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  1. Challenges and Opportunities
    • •Rapidity & amount of change in recent decades in health care
    • •New administrative structures, technology, professional roles, ways of providing care
    • •Opportunities to adapt to new demands in a positive way, becomes a challenge
  2. Meanings & Types of Change
    • •The process of making something different from what it was
    • •Disrupts equilibrium
    • •Involves endings, transitions, & beginnings
    • starts at grieving->acceptance
    • •Those who do not reach acceptance of change experience
    • –Disengagement- ppl quit, doin the min.
    • –Disidentification- ppl vulnerable, they sulk/dwell in past & resist new tasks
    • –Disorientation- ppl dont know where they fit in, do wrong this cuz not sure of thier role/priorities
    • –Disenchantment- ppl get angry, negative, & have distructive behavior

    • •Resistance to change caused by
    • –Threats to self-interest
    • –Embarrassment
    • –Insecurity
    • –Habit
    • –Complacency
    • –Loss of power
    • –Objective disagreement

    • •Reduce resistance to change with
    • –Careful planning
    • –Appropriate timing of communication
    • –Adequate feedback
    • –Employee confidence

    • •Change occurs in response to 3 activities
    • 1. Spontaneous change
    • –Reactive or unplanned
    • Not fully anticipated
    • Cannot be avoided
    • Little or no time to plan response strategies
    • –Short-term or long-term
    • –Responses can be either positive or negative
    • –Successful responses require
    • Flexibility
    • Cohesiveness

    • •Developmental change
    • –Physiopsychologic changes that occur during an individual’s life cycle or the growth of an organization as it becomes more complex
    • –Organizations often grow and develop in unpredictable ways

    • •Planned change
    • –Intended, purposive attempt by an individual, group, organization, or larger social system to influence the status quo of itself, another organism, or a situation –Important skills in planned change
    • Problem-solving
    • Decision-making
    • Interpersonal

    • •Four ways we change
    • –Pendulum- I was wrong before, now I'm right
    • –Change by exception- I'm right, except for
    • –Incremental- I was almost right before but now I'm right
    • –Paradigm- what I knew before was partially right, now I'm more right, but only part of what I'll know 2morrow

    Paradigm change is transformational- combines watz useful about old ways w/ watz useful about new ways & keeps us open to looking for even better ways
  3. Three Broad Approaches to Planned Change
    • •Coercive (empirical-rational)
    • –Based on two beliefs
    • People are rational
    • They will change if it is in their self-interest
    • -power ingredient- knowledge

    • •Middle Ground (normative-reeducative)
    • –Based on assumption that motivation depends on the sociocultural norms and the commitment to these norms
    • -works if ppl have new attitudes & want new knowledge
    • - long process (ppl dont want to change)
    • - power ingredient- interpersonal relationships & change agent uses collaboration

    • •Power-coercive
    • –Power lies with one or more persons of influence
    • –Influence comes thru political power, wealth, status, or ability
    • –Positions of authority enforce change
  4. Change Strategies
    • •Tiffany & Lutjens (1998): Strategies from neutral to most coercive
    • –Educational- unbaised presentaion of facts
    • –Facilitative- provides resources critical to change
    • –Technostructural- new technology
    • –Data-based- collects & uses date 4 change
    • –Communication- takes time
    • –Persuasive- reasoning, arguing, inducment for change
    • –Coercive- obligatory
  5. Frameworks for Change
    (Theorists that follow the normative-reeducative approach0
    • Lewin, Kurt
    • –Change is a result of forces within a field or environment
    • –Force Field Analysis Model
    • Driving forces- moves actions
    • Restraining forces- maintains actions

    • –Three stages
    • Unfreezing- wants to change
    • Moving- plans change & starts it
    • Refreezing- changes made & r stabilized

    • •Lippitt, Gordon
    • - focus on wat changes agent can do not change itself
    • –Seven phases of planned change
    • Diagnose the problem
    • Assess motivation
    • Assess change agent’s motivation
    • Select progressive change objects
    • Choose change agent role
    • Maintain change
    • Terminate helping relationship

    • •Havelock, Ronald
    • –Six-step process
    • Building a relationship
    • Diagnosing the problem
    • Acquiring resources
    • part of unfreezing
    • Choosing the solution
    • Gaining acceptance
    • part of moving
    • Stabilization & self renewal
    • part of refreezing

    • •Rogers, Everett
    • –Diffusion-innovation theory
    • Diffusion:process by which innovation is communicated, becomes social change when diffusions of new ideas results in consequences
    • Three phases in the diffusion of innovation
    • •Invention- collecting info of change, & info analized
    • •Diffusion- telling other of idea, pros/cons
    • •Consequences- may be adapted or rejected
    • - these are not always permenat
    • –Five steps to diffusion of innovation
    • Knowledge- decision makers introduce & comprehend changes
    • Persuasion- ppl get good/bad attitudes about change
    • Decision- ppl makes choice to adapt or not
    • Implementation- ppl act on choice
    • Confirmation- makes sure choice was right, if not changes are made

    • –Five groups of adopters of innovation
    • Innovators- most enthusiatic & introduce change
    • Early adopters- receptive to new ideas
    • Early majority- considers idea for a while before supporting it
    • late majority- are skeptical, accepts ideas after uncertainties resolved
    • Laggards- have traditional values, looks at past more than future
    • Rejectors
  6. Identifying Forces
    • •Internal
    • •External

    internal forces originates inside organization, but may b due to external forces

    strategies are planned to reduce restraing forces & strengthen driving forces

    • cognative dissonance believed to be powerful motivator for change: 4 concepts
    • - ppl like consistancy
    • - dissonance is a result of psychological inconsistancy, which is expirienced as discomfort
    • - dissonance drives ppl to action
    • - dissonance stimulates ppl to attain consistancy & reduces inconsistancy

    degree of dissonnace expirienced is directly r/t importance of issue
  7. Change Agent
    • •Change agent must
    • –Identify source of problem
    • –Assess motivations and capacity for change
    • –Determine and examine alternatives
    • –Determine and implement helping relationship

    • •Change agent works to bring about change
    • –A person or group who initiates, motivates, and implements the change
    • –Leader
    • –Critical thinker
    • –Uses knowledge of change theory to be effective
    • –Highly skilled
    • –Accessible
    • –Trustworthy
    • –Informally or formally designated
    • * formally- change agent is one who has role & responsibilty for change
    • * informally- doesnt have authority to make changes, but has leadership & respect of other leading to persuasion
    • –Can be internal or external to the organization
    • * internal change agent- part of situation or system
    • * external change agent- comes to situation thru outside
  8. Coping With Change
    • •Not always welcome
    • •Produces anxiety
    • •Evokes emotional reactions
    • •Consumes resources and energy
    • •Associated with feelings of loss, grief, and pain

    • •Seven stages of change
    • –Losing focus- confusion
    • –Minimizing the impact- denial
    • –The pit- anger
    • –Letting go of the past- more positive
    • –Testing the limits- optimism
    • –Search for meaning- lokking back at good decision
    • –Integration- transition complete
  9. Resistance to Change
    • •Behavior intended to maintain the status quo
    • •Change agent should anticipate resistance
    • •Resistance is greatest when idea is not concurrent with existing trends
    • •Managing resistance
    • –Communicate with those who oppose change
    • –Clarify information and provide feedback –Be open to revisions
    • –Present negative consequences of resistance
    • –Emphasize positive consequences
    • –Keep resisters involved
    • –Maintain climate of trust, support, and confidence
    • –Divert attention by creating different "disturbance"

    • managinf resistance after analyzing 3 tactics can be used to unfreeze the system:
    • 1. create comfort
    • 2. inducing guilt & anxiety
    • 3. providing psychological safety
  10. Political Strategies That May Help
    • •Analyze the organization and lines of authority
    • •Identify key people affected by the change
    • •Find out likes and dislikes
    • •Build a coalition of support before the change begins
  11. Evidence
    • •Evidence helps build a case for change and comes from
    • –Research
    • –Quality management data
    • –Patient satisfaction data
    • –Someone else’s experience
    • •Incentives may be needed for moving and maintaining the change
    • •If resistance continues, change agent must consider
    • –Change is not workable and a compromise is necessary
    • –Change is appropriate, plan is sufficient, must proceed through coercive means
  12. Communication
    • •Definition
    • –The giving or exchanging of information through verbal or written means
    • –Kozier
    • •"…any means of exchanging information or feeling between two or more people
    • * ratzan defines health communication as " art & technique of informing, influencing, & motivating ppl, insitutions, & public about health issues

    • •The communication process
    • –Sender/encoder
    • –Message
    • –Channel- why to convey message, can be visual, audotiry, touch
    • –Receiver/decoder- use past, knowledge, & personal characteristics to decode
    • –Response or feedback- receiver response is the feedback

    • •Factors that influence the communication process
    • –Developmental stage
    • •Children versus adults- differant ages
    • –Gender
    • •Male versus female
    • females express more emotions or appreciation, menz motivations is primarily control
    • –Roles and relationships
    • •Nurse and client
    • •Nurse and colleague
    • •Nurse and physician
    • –Sociocultural characteristics
    • •Culture
    • •Education
    • •Economic level
    • –Values and perceptions
    • •Values people hold about themselves, others, and the world they live in, & talking or demonstrating pain
    • –Space and territoriality- proxemics is the study of space relationships maintained by ppl in social interaction& includes space & territory
    • •Four distances
    • –Intimate
    • »1 ½ feet, when assessing & caring 4 pt, always explain space when starting
    • –Personal
    • »1 ½ to 4 feet, when talking to pt
    • –Social
    • »4 to 12 feet, when talking to ppl, groups, harder to b confifential
    • –Public
    • »12 feet and beyond, speaking to groups
    • –Environment
    • •Supports the exchange of information, ideas, or feelings, even the way the furniture is arranged can b a problem
    • –Congruence
    • •Nonverbal behaviors match the verbal message,
    • --interpersonal attutudes- always be respectful, nonjudgemental
  13. Types of Communication
    verbal & nonverbal, the majority is always nonverbal

    • •Oral
    • –Spoken exchange of information, ideas, or feelings using words
    • •4 Concepts of word meanings
    • –Denotative- how word is usually used by ppl that share same language
    • –Connotative- ones personal expirience with word, (love either ppl or thing)
    • –Private- held by individual
    • –Shared- held by 2 ppl

    • –considerations when choosing words
    • •Pace and intonation- pace is speed & intonation is pitch
    • •Simplicity- choice of words
    • •Clarity and brevity- clarity means choosing words that say unmistakenly wat is meant, brevity is using fewer words needed
    • •Timing and relevance- time that ur communicating & whether they care or not
    • •Adaptability- using both verbal & nonverbal
    • •Credibility- being believable & trustworthy
    • •Humor-
    • * paralanguage or paralinguistic sounds sound that accompany verbal language & adds to message

    • –Nonverbal communication or "body language"
    • •Includes:
    • –Eye contact
    • –Facial expression
    • –Body movements
    • –Gestures
    • –Touch
    • –Physical appearance

    • •Therapeutic communication
    • –" interactive process between nurse & client that helps client overcome temporary stress, get along w other ppl, adjust to unalternable, & to overcome psychological blocks which stand in the way of self-realizations"
    • - purposeful use of dialogue for pt insight, control of s/s & healing
    • - always has specific purpose or direction, & is planned
    • mindful thinking- req. paying undivided attention wat pt says, feels, & putting aside own feelings
    • –Focuses on client’s thoughts and concerns:
    • •Using silence
    • •Providing general leads
    • •Being specific and tentative
    • •Using open-ended questions
    • •Using touch
    • •Restating or paraphrasing
    • •Seeking clarification
    • •Perception checking or seeking consensual validation
    • •Offering self
    • •Giving information
    • •Acknowledging
    • •Clarifying time or sequence
    • •Presenting reality
    • •Focusing
    • •Reflecting
    • •Summarizing and planning

    • •Written communication
    • –Characteristics of effective written communication
    • •Appropriate language and terminology
    • •Correct grammar, spelling, and punctuation
    • •Logical organization
    • •Appropriate use and citation of resources
  14. Barriers to Communication
    • –Stereotyping
    • –Agreeing and disagreeing
    • –Being defensive
    • –Challenging
    • –Probing
    • –Testing
    • –Rejecting
    • –Changing topics and subjects
    • –Unwarranted reassaurence
    • –Passing judgment
    • –Giving common advice
  15. Nursing Documentation
    • •Essential for effective communication of client status between health care providers
    • •Other uses
    • –Audit for quality assurance
    • –Research
    • –Education
    • –Reimbursement
    • –Legal documentation
    • - health care analysis

    • •Methods of documentation
    • –Source-oriented- everyone wirtes in differant section
    • –Problem-orient- SOPIER
    • –Focus charting- pts concerns & strenths (D) data, (A)action, (R)response, has flow sheet
    • –Core- focuses on nursing process, (D) database, (A)action, (E)evaluation
    • –Charting by exception (CBE)- only certain findings or exceptions to norm, has flow sheet,
    • –FACT- same as CBE, (F)flow of services, (A)assessment, (C)concise progress notes, (T)timely entries
  16. Communication Through Technology
    • –Nurses’ stations
    • –Bedside
    • –Hand-held systems

    • creates a faster way to communicate
    • same rules apply like communicating in person, remember that reciever cant see expessions & hear tone
  17. Challenges and Opportunities
    of group process
    • •Healthcare professionals should be active in decisions about all aspects of health care
    • •Decisions are typically made by groups
    • •Opportunities for nurses to participate in decision-making groups
  18. Groups
    • •Three or more individuals who have a common purpose, interact with each other, influence each other and are interdependent
    • •Exist to help achieve goals that may be unattainable by an individual effort
    • •Types of groups
    • –Primary
    • Small, intimate
    • Relationships are personal, spontaneous, sentimental, cooperative, and inclusive
    • Face-to-face interactions
    • Sense of "we" and "our" versus "I" or "mine"
    • People turn to primary group when they need help (ex. family)

    • –Secondary
    • Larger
    • Impersonal
    • Means of getting things done
    • Often no fact-to-face contact
    • Members need not know each other in inclusive sense
  19. Functions of groups
    • •Socialization
    • •Support
    • •Task completion
    • •Camaraderie
    • •Information
    • •Normative
    • •Empowerment
    • •Governance
  20. Two Categories of Group functions
    • •Functional perspectives
    • -task completion
    • -information
    • -normative function
    • -empowerment
    • -governance
    • •Interpersonal perspectives
    • -affiliation
    • -affection
    • -socialization
    • -support
    • - camaraderie
    • - power
  21. Three Levels of Group Formality
    • •Formal
    • –Work organization, usually to carry out task not to meet needs of group
    • - standing formal group- have permenant designation w/i organizational stucture
    • - ad hoc formal group- is created for specific issue
    • •Semiformal
    • –Churches, lodges, social clubs, PTAs, labor unions
    • - usually voluntary
    • -objectives & goals are fixed
    • •Informal- provide persons education & contribute alot to their culture values; members dont depend on each other
    • –Friendship
    • –Hobby
    • –Convenience
    • –Work
    • –Self-protective
  22. Group Development
    • •Three phases
    • –Orientation
    • Members seek acceptance
    • High anxiety (primary tension)
    • Uncertainty and insecurity
    • –Working
    • Comfortable
    • Problem solving
    • - problem solving done by consensus not vote
    • –Termination
    • Evaluating and summarizing expirience
    • - group may feel satisfaction, anger, fustration depending on result
    • •Mature stage: Crenshaw’s 4th stage
    • –Between working and termination
    • –Acceptance and openness
    • –Sense of "we" or cohesiveness
    • •Six stages of team development
    • –Orientation- uncertainty, unfamiliarty, mistrust, non participtaiton
    • –Forming- acceptance of each other, learning communication, motivated
    • –Storming- team spirit, trust are developed, conflict may arise, impatience, frustration
    • –Norming- high comfort, ID responsibilities, team interaction, resolution of conflict
    • –Performing- clear on purpose, unity/cohesion, problem solve & acceptance actions
    • –Terminating- members seperate, team closure
  23. Group Process
    "unique way group interrelates & begins to work together"
    • •Commitment
    • –To the goals and output of the group
    • –Members must give up self-interest
    • •Leadership Style
    • –Different ways a leader influences others to accomplish goals
    • •Decision-making methods
    • –Effective decisions are made when
    • Group determines which decision method to adopt
    • Group listens to all ideas
    • Members feel satisfied
    • Expertise of group is well used
    • Problem-solving
    • Atmosphere is positive
    • Time is used effectively
    • Members feel committed
    • •Several methods to make decisions
    • –Brainstorming- group meet, get ides together then solutions made
    • *for brainstorming- 1. must b trust, 2. must b a critisms-free atmosphere, 3. ideas get approval, then ideas get analylized
    • –Normal group technique (NGT)- everyone get an idea, writes it down then openly talked about "round robin style"
    • –Delphi technique- when desicion that req. more time or responses from differant locations, data gathered by interviews & questioniers, no one know others responses, agreements reached by consensus, voting, mathetical average
  24. Member Behaviors
    • •Individual roles
    • –Task
    • –Maintenance or building roles
    • –Dysfunctional
    • •Group roles
    • –Maintain continuity, cohesiveness, and stability
    • Group task roles provide stimulus for achievement of group goals
    • Group maintenance serve human needs for recognition and worth
    • Group dysfunction delays or disrupts achieving goals
    • Interactive patterns
    • –Analyzed by using sociogram
    • –Indicates verbal interaction from all members of the group to all members of the group
    • - by using this nurses can analyze strengths & weakness in group interaction patterns
    • •Cohesiveness
    • –A sense of being "we"
    • –Groups with cohesiveness feel satisfaction, those without feel disintegration
    • •Power
    • –Ability to influence another person in some way or the ability to do something
  25. task roles that faciliates group work
    • *initiator-orienters - propose goals, activities, or plans actions to achieve goals
    • *information givers- gives facts, info, evidance, or expirience useful in achieving group task
    • *info seeker- trys to find factual data
    • *opinion givers- state thier own beliefs & thoughts about group values
    • *opinion seekers- clarify values associated w/ problem or task & possible solution
    • *clarifiers- making things clear
    • *elaborators- develops ideas or suggestions, they take an idea & give substance to it, may predict outcomes r/t particular appoach
    • * evaluators- assess comparative worth of info or ideas, may identifiy advantages & disadvantages
    • *summarizers- reviews watz been discussed or decided thru-out desicion making
    • *coordinators- organize
    • *critics- evaluates problem & get solution
    • *consensus tester- check if agreement made
    • *energizers- want group to increase productivity (quantitive, qualitive)
    • *recorders- take minutes
  26. Facilitating Group Discussion
    • •Techniques for the group leader
    • –Ask open-ended questions
    • –Encourage questions
    • –Respond with positive statements
    • -respond to positive statements
    • –Reinforce participants’ contributions
    • –Avoid negative comments
    • –Avoid taking sides on issues
    • –Avoid involvement in small breakout work groups
    • –Seek equal contributions
  27. group process skills
    • -active listening
    • -focusing discussions on purpose
    • -reflecting
    • - clarifying
    • - summarizing
    • - faciliating
    • - interpreting
    • - questioning
    • - confirming
    • - encouraging
  28. Group Problems
    • •Monopolizing
    • –Domination by one member deprives others from participation
    • –Strategies
    • Interrupt simply, directly, and supportively
    • Reflect the person’s behavior
    • Reflect the group’s feelings
    • Confront the person and/or group

    • •Conflict
    • –Disagreement, impatience, and argument among members
    • –Beneficial when members feel involved
    • –Reasons for nonproductive conflict
    • Impossible or unclear task
    • Concerns of personal tasks greater than the group
    • Members have opposing views and conflicting interests
    • –With nonproductive conflict intervention should occur early
    • –Strategies
    • Interpreting
    • Reflecting
    • Confronting
    • Voicing the unmentionable

    • •Groupthink
    • –Negative outcome of group decision due to failure to think critically about decisions
    • Group overestimates its power and morality
    • Group becomes close-minded
    • Group experiences pressure to conform

    • •Scapegoating
    • –When someone is unfairly held responsible for a negative event or outcome
    • –Negates any responsibility for what occurs in a group

    • •Silence and apathy
    • –Nonparticipation by one or more group members
    • –Sometimes handled by nonintervention
    • –May be related to members
    • Opinion of the task
    • Feelings of inadequacy
    • Interpersonal issue such as anger or fear

    • •Transference and countertransference
    • –Transfer of feelings originally evoked by person of significant importance to people in the present setting
    • –Response to transference is countertransference
  29. Types of Healthcare Groups
    • •Committees- ppl selected to manage particular issue or topic has specific purpose
    • •Teams- have stucture, purpose, & clearly defined roles, sense of shared leadership, accountability, synergy
    • •Task force- group has task to b done by certain time, dissolved when finished
    • •Teaching groups- give info to ppl
    • •Self-help groups- group that come together to face common problem
    • •Self-awareness/growth groups- to develop interpersonal strengths, purpose is to improve a persons functioning in group
    • •Therapy groups- psychtherapy that works thru self-understanding, how to handle stress, & changing behaviors
    • •Work-related social support groups- help reduce stress
    • •Interdisciplinary groups- to provide high quality of care
    • •Professional nursing organizations- to promote quality health care & support the needs of nurses w/i thier membership
  30. Issues important to nursing
    • Cost containment
    • ◦3rdparty payers are restricting coverage, high deductibles and co-pays, costs of coverage increasing –many people not covered
    • Access to health care
    • ◦Uncovered need availiabilityof primary care and preventative care
  31. Issues important to nursing:

    Cost-containment strategies
    • ◦Resource management
    • Financial-controlling costs by bypassing usual restrictions
    • Physical-reuse of areas, reconfiguring what have
    • Human –effective time management, ―more with less
    • ◦Critical pathways
    • Interdisciplinary plans for managing care ◦Utilization of assistive personnel
    • Controversial attempt at resource utilization
    • Relieve the professional nurse of tasks that can safely and effectively be delegated
  32. Challenges and Opportunities
    • Changing paradigm of health care
    • ◦Refer to the Comparison of Old Health Care Paradigm with New Paradigm box on p. 305
    • Rising health care costs lead to cost containment
    • Forced to do more with fewer resources
    • Commitment to high-quality care challenges nurses to find ways to provide care with fewer resources
    • Nursing can create new roles and redefine nursing
  33. Selected Nursing Issues
    • Access to health care
    • ◦45 mil estimated to be uninsured
    • ◦60 mil w/o health insurance for a portion of the year
    • ◦Many more are underinsured

    • ◦Barriers to accessing health care include
    • Cost of care
    • Lack of insurance
    • Problems with insurance
    • Difficulty getting appointments
    • Difficulty finding services
    • Lack of transportation
    • ◦Nursing’s Agenda for Health Care Reform
    • Basic components ―ore of Care
    • ◦Cost-effective, community-based care in a restructured health care system
    • ◦AONE position for effective health care
    • Encourage consumer partnerships
    • Allow access to basic health care services
    • Increase access
    • Create incentives that promote health, wellness, and prevention
    • Promote affordable, safe, effective care
    • Provisions for skilled and long-term care
    • Provisions for catastrophic care
    • Finance health care through a combination of public and private sector funding
  34. Concepts of Health, Wellness, and Well-Being
    • Health
    • ◦defined as presence or absence of disease
    • ◦World Health Organization definition (WHO)
    • state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity
    • definition does the following:
    • ◦Reflects concern for the total person
    • ◦Places health in the context of environment
    • ◦Equates health with productive and creative living

    • ◦Defined in terms of role and performance
    • Sick role
    • ◦Not held responsible for the illness
    • ◦Exempt from the usual social tasks
    • ◦Obligation to get well
    • ◦Obligation to seek competent help to treat the illness

    • ◦Dubos viewed health as a creative process Included quality of life, social, emotional, mental, spiritual, and biologic fitness
    • Resulted from adaptations to the environment
    • Believed complete well-being is unobtainable
    • ◦1980: ANA defined health as a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible

    • Wellness and Well-Being
    • ◦Process of identifying needs for improvement and making choices that facilitate a higher level of health
    • ◦Basic concepts include
    • Self-responsibility
    • Ultimate goal
    • Dynamic growing process
    • Daily decision making
    • Whole being of the individual
  35. Illness and Disease
    • Illness
    • ◦Personal state
    • ◦May or may not be related to disease
    • ◦Subjective
    • Disease
    • ◦alteration in body functions --> to reduction of capacities/shortening normal life span

    • Deviance
    • ◦Behavior that goes against social norms

    • Disease prevention
    • ◦Taking action to avoid later illness
    • ◦3 levels
    • Primary-avoiding health problems before they begin
    • Secondary-recognize risk and take action to prevent
    • Tertiary-treatment or rehab
  36. Models of Health and Wellness
    • Leavell and Clark’s Agent-Host-Environment Model
    • ◦Also called Epidemiological triangle
    • ◦Addresses communicable disease
    • ◦Used primarily to predict illness
    • ◦Three dynamic interactive elements
    • Agent-env. factor or stressor
    • Host-person who may or may not be at risk of disease
    • Environment-pre-disposing factors
    • ◦Factors are constantly interacting with the others
    • ◦Health is an ever-changing state
    • ◦When in balance, health is maintained
    • ◦When not in balance, disease occurs

    • Dunn’s Level of Wellness
    • Interaction of the environment with illness-wellness continuum
    • Health axis extends from peak wellness to death
    • Environmental axis extends from very favorable to unfavorable
    • * intersection of 2 axis forms four health/wellness quads
    • 1. high-level wellness in favorable envr.
    • 2. emergent high level wellness in unfavorable envr.
    • 3. protected poor health in favorable envr.
    • 4. poor health in unfavorable envr.

    • Health and wellness continuum
    • ◦Dimensions
    • Physical health
    • Intellectual health
    • Social health
    • Emotional health
    • Environmental health
    • Spiritual health
  37. Health Status, Beliefs, and Behaviors
    • Health status
    • ◦state of an individual’s health at a given time (anxiety, depression, illness)

    • Health belief
    • ◦Perception of the relationship between things like actions or objects and health

    • Health behaviors
    • ◦Actions ppl take to reach their max. physical & mental potential
  38. Health Belief Models
    • Health Locus of Control Model- how nurses determine who is likely to take action bout health meaning if ppl think they have control of their health
    • ◦Internally controlled
    • Believe theyhave a major influence on their own health status
    • ◦Externally controlled
    • Believe health is controlled by outside forces

    • Rosenstock & Becker's Health Belief Model
    • ◦Based on motivational theory
    • ◦Assumed that good health is an objective common to all people
    • people don’t take advantage of services offered –why?
    • ◦Three components
    • Individual perceptions
    • ◦ perceived Susceptibility
    • ◦ perceivedSeriousness
    • ◦ perceived Threat
    • Modifying factors- changes perceptions
    • ◦Demographic
    • ◦Sociopsychologic
    • ◦Structural
    • ◦Cues to action
    • Variables likely to affect initiating action
    • ◦Benefits- knowing wat is does
    • ◦Barriers- cost, inconvenience, lifestyle
  39. International Initiative for Health and Wellness
    • Health for All is proclaimed as an international goal by the (WHO)
    • Global priorities and targets
    • ◦1. Health equity; childhood stunting
    • ◦2. Survival of maternal mortality rate, child mortality rate; Increase life expectancy
    • ◦3. Reverse global trends of 5 major pandemics
    • ◦4. Eradicate and eliminate certain diseases
    • ◦5. Improve access to water, sanitation, food, and shelter
    • ◦6. measures to promote health
    • ◦7. Develop, implement, and monitor national HFA policies
    • ◦8. Improve access to comprehensive, essential, quality health care
    • ◦9. Implement global and national information and surveillance systems
    • ◦10. Support research for health

    • U.S. goals for health
    • ◦Healthy Ppl 2010published by DHS
    • ◦Two broad goals
    • Increase in quality and years of healthy life
    • Elimination of health disparities
  40. National Initiative for Health and Wellness
    • Healthy People 2010
    • ◦Major public health concerns
    • Increased physical activity
    • Weight management
    • Reduction in tobacco use and substance abuse
    • Responsible sexual behavior
    • Promotion of mental health
    • Reduction of injury and violence
    • Improvement in environmental quality
    • Greater access to immunization and health care
  41. Nursing in an Era of Shortage
    • Cyclic periods of shortages throughout time
    • Predictions of 400,00 job vacancies by 2020
    • One out of three nurses younger than age 30 plan to leave their jobs within 1 year because of dissatisfaction and stress
    • Nurses are leaving the hospitals more than they are leaving health care
    • Magnet hospitals
    • ◦Purpose is to attract and retain nurses
    • ◦formal procedure through ANA’s credentialing center for recognition of magnet hospitals
    • ◦60% of nurses work in acute care
    • ◦Future nurses will work in the community and the home
    • ◦Computer technology and communication abilities will decrease need for face to face healthcare.
    • ◦Invasive procedures will become non-invasive requiring little skilled care
    • ◦Knowledge and skills will need to be updated more rapidly requiring higher level CEUs.
  42. Home Health Nursing
    Definition: Care provided to ppl & families in their residence for purpose of promoting, maintaining, or restoring health or for max. level of independence while min. the effects of disability & illness, including terminal illness.

    • -factors that contribute to HHN:
    • --increase in elders
    • --3rd party perfers HHN
    • --way we r able to provide care thru techn
    • --ppl prefer homecare
  43. Perspectives of Home Health Nursing
    • Care focuses on the client
    • Nurse’s role is to advocate for the client
    • Nurse must establish trust and rapport to be granted access into someone’s home

    all pt behaviors are more natural,
  44. Clark Advantages of HH Nursing
    • Convenience
    • Access
    • Information
    • Relationship
    • Cost
    • Outcomes

    HHN ususally have a BSN or higher
  45. Home health care
    • Able to be supportive and assess caregiver problems in the home
    • Funding usually comes from Medicaid and Medicare
    • Based on a prospective payment system-not covering as many visits as needed.
    • Continuity of care provided by starting discharge planning on hospital admission so transition to home care is smooth
  46. Nursing Process in Home Health
    • Focus is on needs of individual and their caregiver
    • ◦Assess, dx, plan, implement,and evaluate
    • ◦Implement tx plan
    • ◦Plan and perform nsg interventions
    • ◦Teach family and client home care and self care
    • ◦Coordinate and use referrals
    • ◦Provide and monitor technical care
    • ◦Collaborate with other disciplines
    • ◦dvocate for clients right to self determination
  47. Home Health vs. Hospital Nursing Differences
    • Hospital
    • Directed care by administration
    • Doctor’s Environment
    • Other healthcare members around to catch problems
    • Surrounded by medical help
    • Lots of supplies and equipmen

    • Home Health **
    • Function Autonomously and Independently
    • Client’s environment
    • Only nurse sees patient
    • Alone with a phone for contact
    • Make do with what is availiable

    • Simularities
    • Hospital
    • Care guided by physician orders and hospital policy
    • Role as collaborator

    • Homehealth
    • Care guided by physician orders
    • Role as collaborator with other medical personel
  48. Community
    Definition: A social group determined by geographic boundaries and/or common values or interests
  49. Community Health Nursing
    Provision of strategies or interventions to prevent disease and promote health for populations and communities as a whole.

    • Settings for community nursing
    • Faith communities
    • Community centers
    • Schools
    • Occupational health
    • Rural Health nursing

    • Nursing process in community nursing
    • Assess through epidemilogical studies
    • Assess community sub-systems
    • ◦Recreation, physical environment, Education, Safety and Transportation, Politics and government, Health and Social Services, Communication, and Economics
    • ◦Assess demographics
    • Do a windshield survey in your Elder Project process, looking at the community (physical, social, economics, safety, transportation, politics, community)
  50. Challenges and Opportunities
    • •Challenges of working in spiritually diverse environment
    • –Be open to differences in beliefs about health and illness
    • –Establish trust and acceptance of different beliefs of clients
    • –Understand how spiritual beliefs may influence clients’ belief about the cause of illness and acceptance of treatment
    • –Integrate spiritual beliefs into care
    • –Opportunity for nurse to enrich their lives through understanding the beliefs of clients
    • –Faith-based healing is shown to have positive effects
  51. Concepts Related to Spirituality
    • •Spirituality
    • –That which gives essence to the soul, involving one’s relationship with God or a higher power
  52. Cultural Concepts of Spirituality
    • •Expression through a particular religion or outside of organized religious systems
    • •Connectedness with others, the environment, and the creator
    • •Blending of different religious and philosophical traditions
    • –Burkhardt defines aspects of spirituality as
    • Dealing with the unknown and uncertainties in life
    • Finding meaning and purpose in life
    • Ability to draw upon inner resources and strength
    • Having connectedness with oneself and with God or a Higher Being
  53. Religion
    •Provides a way of spiritual expression that guides people in responding to life’s questions and crises

    • •Organized religions offer
    • –Sense of community
    • –Collective study of scripture
    • –Performance of ritual
    • –Use of disciplines, practices, commandments, and sacraments
    • –Ways of taking care of the person’s soul

    • •Religious practices and rituals relate to life events
    • –Religious rules of conduct apply to daily life
    • –Religious development may or may not parallel spiritual development
    • •Faith
    • –Belief in something that cannot be directly observed
  54. Spiritual Development
    •Occurs in a linear fashion
  55. Faith
    • •Westerhoff’s four stages of faith
    • –Experienced faith
    • –Affiliative faith
    • –Searching faith
    • –Owned faith
    • •Fowler’s seven stages of faith
    • –Parallel the developmental stages described by Piaget
  56. Prayer and Meditation
    • •Prayer is a communication or petition to God in word or thought
    • •Prayers may be
    • –Petition
    • –Request
    • –Thanksgiving
    • –Spiritual communion


    • •Formal prayers are printed in prayer books
    • •Daily prayer maybe prescribed by some religions
    • •Meditation is an internal reflection or contemplation
    • –Mediation can provide relaxation from stress and renew energy
  57. Selected Spiritual and Religious Beliefs Influencing Nursing Care
    • •Holy days
    • –Days of special religious observance
    • •A weekly day set for rest, prayer, readings
    • •Special days of celebration and feasting
    • –Many require fasting, extended prayer, and reflection or ritual observances

    • •Sacred writings and symbols
    • –Believed to be the thought or word of God or Supreme Being
    • –Tell the stories of the religion’s leaders, kings, heroes
    • –Contain rules or commandments or other guidelines for living
    • –Interpretations of these laws provide the foundation for ethical debates

    • •Religious symbols
    • –Jewelry, medals, body ornamentation may carry religious significance
    • –Pictures or statues
    • •Dress
    • –Many religions have laws and traditions that dictate dress

    • •Health beliefs and practices
    • –Magico-religious and holistic health belief systems
    • –Health and illness are controlled by supernatural forces
    • –Holistic health holds that the forces of nature must be maintained in balance and harmony
  58. Healing
    • •Four types of healing that involve spiritual and/or religious belief
    • –Spiritual
    • –Inner
    • –Physical
    • –Deliverance
  59. Diet
    • •Dietary beliefs
    • –Orthodox Jews
    • Kosher diet
    • –Islamic
    • Forbid eating any meat of the pig
    • Animals must be slaughtered according to religious law
    • Alcohol is strictly forbidden
    • Fasting

    • •Dietary beliefs
    • –Hinduism, Buddhism, Jainism
    • Predominantly vegetarians
    • –Christian
    • Varies widely
    • Avoid meat on certain days
    • Discourages alcohol, caffeine, meat
  60. Pain
    • •Pain and its spiritual meaning
    • –Punishment for bad deeds
    • –Manage pain through prayer and meditation
  61. Childbirth and Perinatal Care
    • •Christian: Baptism during infancy
    • •Jewish: Circumcision
    • •Muslim: Call to prayer
  62. Death and Dying
    • •Care immediately before death, at death, after death
    • •Autopsy
    • •Cremation
    • •Organ donation
    • •Euthanasia
    • •Death-related rituals
  63. Spiritual Distress
    • •When an individual experiences a disturbance in his or her belief
    • •May ask questions, "Why is God allowing this to happen to me?"
    • •May be result of
    • –Physiological problems
    • –Treatment concerns
    • –Situational issues
    • –Impaired religiosity
  64. Providing Spiritually Competent Care
    • •Spiritual assessment
    • –Use broad statements and open-ended questions
  65. Spiritual Assessment Method, SPIRIT
    • •Spiritual belief system
    • •Personal spirituality
    • •Integration and involvement in a spiritual community
    • •Ritualized practices and restrictions
    • •Implications for medical care
    • •Terminal events planning
  66. Providing Spiritually Competent Care
    • •Areas to consider
    • –Environment
    • –Behavior
    • –Verbalization
    • –Interpersonal relationships

    • •Diagnosing, planning and implementing spiritually competent care
    • –Six nursing diagnoses related to spirituality
    • Spiritual distress
    • Risk for spiritual distress
    • Readiness for enhanced spiritual well-being
    • Impaired religiosity
    • Risk for impaired religiosity
    • Readiness for enhanced religiosity

    • •Nurses can help clients meet spiritual and religious needs by
    • –Providing presence
    • –Supporting religious practices
    • –Assisting clients with prayer and meditation
    • –Referring clients for spiritual counseling

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