Health Care Delivery and Nursing Practice

1. Health Care Delivery and Nursing Practice Dr. Belal M. Hijji, RN, PhD 29.08.2010

2. Learning Outcomes • At the end of this lecture, students will be able to: • Define nursing and identify phenomena that are the focus of nursing care and research • Distinguish between the terms “patient” and “client” • Discuss Maslow’s hierarchy of human needs • Define health, wellness, and health promotion • Identify the factors that influence health care delivery

3. The Health Care Industry And The Nursing Profession Definition of Nursing • Nightingale (1858) noted that the goal of nursing was “to put the patient in the best condition for nature to act upon him”. • Nursing leaders said that nursing is both an art and a science. • The American Nurses Association (ANA, 1995) defined nursing as “the diagnosis and treatment of human responses to health and illness”. The following is list of phenomena that are the focus for nursing care and research: • Self-care processes • Physiologic and pathophysiologic processes • Comfort, pain, and discomfort • Emotions related to experiences of health and illness • Meanings ascribed to health and illnesses • Decision making and ability to make choices • Perceptual orientations such as self-image and control over one’s body and environments • Transitions across the life span • Affiliative relationships, including freedom from oppression and abuse

4. The Patient/ Client: Consumer of Nursing and Health Care Health Care in Transition • The patient is a central figure in health care services. • The term patient means “to suffer”; is used to describe those who are recipients of care and dependent. • The term client means “to lean” connoting alliance and interdependence. • The patient who seeks care for a health problem is also an individual, a member of a family, and a citizen of the community. • Patients’ needs vary depending on their problem, associated circumstances, and past experiences. One of the nurse’s important functions in health care delivery is to identify the patient’s immediate needs and take measures to address them.

5. The Patient’s Basic Needs • Certain needs are basic to all people and require satisfaction.Such needs are addressed on the basis of priority. Once anessential need is met, the person experiences a need on a higherlevel. Approaching needs according to priority reflects Maslow’shierarchy of needs (Next slide). Maslow’s Hierarchy • Maslow ranked human needs as follows: physiologic needs; safety and security; belongingness and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. • Lower-level needs always remain, but a person’s ability to pursue higher-level needs indicates that he or she is moving toward psychological health and well-being.

7. Health, Wellness, And Health Promotion • The US health care system is currently placing greater emphasis on health and its promotion. Similarly, a growing portion of nurses is directing its efforts toward health promotion and disease prevention.

8. HEALTH • The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” (Hood & Leddy, 2002). Such a definition does not allow for any variation in degrees of wellness or illness. • On the other hand, the concept of a health–illness continuum allows for a greater range in describing a person’s health status. • The limitations of the WHO definition of health are clear in relation to chronic illness and disability. A chronically ill person cannot meet the standards of health as established by the WHO definition. However, when viewed from the perspective of the health–illness continuum, people with chronic illness or disability can be understood as having the potential to attain a high level of wellness, if they are successful in meeting their health potential within the limits of their chronic illness or disability.

9. WELLNESS • Wellness has been defined as being equivalent to health. • Cookfair (1996) indicated that wellness “includes a conscious and deliberate approach to an advanced state of physical, psychological, and spiritual health and is a dynamic, fluctuating state of being”. • Leddy and Pepper (1998) contended that wellness is indicated by the capacity of the person to perform to the best of his or her ability, the ability to adjust and adapt to varying situations, a reported feeling of well-being, and a feeling that “everything is together” and harmonious.

10. Health Promotion • Great emphasis is placed on health, health promotion, wellness, and self-care. Health is seen as resulting from a lifestyle that is oriented toward wellness. The result has been the evolution of a wide range of health promotion strategies, including screening, genetic testing, lifetime health monitoring programs, environmental and mental health programs, risk reduction, and nutrition and health education. • A growing interest in self-care skills is evidenced by the large number of health related publications, conferences, and workshops designed for the lay public. • Individuals are increasingly knowledgeable about their health and are encouraged to take more interest in and responsibility for their health and well-being. Self-care education programs emphasize health promotion, disease prevention, management of illness, self-medication, and judicious use of the professional health care system. • Special efforts are being made by health care professionals concerning lifestyle and health practices. Stress, improper diet, lack of exercise, smoking, drugs, high-risk behaviors and poor hygiene are all lifestyle behaviors known to have a negative effect on health.

11. Influences on Health Care Delivery • The health care delivery system is rapidly changing as the population and its health care needs and expectations change. • The shifting demographics of the population, the increase in chronic illnesses and disability, the greater emphasis on economics, and technological advances have resulted in changing emphases in health care delivery and in nursing.

12. Population Demographics • The population expansion is attributed in part to improved public health services and improved nutrition. • Not only is the population increasing, but the composition of the population is also changing. The decline in birth rate in the US, for example, and the increase in life span attributed to improved health care have resulted in fewer school-age children and more senior citizens, most of whom are women. • The number of homeless people increased significantly. • The population has become more culturally diverse as increasing numbers of people from different national backgrounds

13. Changing Patterns of Disease • During the past 50 years, the health problems have changed significantly. Many infectious diseases have been controlled or eradicated; others, such as tuberculosis, acquired immunodeficiency syndrome (AIDS), and sexually transmitted diseases, are on the rise. • An increasing number of infectious agents are becoming resistant to antibiotic therapy as a result of widespread inappropriate use of antibiotics. • The chronicity of illnesses is increasing because of the lengthening life span of patients and the expansion of successful treatment options for conditions such as cancer and HIV infection • Because of chronicity, many people are learning to protect and maximize their health within the constraints of chronic illness and disability. • As chronic conditions increase, health care broadens from a focus on cure and eradication of disease to include the prevention or rapid treatment of exacerbations of chronic conditions. • Nursing plays a prominent role in the current focus on management of chronic illness and disability.

14. Advances in Technology and Genetics • Advances in technology and genetics have occurred with great frequency during the past several decades. • Sophisticated techniques and devices have revolutionized surgery and diagnostic testing, making it possible to perform many procedures on an outpatient basis. • This is also an era of sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information. • Such scientific and technological advances are themselves stimulating brisk change in health care delivery strategies.

15. Economic Changes • The provision of comprehensive and quality health care for all citizens prompted governmental concern about increasing health care costs and wide variations in charges among providers. • Nurses, in hospitals, care for patients who are older and sicker and require more nursing services; community nurses care for patients who have been discharged earlier and need acute care services with high-technology and long-term care. • Nurses in hospitals must assume responsibility with other health care providers for maintaining quality care while facing pressures to discharge patients and decrease staffing costs. These nurses must also work with nurses in community settings to ensure continuity of care.

16. Demand for Quality Care • The general public, in the US, has become increasingly interested in and knowledgeable about health care and health promotion. • The general public has begun to subscribe strongly to the belief that quality health care constitute a basic right, rather than a privilege. In 1977, the National League for Nursing (NLN) said that nurses are responsibility to uphold patients’ rights to privacy, confidentiality, informed participation, self-determination, and access to health records. • The ANA promotes the delivery of quality health and nursing care. The ANA assesses the quality of health care provided and lobbies legislators to pass bills related to health insurance or length of hospital stay for new mothers. • Efforts to provide full health care coverage for citizens, particularly children, represent measures by state governments to promote access to health care. Legislative support of advanced practice nurses in individual practice is a recognition of the contribution of nursing to the health of consumers, particularly underserved populations.

17. Quality Improvement and Evidence-Based Practice In the 1980s, health care institutions implemented ongoing quality assurance (QA) programs which were required for reimbursement for services and for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). QA programs sought to establish accountability on the part of the health professions to society for the quality, appropriateness, and cost of health services provided. Objective and measurable indicators were used to monitor, evaluate, and communicate the quality and appropriateness of care delivered. QA criteria were identified as measures to ensure minimal expectations only; they did not provide mechanisms for identifying causes of problems or for determining systems or processes that need improvement.

18. Continuous quality improvement (CQI) was identified as a more effective mechanism for improving the quality of health care. Quality improvement efforts have focused on ensuring that the care provided meets or exceeds JCAHO standards. QA focuses on individual incidents or errors and minimal expectations, while CQI focuses on the processes used to provide care, with the aim of improving quality by assessing and improving those interrelated processes that most affect patient care outcomes and patient satisfaction. In health care agencies, nurses have many opportunities to be involved in quality improvement. One such opportunity is through facilitation of evidence-based practice. Evidence-based practice—identifying and evaluating current literature and research and incorporating the findings into care guidelines—has been designated as a means of ensuring quality care.