing Touch Decrease Pain, Anxiety, and Opioid Use in Clients Undergoing Knee Replacement? EVIDENCE-BASED PRACTICE
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religion, or it can be practiced completely apart from religion. The Western approach to yoga tends to be more fitness oriented with the goal of managing stress, learning to relax, and increasing vitality and well-being. A typical yoga session lasts 20 minutes to an hour. Some people spend 30 minutes doing the poses and another 30 minutes do- ing breathing practices and meditations. Others spend the majority of the time doing poses and end with a short meditation or relaxation procedure. Even for those who are inactive and out of shape, sick, or weak, sets of easy exercises can help to loosen the joints and stimulate circulation. If practiced regularly, these simple exercises alone make a great difference in people’s health and well-being.
• In an integrative review of the literature, Okonta (2012) found that eight of nine studies demonstrated a reduction in high blood pres- sure among those clients who practiced yoga. In addition to the blood pressure effects, yoga was shown to effectively reduce blood glucose level, cholesterol level, and body weight.
• A study conducted in Taiwan with both community-dwelling and institutionalized older adults demonstrated that different forms of yoga may be better tolerated and more effective in certain clients (Chen, Wang, & Chen, 2011). The program included warm-up, hatha yoga, relaxation, and guided-imagery meditation.
MEDITATION Meditation is a general term for a wide range of practices that in- volve relaxing the body and easing the mind. Meditation is a process that anyone can use to calm themselves, cope with stress, and, for those with spiritual inclinations, feel as one with God or the universe. Meditation can be practiced individually or in groups and is easy to learn. It requires no change in belief system and is compatible with most religious practices.
If practiced regularly, such as 20 minutes twice a day, medita- tion produces widespread positive effects on physical and psycho- logical functioning. The autonomic nervous system responds with a decrease in heart rate, lower blood pressure, decreased respiratory rate and oxygen consumption, and a lower arousal threshold. People who meditate say that they have clearer minds and sharper thoughts. Meditation’s residual effects—improved stress-coping abilities—are a protection against daily stress and anxiety. All other self-healing methods are improved with the practice of meditation. See Box 19–1 for guidelines for performing meditation.
HYPNOTHERAPY Hypnotherapy is the application of hypnosis in a wide variety of medical and psychological disorders. Hypnosis is a trance state or an altered state of consciousness in which an individual’s concentration is focused and distraction is minimized. People in trances are aware of what is going on around them but choose not to focus on it and can return to normal awareness whenever they choose. Hypnosis is not a surrender of control; it is only an advanced form of relaxation. Hypnotherapy can be used to help people gain self-control, improve self-esteem, and become more autonomous. In some medical facili- ties, hypnosis is routinely used with a variety of conditions, usually in conjunction with other forms of medical, surgical, psychiatric, or psychological treatment. It can be used with nonmedical clients as well, in working through problems of living or situations of perfor- mance anxiety, and in changing bad habits. Depending on the com- plexity and seriousness of the complaint, treatment typically runs from 2 to 10 sessions.
BOX 19–1 Guidelines for Meditation and Progressive Relaxation
1. Create a special time and place for meditation. Ideally, choose the early morning or evening, and wait at least 2 hours after eating so that complete energy is devoted to meditation rather than to digestive demands. A quiet, comfortable place, devoid of distractions, is helpful.
2. Sit either cross-legged on the floor or upright in a straight- backed chair, keeping the spine straight and the body relaxed. Avoid a lying position because it increases the tendency to fall asleep.
3. Support the palms on the thighs, and close the eyes. 4. Follow deep-breathing or progressive relaxation exercises.
• Tense and tighten your right fist. Focus on the feeling of tension as you do so.
• Allow the muscles in your right fist to relax. Contrast the difference in feeling from tension to relaxation.
• Repeat the preceding two steps for the left fist. • Now tense and relax both your left and right fists. • Focus on and relish the feeling of relaxation. • Now tighten the muscles in both fists and both arms. Feel
the tension, fully relax the muscles, and again focus on the sensation of relaxation.
• Progressively tighten and relax each muscle group in the body: toes, ankles, knees, buttocks and groin, stomach and lower back muscles, chest and upper back muscles, shoulders, forehead, jaw muscles.
• Couple deep breathing with progressive relaxation. While relaxing your muscles, inhale deeply, send the breath to the fist (or other muscle group), and exhale.
5. If using a mantra, repeat the word or phrase either aloud or silently while exhaling. When distracting thoughts arise, allow them to drift into and out of your mind without giving them undue attention; then refocus on your breathing or your mantra.
6. Practice this process daily for 10- to 20-minute periods.
GUIDED IMAGERY Imagery refers to a two-way communication between the con- scious and unconscious mind and involves the whole body and all of its senses. Most of us image frequently throughout the day. Worry is the most common form of imagery that affects our health. In our imagination, we react to current stressors and anticipated dangers. Our bodies become aroused and tense and we activate the fight-or- flight mechanism. Guided imagery is a state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiological reactions. Guided imagery can help us learn how to stop troublesome thoughts and focus on images that help us relax and decrease the negative impact of stressors.
In guided imagery, the images may be created by the therapist based on the needs and desires of the client. Clients can also create the images as a way to understand the meaning of symptoms or to access inner resources. Imagery stimulates changes in many body functions such as heart rate, blood pressure, respiratory patterns, brain wave rhythms and patterns, electrical characteristics of the skin, local blood flow and temperature, gastrointestinal motility and secretions, sexual arousal, and levels of various hormones and neurotransmitters.
The AHNA and an organization called Beyond Ordinary Nurs- ing offer a nurses’ certificate program in imagery. The program con- sists of 108 hours of in-depth, hands-on training to provide nurses with experience in relaxation and therapeutic imagery skills. These
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and go out to the parks to practice qi gong or t’ai chi, even in the middle of winter. These Eastern practices can be done alone, in pairs, or in large groups.
PILATES Pilates (pronounced pih-lah-tes) is a method of physical move- ment and exercise designed to stretch, strengthen, and balance the body, in particular the core or center including the abdominal re- gion. It is based in principles of yoga, Zen meditation, and ancient Greek and Roman physical regimens. Pilates exercises were devel- oped by Joseph Pilates, a German national in England at the out- break of World War I, who was interned in a prison camp. While there, he devised his system of exercises to strengthen his frail asth- matic body, which he then taught to his fellow inmates. Exercises, coupled with focused breathing patterns, are done on the floor or with simple types of equipment. Benefits include increased lung ca- pacity, improved flexibility and joint health, muscular coordination, increased bone density, and better posture and balance. Pilates can help rehabilitate back, knee, hip, shoulder, and stress injuries, and relieve muscle aches.
Spiritual Therapy Health care sciences have begun to demonstrate that spirituality, faith, and religious commitment may play a role in promoting health and reducing illness. For more information about spirituality, see Chapter 41 .
FAITH AND PRAYER Faith refers to our beliefs and expectations about life, ourselves, and others. In a religious context, faith refers to a belief in a Supreme Be- ing who listens and responds to people and who cares about their well-being. In a spiritual context, faith is thought of as the power to accept the nature of life as it is and live in the present moment. It is a sense of letting go of the need to control while trusting and waiting for the moment when answers come.
Prayer is most often defined simply as a form of communica- tion and fellowship with the Deity or Creator. The universality of prayer is evidenced in all cultures having some form of prayer. Prayer has been and continues to be used in times of difficulty and illness
skills are used to promote healing; decrease pain and symptoms; minimize side effects; manage chronic illness; prepare for proce- dures, surgery, or childbirth; and access inner wisdom and resources. Table 19–2 describes several types of imagery.
BIOFEEDBACK Biofeedback is a method by which a person can learn to control certain physiological responses of the body. The technique uses elec- tronic equipment to provide clients with visible or audible evidence that they are controlling their body in the desired manner. For ex- ample, a sensor attached from a person to a computer screen shows a wave pattern changing as the person concentrates on processes such as increasing blood flow in the hands, decreasing sweat gland activity, lowering blood pressure, and controlling incontinence.
CLINICAL ALERT!
Although meditation, biofeedback, and imagery are different tech- niques, all three involve the process of physical resting and rhythmic breathing.
QI GONG AND T’AI CHI A number of therapies focus on movement, body awareness, and breathing and their purpose is to maintain health as well as to cor- rect specific problems. Qi gong (pronounced chee-goong) is a Chinese discipline consisting of breathing and mental exercises combined with body movements. T’ai chi (pronounced teye chee) arose out of qi gong and is a discipline that combines physical fit- ness, meditation, and self-defense. Both disciplines consist of soft, slow, continuous movements that are circular in nature. The soft- ness of movements develops energy without nervousness. The slowness of movements requires attentive control that quiets the mind and develops one’s powers of awareness and concentration. The continuous circular nature of the movements develops strength and endurance.
Almost anyone can participate in movement-oriented thera- pies. They can be learned by the young and old, by people physi- cally challenged or physically fit, and by those in good health and those recovering from long-term injury or illness. In China, 80-, 90-, and 100-year-old people get up every morning before dawn
Type Description Example Cellular Imagine events at cellular level. Imagine natural killer cells surrounding and attacking cancer cells.
End state Imagine self in the situation wished for. See self as strong and healthy.
Energetic Imagine free-flowing energy. Feel self pulling up energy from the earth through the soles of the feet.
Feeling state Move from a feeling state of tension to one of peace.
May imagine self at a beach or floating gently on the water.
Physiological Involves entire body. Imagine all blood vessels relaxed and wider in order to lower blood pressure.
Psychological Involves perception of self. Imagine a dialogue with a person with whom one is in conflict in an effort to find a new solution to the problem.
Spiritual Make contact with God or the Divine. Imagine being held in the hands of God where you are perfectly safe.
TABLE 19–2 Types of Imagery
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1860. Humor involves the ability to discover, express, or appreciate the comical or bizarre, to be amused by one’s own imperfections or the whimsical aspects of life, and to see the funny side of an other- wise serious situation. Humor in nursing can be a universal language among clients of all ages and cultures. Elaboration on these functions of humor in nursing situations follows:
• Establishing relationships. Humor decreases the social distance between individuals and assists in putting them at ease. When ten- sion is decreased, people can focus on the message and on other people rather than on their own feelings. Use of humor helps the nurse establish rapport with clients, an important factor in achiev- ing success in nursing interventions.
• Relieving tension and anxiety. The effective use of humor relieves the tension of emotionally charged events. The personal nature of humor, for example, helps clients deal with the impersonal nature of wearing a hospital gown and numbered ID band and with em- barrassing questions and uncomfortable tests. People can also use humor to decrease stress.
• Facilitating learning. Many lectures and presentations be- gin with a joke or cartoon. Humor not only reduces the pre- senter’s anxiety but also gains the audience’s attention. People learn more when humor is used and anxiety levels are reduced. People also recall more information when they associate in- formation with a joke. Use of humor in instruction, however, needs to be carefully planned so that it will contribute to learning.
• Coping with painful feelings. People may use humor to blunt the immediate effect of situations that are too painful, such as the ef- fect of a threatening diagnosis or treatment. Humor diminishes anxiety and fear and reduces tension, thus enabling the person to confront and deal with the situation (Old, 2012).
Humor also has physiological benefits that involve alternating states of stimulation and relaxation. Laughter stimulates increases in respiratory rate, heart rate, muscular tension, and oxygen exchange. A state of relaxation follows laughter, during which heart rate, blood pressure, respiration, and muscle tension decrease. Humor stimulates
even in the most secular societies. In directed prayer, the praying person asks for a specific outcome, such as for the cancer to go away or for the baby to be born healthy. In contrast, in nondirected prayer, no specific outcome is asked. The praying person simply asks for the best thing to occur in a given situation.
Prayer can also be described according to form. Colloquial prayer is an informal talk with God, as if one were talking to a good friend. Intercessory prayer is asking God for things for oneself or oth- ers. The focus is on what God can provide. Intercessory prayer for others may be called “distant” prayer, if the person being prayed for is remote from the person who is praying. This form of prayer is of in- terest to researchers. In one example, participants with cancer whom the research team randomly allocated to the experimental group to receive remote intercessory prayer showed small but significant im- provements in spiritual well-being (Olver & Dutney, 2012). Ritual prayer is the use of formal prayers or rituals such as prayers from a prayer book or the Jewish siddur, or the Catholic practice of saying the rosary. Meditative prayer, also known as contemplative prayer, is similar to meditation and is a process of focusing the mind on an aspect of spiritual belief for a period of time. Prayer is a self-care strat- egy that provides comfort, increases hope, and promotes healing and psychological well-being.
Miscellaneous Therapies Some therapies do not fit into any of the above categories. These include music therapy, humor and laughter, bioelectromagnetics, detoxifying therapies, animal-assisted therapy, and horticultural therapy.
MUSIC THERAPY Health is about balance or harmony of body, mind, and spirit. In a state of optimal health, all frequencies are in harmony, like a finely tuned piano. In fact, music is often used in healing, from the ancient sounds of the drum, rattle, bone flute, and other primi- tive instruments to the use of current music as a prescription for health.
Music therapy can be used in a variety of practice set- tings. Quiet, soothing music without words is often used to in- duce relaxation (Figure 19–5 •). Music recordings are often used to relax and distract clients in operative settings, intensive care units, birthing rooms, rehabilitation and physical therapy units, and sleep induction units. Music has been shown to reduce both pain intensity and distress in clients who have undergone ab- dominal surgery (Vaajoki, Pietilä, Kankkunen, & Vehviläinen- Julkunen, 2012).
CLINICAL ALERT!
CAM modalities may be combined, for example, listening to music while being massaged with essential oils.
HUMOR AND LAUGHTER Health care professionals recently have focused on the positive ef- fects of humor and laughter on health and disease, although Flor- ence Nightingale wrote about the therapeutic effects of laughing in
Figure 19–5 • Listening to music can provide a variety of therapeutic benefits. Image Source/Alamy.
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binds to lead. The U.S. Federal Drug Administration has approved EDTA for the treatment of lead poisoning, hypercalcemia, and ven- tricular fibrillation secondary to digitalis toxicity.
ANIMAL-ASSISTED THERAPY Animal-assisted therapy is the use of specifically selected animals as a treatment modality in health and human service settings. It has been shown to be a successful intervention for people with a variety of physical or psychological conditions. Therapeutic horseback rid- ing, or hippotherapy, is the use of the rhythmic movement of the horse to increase sensory processing and improve posture, balance, and mobility in people with movement dysfunctions.
Throwing an object for a dog to retrieve or brushing the animal increases upper extremity range of motion. Reaching for the object the dog has retrieved improves coordination. Ambulating with a dog improves mobility. Recalling the animal’s name helps with memory. Using simple commands to the animal increases language produc- tion. Attending to the animal and the situation increases attention and concentration. A review of research studies on therapy with dogs showed improved pain relief, reduced blood pressure and stress hormones, and the ability of trained dogs to detect real or pending abnormal conditions such as seizures, migraine headaches, or hypo- glycemia (Marcus, 2013).
Resident animals live at long-term health care facilities. Species include fish, birds, hamsters, gerbils, guinea pigs, rabbits, cats, and dogs. Some staff report that full-time pets become so perceptive that they actually gravitate to the rooms of people who are the most iso- lated or depressed. The contributions companion animals (personal pets) make to the emotional well-being of people include providing unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy toward others; a reason to get up in the morning; and a source of reassurance.
HORTICULTURAL THERAPY Horticultural therapy, also called gardening or a healing garden, is an adjunct therapy to occupational and physical therapy. People may view nature, visit a healing garden or a wander garden, or ac- tually participate in gardening. When it is a communal activity, gardening decreases social isolation by fostering interactions with others. Horticultural therapy stimulates the five senses, provides leisure activities, improves motor function, provides a sense of achievement, and improves self-esteem (Annerstedt & Währborg, 2011). Nurses must also be aware, however, that clients who are prone to infection should not come into contact with garden soil, perform activities that can cause skin punctures or scratches, or come in proximity to stagnant water that can contain insects or in- fectious organisms.
In summary, the CAM methods and modalities listed and described in this chapter are only a sample of those available. Others range from quite common and accepted oral supplements such as probiotics to ear candling, also called thermal-auricular therapy, which may be considered of no benefit or even to be dan- gerous. In every case, the nurse remains open minded, reviews the literature for current evidence of therapeutic value, and advo- cates for the client in the use of the most beneficial approaches to their health care.
the production of catecholamines and hormones. It also releases en- dorphins, thereby increasing pain tolerance.
Humor can bring out and integrate people’s positive emotions: hope, faith, will to live, festivity, purpose, and determination. It there- fore has healing properties. To use humor effectively, nurses need to be aware of their own feelings as well as the feelings of others and cul- tural variations in what people consider humorous. There may be a fine line between what is humorous to one person and insulting to another. Resources for more information on humor in health care can be found on the Journal of Nursing Jocularity and the Associa- tion for Applied and Therapeutic Humor websites.
BIOELECTROMAGNETICS Bioelectromagnetics is the emerging science that studies how liv- ing organisms interact with electromagnetic fields. It works on the principle that every animal, plant, and mineral has an electromag- netic field that enables organic beings and inorganic objects, such as crystals, to communicate and interact as part of a single, unified en- ergy system. Magnetic fields are able to penetrate the body and affect the functioning of cells, tissues, organs, and systems. These therapies work best in combination with other healing modalities and are con- sidered to be adjunct treatments to conventional medicine.
Magnet therapy is among the most common and controversial energy therapies (Synovitz & Larson, 2013). Contraindications for magnetic therapy include pregnancy, pacemakers, implanted defi- brillators, aneurysm clips in the brain, cochlear implants, or other implanted electrical devices. It should not be used by people on anti- coagulants, those with an actively bleeding or open wound, or those with a freshly torn muscle.
DETOXIFYING THERAPIES Many cultures and religions, past and present, have rituals of purifi- cation. Some people adopt the concept of detoxification, the belief that physical impurities and toxins must be cleared from the body to achieve better health. These types of cleansing therapies may be in- cluded as a part of Ayurvedic practices.
The use of water as a healing treatment is known as hydrother- apy. The use of hot and cold moisture in the form of solid, liquid, or gas makes use of the body’s response to heat and cold. Hydro- therapy is used to decrease pain, decrease fever, reduce swelling, re- duce cramps, induce sleep, and improve physical and mental tone. It must be used with great care in the very young or old who have poor heat regulation and also with people experiencing a prolonged illness or fatigue.
Colonics, or colon therapy, is based on the idea that high-fat, Western diets lead to an accumulation of a substance in the colon, which in turn produces toxins that lead to disease. Colonics is the procedure for washing the inner wall of the colon by filling it with water or herbal solutions and then draining it. Colon cleansing is a controversial method of detoxification. Contraindications include people in a weakened state and those having ulcerative colitis, diver- ticulitis, Crohn’s disease, severe hemorrhoids, or tumors of the large intestine or rectum.
Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body. Ethylene di- amine tetraacetic acid (EDTA) is a synthetic amino acid that readily
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LIFESPAN CONSIDERATIONS Examples of the Uses of Massage
Following are a few of the many examples illustrating the uses of massage in children, adults, and older adults.
CHILDREN Infant massage is gaining in popularity in the United States. Infant massage produces weight gain in premature infants, reduces com- plications in cocaine babies, and helps depressed mothers soothe their babies. In healthy babies, it improves parent–infant bonding, eases painful procedures such as immunizations, reduces pain from teething and constipation, reduces colic, induces sleep, and makes parents feel they are doing something good for their baby.
ADULTS • Massage is usually contraindicated until after the first trimester
of pregnancy, because of the danger of miscarriage during that time. During the second and third trimesters, massage can ease pain and provide comfort to the pregnant woman. Mas- sage relaxes the woman and reduces the flow of stress hor- mones to the baby. It also nurtures the woman, which helps her nurture her baby after birth. Pregnancy massage is usually done in a side-lying position with plenty of pillows or cushions for support. The massage usually is done to the neck, arms/hands,
back, pelvis, legs, and feet. Since not all massage therapists are trained in pregnancy massage, consumers must ask about the experience and credentials of a particular therapist.
• Massage has become popular among athletes. Prior to the ath- letic event, massage loosens, warms, and readies the muscles for intensive use, especially when combined with stretching. Besides helping prevent injury, it can improve performance and endurance. Post-event massage relieves pain, prevents stiffness, and returns the muscles to their normal state more rapidly. The use of massage in sports health care is increasing rapidly in both training and competition. Recreational athletes have also discovered the benefits of sports massage as a regu- lar part of their workouts.
OLDER ADULTS A study compared physical functioning, bodily pain, role limitations due to physical issues, emotional well-being, role limitations due to emotional/personal problems, social functioning, energy/fatigue, general health, and change in health in older adults known to have used massage therapy to those who had not (Munk & Zanjani, 2011). In every case, those who had received a massage in the previous year scored higher—indicating better health.
Critical Thinking Checkpoint
Tim Le is a 68-year-old accountant who has been diagnosed with gastric cancer. He lost a great deal of weight before the diagnosis and during treatment with chemotherapy and radiation. He is now admitted to the hospital with pain and weakness preventing him from working or performing many activities of daily living. His wife, Susan, stays with him the majority of the day. His elderly parents visit often and bring him homemade food and drink. They do not speak English. In the process of placing bathing items in Tim’s bedside stand, the nurse notes several plastic bags of a tea-like product in the drawer.
1. What aspects of this case suggest that it would be appropriate for the nurse to discuss the use of alternative therapies with the client or family?
2. Which alternative therapies might be most useful for this client and are in keeping with the principle of “do no harm”?
3. How should the nurse respond to finding the bags in the client’s drawer? What options should be considered and what are the likely results of each?
4. How might the nurse’s own belief system influence his or her interactions with the client and family regarding CAM?
See Critical Thinking Possibilities on student resource website.
• The concepts common to most alternative practices include holism, humanism, balance, spirituality, energy, and healing environments.
• We create healing environments when we provide holistic nurs- ing care, take time to be with clients in deeply caring ways, and balance technology and compassion.
• If we do not create healing environments for ourselves, we are in danger of nursing “burnout.”
• Ancient health care practices typically include an entire set of values, attitudes, and beliefs that generate a philosophy of life, not simply a group of remedies.
• Many prescription drugs sold in the United States are derived from plants.
• Although many botanical and nutritional supplements can be help- ful in certain conditions, their effectiveness and safety are not all well studied.
• Manual healing methods include chiropractic, massage, acu- puncture, acupressure, reflexology, and hand-mediated biofield therapies.
• Mind–body therapies such as yoga, meditation, hypnotherapy, guided imagery, biofeedback, qi gong, t’ai chi, and Pilates all focus on realigning or creating balance in mental and physical processes to bring about healing.
• Other CAM approaches include faith and prayer, music therapy, humor and laughter, bioelectromagnetics, detoxifying therapies, animal-assisted therapy, and horticultural therapy.
CHAPTER HIGHLIGHTS
Chapter 19 Review
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1. A client asks the nurse the differences between traditional thera- pies and alternative therapies. What is the best response? 1. Alternative therapies cost less than traditional therapies. 2. Alternative therapies are used if traditional therapies are
ineffective. 3. Alternative therapies can be as effective as traditional
therapies for some conditions. 4. Alternative therapies utilize products from nature but
traditional therapies do not. 2. Before meeting with a client with a terminal illness, a new
graduate nurse reviews information on spirituality. Which is the best explanation of spirituality? 1. That which gives people purpose and meaning in their lives 2. A formalized religious dogma 3. A nondenominational community service 4. People being responsible for their life patterns
3. Which nursing action is most likely to create a healing environment? 1. Use technology to prevent health care–associated infections. 2. Empower clients to make healthy decisions for themselves. 3. Assist clients to obtain a safe and comfortable place to live. 4. Ensure that primary care providers’ orders are carried out.
4. A client asks the nurse to state one of the primary principles associated with naturopathy. Which of the following is the best response? 1. A higher being guides the learning needed to treat disease. 2. It focuses on environmental causes when treating illnesses. 3. It focuses on early detection and treatment of disease. 4. It is a way of life to maintain health and prevent disease.
5. From the perspective of traditional Chinese medicine, which is the best definition of disease? 1. Imbalance or disruption in food digestion 2. Imbalance or interruption in the flow of qi 3. Imbalance or disruption in key social relationships 4. Imbalance or disruption in thoughts or emotions
6. A client asks how herbs are similar to prescribed medications. What is the nurse’s best answer? 1. “They are nothing alike. You should ask your doctor these
types of questions.” 2. “Thirty percent of current prescription drugs are derived from
plants.” 3. “Medications are much more effective than herbs.” 4. “Herbs are more dangerous than prescribed medications.”
7. What is a rationale for assessment of clients’ use of herbs? 1. There are potential adverse interactions between some
herbs and some medications. 2. Clients should not take anything that is not prescribed by
the primary care provider. 3. These data will contribute to the body of knowledge on the
use of herbs. 4. It is important to establish a pattern that clients tell nurses
everything. 8. Which oils may be placed directly on the skin?
1. Rose and orange 2. Green apple and jasmine 3. Clary sage and rosemary 4. Lavender and tea tree
9. What are the effects of massage as a manual healing method? Select all that apply. 1. Communication and caring 2. Mental and physical relaxation 3. Increased muscle strength 4. Speeds the removal of waste products 5. Lowers blood pressure and heart rate
10. Your friend is considering in vitro fertilization in hopes of be- coming pregnant. Which one of the following is an accurate statement? 1. “There is some evidence that acupuncture improves the
chance of pregnancy in this situation.” 2. “Massage therapy may increase your sense of relaxation,
which may help in getting pregnant.” 3. “Ask your doctor about which herbs will increase the
likelihood of pregnancy.” 4. “Research suggests that yoga improves the chance of
pregnancy in this situation.” See Answers to Test Your Knowledge in Appendix A.
TEST YOUR KNOWLEDGE
Suggested Readings Dossey, B. M., & Keegan, L. (2013). Holistic nursing:
A handbook for practice (6th ed.). Burlington, MA: Jones & Bartlett. The authors joined with the American Holistic Nurses Association in this book. The purposes are to (a) expand an understanding of an integral worldview, healing, and the nurse as an instrument of healing; (b) explore the unity and relatedness of nurses, clients, and others; and (c) develop caring healing interventions to strengthen the whole person.
Related Research Recent research. (2012). Journal of the Australian Traditional-
Medicine Society, 18, 167–171. Abstracts of current research articles on foot reflexology, herbal medicine, TCM, nutrition, naturopathy, massage therapy, and aromatherapy.
Saeloo, J., Hatthakit, U., & Nilmanat, K. (2012). Development and evaluation of a self-healing nursing model using Bud- dhist meditation to treat hypertension. Pacific Rim Interna- tional Journal of Nursing Research, 16(1), 64–77.
References American Holistic Nurses Association. (2012). About us.
Retrieved from http://www.ahna.org/AboutUs/ MissionStatement/tabid/1931/Default.aspx
Annerstedt, M., & Währborg, P. (2011). Nature-assisted therapy: Systematic review of controlled and observa- tional studies. Scandinavian Journal of Public Health, 39, 371–388. doi:10.1177/1403494810396400
Chen, K., Wang, H., Li, C., & Chen, M. (2011). Community vs. institutional elders’ evaluations of and preferences for yoga exercises. Journal of Clinical Nursing, 20, 1000–1007. doi:10.1111/j.1365-2702.2010.03337.x
Fontaine, K. L. (2011). Complementary & alternative therapies for nursing practice (3rd ed.). Upper Saddle River, NJ: Prentice Hall.
Hardwick, M., Pulido, P., & Adelson, W. (2012). Nursing intervention using healing touch in bilateral total knee arthroplasty. Orthopaedic Nursing, 31(1), 5–11. doi:10.1097/NOR.0b013e31824195fb
Manheimer, E., Cheng, K., Wieland, L. S., Min, L. S., Shen, X., Berman, B. M., & Lao, L. (2012). Acupuncture for treat- ment of irritable bowel syndrome. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD005111. doi:10.1002/14651858.CD005111.pub3
Marcus, D. A. (2013). The science behind animal-assisted therapy. Current Pain and Headache Reports, 17(4), 322.doi:10.1007/s11916-013-0322-2
READINGS AND REFERENCES
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Munk, N., & Zanjani, F. (2011). Relationship between massage therapy usage and health outcomes in older adults. Journal of Bodywork and Movement Therapies, 15, 177–185. doi:10.1016/j.jbmt.2010.01.007
National Center for Complementary and Alternative Medicine. (2012). Homeopathy: An introduction. Retrieved from http://www.nccam.nih.gov/health/homeopathy
Okonta, N. (2012). Does yoga therapy reduce blood pres- sure in patients with hypertension?: An integrative review. Holistic Nursing Practice, 26, 137–141. doi:10.1097/ HNP.0b013e31824ef647
Old, N. (2012). Survival of the funniest—Using therapeutic humour in nursing. Kai Tiaki Nursing New Zealand, 18(8), 17–19.
Olver, I., & Dutney, A. (2012). A randomized, blinded study of the impact of intercessory prayer on spiritual well-being in patients with cancer. Alternative Therapies in Health & Medicine, 18(5), 18–27.
Paley, C. A., Johnson, M. I., Tashani, O. A., & Bagnall, A. M. (2011). Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD007753. doi:10.1002/14651858.CD007753.pub2
Rolfes, S. R., Pinna, K., & Whitney, E. (2012). Understanding normal and clinical nutrition (9th ed.). Belmont, CA: Wadsworth Cengage Learning.
Synovitz, L. B., & Larson, K. L. (2013). Complementary and alternative medicine for health professionals: A holistic approach to consumer health. Burlington, MA: Jones & Bartlett.
Torres, E. (2011). Incorporating Mexican traditional medicine, curanderismo, into modern medicine. Migrant Health Newsline, 28(6), 4–6.
Vaajoki, A., Pietilä, A., Kankkunen, P., & Vehviläinen- Julkunen, K. (2012). Effects of listening to music on pain intensity and pain distress after surgery: An inter- vention. Journal of Clinical Nursing, 21(5/6), 708–717. doi:10.1111/j.1365-2702.2011.03829.x
Selected Bibliography Baird, C., Murawski, M., & Wu, J. (2010). Efficacy of guided
imagery with relaxation for osteoarthritis symptoms and medication intake. Pain Management Nursing, 11, 56–65. doi:10.1016/j.pmn.2009.04.002
Bazuin, D., & Cardon, K. (2011). Creating healing intensive care unit environments: Physical and psychological considerations in designing critical care areas. Critical Care Nursing Quarterly, 34, 259–267.
Chukumnerd, P., Hatthakit, U., & Chuaprapaisilp, A. (2011). The experience of persons with allergic respiratory symptoms: Practicing yoga as a self-healing modality. Holistic Nursing Practice, 25(2), 63–70. doi:10.1097/ HNP.0b013e31820dbbae
France, N., Byers, D., Kearney, B., & Myatt, S. (2011). Creat- ing a healing environment: Nurse-to-nurse caring in the critical care unit. International Journal for Human Caring, 15(1), 44–48.
Harris, M., & Richards, K. (2010). The physiological and psychological effects of slow-stroke back massage
and hand massage on relaxation in older people. Journal of Clinical Nursing, 19, 917–926. doi:10.1111/j.1365-2702.2009.03165.x
Kligler, B., Homel, P., Harrison, L. B., Levenson, H. D., Kenney, J. B., & Merrell, W. (2011). Cost savings in inpatient oncol- ogy through an integrative medicine approach. American Journal of Managed Care, 17, 779–784.
Kryak, E., & Vitale, A. (2011). Reiki and its journey into a hospital setting. Holistic Nursing Practice, 25, 238–245. doi:10.1097/HNP.0b013e31822a02ad
Libster, M. M. (2012). The nurse-herbalist: Integrative insights for holistic practice. University Park, IL: Golden Apple.
Nathenson, P. (2012). Application of holistic nursing in the re- habilitation setting. Rehabilitation Nursing, 37(3), 114–118. doi:10.1002/RNJ.00028
Wall, M., & Duffy, A. (2010). The effects of music therapy for older people with dementia. British Journal of Nursing, 19, 108–113.
Wyatt, G., Sikorskii, A., Wills, C., & Su, H. (2010). Complemen- tary and alternative medicine use, spending, and quality of life in early stage breast cancer. Nursing Research, 59, 58–66. doi:10.1097/NNR.0b013e3181c3bd26
Zimmerman, K. (2012). Basics of homeopathy: Treatment options in pregnancy. International Journal of Childbirth Education, 27(3), 21–25.
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CLIENT: Manuela AGE: 55 CURRENT MEDICAL DIAGNOSIS: Still’s Disease Medical History: Manuela has experienced some type of health challenge for most of her adult life. She was diagnosed with adult- onset Still’s disease (AOSD) at about age 35 after several years of tests to try to determine exactly what syndrome her symptoms re- flected. She complained of joint pain, rash, and fevers, which came and went, and she had an enlarged spleen and liver. This disease has many similarities with rheumatoid and autoimmune diseases, but those conditions were all removed from consideration because the tests were negative. AOSD is a chronic condition for which there is no known cure. In addition to joint deterioration, it can progress to affect the lungs and heart. Initial treatment consists of steroids and nonsteroidal anti-inflammatory drugs (NSAIDS). If those are ineffec- tive, other medications such as gold and chemotherapeutics are used; however, they have severe side effects such as kidney damage and bone marrow suppression. The condition worsens when the person is under physical or emotional stress. Manuela
underwent a hip replacement about 4 years ago and recently has had several hospitalizations for respiratory failure. Personal and Social History: Manuela has never married and has lived near or with her parents or siblings for all her life. She has many friends, drives, and has an active social life when she is feeling well. She uses the computer extensively for communication, especially when having visitors or talking by phone is too exhausting. She must follow a strict diet of food and liquids that are easy to swallow and digest. She is a spiritual person but not overly religious. She is quick to laugh and generally has an optimistic outlook, but expresses awareness that her life could end at any time—certainly long before her full life expectancy.
Manuela is a college graduate but has been able to work only part time for most of her life. Recently, she was declared permanently disabled, which allows her access to financial and other support sys- tems. She is creative in adapting her living situation to her disabilities and unwilling to give up her beloved pet dog.
Questions American Nurses Association Standard of Practice #3 is Outcomes Identification: The nurse consults with the client and family in formulating measureable goals consistent with the client’s culture, values, and environment. As you learned in Chapter 16 , Manuela’s needs fall into the category of tertiary prevention in which rehabilitation and movement toward optimal levels of functionality within the individual’s constraints are the focus. 1. What are some outcomes for Manuela that would reflect
this focus? 2. Do you need to know her personal definitions of health and
health beliefs (Chapter 17 ) before you can work with her to set expected outcomes?
American Nurses Association Standard of Practice #5b is Health Teaching and Health Promotion: The nurse customizes the client’s teaching to promote a healthy environment. 3. What are some aspects of Manuela’s situation that you would
consider incorporating into a teaching plan to maximize a safe environment for her?
American Nurses Association Standard of Professional Performance #13 is Collaboration: Nurses work with the client, family, and other health care providers in planning, implementing, and evaluating care. 4. Which health care team members other than physicians
and nurses would likely be important to include in Manuela’s care plan?
American Nurses Association Standard of Professional Performance #9 is Research. 5. What evidence might you have or seek to support the use
of alternative or complementary treatment modalities in Manuela’s care?
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
4 Meeting the StandardsIn this unit, we have explored concepts related to health, health promotion, wellness, illness, culture and heritage, and complementary and alternative healing modalities. These topics heighten awareness of the individualistic nature of the relationship between the nurse and the client and the importance of assessing the breadth of factors that affect health decisions and behaviors. In the case described below, you will see how one person demonstrates complicated, interrelated, personal definitions of health and illness influenced by her medical condition, her heritage, and her demographic character- istics (e.g., age and family structure). These definitions and perspectives in turn influence her choices for care and support—including the role of her nurses.
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UNIT
5 Life Span Development
20 Concepts of Growth and Development 312
21 Promoting Health from Conception Through Adolescence 328
22 Promoting Health in Young and Middle-Aged Adults 353
23 Promoting Health in Older Adults 364
24 Promoting Family Health 386
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INTRODUCTION It is important for nurses to understand normal growth and devel- opment because it provides a framework for health assessment and health promotion throughout the life span. For example, teaching, a major nursing role, is more effective when the nurse incorporates growth and development needs and concepts. Furthermore, The Joint Commission, the accreditation body for hospitals and health care or- ganizations, requires health care providers to be knowledgeable about the characteristics and needs of the age groups with which they come into contact. This ensures safe and effective age-specific client care.
The terms growth and development both refer to dynamic processes. Often used interchangeably, these terms have different meanings. Growth is physical change and increase in size. It can be measured quantitatively. Indicators of growth include height, weight, bone size, and dentition. The pattern of physiological growth is similar for all people. However, growth rates vary during different stages of growth and development. The growth rate is rapid during the prenatal, neonatal, infancy, and adolescent stages and slows dur- ing childhood. Physical growth is minimal during adulthood.
Development is an increase in the complexity of function and skill progression. It is the capacity and skill of a person to adapt to the environment. Development is the behavioral aspect of growth (e.g., a person develops the ability to walk, talk, run, and think).
Growth and development are independent, interrelated pro- cesses. For example, an infant’s muscles, bones, and nervous system must grow to a certain point before the infant is able to sit up, walk, or talk. Growth generally takes place during the first 20 years of life;
development takes place during that time and also continues after that point. Principles of growth and development are shown in Box 20–1.
FACTORS INFLUENCING GROWTH AND DEVELOPMENT Many factors can influence growth and development. Knowledge of these factors helps the nurse to intervene to promote positive growth and development of the individual.
Genetics The genetic inheritance of an individual is established at conception. It remains unchanged throughout life and determines such charac- teristics as gender, physical characteristics (e.g., eye color, potential height), and, to some extent, temperament.
Temperament Temperament (i.e., the way individuals respond to their external and internal environment) sets the stage for the interactive dynamics of growth and development. Temperament may persist throughout the life span, though caution must be taken not to irrevocably “label” or categorize infants and children.
Family The purpose of a family is to provide support and safety for the child. The family is the major constant in a child’s life. Families are involved in their children’s physical and psychological well-being and
After completing this chapter, you will be able to: 1. Differentiate between the terms growth and development. 2. Describe essential principles related to growth and
development. 3. List factors that influence growth and development. 4. Explain the concept of temperament. 5. Describe the stages of growth and development according
to various theorists. 6. Describe characteristics and implications of Freud’s five
stages of development. 7. Identify Erikson’s eight stages of development.
LEARNING OUTCOMES
20 Concepts of Growth and Development
KEY TERMS
accommodation, 319 adaptation, 319 adaptive mechanisms, 315 assimilation, 319 attachment, 319 cognitive development, 319
defense mechanisms, 315 development, 312 developmental stages, 315 developmental task, 316 ego, 314 fixation, 315
growth, 312 id, 314 libido, 315 maturation, 313 moral, 320 moral behavior, 321
moral development, 321 morality, 320 personality, 314 superego, 315 temperament, 312 unconscious mind, 314
8. Identify developmental tasks associated with Havighurst’s six age periods.
9. Compare Peck’s and Gould’s stages of adult development. 10. State the four characteristics of Bowlby’s attachment theory. 11. Explain Piaget’s theory of cognitive development. 12. Compare Kohlberg’s and Gilligan’s theories of moral
development. 13. Compare Fowler’s and Westerhoff’s stages of spiritual
development.
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STAGES OF GROWTH AND DEVELOPMENT The rate of a person’s growth and development is highly individ- ual; however, the sequence of growth and development is predict- able. Stages of growth usually correspond to certain developmental changes (Table 20–1).
Growth and development theories commonly include the fol- lowing major components: biophysical, psychosocial, cognitive, moral, and spiritual. A discussion follows of some of the major theo- ries relating to these components, as well as other well-known growth and development theories.
GROWTH AND DEVELOPMENT THEORIES Researchers have advanced several theories about the various stages and aspects of growth and development, particularly with regard to infant and child development.
Biophysical Theory Biophysical development theories describe the development of the physical body—how it grows and changes. These changes are com- pared against established norms. Arnold Gesell (1880–1961) is often identified as the “father of child development” in the United States. His theory states that development is directed by genetics. He conducted extensive research at Yale University in the 1920s and 1930s, asserting that child development is a process of maturation, or differentiation
development. Children are socialized through family dynamics. The parents set expected behaviors and model appropriate behavior.
Nutrition Adequate nutrition is an essential component of growth and devel- opment. For example, poorly nourished children are more likely to have infections than are well-nourished children. In addition, poorly nourished children may not attain their full height potential.
Environment A few environmental factors that can influence growth and develop- ment include living conditions of the child (e.g., homelessness), so- cioeconomic status (e.g., poor versus financially stable), climate, and community (e.g., provides developmental support versus exposes the child to hazards).
Health Illness, injury, or congenital conditions (e.g., congenital cardiac con- ditions) can affect growth and development. Being hospitalized is stressful for a child and can affect coping mechanisms of the child and family. Prolonged or chronic illness may affect normal develop- mental processes.
Culture Cultural customs can influence a child’s growth and development. Nutritional practices may influence the rate of growth for infants. Child-rearing practices may influence development.
BOX 20–1 Principles of Growth and Development
• Growth and development are continuous, orderly, sequential processes influenced by maturational, environmental, and genetic factors.
• All humans follow the same pattern of growth and development.
• The sequence of each stage is predictable, although the time of onset, the length of the stage, and the effects of each stage vary with the individual.
• Learning can either help or hinder the maturational process, depending on what is learned.
• Each developmental stage has its own characteristics. For example, Piaget suggested that in the sensorimotor stage (birth to 2 years) children learn to coordinate simple motor tasks.
• Growth and development occur in a cephalocaudal direction, that is, starting at the head and moving to the trunk, the legs, and the feet (Figure 20–1 •). This pattern is particularly obvious at birth, when the head of the infant is disproportionately large.
• Growth and development also occur in a proximodistal direction, that is, from the center of the body outward (see Figure 20–1). For example, infants can roll over before they can grasp an object with the thumb and second finger.
• Development proceeds from simple to complex, or from single acts to integrated acts. To accomplish the integrated act of drinking and swallowing from a cup, for example, the child must first learn a series of single acts: eye–hand coordination, grasping, hand–mouth coordination, controlled tipping of the cup, and then mouth, lip, and tongue movements to drink and swallow.
• Development becomes increasingly differentiated. Differenti- ated development begins with a generalized response and progresses to a skilled specific response. For example, an
infant’s initial response to a stimulus involves the total body; a 5-year-old child can respond more specifically with laughter or fear.
• Certain stages of growth and development are more criti- cal than others. It is known, for example, that the first 10 to 12 weeks after conception are critical. The incidence of con- genital anomalies as a result of exposure to certain viruses, chemicals, or drugs is greater during this stage than others.
• The pace of growth and development is uneven. It is known that growth is greater during infancy than during childhood. Asynchronous development is demonstrated by rapid growth of the head during infancy and the extremities at puberty.
Figure 20–1 • Cephalocaudal and proximodistal growth.
Proximodistal growth occurs from the center of the body out.
Cephalocaudal growth occurs from the head down.
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Stage Age Significant Characteristics Nursing Implications Neonatal Birth–28 days Behavior is largely reflexive and develops
to more purposeful behavior. Assist parents to identify and meet unmet needs.
Infancy 1 month–1 year Physical growth is rapid. Control the infant’s environment so that physical and psychological needs are met.
Toddlerhood 1–3 years Motor development permits increased physical autonomy. Psychosocial skills increase.
Safety and risk-taking strategies must be balanced to permit growth.
Preschool 3–6 years The preschooler’s world is expanding. New experiences and the preschooler’s social role are tried during play. Physical growth is slower.
Provide opportunities for play and social activity.
School age 6–12 years Stage includes the preadolescent period (10–12 years). Peer group increasingly influences behavior. Physical, cognitive, and social development increases, and communication skills improve.
Allow time and energy for the school-age child to pursue hobbies and school activities. Recognize and support child’s achievements.
Adolescence 12–20 years Self-concept changes with biologic development. Values are tested. Physi- cal growth accelerates. Stress increases, especially in face of conflicts.
Assist adolescents to develop coping behaviors. Help adolescents develop strategies for resolving conflicts.
Young adulthood 20–40 years A personal lifestyle develops. Person establishes a relationship with a significant other and a commitment to something.
Accept adult’s chosen lifestyle and assist with necessary adjustments relating to health. Recognize the person’s commitments. Support change as necessary for health.
Middle adulthood 40–65 years Lifestyle changes due to other changes; for example, children leave home, occupational goals change.
Assist clients to plan for anticipated changes in life, to recognize the risk factors related to health, and to focus on strengths rather than weaknesses.
OLDER ADULTHOOD Young-old 65–74 years Adaptation to retirement and changing
physical abilities is often necessary. Chronic illness may develop.
Assist clients to keep physically and socially active and to maintain peer group interactions.
Middle-old 75–84 years Adaptation to decline in speed of movement, reaction time, and increasing dependence on others may be necessary.
Assist clients to cope with loss (e.g., hearing, sensory abilities and eyesight, death of loved one). Provide necessary safety measures.
Old-old 85 and over Increasing physical problems may develop. Assist clients with self-care as required, and with maintaining as much independence as possible.
TABLE 20–1 Stages of Growth and Development
and refining of abilities and skills, based on an in-born “timetable.” Although children benefit from experience, they will achieve matu- rational milestones such as rolling over, sitting, and walking at specific times. Gesell’s (1934) most important work is found in An Atlas of Infant Behavior. His research documented a fixed sequence of devel- opmental milestones of children from infancy through adolescence (Ball, 1977). Gesell observed children through a one-way mirror to determine their developmental milestones. As he collected data through observation, he also utilized photography to obtain an ob- jective image of a child’s developmental milestones. His goal was to produce a complete understanding of a child’s development. The pho- tographs were inspected and 10 stages of development were identified. Each stage identified was assigned a percentage frequency for which the developmental milestone occurred (Varga, 2011).
Psychosocial Theories Psychosocial development refers to the development of personality. Personality, a complex concept that is difficult to define, can be considered as the outward (interpersonal) expression of the inner
(intrapersonal) self. It encompasses a person’s temperament, feelings, character traits, independence, self-esteem, self-concept, behavior, ability to interact with others, and ability to adapt to life changes.
Many theorists attempt to account for psychosocial develop- ment in humans, specifically the development of an individual’s per- sonality and the causes of behavior.
FREUD (1856–1939) Sigmund Freud introduced a number of concepts about develop- ment that are still used today. The concepts of the unconscious mind, defense mechanisms, and the id, ego, and superego are Freud’s. The unconscious mind is the part of a person’s mental life of which the person is unaware. This concept of the unconscious is one of Freud’s major contributions to the field of psychiatry. The id resides in the un- conscious and, operating on the pleasure principle, seeks immediate pleasure and gratification. The ego, the realistic part of the person, balances the gratification demands of the id with the limitations of social and physical circumstances. The methods the ego uses to fulfill the needs of the id in a socially acceptable manner are called defense
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mechanisms. Defense mechanisms, or adaptive mechanisms as they are more commonly called today, are the result of conflicts be- tween the id’s impulses and the anxiety created by the conflicts due to social and environmental restrictions. The third aspect of the person- ality, according to Freud, is the superego. The superego contains the conscience and the ego ideal. The conscience consists of society’s “do not’s,” usually as a result of parental and cultural expectations. The ego ideal comprises the standards of perfection toward which the individ- ual strives. Freud proposed that the underlying motivation to human development is a dynamic, psychic energy, which he called libido.
According to Freud’s theory of psychosexual development, the personality develops in five overlapping stages from birth to adult- hood. The libido changes its location of emphasis within the indi- vidual from one stage to another. Therefore, a particular body area has special significance to a client at a particular stage. The first three stages (oral, anal, and phallic) are called pregenital stages. The culmi- nating stage is the genital stage. Table 20–2 indicates characteristics for each stage. Freudian theory asserts that the individual must meet the needs of each stage in order to move successfully to the next devel- opmental stage. For example, during an infant’s oral stage, nurses can assist an infant’s development by making feeding a pleasurable experi- ence. This provides comfort and security for the infant. Freud also em- phasized the importance of infant–parent interaction. Therefore, the nurse as a caregiver should provide a warm, caring atmosphere for an infant and assist parents to do so when the infant returns to their care.
If the person does not achieve satisfactory progression at one stage, the personality becomes fixated at that stage. Fixation is im- mobilization or the inability of the personality to proceed to the next stage because of anxiety. For example, making toilet training a positive experience during the anal stage enhances the child’s feeling of self-control. If, however, the toilet training was a negative experi- ence, the resulting conflict or stress can delay or prolong progression through a stage or cause a person to regress to a previous stage. Ide- ally, an individual progresses through each stage with balance be- tween the id, ego, and superego.
ERIKSON (1902–1994) Erik H. Erikson (1963, 1964) adapted and expanded Freud’s theory of development to include the entire life span, believing that people
Stage Age Characteristics Task to be Attained Oral Birth–11⁄2 years Pleasure is accomplished by exploring the
mouth and by sucking. Weaning
Anal 11⁄2–3 years Pleasure is accomplished by exploring the organs of elimination.
Bowel and bladder control Toilet training
Phallic 4–6 years Pleasure is accomplished by exploring the genitals. The child is attracted to the parent of the opposite sex.
Resolution of the Oedipus or Electra complex
Latency 6 years–puberty Pleasure is directed by focusing on relationships with same-sex peers and the parent of the same sex.
Engagement in activities, such as sports, schoolwork, and socialization with the same-sex peers
Genital Puberty and after Pleasure is directed in the development of sexual relationships.
Engagement in activities to promote independence
Adapted from The Ego and the Mechanism of Defense, by S. Freud, copyright 1946. New York, NY: International Universities Press.
TABLE 20–2 Freud’s Five Stages of Development
continue to develop throughout life. He described eight stages of development.
Erikson’s theory proposes that life is a sequence of develop- mental stages or levels of achievement. Each stage signals a task that must be accomplished. The resolution of the task can be com- plete, partial, or unsuccessful. Erikson believed that the more suc- cess an individual has at each developmental stage, the healthier the personality of the individual. Failure to complete any developmental stage influences the person’s ability to progress to the next level. These developmental stages can be viewed as a series of crises or conflicts. Successful resolution of these crises supports healthy ego develop- ment. Failure to resolve the crises damages the ego.
Erikson’s eight stages reflect both positive and negative aspects of the critical life periods. The resolution of the conflicts at each stage enables the person to function effectively in society. Each phase has its own developmental task, and the individual must find a balance be- tween, for example, trust versus mistrust (stage 1) or integrity versus despair (stage 8).
Stage one is trust versus mistrust which is birth to 18 months of age. The infant learns to trust the primary care giver to meet their needs for food, shelter, and personal care. In early childhood age 18 months to three years the development task is autonomy versus shame and guilt. The child begins to identify with the development of control of bodily functions (Erikson, 1963).
Initiative versus guilt is the developmental task of late child- hood. The child is between the ages of three and five years. At this stage the child becomes assertive and is aware of their own behavior. If this task is not successfully achieved the child will have a decreased self-confidence and feeling of fear will result (Erikson, 1963).
From age six to 12 years the developmental task is industry ver- sus inferiority. Successful attainment indicates the child’s ability to create. A negative response is withdrawal and a sense of hopelessness (Erikson, 1963).
From age 12 to 20 years the adolescent’s central task is intimacy versus isolation. The individual is exploring relationships with other individuals while also exploring work experiences. A negative resolu- tion would be the avoidance of career or relationship.
Adulthood is generativity versus stagnation. The adult age 25– 65 years is creative and develops other interests. From age 65 years
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fixated at one stage or regress to a previous stage under anxious or stressful conditions. For example, a middle-aged woman who has never satisfactorily accomplished the task of resolving identity versus role confusion might regress to an earlier stage when stressed by an illness with which she cannot cope.
HAVIGHURST (1900–1991) Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. He described growth and development as occurring during six stages, each associated with 6 to 10 tasks to be learned (Box 20–2).
Havighurst promoted the concept of developmental tasks in the 1950s. A developmental task is “a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to his [sic] happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks” (Havighurst, 1972, p. 2).
Havighurst’s developmental tasks provide a framework that the nurse can use to evaluate a person’s general accomplishments. How- ever, these tasks are presented as very broad categories and some nurses find them of limited use when assessing specific accomplish- ments, particularly those of infancy and childhood. Also, in a multi- cultural society, the definition of success of tasks may vary with values and belief systems (e.g., not all individuals may wish to marry or bear children), making these tasks less relevant for some.
PECK Theories and models about adult development are relatively recent compared with theories of infant and child development. Research into adult development has been stimulated by a number of factors, including increased longevity and healthier old age. In the past, de- velopment was viewed as complete by the time of physical maturity, and aging was considered a decline following maturity. The emphasis was on the negative aspects rather than the positive aspects of aging. However, Robert Peck (1968) believes that although physical capabil- ities and functions decrease with old age, mental and social capacities tend to increase in the latter part of life.
Peck proposes three developmental tasks during old age, in con- trast to Erikson’s one (integrity versus despair):
1. Ego differentiation versus work-role preoccupation. An adult’s identity and feelings of worth are highly dependent on that per- son’s work role. On retirement, people may experience feelings of worthlessness unless they derive their sense of identity from a number of roles so that one such role can replace the work role or occupation as a source of self-esteem. For example, a man who likes to garden or golf can obtain ego rewards from those activi- ties, replacing rewards formerly obtained from his occupation.
2. Body transcendence versus body preoccupation. This task calls for the individual to adjust to decreasing physical capacities and at the same time maintain feelings of well-being. Preoccupation with declining body functions reduces happiness and satisfac- tion with life.
3. Ego transcendence versus ego preoccupation. Ego transcendence is the acceptance without fear of one’s death as inevitable. This acceptance includes being actively involved in one’s own future beyond death. Ego preoccupation, by contrast, results in holding onto life and a preoccupation with self-gratification.
to death the individual’s central task is integrity versus despair. The individual accepts their life and ultimate death (Erikson, 1963). See Figures 20–2 and 20–3 •.
When using Erikson’s developmental framework, nurses should be aware of indicators of positive and negative resolution of each de- velopmental stage. According to Erikson, the environment is highly influential in development. Nurses can enhance a client’s develop- ment by being aware of the individual’s developmental stage and assisting with the development of coping skills related to stressors ex- perienced at that specific level. Nurses can strengthen a client’s posi- tive resolution of a developmental task by providing the individual with appropriate opportunities and encouragement. For example, a 10-year-old child (industry versus inferiority) can be encouraged to be creative, to finish schoolwork, and to learn how to accomplish these tasks within the limitations imposed by health status.
Erikson emphasized that people must change and adapt their behavior to maintain control over their lives. In his view, no stage in personality development can be bypassed, but people can become
Figure 20–2 • Trust is established when the infant’s basic needs are met. Tyler Olson/Fotolia.
Figure 20–3 • Assistive devices help maintain independence and self-esteem, which also helps older adults maintain ego integrity and adapt and cope with the realities of aging. Pressmaster/Fotolia.
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• Stage 4 (ages 28–34). Marriage and careers are well established. Individuals question what life is all about and wish to be accepted as they are, no longer finding it necessary to prove themselves.
• Stage 5 (ages 34–43). This is a period of self-reflection. Individu- als question values and life itself. They see time as finite, with little time left to shape the lives of adolescent children.
BOX 20–2 Havighurst’s Age Periods and Developmental Tasks
INFANCY AND EARLY CHILDHOOD 1. Learning to walk 2. Learning to take solid foods 3. Learning to talk 4. Learning to control the elimination of body wastes 5. Learning sex differences and sexual modesty 6. Achieving psychological stability 7. Forming simple concepts of social and physical reality 8. Learning to relate emotionally to parents, siblings, and other
people 9. Learning to distinguish right from wrong and developing
a conscience
MIDDLE CHILDHOOD 1. Learning the physical skills necessary for ordinary games 2. Building wholesome attitudes toward oneself as a growing
organism 3. Learning to get along with age-mates 4. Learning an appropriate masculine or feminine social role 5. Developing fundamental skills in reading, writing, and
calculating 6. Developing concepts necessary for everyday living 7. Developing conscience, morality, and a scale of values 8. Achieving personal independence 9. Developing attitudes toward social groups and institutions
ADOLESCENCE 1. Achieving new and more mature relations with age-mates
of both sexes 2. Achieving a masculine or feminine social role 3. Accepting one’s physique and using the body effectively 4. Achieving emotional independence from parents and other
adults 5. Achieving assurance of economic independence 6. Selecting and preparing for an occupation 7. Preparing for marriage and family life
8. Developing intellectual skills and concepts necessary for civic competence
9. Desiring and achieving socially responsible behavior 10. Acquiring a set of values and an ethical system as a guide
to behavior
EARLY ADULTHOOD 1. Selecting a mate 2. Learning to live with a partner 3. Starting a family 4. Rearing children 5. Managing a home 6. Getting started in an occupation 7. Taking on civic responsibility 8. Finding a congenial social group
MIDDLE AGE 1. Achieving adult civic and social responsibility 2. Establishing and maintaining an economic standard of living 3. Assisting teenage children to become responsible and happy
adults 4. Developing adult leisure-time activities 5. Relating oneself to one’s spouse as a person 6. Accepting and adjusting to the physiological changes
of middle age 7. Adjusting to aging parents
LATER MATURITY 1. Adjusting to decreasing physical strength and health 2. Adjusting to retirement and reduced income 3. Adjusting to death of a spouse 4. Establishing an explicit affiliation with one’s age group 5. Meeting social and civil obligations 6. Establishing satisfactory physical living arrangements
From Developmental Tasks and Education, 3e by Robert James Havinghurst. Copyright ©1952 by Longman Publishers, renewed 1980.
GOULD Roger Gould is another theorist who has studied adult develop- ment. He believes that transformation is a central theme during adulthood: “Adults continue to change over the period of time considered to be adulthood and developmental phases may be found during the adult span of life” (Gould, 1972, p. 33). Accord- ing to Gould, the 20s is the time when a person assumes new roles; in the 30s, role confusion often occurs; in the 40s the person be- comes aware of time limitations in relation to accomplishing life’s goals; and in the 50s, the acceptance of each stage as a natural progression of life marks the path to adult maturity. Gould’s study of 524 men and women led him to describe seven stages of adult development:
• Stage 1 (ages 16–18). Individuals consider themselves part of the family rather than individuals and want to separate from their parents.
• Stage 2 (ages 18–22). Although the individuals have established autonomy, they feel it is in jeopardy; they feel they could be pulled back into their families.
• Stage 3 (ages 22–28). Individuals feel established as adults and autonomous from their families. They see themselves as well de- fined but still feel the need to prove themselves to their parents. They see this as the time for growing and building for the future (Figure 20–4 •).
Figure 20–4 • Young adults develop meaningful relationships and begin considering a home and family for themselves. Taxi/Getty Images.
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CONCEPT MAP Overview of Growth and Development Psychosocial Theories and Theorists
Theories
Freud
personality develops
in five overlapping stages from
birth to adulthood
5 stages: • Oral • Anal • Phallic • Latency • Genital
theorist theorist theorist theoristtheorist
Erikson
stages reflect
positive and
negative aspects of the critical
life periods
8 stages: • Trust vs. Mistrust • Autonomy vs. Shame & Doubt • Initiative vs. Guilt • Industry vs. Inferiority • Identity vs. Role Confusion • Intimacy vs. Isolation • Generativity vs. Stagnation • Integrity vs. Despair
Havighurst
believed
• Growth & development occurs during 6 age periods (infancy to later maturity) • Each age period has developmental tasks • Achieving the developmental tasks helps the individual transition to the next developmental period
Peck
adult development
• Three developmental tasks during old age: • Ego differentiation vs. work-role • Body transcendence vs. body preoccupation • Ego transcendence vs. ego preoccupation
Gould
adult development
7 stages: • 1: 16–18 years • 2: 18–22 years • 3: 22–28 years • 4: 28–34 years • 5: 34–43 years • 6: 43–50 years • 7: 50–60 years
Growth and Development
Psychosocial Development
• Stage 6 (ages 43–50). Personalities are seen as set. Time is accepted as finite. Individuals are interested in social activities with friends and spouse and desire both sympathy and affection from spouse.
• Stage 7 (ages 50–60). This is a period of transformation, with a real- ization of mortality and a concern for health. There is an increase in warmth and a decrease in negativism. The spouse is seen as a valuable companion (Gould, 1972, pp. 525–527).
Temperament Theories Early research on temperament, conducted in the 1950s by Stella Chess and Alexander Thomas, identified nine temperamental qualities seen in children’s behavior (Table 20–3). Temperament is multidimensional leading to the development of a child’s person- ality traits. Temperament has a role in the development of anxiety, depression, attention deficit disorder, and other types of behavior
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must exist before intellectual abilities can develop. Piaget’s cognitive developmental process is divided into five major phases: the senso- rimotor phase, the preconceptual phase, the intuitive thought phase, the concrete operations phase (Figure 20–5 •), and the formal opera- tions phase.
A person develops through each of these phases, each of which has its own unique characteristics (Table 20–4). In each phase, the person uses three primary abilities: assimilation, accommodation, and adaptation. Assimilation is the process through which humans encounter and react to new situations by using the mechanisms they already possess. In this way, people acquire knowledge and skills as well as insights into the world around them. Accommodation is a process of change whereby cognitive processes mature sufficiently to allow the person to solve problems that were unsolvable before. This adjustment is possible chiefly because new knowledge has been as- similated. Adaptation, or coping behavior, is the ability to handle the demands made by the environment.
Nurses can employ Piaget’s theory of cognitive development when developing teaching strategies. For example, a nurse can expect a toddler to be egocentric and literal; therefore, explanations to the toddler should focus on the needs of the toddler rather than on the needs of others. A 13-year-old can be expected to use rational think- ing and to reason; therefore, when explaining the need for a medica- tion a nurse can outline the consequences of taking and not taking the medication, enabling the adolescent to make a rational decision. Nurses must remember, however, that the range of normal cognitive development is broad, despite the ages arbitrarily associated with each level. When teaching adults, nurses may become aware that some adults are more comfortable with concrete thought and slower to acquire and apply new information than are other adults.
Behaviorist Theory Behaviorist theory states that learning takes place when an individu- al’s response to a stimulus is either positively or negatively reinforced. The more rapid, consistent, and positive the reinforcement is, the more likely a behavior is to be learned and retained.
B. F. Skinner (1904–1990) believed that organisms learn as they respond to or “operate on” their environment. His research led to the term operant conditioning, in which he maintained that rewarded or reinforced behavior will be repeated; behavior that is punished will be suppressed. Most of his work was with laboratory animals.
(De Pauw & Mervielde, 2010). When parents understand a child’s temperament characteristics, they are better able to shape the envi- ronment to meet the child’s needs.
Attachment Theory Attachment theory shares a common belief with Freud’s psychoana- lytic theories that early childhood experiences have a strong influence on the child’s development and later behavior. British psychologist and physician John Bowlby (1907–1990) worked extensively with children suffering separation and loss during wartime, researching and explain- ing how they responded. He hypothesized that humans have an essen- tial need for attachment, or lasting, strong emotional bonds, to others and that the infant–caregiver relationship is the first such attachment. Attachment, Bowlby believed, also served as a protective or survival mechanism for the infant. Characteristics of Bowlby’s attachment theory include the desire to be near the attachment figure, a return to the attachment figure when threatened or for comfort, the use of the attachment figure as a security base from which the child can explore the surrounding environment, and expression of anxiety (separation anxiety) when the attachment figure is absent (Bowlby, 1999).
Cognitive Theory Cognitive development refers to the manner in which people learn to think, reason, and use language and other symbols. It in- volves a person’s intelligence, perceptual ability, and ability to pro- cess information. Cognitive development represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving, and from understanding concrete ideas to understanding abstract concepts.
The most widely known cognitive theorist is Jean Piaget (1896–1980). His theory of cognitive development has contributed to other theories, such as Kohlberg’s theory of moral development and Fowler’s theory of the development of faith, both discussed later in this chapter.
According to Piaget (1966), cognitive development is an orderly, sequential process in which a variety of new experiences (stimuli)
Characteristic Examples of Behavior Style Activity level Active, restless, always on the move versus
quiet, inactive
Sensitivity Apparently oblivious to stimuli versus reacts to minimal stimuli
Intensity Minimal reaction to stimuli versus reacts strongly and intensely
Adaptability Responds smoothly to unexpected events versus resists change
Distractibility Focuses on tasks versus easily distracted by minimal stimuli
Approach/ withdrawal
Jumps right into activities versus hesitant to engage, slow to warm up
Mood Cheerful, happy versus serious, somber
Persistence Sticks to tasks versus easily gives up
Regularity Demonstrates patterns of behavior versus random activity
TABLE 20–3 Characteristics of Temperament
Figure 20–5 • School-age (7 to 11 years) children can understand cause-and-effect and concrete relationships or problems. Petro Feketa/Fotolia.
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Phases and Stages Age Significant Behavior
Sensorimotor phase Birth–2 years
Stage 1 Use of reflexes Birth–1 month The use of reflexes
Stage 2 Primary circular reaction 1–4 months Sucking habits are developed such as thumb sucking and the protrusion of the tongue when the infant is hungry. The infant acknowledges objects visually, grasps at objects, and is attracted by sounds.
Stage 3 Secondary circular reaction 4–8 months The infant begins to discover and rediscover the external environment.
Stage 4 Coordination of secondary schemata 8–12 months First actual intellectual behavior patterns emerge. The infant begins to distinguish the ends and the means. The infant is utilizing cognitive development to attain a goal.
Stage 5 Tertiary circular reaction 12–18 months The child discovers new ways of solving problems by utilizing experimentation.
Stage 6 Inventions of new means 18–24 months Possesses mental images of the environment and utilizes cognitive skills to solve problems. The child’s play time is an imitation of what has been seen leading to pretend play.
Preconceptual phase 2–4 years Uses an egocentric approach to accommodate the demands of an environment. Everything is significant and relates to “me.” Explores the environment. Language development is rapid. Associates words with objects.
Intuitive thought phase 4–7 years Egocentric thinking diminishes. Thinks of one idea at a time. Includes others in the environment. Words express thoughts.
Concrete operations phase 7–11 years Solves concrete problems. Begins to understand relationships such as size. Understands right and left. Cognizant of viewpoints.
Formal operations phase 11–15 years Uses rational thinking. Reasoning is deductive and futuristic.
Adapted from The Origin of Intelligence, by J. Piaget, 1966, New York, NY: W. W. Norton and Company, Inc.; and The Psychology of the Child, by J. Piaget and B. Inhelder, 1969, New York, NY: Basic Books, HarperCollins.
TABLE 20–4 Piaget’s Phases of Cognitive Development
Social Learning Theories Social learning theory is based on the principle that individuals learn by observing and thinking about the behavior of the self and others and can be seen as spanning both behaviorist and cognitive learning theories.
BANDURA In contrast to Skinner’s “operant conditioning,” Albert Bandura, a foremost social learning theorist, believes that learning occurs through imitation and practice and requires more awareness, self- motivation, and self-regulation of the individual. In Bandura’s “social learning theory,” the individual actively interacts with the environ- ment to learn new skills and behaviors. Social learning theorists con- tend that this process may not always lead to change in the individual’s behavior; in contrast, behaviorist theory says that learning will result in a permanent change in behavior.
VYGOTSKY (1896–1934) Lev Vygotsky, referred to as a “social constructivist,” explored the con- cept of cognitive development within a social, historical, and cultural context, arguing that adults guide children to learn and that develop- ment depends on the use of language, play, and extensive social inter- action. These ideas also support the benefit of adult social learning opportunities via group interaction and observation. Vygotsky sup- ported social learning and reinforcement through work, group dis- cussion, and other means of interaction.
Ecologic Systems Theory Urie Bronfenbrenner (1917–2005) expounded the ecologic systems theory of development. He viewed the child as interacting with the environment at different levels, or systems. Bronfenbrenner believed each child brings a unique set of genes—and specific attributes such as age, gender, health, and other characteristics—to his or her interac- tions with the environment.
The ecologic systems theory has five levels or systems. The mi- crosystem includes close relationships the child has on a daily basis (e.g., home, school, friends). The mesosystem level includes relation- ships of microsystems with one another (e.g., the relationship be- tween family and school). The exosystem includes those settings that may influence the child but with which the child does not have daily contact (e.g., parent’s job, local school board). The macrosystem level includes the actions, attitudes, and beliefs of the child’s culture and society. Finally, the chronosystem involves the time period in which the child is growing up as it influences views of health and illness.
Theories of Moral Development Moral development, a complex process not fully understood, involves learning what ought to be and what ought not to be done. It is more than imprinting parents’ rules and virtues or values on children. The term moral means “relating to right and wrong.” The terms moral- ity, moral behavior, and moral development need to be distinguished from each other. Morality refers to the requirements necessary
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CONCEPT MAP Overview of Growth and Development Theories and Theorists
Piaget
Biophysical
Gesell
Development is a maturational process that occurs on a set "time-table"
Behaviorism
Skinner
theorytheory theory theorytheory
Stimulus-response behavior; rewards reinforce positive behavior
Cognitive Development
5 major phases: • Sensorimotor • Preconceptual • Intuitive • Concrete operations • Formal operations
BanduraVygotsky
Individual learns through imitation and practice; self-regulation, self-efficacy are important
Ecologic
Bronfenbrenner
Views the child as interacting with the environment at different levels or systems: • Microsystem • Mesosystem • Exosystem • Macrosystem • Chronosystem
Growth and Development
Social construction of learning: child is guided by adults within a social, historical, and cultural context
Social Learning
for people to live together in society; moral behavior is the way a person perceives those requirements and responds to them; moral development is the pattern of change in moral behavior with age (see Chapter 5 ).
KOHLBERG (1927–1987) Lawrence Kohlberg’s (1984) theory specifically addresses moral de- velopment in children and adults. The morality of an individual’s de- cision was not Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision. According to Kohlberg, moral de- velopment progresses through three levels and six stages. Levels and stages are not always linked to a certain developmental stage or age,
because some people progress to a higher level of moral development than others.
At Kohlberg’s first level, called the premoral or preconventional level, children are responsive to cultural rules and labels of good and bad, right and wrong. However, children interpret these in terms of the physical consequences of their actions, that is, punishment or reward. At the second level, the conventional level, the individual is concerned about maintaining the expectations of the family, group, or nation and sees this as right. The emphasis at this level is confor- mity and loyalty to one’s own expectations as well as society’s. Level three is called the postconventional, autonomous, or principled level. At this level, people make an effort to define valid values and principles
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Perkins, Finegood, and Swain (2013) reviewed the literature related to parenting roles, stress, and poverty. They found that each one of these factors contributed to the development of adverse mental and physical health outcomes. According to the literature, economic stress contributes to a parent’s emotional distress, leading to a more authoritarian parenting style. Children living in poverty develop poor language skills as a result of authoritarian parenting styles and in- creased stress. Low socioeconomic status produced stress in the child and resulted in deficient physiological brain development. The cortisol levels of children under stress is increased, leading to
decreased structure of the hippocampus. This area of the brain as- sists in controlling stress.
Parenting styles that promoted a child’s independence and nurtur- ing led to the development of stronger language skills. It is important to educate parents on strategies to promote positive relationships with their children even while experiencing low economic status.
IMPLICATIONS Nurses within the community have a role in educating parents on positive parenting skills that will enhance a child’s language skills and emotional development.
Evidence-Based Practice How Does a Parent’s Socioeconomic Status Affect the Child’s Mental and Physical Health Outcomes?
Level Stage I. Preconventional
Egocentric Point of View A person begins to understand the rules of right and wrong.
1. Punishment and Obedience Actions are judged in terms of physical consequences.
2. Individual Instrumental Purpose and Exchange An individual engages in actions that are right to meet his or her needs. The individual separates his or her own interests from the interest of authorities.
II. Conventional A person is concerned about other people and their feelings.
3. Mutual Interpersonal Expectations, Relationships, and Conformity An individual is in relationships with other people. The individual is paying attention to the feelings of others. The individual puts oneself in the other person’s shoes.
Social Perspective A person is doing his or her duty to society.
4. Social System and Conscience Maintenance An individual fulfills the duties assigned by authority figures, thus fulfilling obligations set forth by society’s laws
III. Postconventional The person upholds the basic rights, values, and legal contracts of the society.
5. Prior Rights and Social Contract An individual has an obligation to obey the law. There is a commitment to family and work obligations. The individual has a responsibility to consider the moral and legal point of view in ascertaining what will provide the greatest good for people.
Universal Focus 6. Universal Ethical Principle An individual follows what is right in accordance with ethical principles.
Adapted from Essays on Moral Development, Vol.1: The Philosophy of Moral Development, 1981, by L. Kohlberg, San Francisco, CA: Harper & Row.
TABLE 20–5 Kohlberg’s Stages of Moral Development
without regard to outside authority or to the expectations of others (Table 20–5).
GILLIGAN (1936–PRESENT) After more than 10 years of research with female subjects, Carol Gilligan reported that women often consider the dilemmas Kohl- berg used in his research to be irrelevant. Women scored consistently lower on Kohlberg’s scale of moral development despite the fact that they approached moral dilemmas with considerable sophistication. Gilligan believes that most frameworks for research in moral devel- opment do not include the concepts of caring and responsibility.
Gilligan (1982) contends that moral development proceeds through three levels and two transitions, with each level representing a more complex understanding of the relationship of self and others, and each transition resulting in a crucial reevaluation of the conflict between selfishness and responsibility:
• Stage 1: caring for oneself. In this first stage of development, the person is concerned only with caring for the self. The individual
feels isolated, alone, and unconnected to others. There is no con- cern or conflict with the needs of others because the self is the most important. The focus of this stage is survival. The transition of this stage occurs when the individual begins to view this ap- proach as selfish and moves toward responsibility. The person be- gins to realize a need for relationships and connections with other people.
• Stage 2: caring for others. During this stage, the individual recog- nizes the selfishness of earlier behavior and begins to understand the need for caring relationships with others. Caring relationships bring with them responsibility. The definition of responsibility includes self-sacrifice, where “good” is considered to be “caring for others.” The individual now approaches relationships with a focus of not hurting others. This approach causes the individual to be more responsive and submissive to others’ needs, exclud- ing any thoughts of meeting one’s own needs. A transition from goodness to truth occurs when the individual recognizes that this approach can cause difficulties with relationships because of the
EVIDENCE-BASED PRACTICE
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lack of balance between caring for oneself and caring for others. The woman makes decisions on personal intentions and conse- quences of actions rather than on how she thinks others will react.
• Stage 3: caring for self and others. During this last stage, a person sees the need for a balance between caring for others and caring for the self. The concept of responsibility now includes respon- sibility for the self and for other people. Care remains the focus on which decisions are made. However, the person recognizes the interconnections between the self and others and realizes that if one’s own needs are not met, other people may also suffer.
Gilligan (1982) believes women often see morality in the integ- rity of relationships and caring, so that the moral problems they en- counter are different from those of men. Men tend to consider what is right to be what is just, whereas for women, taking responsibility for others as a self-chosen decision is what is right (p. 140). The ethic of justice, or fairness, is based on the idea of equality: Everyone should receive the same treatment. This is the development path usually fol- lowed by men and widely accepted by moral theorists. By contrast, the ethic of care is based on the premise of nonviolence: No one should be harmed. This is the path typically followed by women but given little attention in the literature of moral theory.
In the development of maturity, according to Gilligan (1982), both viewpoints blend “in the realization that just as inequality ad- versely affects both perspectives in an unequal relationship, so too violence is destructive for everyone involved” (p. 174). The blending of these two perspectives could give rise to a new view of human de- velopment and a better understanding of human relations.
Theories of Spiritual Development The spiritual component of growth and development refers to in- dividuals’ understanding of their relationship with the universe and their perceptions about the direction and meaning of life. Spiritual- ity and faith are distinctly different from religious beliefs, but religion may allow for their expression.
FOWLER James Fowler describes the development of faith as a force that gives meaning to a person’s life. He uses the term faith as a form of knowing, a way of being in relation to “an ultimate environment.” To Fowler, “faith is a relational phenomenon; it is an active ‘mode- of-being-in-relation’ to another or others in which we invest com- mitment, belief, love, risk and hope” (Fowler & Keen, 1985, p. 18).
Fowler’s theory and developmental stages were influenced by the work of Piaget, Kohlberg, and Erikson. Fowler believes that the development of faith is an interactive process between the person and the environment (Fowler, Streib, & Keller, 2004). In each of Fowler’s stages, new patterns of thought, values, and beliefs are added to those already held by the individual; therefore, the stages must follow in se- quence. Faith stages, according to Fowler, are separate from the cog- nitive stages of Piaget: They evolve from a combination of knowledge and values. Stage 0 occurs from the age of zero to three. There is a for- mulation of concepts about self and the environment. The intuitive project stage occurs from the ages of four to six. The child has a com- bination of images and beliefs. The child is introduced to images and beliefs from trusted people. The child also utilizes their own imagi- nation and experiences in their spiritual development. The mythic- literal stage ranges from age seven to 12 and encompasses symbols,
stories, and myths that possess spiritual meaning. The synthetic- conventional stage begins with adolescence. The environment is structured by the expectations and judgment of others. After the age of 18 the adult builds one’s own spiritual system. This is known as the individuating-reflexive stage. The paradoxical-consolidative phase occurs after 30 years of age with the awareness of truth from many different viewpoints. The last phase is universalizing. An individual may not ever reach this stage. In this stage the individual expresses the principles of love and justice in their life (Fowler and Keen, 1985).
WESTERHOFF Westerhoff (2012) describes faith as a way of being and behaving that evolves from an experienced faith guided by parents and oth- ers during a person’s infancy and childhood to an owned faith that is internalized in adulthood and serves as a directive for personal action. The first stage is Experienced Faith. Infants through early adolescents interact with others in learning faith traditions. Affili- ative Faith is in late adolescence. At this stage there is active partici- pation in faith-based traditions. The teen feels a sense of belonging to that faith. In young adulthood the individual begins the stage Searching Faith. The young adult may doubt or question the faith. The stage of Owned Faith occurs in middle adulthood to old age. In this stage faith becomes very personal and the person stands up for what they believe. For the client who is ill, faith—whether in a higher authority (e.g., God, Allah, Jehovah), in the client’s own self, in the health care team, or in a combination of all—provides strength and trust.
APPLYING GROWTH AND DEVELOPMENT CONCEPTS TO NURSING PRACTICE Different theories explain one or more aspects of an individual’s growth and development. Typically, theorists examine only one as- pect of an individual’s development, such as the cognitive, moral, or physical aspects. The area chosen for examination usually reflects the researcher’s academic discipline and personal interest. The theorists may also limit the population that is studied to a particular part of the life span, such as infancy, childhood, or adulthood.
Although such theories can be useful, they have limitations. First, the theory chosen may explain only one aspect of the growth and development process. Yet a person does not develop in frag- mented sections but rather as a whole human being. Thus the nurse may find it necessary to apply several theories for an adequate under- standing of the growth and development of a client.
Another limitation of some theories is the suggestion that cer- tain tasks are performed at a specific age. In most cases, the child or adult does accomplish the task at the time specified by the guide- lines. In other cases, however, the nurse may find that an individual does not accomplish the task or meet the milestone at the exact time suggested by the theory. Such individual differences are not easily defined or categorized by a single theory. Human development is a complex synthesis of biophysical, cognitive, psychological, moral, and spiritual development. Nurses should expect individual varia- tions and take these into consideration when applying these theo- ries about growth and development. In so doing, they will be better able to understand a client’s development and plan effective nursing interventions.
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CONCEPT MAP Overview of Growth and Development Moral and Spiritual Theories and Theorists
Gilligan
Moral Development
Kohlberg
3 levels: • Preconventional • Conventional • Postconventional
Moral and Spiritual Theories
• Research with women subjects
• 3 stages in the process of developing an ethic of care: • Stage 1: caring for oneself • Stage 2: caring for others • Stage 3: caring for self and others
Westerhoff
4 stages: • Experience faith • Affiliative faith • Searching faith • Owned faith
Fowler
7 stages: • Undifferentiated • Intuitive-projective • Mythic-literal • Synthetic-conventional • Individuating-reflexive • Paradoxical-consolidative • Universalizing
Growth and Development
Spiritual Development
In nursing, developmental theories can be useful in guiding as- sessment, explaining behavior, and providing a direction for nursing interventions. An understanding of a child’s intellectual ability helps a nurse to anticipate and explain certain reactions, responses, and needs. Nurses can then encourage client behavior that is appropriate for that particular developmental stage.
Theories are also useful in planning a nursing intervention. For instance, choosing the appropriate toy for a 3-year-old boy requires
some knowledge of the physical and cognitive development of the child, as well as a sensitivity for individual preferences.
In adult care, knowledge about the physical, cognitive, and psy- chological aspects of the aging process is a fundamental aspect of administering sensitive nursing care. For example, nurses can use their familiarity with the theories of development to help clients un- derstand and anticipate the psychosocial changes that take place after retirement or the physical limitations that come with aging.
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Critical Thinking Checkpoint
Finnegan, an inquisitive, energetic 2-year-old, is diagnosed with am- blyopia (lazy eye) and far-sightedness in his stronger eye. Untreated, this condition will lead to blindness in the affected eye. Treatment in- cludes wearing an eye patch over his stronger eye for 2 hours a day and wearing glasses with a corrective lens at all times when he is awake. Finnegan’s mother says he resists actively when she or his father places the patch and that it is “almost impossible” to get him to leave his glasses on.
1. According to Erikson, at what stage of development is Finnegan?
2. What strategies could you suggest Finnegan’s parents use to increase his cooperation with treatment?
3. Specifically describe strategies based on Piaget’s theory of cognitive development and the theory of social learning.
See Critical Thinking Possibilities on student resource website.
• The terms growth and development represent independent, inter- related, and dynamic processes.
• Growth is physical change and increase in size. The pattern of physiological growth is similar for all people.
• Development is an increase in the complexity of function and skill progression. It is the capacity and skill of the individual to adapt to the environment.
• Temperament, the way in which individuals respond to their exter- nal and internal environments, influences the interactive dynamics of growth and development.
• The rate of a person’s growth and development is highly individual, but the sequence of growth and development is predictable.
• Components of growth and development are generally catego- rized as biophysical, psychosocial, cognitive, moral, and spiritual.
• Psychosocial development refers to the development of person- ality. Psychosocial theorists include Freud, Erickson, Havighurst, Peck, and Gould.
• Attachment theory states that humans have a need for a strong emotional bond to others. Bowlby lists four characteristics of attachment.
• Cognitive development refers to the manner in which people learn to think, reason, and use language. The most widely known cogni- tive theorist is Piaget.
• Behaviorist theory emphasizes stimulus-response and either posi- tive or negative reinforcement as the basis for learning and behav- ior change.
• Social learning theory states that learning can occur by observa- tion. Role modeling and learning from watching role models are a part of social learning theory.
• Moral development, a complex process not fully understood, in- volves learning what ought to be and what ought not to be done. Kohlberg’s theory focuses on the reasons an individual makes a decision. Gilligan posits that the moral development of women and men has a different focus, justice versus caring and responsibility.
• The spiritual component of growth and development refers to in- dividuals’ understanding of their relationship with the universe and their perceptions about the direction and meaning of life. Fowler and Westerhoff are two theorists who describe stages of spiritual development or faith.
• In nursing, developmental theories can be useful in guiding as- sessment, explaining behavior, and providing a direction for nurs- ing interventions.
CHAPTER HIGHLIGHTS
Chapter 20 Review
1. The parents of a 5-month-old infant and a 3-year-old child ask the nurse about the sequence and timing of developmental milestones for the infant. Which is the most appropriate response? 1. “This infant should reach the milestones at the same time as
your older child.” 2. “The infant may reach the milestones in a different order than
your older child.” 3. “The sequence of reaching each milestone should follow the
same pattern but may be at a different rate.” 4. “There are no predictable patterns. Try to enjoy the
uniqueness of each child.”
2. The nurse knows that the study of growth and development is an exploration of which of the following? 1. Physical changes of the growing child 2. Increasing complexity of function and skill progression of the
growing child 3. Environmental factors such as family, religion, and culture of
the growing child 4. Physical developments and the increasing level and
progression of function and skill of the growing child
TEST YOUR KNOWLEDGE
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Suggested Reading Zhang, Y., Haraksingh, R., Grubert, F., Abyzov, A., Gerstein, M.,
Weissman, S., & Urban, A. E. (2013). Child development and structural variation in the human genome. Child Development, 84(1), 34–48. doi:10.1111/cdev.12051 The authors of this article discussed how child develop- ment and structural aberrations of the genome can affect a child’s development. Knowledge of the genotype and phe- notype as they relate to disease is central to understanding childhood development.
Related Research Brazeau, J. N., Teatero, M. L., Rawana, E. P., Brownlee, K., &
Blanchette, L. R. (2012). The strengths assessment in- ventory: Reliability of the new measure of psychosocial strengths for youth. Journal of Child and Family Studies, 21, 384–390. doi:10.1007/s10826-011-9489-5
Dobrin, N., & Kallay, E. (2013). The investigation of the short- term effects of a primary prevention program targeting the development of emotional and social competencies in preschoolers. Cognition, Brain, Behavior, 17(1), 15–34.
Gagne, C., & Harnois, I. (2013). The contribution of pyschoso- cial variables in explaining preschooler’s physical activity. Health Psychology, 32(6), 657–665. doi:10.1037/ a0031638
Lillard, A. S., Lerner, M. D., Hopkins, E. J., Dore, R. A., Smith, E. D., & Palmquist, C. M. (2013). The impact of pretend play on children’s development: A review of the evidence. Psychological Bulletin, 139(1), 1–34. doi:10.1037/a0029321
Pelley, T. J., Brown-Kirschman, K. J., Odar, C. C., Butz, C. L., Rye, M., Fabia, R. B., & Besner, G. E. (2013). The de- velopment and preliminary validation of the psychosocial
adjustment to burn questionnaire. Clinical Practice in Pedi- atric Psychology, 1(2), 171–183. doi:10.1037/cpp0000019
References Ball, R. S. (1977). The Gesell developmental schedules: Arnold
Gesell (1880–1961). Journal of Abnormal Child Psychol- ogy, 5, 233–239. doi:10.1007/BF00913694
Bowlby, J. (1999). Attachment: Attachment and loss, Vol. 1 (2nd ed.). New York, NY: Basic Books.
De Pauw, S. W., & Mervielde, I. (2010). Temperament, person- ality, and developmental psychopathology: A review based on the conceptual dimensions underlying childhood traits. Child Psychiatry and Human Development, 41, 313–329. doi:10.1007/s10578-009-0171-8
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: W. W. Norton. Copyright renewed 1978 and 1991.
READINGS AND REFERENCES
3. The nurse examines a 2-year-old child recently hospitalized with pneumonia. Which pattern of behavior is most likely to be exhibited by the child? 1. Lies quietly while the nurse listens to the lungs 2. Asks many questions about what the nurse is doing and
hearing 3. Fusses, cries, and pushes the nurse away during
assessment of the breath sounds 4. Enjoys playing “nurse” with the stethoscope, and listens
to self and others’ breath sounds 4. A 14-year-old is scheduled to have surgical repair of a spinal
curvature (scoliosis). The adolescent will be hospitalized for about 2 weeks. Which nursing intervention will be most helpful during the hospital stay? 1. Have peers visit frequently during the day. 2. Instruct parents to room-in with her. 3. Encourage her to go to the recreation room. 4. Encourage her to arrange for her teachers to provide her
with homework. 5. A 65-year-old man who recently retired from 40 years of work
as an independent contractor is scheduled for a physical examination. The nurse should be concerned about which comment? 1. “My wife and I are planning to drive to Nebraska in June
to visit our grandkids.” 2. “Every day, when I wake up, it’s hard to find a reason to get
out of bed.” 3. “I often take ibuprofen for the pain in my knees.” 4. “People still call me for advice on building projects. I may
never get to retire!” 6. An 11-year-old child is scheduled for a yearly physical
examination. The accompanying parent expresses concern because the child “seems all wrapped up in the soccer teammates and other peers, leaving very little time for the family.” Using Havighurst’s developmental tasks, what would be the nurse’s best response? 1. “This is somewhat unusual. Are there problems that we
need to discuss?” 2. “Although this is normal for 11-year-olds, this transition can
be difficult for families.” 3. “Become involved in her life and insist that she set aside
time for the family.” 4. “This is normal development. You need to let her grow up.”
7. A nurse decides that a review of which theorist would be help- ful before teaching 4- and 5-year olds in a preschool class how to brush their teeth? 1. Fowler 2. Erikson 3. Gould 4. Peck
8. A 5-year-old boy arrives for the preadmission work-up for a surgical procedure. When the nurse brings in the intravenous (IV) control pump the child states: “It’s going to bite me because I have been bad.” Using knowledge of Piaget, Erikson, and Fowler, which is the best nursing action? 1. Reassure him by providing opportunities to touch and
explore the machine, as well as explaining how it works. 2. Understand that his imagination is out of control. Tell him
that his fears are unfounded and that he needs to be a “big boy.”
3. Recognize that he is too young to understand and that he needs to be quickly distracted.
4. Acknowledge his need for fantasy by reassuring him that if he is a “good boy” the bad machine will not bite him.
9. A 15-month-old is admitted to the hospital for hernia surgery. When his mother leaves him, he cries inconsolably. Using knowledge of attachment theory and cognitive theory, which is the best nursing action? 1. Encourage his mother to stay with him as much as possible. 2. Put a picture of his mother in his crib to remind him that
she will return soon. 3. Hold and cuddle him as much as possible. 4. Distract him with toys and music.
10. Which behavior is of most concern to the nurse caring for a 25-year-old client after surgery for an appendectomy? 1. The client states: “It will be good to get back on my bike.
I miss the exercise.” 2. The client states: “I have no problem living at my parents’
house. They have lots of room and money and it’s a very comfortable and easy lifestyle for me.”
3. The client gets out of bed and walks to the bathroom with assistance.
4. Several age-mate friends visit while the client is hospitalized.
See Answers to Test Your Knowledge in Appendix A.
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Erikson, E. H. (1964). Insight and responsibility: Lectures on the ethical implications of psychoanalytic insight. New York, NY: W. W. Norton.
Fowler, J., & Keen, S. (1985). Life maps: Conversations in the journey of faith. Waco, TX: Word Books.
Fowler, J. W., Streib, H., & Keller, B. (2004). Manual for faith development research (3rd ed.). Bielefeld, Germany: Research Center for Biographical Studies in Contemporary Religion, Bielefeld University; and Atlanta, GA: Center for Research in Faith and Moral Development, Emory University.
Freud, S. (1946). The ego and the mechanism of defense. New York, NY: International Universities Press.
Gesell, A. (1934). An atlas of infant behavior: A systematic delineation of the forms and early growth of human behav- ior patterns. New Haven, CT: Yale University Press.
Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press.
Gould, R. L. (1972). The phases of adult life: A study in developmental psychology. American Journal of Psychiatry, 129, 33–43.
Havighurst, R. J. (1972). Developmental tasks and education (3rd ed.). New York, NY: Longman.
Hollander, A. (1980). How to help your child have a spiritual life: A parent’s guide to inner development. New York, NY: A & W Publishers.
Kohlberg, L. (1981). Essays on moral development: Vol. 1, The philosophy of moral development. San Francisco, CA: Harper & Row.
Kohlberg, L. (1984). Essays on moral development: Vol. 2, The psychology of moral development. San Francisco, CA: Harper & Row.
Peck, R. (1968). Psychological developments in the second half of life. In B. L. Neugarten (Ed.), Middle age and aging. Chicago, IL: University of Chicago Press.
Perkins, S. C., Finegood, E. D., & Swain, J. E. (2013). Poverty and language development: Roles of parenting and stress. Innovations in Clinical Neuroscience, 10(4), 10–19.
Piaget, J. (1966). Origins of intelligence in children. New York, NY: W. W. Norton.
Piaget, J., & Inhelder, B. (1969). The psychology of the child. New York, NY: Basic Books, HarperCollins.
Varga, D. (2011). Look—Normal: The colonized child of devel- opmental science. History of Psychology, 14(2), 137–157. doi:10.1037/a0021775
Westerhoff, J. (2012). Will our children have faith? (rev. ed.). New York, NY: Morehouse Publishing.
Selected Bibliography Bryant-Davis, T., Ellis, M. U., Burke-Maynard, E., Moon, N.,
Counts, P. A., & Anderson, G. (2012). Religiosity, spirituality, and trauma recovery in the lives of children and adoles- cents. Professional Psychology: Research and Practice, 43(4), 306–314. doi:10.1037/a0029282
Fowler, J. W. (1995). Stages of faith: The psychology of human development. San Francisco, CA: HarperCollins.
Freud, S. (1923). The ego and the id. London, England: Hogarth Press.
Freud, S. (1961). The ego and the id and other works (Vol. 19) (J. Strachey, Trans.). London, England: Hogarth Press and the Institute of Psychoanalysis.
Havighurst, R. J. (2003). Developmental tasks and education (4th ed.). Temecula, CA: Textbook Publishers.
Lydon-Lam, J. (2012). Models of spirituality and consideration of spiritual assessment. International Journal of Childbirth Education, 27(1), 18–22.
Whittington, F. J., & Kunkel, S. R. (2013). Think globally, act locally: The maturing of a worldwide science and practice of aging. Journal of the American Society on Aging, 37(1), 6–11.
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INTRODUCTION Knowledge of growth and development is essential for nurses if they are to identify developmental needs and problems. This chapter applies the concepts of growth and development intro- duced in Chapter 20 to the prenatal period and to the neonate, infant, toddler, preschooler, school-age child, and adolescent. Each developmental stage includes physical, psychosocial, cogni- tive, moral, and spiritual aspects. Health assessment and promo- tion of health and wellness are emphasized.
CONCEPTION AND PRENATAL DEVELOPMENT Prenatal or intrauterine development lasts approximately 9 calen- dar months (10 lunar months) or 38 to 40 weeks, depending on the method of calculation. (A lunar month is 28 days.) If the time is cal- culated from the day of conception, this stage of life is about 38 weeks or 91⁄2 lunar months. If the time is calculated from the first day of the last menstrual period, it is 10 lunar months or 40 weeks.
Traditionally, pregnancy has been divided into three peri- ods called trimesters, each of which lasts about 3 months. Each trimester includes certain landmarks for developmental changes in the mother and the fetus. There are two phases of intrauterine life, embryonic and fetal. The embryonic phase, occurring in the first trimester, is the period during which the fertilized ovum develops into an organism with most of the features of the hu- man. This period is considered to encompass the first 8 weeks of pregnancy.
Within the first 3 weeks of life, the embryonic tissues differ- entiate into three layers—the ectoderm (outer layer), mesoderm (middle layer), and endoderm or entoderm (inner layer). The ectoderm and endoderm are formed by the second week; the me- soderm forms in the third week. The ectoderm forms a long tube for the development of the brain and spinal cord. The endoderm creates the gastrointestinal tract. A single tubular heart forms out- side the body cavity of the embryo. Basic organ formation con- tinues through the eighth week. By the eighth week the umbilical cord and circulatory system are established (London, Ladewig, Ball,
abusive head trauma, 334 adolescence, 334 adolescent growth spurt, 345 amblyopia, 338 Apgar scoring system, 334 apocrine glands, 345 Denver Developmental Screening
Test (DDST-II), 335 eccrine glands, 345 ectoderm, 328 ejaculation, 345 embryonic phase, 328 emmetropic, 338
endoderm, 328 entoderm, 328 failure to thrive (FTT), 333 fetal phase, 329 fontanels, 331 hyperopic, 338 identification, 340 imagination, 340 inflicted traumatic brain injury, 334 introjection, 340 lanugo, 329 menarche, 344 mesoderm, 328
myopic, 338 normocephaly, 330 peer groups, 346 placenta, 329 primary sexual
characteristics, 345 puberty, 344 regression, 337 repression, 340 sebaceous glands, 345 secondary sexual
characteristics, 345 self-concept, 336
separation anxiety, 337 shaken baby syndrome
(SBS), 334 stereognosis, 342 strabismus, 338 sudden infant death
syndrome (SIDS), 334 sutures, 331 teratogen, 329 trimesters, 328 vernix caseosa, 329
KEY TERMS
After completing this chapter, you will be able to: 1. Describe usual physical development from infancy through
adolescence. 2. Identify tasks characteristic of different stages of develop-
ment from infancy through adolescence. 3. Trace psychosocial development according to Erikson from
infancy through adolescence. 4. Explain cognitive development according to Piaget from
infancy through adolescence. 5. Describe moral development according to Kohlberg from
childhood through adolescence.
LEARNING OUTCOMES
21 Promoting Health from Conception Through Adolescence
6. Describe spiritual development according to Fowler through- out childhood and adolescence.
7. Identify assessment activities and expected characteristics from birth through late childhood.
8. Identify essential activities of health promotion and protection to meet the needs of infants, toddlers, preschoolers, school- age children, and adolescents.
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Bindler, & Cowen, 2011). Three other events occur concurrently during the first 3 weeks:
1. The embryo is implanted in the endometrium of the uterus. 2. The fetal membranes differentiate into the chorion, precursor to
the placenta, and the amnion, precursor to the amniotic sac. 3. Placental function starts. The placenta is a flat, disk-shaped
organ that is highly vascular. It normally forms in the upper seg- ment of the endometrium of the uterus. Its function is to facili- tate exchange of nutrients and gas between the embryo or fetus and the mother.
The fetal phase of development, occurring in the second and third trimester of pregnancy, is characterized by a period of rapid growth in the size of the fetus. Both genetic and environmental fac- tors affect its growth.
At the end of the second trimester, or 6 lunar months, the fetus resembles a small baby. Because very little fat is present beneath the skin, the skin appears wrinkled, red, and transparent. Underlying ves- sels are visible. A protective covering called vernix caseosa begins to develop over the skin. This is a white, cheese-like substance that adheres to the skin and can become one eighth inch thick by birth. Lanugo, a fine downy hair, also covers the body. At about 5 months, the mother can feel movement of the fetus, and the first fetal heart- beat may be heard.
At the end of the third trimester (91⁄2 lunar months), the fetus has developed to approximately 50 cm (20 in.) and 3.2 to 3.4 kg (7.0 to 7.5 lb). The lanugo has disappeared, and the skin is a more normal color and appears less wrinkled. A large amount of subcutaneous fat makes the baby look more rotund. The baby gains most of its weight during the last 2 months in utero. Box 21–1 lists maternal factors that can lead to impaired fetal development.
Health Promotion During the intrauterine stage of development, the embryo or fetus relies on the maternal blood flow through the placenta to meet its basic survival needs. The health of the mother is essential for proper growth and development.
OXYGEN To meet the fetal demands for oxygen, the pregnant mother gradually increases her normal blood flow by about one third, peaking at about
• Poor nutrition and inadequate weight gain • Excessive nausea and vomiting (hyperemesis gravidarum) • Low hemoglobin levels • Gestational diabetes • Positive protein in the urine • Hypertension • Maternal infection • Smoking • Drug use • Teenage pregnancy • Increased maternal age over 35 years • Lack of adequate prenatal care • Low socioeconomic status • Previous pregnancy complications • Genetic abnormalities
Maternal Factors That Contribute to Impaired Fetal DevelopmentBOX 21–1
8 months. Respiratory rate and cardiac output increase significantly during this period. Initially the heart of the embryo lies outside its body. It is then repositioned in the chest early in the second trimes- ter. Fetal circulation travels from the placenta through two umbili- cal arteries, which carry deoxygenated blood away from the fetus. By 20 weeks the fetal heartbeat is audible through a fetoscope; the heart- beat is audible as early as the 10th week if a Doppler stethoscope with ultrasound is used.
NUTRITION AND FLUIDS The fetus obtains nourishment from the placental circulation and by swallowing amniotic fluid. Nutritional needs are met when the mother eats a well-balanced diet containing sufficient calories and nutrients to meet both her needs and those of the fetus. Adequate folic acid, one of the B vitamins, is important in order to prevent neural tube defects (e.g., spina bifida) in the fetus. Two objectives of Healthy People 2020 are to reduce the occurrence of neural tube defects and to increase the proportion of pregnancies begun with the recommended folic acid level (U.S. Department of Health and Human Services [ USDHHS], 2010, n.d.). Neural tube defects occur in the first few weeks of fetal development. As a result, it is recommended that all women capable of becoming pregnant consume 400 micrograms of folic acid daily. The nurse should teach the client about folic-rich foods (e.g., green leafy vegetables, oranges, dried beans, breakfast cereal) and suggest she take a vitamin supplement that contains folic acid.
SLEEP AND ACTIVITY The fetus sleeps most of the time and develops a pattern of sleep and wakefulness that usually persists after birth. The mother can feel fetal activity at about the fifth lunar month of pregnancy.
ELIMINATION Throughout pregnancy, fetal feces are formed in the intestines from swallowed amniotic fluid, but are normally not excreted until after birth. Inadequate oxygenation of the fetus during the third trimester can result in relaxation of the anal sphincter and passage of feces into the amniotic fluid. Urine normally is excreted into the amniotic fluid after the kidneys mature (16 to 20 weeks).
TEMPERATURE MAINTENANCE Amniotic fluid usually provides a safe and comfortable temperature for the fetus. Significant changes in maternal temperature can alter the temperature of the amniotic fluid and the fetus. Significant tem- perature increases due to illness, hot whirlpool baths, or saunas may result in birth defects. In the last weeks of gestation, the fetus develops subcutaneous fatty tissue stores that will help maintain body temper- ature at birth.
SAFETY As stated earlier, the body systems form during the embryonic period. As a result, the embryo is particularly vulnerable to damage from a teratogen, which is anything that adversely affects normal cellular development in the embryo or fetus (Venes, 2013). It is important for the nurse to inquire about possible pregnancy when giving medica- tions that are known teratogens and to ask when the woman is sched- uled for tests that involve radiography (x-ray).
Smoking, alcohol, and drugs can affect the environment for the fetus. Exposure to environmental tobacco smoke has been associated with preterm births, stillbirth, miscarriage, and low-birth-weight
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infants (Hill, Young, Briley, Carter, & Lang, 2013). Mothers who use drugs, alcohol, and tobacco have strong adverse birth consequences. One in ten pregnant women with a history of substance abuse dur- ing pregnancy experienced adverse birth outcomes (Kothari, Wendt, Liggins, Overton, & del Carmen Sweezy, 2010). Fetal alcohol spec- trum disorders (FASD) is a term that refers to specific diagnoses given to infants and children who have been exposed to alcohol pre- natally. It ranks as the leading cause of mental retardation. Thomas, Warren, and Hewitt (n.d.) reported that alcohol exposure to the de- veloping embryo and fetus disrupts every step in the development of the central nervous system.
NEONATES AND INFANTS (BIRTH TO 1 YEAR) Babies are considered neonates from birth to the end of the first month. Infants are babies from 1 month to 1 year of age.
Physical Development A neonate’s basic task is adjustment to the environment outside the uterus, which requires breathing, sleeping, sucking, eating, swallow- ing, digesting, and eliminating. Infants continue to grow and develop rapidly during the first year, learning more skills as they interact with their world. Infants undergo significant physiological changes in weight, length, head growth, vision, hearing, smell, taste, touch, reflexes, and motor development. Some of these changes can be as- sessed using standardized growth charts based on growth of groups of American children (Centers for Disease Control and Prevention [CDC], 2000). The Child Growth Standards from the World Health Organization (WHO) (n.d.) provide documentation on physical growth curves and motor milestones to be achieved. Growth charts are available in a variety of languages. From 1997 to 2003 the WHO Multicentre Growth Reference Study was conducted to generate new growth curves for infants and children.
WEIGHT At birth, most babies weigh from 2.7 to 3.8 kg (6.0 to 8.5 lb). Just af- ter birth, most infants lose 5% to 10% of their birth weight because of fluid loss. This weight loss is normal, and infants usually regain that weight in about 1 week. After several days, babies usually gain weight at the rate of 150 to 210 g (5 to 7 oz) weekly for 6 months. By 5 months of age, infants usually reach twice their birth weight, and by age 12 months, three times their birth weight. Studies have shown that increased weight gain in early infancy leads to an increased risk of obesity later in life (Oddy, 2012). Exclusive breast-feeding in the first 4 to 6 months may be helpful in preventing excessive weight gain.
Li, Fisher, Peng, Williams, and Burd (2012) examined the mortality rates of birth mothers of children with fetal alcohol spectrum disor- ders (FASD). These researchers used a retrospective case control methodology. They gathered their data from the North Dakota FASD Registry. This registry identifies birth mothers. They also examined mothers’ death certificates. They then compared the mortality rates of birth mothers of the same age who were born and died in the same year as the birth mothers of children with FASD. The study
found that birth mothers of children with FASD had a 4.93% death rate compared to the control group of birth mothers of children with- out FASD whose death rate was 0.11%.
IMPLICATIONS All women of childbearing age should be educated about the risk of FASD and, if seeking to become pregnant, encouraged to abstain from alcohol. Pregnant women who have a diagnosis of substance abuse should be referred to an alcohol or drug treatment program.
Evidence-Based Practice How Do Fetal Alcohol Spectrum Disorders Contribute to Premature Mortality Rates in Mothers?
LENGTH The average length of a European American newborn in the United States is about 50 cm (20 in.). Female babies are, on average, smaller than male babies. Babies from different ethnic groups may vary by height, weight, and head circumference, so ethnicity must be con- sidered when determining what is “normal” for any particular infant. The WHO Multicentre Growth Reference Study, conducted from 1997 through 2003, demonstrates, however, that children worldwide who live in a healthy environment and are well fed (including exclu- sive breast-feeding for the first 4 to 6 months of life) will show similar patterns of growth (de Onis, 2011).
Two recumbent lengths are the crown-to-rump length (the sit- ting length) and the head-to-heel length (from the top of the head to the base of the heels) (Figure 21–1 •). Normally the crown-to- rump length is approximately the same as the head circumference. By 6 months infants gain another 13.75 cm (5.5 in.) of height. By 12 months they add another 7.5 cm (3 in.). The rate of increase in height is largely influenced by the baby’s size at birth and by nutrition.
HEAD AND CHEST CIRCUMFERENCE Assessment of head circumference is particularly important in infants and children to determine the growth rate of the skull and the brain. An infant’s head should be measured at every visit to the primary care provider or nurse until the child is 2 years old (Figure 21–2 •). Nor- mal head circumference (normocephaly) is often related to chest cir- cumference. At birth the average infant’s head circumference is 35 cm (14 in.) and generally varies only 1 or 2 cm (0.5 in.). The chest circum- ference of the newborn is usually less than the head circumference by
Figure 21–1 • Measuring an infant head to heel, from the top of the head to the base of the heels.
EVIDENCE-BASED PRACTICE
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gradually decreases until closure occurs between 9 and 18 months. The posterior fontanel between the parietal bones and the occipital bone closes between 2 and 3 months after birth (Figure 21–3 •).
VISION The newborn can follow large moving objects and blinks in response to bright light and sound. The pupils of the newborn respond slowly, and the eyes cannot focus on close objects. By 1 month the infant can focus his or her gaze on objects and follow moving ones. At 4 months the infant recognizes a parent’s smile, although social smiles may ap- pear as early as 2 months. The 4-month-old has almost complete color vision and follows objects through a 180-degree arc. A 5-month-old infant reaches for objects. Between 6 and 10 months the infant can fix on an object and follow it in all directions. By 12 months depth perception has fully developed, and the infant will consistently be able to recognize where a change in level occurs, such as at the edge of the bed.
HEARING Newborns with intact hearing will react with a startle to a loud noise, a reaction called the Moro reflex. Within a few days, they are able to distinguish different sounds. For example, they can tell the difference between their mother’s voice and that of another woman. By 2 to 3 months they will actively coo, smile, or gurgle to sounds and voices. Between 3 and 6 months the infant will look for sounds, pausing an activity to listen and responding with distress or pleasure to angry or happy voices. Between 6 and 9 months individual words begin to take on meaning and the infant may look at named objects or people. The 9- to 12-month-old infant understands many words (e.g., “no,” “hot,” “dog”), uses gestures (e.g., waves “bye-bye”), may articulate one or two words with a specific reference (e.g., “mama,” “dada”), and, by 1 year of age, responds to simple commands.
about 2.5 cm (1 in.). As the infant grows, the chest circumference be- comes larger than the head circumference. At about 9 or 10 months, the head and chest circumferences are about the same, and after 1 year of age the chest circumference is larger.
HEAD MOLDING The heads of many newborn babies are misshapen because of the molding of the head that occurs during vaginal deliveries. Molding of the head is possible because of fontanels and sutures in the skull. Fontanels are unossified (i.e., without bone formation) membra- nous gaps in the bone structure of the skull. Sutures are junction lines of the skull bones that override to provide flexibility for molding of the head. Within a week, a newborn’s head usually regains its sym- metry, which is reassuring to the parents. The larger anterior fontanel (4 to 6 cm [1.6 to 2.4 in.] in diameter and diamond shaped) can in- crease in size for several months after birth. After 6 months the size
Figure 21–2 • An infant’s head circumference is measured around the skull above the eyebrows, and around the occiput. Glow Wellness/Getty Images.
Figure 21–3 • The bones of the skull, showing the fontanels and suture lines.
Posterior fontanel
Sagittal suture
Coronal suture
Anterior fontanel
Lambdoid suture
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At 1 month of age the infant lifts the head momentarily when prone, turns the head when prone, and has a head lag when pulled to a sit- ting position. Head lag should be minimal by 4 months of age. Af- ter 6 months infants may sit without support (Figure 21–4 •). At 9 months they can reach, grasp a rattle, and transfer it from hand to hand. At 12 months they can turn the pages of a book, put objects into a container, walk with some assistance, and help to dress themselves.
Psychosocial Development According to Erikson (1963), the central crisis at this stage is trust versus mistrust. Resolution of this stage determines how the person approaches subsequent developmental stages. During the first year of life, infants depend on the parents for all their physiological and psychological needs. Fulfillment of these needs is required for the in- fant to develop a basic sense of trust. Parents can enhance this sense of trust by (a) being sensitive to the infant’s needs and meeting these needs promptly and skillfully, (b) responding consistently to an in- fant’s needs, and (c) providing a predictable environment in which routines are established. Nurturing behavior, such as consistent care, handling, stroking, and cuddling, is essential for healthy psychoso- cial development. By 8 months, most infants exhibit attachment to their parents and may show displeasure when left with strangers.
The newborn reacts socially to caregivers by paying attention to the face or voice and by cuddling when held. The baby is able to in- teract with the environment by responding to various stimuli such as touch and sound. Table 21–1 provides examples of motor and social development.
Infants have no understanding of waiting and no time frame by which to measure waiting. Crying is their initial reaction to stress, and the major way they communicate stress. Infants learn gradu- ally to tolerate stress. According to Freud, infants have an oral focus,
SMELL AND TASTE The senses of smell and taste are functional shortly after birth. Newborns prefer sweet tastes and tend to decrease their sucking in response to liquids with a salty content. They are able to recognize the smell of their mother’s milk and respond to this smell by turning toward the mother.
TOUCH The sense of touch is well developed at birth. Skin-to-skin touching is important for an infant’s development. The infant responds positively to the warmth, love, and security it perceives when touched, held, and cuddled. The newborn is sensitive to temperature extremes and has poor self-regulation of body temperature. In response to pain, young babies react diffusely, with a whole-body reaction, and cannot isolate the source of discomfort.
REFLEXES Reflexes of the newborn are unconscious, involuntary responses of the nervous system to external and internal stimuli. Reflexes nor- mally present at birth are the sucking, rooting, Moro, palmar grasp, plantar, tonic neck, stepping, and Babinski reflexes (Box 21–2). Infant reflexes disappear during the first year of life in an ordered sequence, a process that allows the infant to develop voluntary movements. In addition, the abilities to yawn, stretch, sneeze, burp, and hiccup are all present at birth.
MOTOR DEVELOPMENT Motor development is the development of the baby’s abilities to move and control the body. Initially, body movement is uncoordinated.
BOX 21–2 Infant Reflexes
• Sucking reflex: A feeding reflex that occurs when the infant’s lips are touched. The reflex persists throughout infancy.
• Rooting reflex: A feeding reflex elicited by touching the baby’s cheek, causing the baby’s head to turn to the side that was touched. The reflex usually disappears after 4 months.
• Moro reflex: Often assessed to estimate the maturity of the central nervous system. A loud noise, a sudden change in posi- tion, or an abrupt jarring of the crib elicits this reflex. The infant reacts by extending both arms and legs outward with the fin- gers spread, then suddenly retracting the limbs. Often the infant cries at the same time. This reflex disappears after 4 months.
• Palmar grasp reflex: Occurs when a small object is placed against the palm of the hand, causing the fingers to curl around it. This reflex disappears after 3 to 6 months.
• Plantar reflex: Similar to the palmar grasp reflex; an object placed just beneath the toes causes them to curl around it. This reflex disappears after 8 to 10 months.
• Tonic neck reflex (TNR) or fencing reflex: A postural reflex. When a baby who is lying on its back turns its head to, for example, the right side, the left side of the body shows a flexing of the left arm and the left leg. This reflex disappears after 4 to 6 months.
• Stepping reflex (walking or dancing reflex): Can be elicited by holding the baby upright so that the feet touch a flat surface. The legs then move up and down as if the baby were walking. This reflex usually disappears at about 2 months.
• Babinski reflex: When the sole of the foot is stroked, the big toe rises and the other toes fan out. A newborn baby has a positive Babinski. After age 1, the infant exhibits a negative Babinski; that is, the toes curl downward. A positive Babinski after age 1 can indicate possible upper motor neuron damage.
Figure 21–4 • An infant sits without support at 6 months of age. D. Hurst/Alamy.
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Health Risks Neonates and infants are subject to a number of health problems that require interventions from health care personnel. Safety concerns are of particular importance.
FAILURE TO THRIVE The term failure to thrive (FTT) is generally used to describe in- fants whose weight is less than normal for gestational age, gender, genetic potential, and medical condition (Kirkland & Motil, 2013). The CDC recommends use of the WHO growth charts to assess the development of infants (Grummer-Strawn, Reinold, & Krebs, 2010). Weight is altered initially, followed by length and head circumfer- ence. The child who falls below the fifth percentile for weight and height or whose growth declines across two percentiles on a stan- dard growth chart over time should be considered for FTT. FTT may have organic causes (e.g., cardiac disease) or inorganic causes, which usually involve the parent–child relationship. Infants with inorganic failure to thrive show delayed physical and emotional development without any physical cause. They are often malnourished and may be deprived of nurturing during infancy.
INFANT COLIC Colic is acute abdominal pain caused by periodic contractions of the intestines. It occurs in infants as young as 2 weeks of age and for most infants disappears by 3 months of age. When an infant’s crying lasts up to 10 to 12 hours a day it is described as colicky. A crying or fussy period lasting 1 to 2 hours a day is usually considered normal. Al- though the direct cause is not known, colic tends to occur in babies with sensitive temperaments. Factors such as swallowing air, feeding too rapidly, allergies, taking excessive amounts of carbohydrates, in- fant emotional distress, and anxiety of the caregiver may be associ- ated with colic.
To help relieve the colic, the nurse can assess the infant dur- ing feeding and suggest possible position changes. Ball, Bindler, and Cowen (2014) recommend the establishment of a warm and car- ing environment. The parents’ mental status should be assessed. In a study conducted in Sweden, Landgren and Hallstrom (2010) in- terviewed parents about their experiences caring for an infant with colic. The parents reported feelings of frustration and helplessness.
many of their activities and pleasures are mouth centered, and they reduce tension by sucking and chewing on objects. Nurses and par- ents can reduce the stress of an infant by maintaining the infant’s routine as much as possible and providing a consistent, predictable environment.
Cognitive Development According to Piaget (1966), cognitive development is a result of interaction between an individual and the environment. Piaget re- ferred to the initial period of cognitive development as the senso- rimotor phase. This phase has six stages, three of which take place during the first year. From 4 to 8 months infants begin to have per- ceptual recognition. By 6 months they respond to new stimuli, and they remember certain objects and look for them for a short time. By 12 months infants have a concept of both space and time. At 1 year of age the infant has proceeded from reflexive ability of the newborn to using one or two actions to attain a goal. The critical development of the infant brain is from 20 weeks’ gestation until the age of 3. Both the internal and external environments affect the development of the mind and body. The stimulation of the infant brain enhances the development of neurons. The infant’s primary caregiver interactions are key to enhancing infant brain devel- opment (Marshall, 2011). The American Academy of Pediatrics Council on Communication and Media (2011, p. 1041) stated that “research has found that certain high quality programs have educa- tional benefits for children older than 2 years.” They also reported that “two studies have found that watching programs such as Sesame Street has a negative effect on language development for children younger than 2 years.”
Moral Development Infants are unable to understand right and wrong. When they receive abundant positive responses from the parent such as smiles, caresses, and voice tones of approval in these early months, they learn that certain behaviors are “good” and that pleasure is the consequence. In later months and years, children can tell easily and quickly by changes in parental facial expressions and voice tones that their behavior is either approved or disapproved.
Age Motor Development Social Development Newborn Turns head from side to side when in a prone position. Displays displeasure by crying and satisfaction by soft
vocalizations.
Grasps by reflex when object is placed in palm of hand. Attends to adult face and voice by eye contact and quieting.
4 months Rolls over. Sits with support, holds head steady when sitting.
Babbles, laughs, and exhibits increased response to verbal play.
6 months Lifts chest and shoulders off table when prone, bearing weight on hands.
Starts to imitate sounds. Vocalizes one-syllable sounds: “ma ma,” “da da.”
Manipulates small objects.
9 months Creeps and crawls. Uses pincer grasp with thumb and forefinger.
Complies with simple verbal commands. Displays fear of being left alone (e.g., going to bed). Waves “bye-bye.”
12 months Walks alone with help. Clings to mother in unfamiliar situations. Uses spoon to feed self. Demonstrates emotions such as anger and affection.
TABLE 21–1 Examples of Motor and Social Development in Infancy
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not recommended. It is important for the infant to be in a smoke-free environment. The mother should also avoid smoking, consumption of alcohol, and use of illicit drugs during pregnancy. All of these place the infant at risk for SIDS. It is important for the nurse to instruct the parents on the risk these items have for an increased chance of SIDS. Lastly, nurses should encourage parents and caregivers to offer pacifiers to infants. The use of a pacifier during sleep reduces the risk of SIDS (Moon, Tanabe, Yang, Young, & Hauck, 2012).
Health Assessment and Promotion Physiological health assessment occurs immediately at birth. De- velopmental assessment also begins at birth by using standardized tests. Ongoing nursing assessments continue for the promotion of wellness.
APGAR SCORING Newborn babies can be assessed immediately by means of the Apgar scoring system (Table 21–2). This system provides a numeric in- dicator of the baby’s physiological capacities to adapt to extrauterine life. Each of five signs is assigned a maximum score of 2, so that the maximum score achievable is 10. A score under 7 suggests that the baby is having difficulty, and a score under 4 indicates that the baby’s condition is critical. Apgar scoring is usually carried out 60 seconds after birth and is repeated in 5 minutes. Those with very low scores require special resuscitative measures and care.
It was beneficial when someone else could care for the infant. Nurses guided parents to formulas that were free of cow’s milk. They also en- couraged breast-feeding in place of bottle-feeding. It is important for the nurse to assess the baby’s ability to suck, swallow, and breathe to determine if the infant is having any difficulty with feeding. In ad- dition, the parents’ level of anxiety in feeding the infant should be assessed. Five percent of children experienced feeding difficulties related to the parent’s anxiety (Nicholson, 2013).
CHILD ABUSE Reports of child abuse have increased in recent years, and the stress of having a baby with colic or excessive crying can put some parents at risk for child abuse. This abuse can take various forms including physical abuse, physical neglect, sexual abuse, and emotional abuse and neglect. The term shaken baby syndrome (SBS) has been re- placed by the term abusive head trauma or inflicted traumatic brain injury. This is classified as injuries caused by contact with rota- tional forces (Quinones & Blevins, 2010). The violent shaking of the infant causes a whiplash and results in brain injury. The combined impact, with the soft surface (e.g., mattress), can lead to retinal hem- orrhages and subdural and subarachnoid hemorrhages. The infant may not sustain any external signs of trauma or the diagnostic sign of abusive brain injury. Quinones and Blevins further state the infant may be misdiagnosed with a bacterial or viral infection related to vomiting, fever, and lethargy. Cerebral damage, neurologic defects, blindness, and spinal cord damage can result. Nurses should teach parents about the dangers associated with shaking infants and the need to call their primary care provider if they feel they could harm their baby.
SUDDEN INFANT DEATH SYNDROME The sudden and unexpected death of an infant may be a case of sudden infant death syndrome (SIDS). A postmortem examination usually fails to reveal a cause. The highest incidence of SIDS occurs in the sec- ond to fourth month of life, and boys are more susceptible than girls. Research has shown that sleeping on the back (Figure 21–5 •), not prone and not in a side-lying position, greatly decreases the risk of SIDS. Placing infants to sleep on their side is not recommended, because they can easily roll onto their stomach. It is also recommended that infants be dressed in blanket sleepers and that no blankets, pillows, or stuffed ani- mals be placed in the crib (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Meadows-Oliver and Hen- drie (2013) summarized the expanded “Back to Sleep” guidelines. The infant’s mattress should be firm, and the use of wedges or positioners is
Figure 21–5 • Place infant on back for sleeping. Note the infant’s tonic neck reflex. Jamie Grill/Getty Images.
TABLE 21–2 Apgar Scoring System to Assess the Newborn
Score
Sign 0 1 2
1. Heart rate Absent Slow (below 100 beats/ min) Above 100 beats/min
2. Respirations Absent Slow, irregular Regular rate, crying
3. Muscle tone Flaccid Some flexion of extremities Active movements
4. Reflex irritability None Grimace Cries
5. Color Body pale, cyanotic Body pink. For babies with dark skin (e.g., African American, some Latino, American Indian), check mucous membranes; extremities blue
Body completely pink, pink mucous membranes in babies with dark skin
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TODDLERS (1 TO 3 YEARS) Toddlers develop from having no voluntary control to being able to walk and speak. They also learn to control their bladder and bowels, and they acquire a wide variety of information about their environment.
Physical Development Two-year-old children lose the baby look. Toddlers are usually chubby, with relatively short legs and a large head. The face appears small when compared to the skull, but as the toddler grows, the face seems to grow from under the skull and appears better proportioned. Toddlers have a pronounced lumbar lordosis and a protruding abdomen. The abdom- inal muscles develop gradually with growth, and the abdomen flattens.
WEIGHT Two-year-olds can be expected to weigh approximately four times their birth weight. The weight gain is about 2 kg (5 lb) between ages 1 and 2 years and about 1 to 2 kg (2 to 5 lb) between 2 and 3 years. The 3-year-old should weigh about 13.6 kg (30 lb).
HEIGHT A toddler’s height can be measured as height or length. Height is measured while the toddler stands, and length is measured while the toddler is in a recumbent position. Because the measurements dif- fer slightly, nurses must specify which measurement is used. Between ages 1 and 2 years, the average growth in height is 10 to 12 cm (4 to 5 in.); between 2 and 3 years it slows to 6 to 8 cm (21⁄2 to 31⁄2 in.).
HEAD CIRCUMFERENCE The head circumference of the toddler increases about 2.5 cm (1 in.) each year. By 24 months the head is 80% of the average adult size and the brain is 70% of its adult size.
DEVELOPMENTAL SCREENING TESTS Development can be assessed by observing the infant’s behavior and by using standardized tests such as the Denver Developmental Screening Test (DDST-II). The DDST-II is used to screen chil- dren from birth to 6 years of age. The test is intended to estimate the abilities of a child compared to those of an average group of chil- dren of the same age. Four main areas of development are screened: personal-social, fine motor adaptive, language, and gross motor.
ONGOING NURSING ASSESSMENTS During ongoing assessments, the nurse examines and observes the infant, taking into account variations that occur with developmental age and activity. For example, the pulse of the baby at birth is affected by the child’s activity, rising up to 170 when the infant is crying and falling to as low as 70 during sleep.
In addition, the nurse actively listens to the caregiver for pos- sible problems or areas of concern and reviews with the parent the expected behavior or characteristics for the particular age group. It is important for the caregiver to know that certain behaviors, re- sponses, and activities of the infant are normal and expected. It is also important to discuss the many individual differences that can, quite normally, occur.
The assessment interview is also a time to be supportive of the parent’s role, to assess the attachment of the parent to the infant, and to observe the interactions between the infant and parent. Assess- ment guidelines for the infant are shown in the Developmental As- sessment Guidelines.
The first month of life is critical for physical adjustments to ex- trauterine life and for the psychosocial adjustment of the parents. From 1 month to 1 year, infants experience rapid change, with ad- vances in physical growth and psychosocial development. For a sum- mary of health and wellness promotion, see Box 21–3.
BOX 21–3 Health Promotion Guidelines for Infants
HEALTH EXAMINATIONS • Screening of newborns for hearing loss at 1 month of age,
diagnosis by 3 months of age, with intervention and treatment by 6 months of age (Russ, White, Dougherty, & Forsman, 2010)
• Physical exam at 2 weeks and at 2, 4, 6, 9, and 12 months
PROTECTIVE MEASURES • Immunizations: diphtheria, tetanus, acellular pertussis (DTaP),
inactivated poliovirus vaccine (IPV), pneumococcal (PVC), Haemophilus influenzae type B (HIB), hepatitis B (HepB), hepatitis A (HepA), rotavirus, and influenza vaccines as recom- mended. Varicella and measles-mumps-rubella (MMR) are not given before 12 months of age.
• Fluoride supplements for infants over 6 months of age if there is inadequate water fluoridation (less than 0.3 parts per million)
• Screening for tuberculosis • Screening for metabolic conditions including phenylketonuria
(PKU) • Prompt attention for illnesses • Appropriate skin hygiene and clothing
INFANT SAFETY • Importance of supervision • Car seat, crib with a firm mattress, playpen, bath, and home
environment safety measures • No stuffed animals, pillows, or blankets in the crib • Position the infant on the back for sleep
• Feeding measures (e.g., avoid propping bottle) • Provide toys with no small parts or sharp edges • Eliminate toxins in the environment (e.g., tobacco, chemicals,
radon, lead, mercury) • Use smoke and carbon monoxide (CO) detectors in home
NUTRITION • Exclusive breast-feeding to 4 to 6 months • Solid foods between 4 and 6 months • Need for iron supplements at 4 to 6 months • Continued breast-feeding to age 12 months • Breast-feeding and bottle-feeding techniques • Formula preparation • Feeding schedule
ELIMINATION • Characteristics and frequency of stool and urine elimination • Diarrhea and its effects
REST/SLEEP • Establish routine for sleep and rest patterns
SENSORY STIMULATION • Touch: holding, cuddling, rocking • Vision: colorful, moving toys • Hearing: soothing voice tones, music, singing • Play: toys appropriate for development
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most children are toilet trained, although they still may have the oc- casional accident when playing or during the night.
Psychosocial Development According to Freud, the ages of 2 and 3 years represent the anal phase of development, when the rectum and anus are the especially signifi- cant areas of the body. Erikson viewed the period from 18 months to 3 years as the time when the central developmental task is autonomy versus shame and doubt.
Toddlers begin to develop their sense of autonomy by asserting themselves with frequent use of the word “no.” They are often frus- trated by restraints to their behavior and between ages 1 and 3 may have temper tantrums. However, with the guidance of their care- givers they slowly gain control over their emotions. Parents need to have a great deal of patience coupled with an understanding of the importance of this developmental milestone. To be effective, caregiv- ers need to give the child some measure of control and at the same time be consistent in setting limits so that the child learns the results of misbehavior. The nurse can also assist the parents and caregivers in promoting the toddler’s development by suggesting the activities summarized in Box 21–4.
Self-concept refers to an individual’s perception of their iden- tity. A child’s self-concept is formed by interpersonal experiences. It is formed in accordance with the child’s ability to perform tasks,
SENSORY ABILITIES Visual acuity is fairly well established at 1 year; average estimates of acuity for the toddler are 20/70 at 18 months and 20/40 at 2 years of age. Accommodation to near and far objects is fairly well developed by 18 months and continues to mature with age. At 3 years of age, the toddler can look away from a toy prior to reaching out and picking it up. This ability requires the integration of visual and neuromuscular mechanisms.
The senses of hearing, taste, smell, and touch become increas- ingly developed and associated with each other. Hearing in the 3-year-old is at adult levels. The taste buds of the toddler are sensi- tive to the natural flavors of food, and the 3-year-old prefers familiar odors and tastes. Touch is a very important sense and a distressed toddler is often soothed by tactile sensations.
MOTOR ABILITIES Fine muscle coordination and gross motor skills improve during the toddler years. At the age of 18 months babies can pick up raisins or cereal pieces and place them in a receptacle. They can also hold a spoon and a cup and can walk upstairs with assistance. They will probably crawl down the stairs.
At 2 years, toddlers can hold a spoon and put it into the mouth correctly. They are able to run, their gait is steady, and they can bal- ance on one foot and ride a tricycle (Figure 21–6 •). In the third year
Developmental Assessment Guidelines
The Infant
In these five developmental areas, does the infant do the following?
PHYSICAL DEVELOPMENT • Demonstrate physical growth (weight, length, head and chest
circumference) within the normal range. • Manifest appropriately sized fontanels for age. • Exhibit vital signs within normal range for age. • Display ability to habituate to stimuli and to calm self.
MOTOR DEVELOPMENT • Perform gross and fine motor milestones within the normal range
for age. • Exhibit reflexes appropriate for age. • Display symmetric movements. • Exhibit no hyper- or hypotonia.
SENSORY DEVELOPMENT • Follow a moving object within normal range for age. • Respond to sounds, such as talking or clapping hands. • Coo, babble, laugh, vocalize, and imitate sounds as expected
for age.
PSYCHOSOCIAL DEVELOPMENT • Interact appropriately with parent through body movements and
vocalizations.
DEVELOPMENT IN ACTIVITIES OF DAILY LIVING • Eat and drink appropriate amounts of breast milk, formula, and/
or solid foods. • Exhibit an elimination pattern within normal range for age. • Exhibit a rest and sleep pattern appropriate for age.
Figure 21–6 • A toddler has enough gross and fine motor ability to jump and kick a ball. Elenathewise/Fotolia.
BOX 21–4 Fostering the Toddler’s Psychosocial Development
• Provide toys suitable for the toddler, including some toys chal- lenging enough to motivate but not so difficult that the toddler will fail. (Failure can intensify feelings of self-doubt and shame.)
• Make positive suggestions rather than negative commands (e.g., “Don’t get into that.”). Avoid an emotional climate of negativism, blame, and punishment.
• Give the toddler choices, all of which are safe; however, limit number to two or three.
• When toddler has a temper tantrum, make sure the child is safe, and then leave.
• Help the toddler to develop inner control by setting and enforcing consistent, reasonable limits.
• Praise the toddler’s accomplishments; give random and spontaneous feedback for positive behavior.
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some activities elicit affection and approval. They also recognize that certain rituals, such as repeating phrases from prayers, also elicit ap- proval. This provides children with feelings of security. By 2 years of age, toddlers are learning what attitudes their parents hold about moral matters.
Spiritual Development According to Fowler (1981), the toddler’s stage of spiritual develop- ment is undifferentiated. Toddlers may be aware of some religious practices, but they are primarily involved in learning knowledge and emotional reactions rather than establishing spiritual beliefs. A tod- dler may repeat short prayers at bedtime, conforming to a ritual, be- cause praise and affection result. This parental or caregiver response enhances the toddler’s sense of security.
Health Risks Toddlers experience significant health problems due to injuries, visual problems, dental caries, and respiratory and ear infections.
INJURIES Injuries are the leading cause of mortality of toddlers. They are curi- ous and like to feel and taste everything. The most common causes of fatal injuries are automobile crashes, drowning, burns, poisoning, and falls. Parents or other caregivers need to take the appropriate preven- tive measures to guard against these health threats (Figure 21–7 •).
academic performance, social acceptance, and physical appearance. Leflot, Onghena, and Colpin (2010) conducted a study on teacher and child relationships. They examined how these relationships affected the child’s self-concept. If a teacher supported the child in a positive way, then the self-concept of the child was improved. In another study, chil- dren who experienced chronic illness were shown to have a diminished self-concept (Ferro & Boyle, 2013). Children learn to develop a sense of self-concept through their immediate social environment, in which their parents play a significant role. If the children’s social interactions with their parents are negative (e.g., constant disapproval regarding eating, toilet training, or other behavior), the children may begin to see themselves as bad. This perception is the basis of a negative self- concept. Parents need to give toddlers positive input so they can de- velop a positive and healthy self-concept. With a healthy self- concept, the toddler is better able to deal with periodic failures later in life.
Although toddlers like to explore the environment, they always need to have a significant person nearby. Parents need to know that young children experience acute separation anxiety, the fear and frustration that come with parental absences. Abandonment is their greatest fear. At this age, the child may have difficulty accepting a bab- ysitter or strongly resist being left by the parents at a day care center. For example, toddlers may become highly anxious when separated from their parents and admitted to a hospital. Regression or revert- ing to an earlier development stage may be indicated by bed-wetting or using baby talk. Nurses can assist parents by helping them under- stand that this behavior is normal and indicates that these toddlers are trying to establish their position in the family.
Experience with separation helps the child cope with paren- tal absences. Children need room for exploration and interac- tion with other children and adults. At the same time, they need to know that the parental bond of a loving and close relationship remains secure.
Toddlers assert their independence by saying “no” or by daw- dling. During the toddler stage, receptive and expressive language skills develop quickly. Children can understand words and follow directions long before they can actually form sentences.
Cognitive Development According to Piaget (1966), the toddler completes the fifth and sixth stages of the sensorimotor phase and starts the preconceptual phase at about 2 years of age. In the fifth stage, the toddler solves problems by a trial-and-error process. By stage 6, toddlers can solve problems mentally. For example, when given a new toy the toddler will not im- mediately handle the toy to see how it works, but will instead look at it carefully to think about how it works.
During Piaget’s preconceptual phase, toddlers develop consider- able cognitive and intellectual skills. They learn about the sequence of time. They have some symbolic thought; for example, a chair may represent a place of safety, and a blanket may symbolize comfort. Concepts start to form in late toddlerhood. A concept develops when the child learns words to represent classes of objects or thoughts. An example of a concrete concept is table, representing a number of ar- ticles of furniture that are all different but all tables.
Moral Development According to Kohlberg (1981), the first level of moral development is the preconventional when children respond to punishment and reward. During the second year of life, children begin to know that
Figure 21–7 • Utilize safety equipment such as life jackets when near the water. Johner Images/Getty Images.
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PRESCHOOLERS (4 AND 5 YEARS) During the preschool period physical growth slows, but control of the body and coordination increase greatly. Preschoolers’ worlds get larger as they meet relatives, friends, and neighbors.
Physical Development Preschool-age children tend to grow more in height than in weight, so by the time children are 4 or 5 years old, they appear taller and thin- ner than toddlers. The posture of preschoolers gradually becomes more erect as the pelvis is straightened and the abdominal muscles become stronger. The extremities of the body grow more quickly than the body trunk, making the child’s body appear somewhat out of proportion. The preschooler’s brain almost reaches its adult size by 5 years.
WEIGHT Weight gain in preschool children is generally slow. By 5 years they should have added only another 3 to 5 kg (7 to 12 lb) to their 3-year-old weight, increasing it to somewhere between 18 and 20 kg (40 and 45 lb).
HEIGHT Preschool children grow about 5 to 6.25 cm (2.0 to 2.5 in.) each year. By 4 years of age they have doubled their birth length and measure about 102 cm (41 in.).
VISION Preschool children are generally hyperopic (farsighted), that is, unable to focus on near objects. As the eye grows in length, it be- comes emmetropic (it refracts light normally). If the eyes become too long, the child becomes myopic (nearsighted), that is, unable to focus on objects that are far away. In severe cases of hyperopia or myopia, glasses may be prescribed. By the end of the preschool years, visual ability has improved; normal vision for the 5-year-old is ap- proximately 20/30. The Snellen E chart can be used to assess the pre- schooler’s vision.
VISION PROBLEMS Early in the toddler years, the child should be screened for amblyopia. Amblyopia (a failure to establish normal neuropathways of vision that leads to reduced visual acuity in one eye) is usually the result of strabismus (cross-eye) but can be caused by refractive errors (e.g., myopia) or opacities in the lens. Initially the child with amblyopia has straight eyes, but the condition can lead to deviation of the “lazy” eye and subsequent loss of vision.
DENTAL CARIES Dental caries occur frequently during the toddler period, resulting from the interactio
