Mary P. is a 57-year-old operating room nurse who works full-time at a local hospital. She is 65 inches tall and weighs 160 pounds. She has a family history of diabetes and heart disease and was recently diagnosed with high blood cholesterol. She has declined the cholesterol-lowering medication her doctor prescribed, and says she would like to explore other methods for lowering her cholesterol first. For the past few weeks, Mary has been taking a tablespoon of coconut oil every day after reading on the Internet that this will lower her cholesterol. She admits she has little time or energy to exercise. Her diet history reveals she often skips breakfast or has a donut or bagel with cream cheese at work. She drinks several cups of coffee each morning with cream and sugar. Lunch is a salad with crackers and iced tea with sugar in the hospital cafeteria. She occasionally drinks one or two glasses of wine in the evening, especially after a stressful day at work. She lives alone and relies on frozen dinners or other convenience foods in the evening. An analysis of her diet reveals an average daily intake of 200 grams carbohydrate, 50 grams protein, and 80 grams of fat.

1. Taking into account her current lifestyle and personal food preferences, what food habits might be difficult for Mary to change?
2. How might her emotions contribute to her food and drink choices?
3. Using Table 1-2, calculate Mary’s average daily kcalorie intake from carbohydrates, protein, and fat. Add these figures to together to arrive at her total daily caloric intake.
4. What percentage of her daily calories is provided by carbohydrates? Protein? Fat?
5. Compare the composition of Mary’s diet with the Acceptable Macronutrient Distribution Ranges (AMDR).
6. How would you use the information above to make dietary recommendations for Mary?
7. What are some credible sources of nutrition information from Table H1-1 that could provide information to help Mary lower her blood cholesterol?

Improving Quality

Improving the quality of health care delivery and patient safety continues to be a political concern and has been at the heart of reform issues for many years. The American Nurses Association (ANA) and the Institute of Medicine (IOM) have increased awareness of health care quality and safety issues, as well as advocated for health care reform. The documents featured at the ANA and IOM websites listed in this week’s Learning Resources focus on many of the current issues surrounding quality and safety in the health care industry.

To prepare:

Review this week’s Learning Resources, focusing on the Six Aims for Improvement presented in the landmark report “Crossing the Quality Chasm: The IOM Health Care Quality Initiative.”
Consider these six aims with regard to your current organization, or one with which you are familiar. In what areas have you seen improvement? What areas still present challenges? As a nurse leader, how can you contribute to improving the organization’s achievement of these aims?
Select one specific quality or safety issue that is presenting a challenge in the organization. Consider at least one quality improvement strategy that could be used to address the issue, as well as which of the six aims for improvement would then be addressed.
Reflect on your professional practice and your experiences with inter-professional collaboration to improve quality and safety. How has inter-professional collaboration contributed to your organization’s efforts to realize the IOM’s six aims for improving health care? Where has inter-professional collaboration been lacking?

Post a description of the quality or safety issue you selected and a brief summary of the impact that this issue has on health care delivery. Describe at least one quality improvement strategy used to address this issue. Then explain which of the six “aims for improvement” are addressed by the strategy. Finally, explain how inter-professional collaboration helps improve quality in this area.

Read a selection of your colleagues’ responses.

Respond in one or more of the following ways:

Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.

Discussion 1

Improving Quality: Patient Center Care

Patient-centered care (PCC) is increasingly being highlighted as an important model to improve quality of health care having been linked to improved patient satisfaction, better health outcomes, and cost-effective care (Bauchat, Seropian & Jeffries, 2016). Lack of communication with patients and providers can affect patient compliance, hospital stays, and overall patient outcomes. Poor communication has been well documented as one of the top three contributors to sentinel events by the Joint Commission (Bauchat, Seropian & Jeffries, 2016). The Institute of Medicine (2012), states that if a health care system can achieve major gains in the six areas of safe, effective, patient-centered, timely, efficient, and equitable care, it would be far better at meeting patient needs. The challenge is to find an effective means of training non-technical skills, such as empathy, to promote a patient-centric model of care; empathy is arguably an important cornerstone to effective PCC (Bauchat, Seropian & Jeffries, 2016).

Impact on Healthcare Delivery

According to Reuben and Tinetti (2012), major efforts have been launched to make care more patient-centered, defined as respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Attention to patient-centered measures and outcomes will be particularly important as the Centers for Medicare and Medicaid Services (CMS) moves increasingly to link health care providers’ reimbursement to their performance on selected measures (Reuben & Tinetti, 2012). Assessments of quality of care and health outcomes have not incorporated patient-centeredness. Measurement of quality has addressed preventive care while outcomes focuses on condition-specific processes. An alternative approach to providing better care would be to focus on a patient’s individual health goals within or across a variety of dimensions (Reuben & Tinetti, 2012).

Quality Improvement Strategy

The VA looked at developing a better relationship between patients, families and health care teams. Beginning in 2010, the VA adopted the Patient Aligned Care Team (PACT) model of care, which is adapted from the patient-centered medical home (Burkhart & et al., 2016). At the same time, the VA also established the Office of Patient-Centered Care and Cultural Transformation to guide transformation toward patient-centered care (PCC) (Burkhart & et al., 2016). This transformation to care for patients involved health coaching, decision-making initiatives, alternative medicine and pet therapy. Access to care improvements included same-day appointments, after hours availability, expanded visitor policy for inpatients, and valet parking (Burkhart & et al., 2016). The aim for improvement was focused directly on patient-centered care.

Aim for Improvement: Patient-Centered Care

Providing patient-centered care means giving patients the information they need to participate actively in decision making about their care with goals of obtaining the most desirable outcome (Knickman & Kovner, 2015). The individual’s culture, social context and specific needs should be addressed and the patient should have input in their own care. The achievement of a truly patient-centered health system will require the participation of patients, family members, physicians, nurses, and other health care providers involved in the provision of care (Knickman & Kovner, 2015). It is this team collaboration that makes the process more effective in patient care. Families should be more involved in the care process and goals should be discussed with the patient to obtain a more realistic approach.

Inter-professional Collaboration

Collaboration in health care has been shown to improve patient outcomes such as reducing preventable adverse drug reactions, decreasing morbidity and mortality rates and optimizing medication dosages (Bosch, Mansell, 2015). Trust must be established to build health care team. One way is consistency in care. Developing trust takes time and a lot of personal contact (Bosch, Mansell, 2015). This may be a challenge in some health care settings due to things such as rotating staff schedules, which contributes to constantly changing teams. Developing a personal relationship with a patient take time and adds to the patient centered approach to individual care.

Conclusion

In conclusion, the Institute of Medicine of the National Academies (2012) defines patient-centered as providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Patient care should reflect individual and safe care as part of achieving quality health care.

References

Bauchat, J. R., Seropian, M., & Jeffries, P. R. (2016). Communication and Empathy in the Patient-Centered Care Model—Why Simulation-Based Training Is Not Optional. Clinical Simulation in Nursing, 12(8), 356-359. doi:10.1016/j.ecns.2016.04.003

Bosch, B., & Mansell, H. (2015). Interprofessional collaboration in health care. Canadian Pharmacists Journal (Sage Publications Inc.),148(4), 176-179. doi:10.1177/1715163515588106

Burkhart, L., Min-Woong, S., Jordan, N., Tarlov, E., Gampetro, P., & LaVela, S. L. (2016). Impact of Patient-Centered Care Innovations on Access to Providers, Ambulatory Care Utilization, and Patient Clinical Indicators in the Veterans Health Administration. Quality Management in Health Care, 25(2), 102-110. doi:10.1097/QMH.0000000000000093

Institute of Medicine of the National Academies. (2012). Crossing the quality chasm: The IOM Health Care Quality Initiative. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

Knickman, J. R., & Kovner, A. R. (Eds.). (2015). Health care delivery in the united states (11th ed.). New York, NY: Springer Publishing.

Reuben, D. B., & Tinetti, M. E. (2012). Goal-oriented patient care—an alternative health outcomes paradigm. New England Journal of Medicine, 366(9), 777-779.

Discussion 2

Quality of care issue: Electronic Health Records.

Today Electronic Health Records (EHRs) are at the center of health care uniting health care professionals, working as one team to improve the quality of care to all patients (Center for Medicare & Medicaid Services, 2012). However, quality of health care throughout the US varies among states, individual providers and even inter-departmental within hospitals (Knickman & Kovner, 2016). Additionally, even with advances in science and technology, 40% of the population is made up of chronic diseases; we need to bridge this gap between acute and chronic care, to ensure patients are receiving what they deserve in a more consistent way (Institute of Medicine, 2001). Providing safe and quality health care is paramount, and the Institute of Medicine (IOM) identified six issues, improving the overall health of the nation: Health care should be safe, effective, patient-centered, timely, efficient, and equitable (2001).

Impact of Delivery

EHRs are a digital version of the patient’s medical records and are an important part of today’s health care. EHRs are real-time, providing up to date information about both medical history and treatment of the individual patients. As nurses, we spend a lot of our time with our patients, so the EHRs provides an up to date record of the nurse-patient interaction. EHRs are an invaluable tool for the day to day events of the patient. By using EHRs, communication improves which allows information to be readily and instantly available to authorized personnel (HealthIT.gov, 2013). Also they have a significant impact on patient-centered care, providing one particular place for all the pertinent information about the patient such as medical history, treatment plans, and laboratory results. Another benefit of EHRs is the instant access to evidence-based practice, allowing incorporation into the treatment of the patient, making treatment more efficient and effective (HealthIT.gov, 2013). Lastly, by having all this information stored digitally and in one place, information can flow across all providers; data can flow from primary care to specialist physician to pharmacy, radiology, emergency room, etc. (HealthIT.gov, 2013).

Strategy for improvement.

When I first started nursing, if someone would have told me I would be charting at computers at the bedside, I would have been very skeptical. In fact, when I was introduced to the idea of EHRs, I thought this was going to take me away from the bedside and put me in front of a computer screen. However, now having used EHRs for many years in different countries, I can see the benefits. It gave me more time with the patient rather than less. Now I find it an integral part of everyday life and communication with all members of the health care team. One strategy for improvement is by working with student nurses, incorporating EHRs into their curriculum. By combining this within their program, it provides a greater knowledge and understanding of the benefits for both the user, the patient and their family (Kowitlawakul, Chan, Pulcini & Wang, 2015). By encouraging acceptance of EHRs, we promote a united front and a positive attitude towards our patient’s overall care. Also we can aim to bridge the gap between the care that the patient is receiving and what they desire for the best outcome for their health (IOM, 2001).

When looking at combining EHRs into nurse education, this allows for the improvement of patient care from many different angles. Mostly I feel this looks at the patient as a whole, promoting a patient-centered approach to care. By looking at the patients holistically, it allows for the patient to be at the forefront of treatment, taking into consideration, their preferences and needs, benefiting and involving them in their medical decision (IOM, 2011).

Inter-professional collaboration

EHRs ensure a safer practice, uniting all medical personnel, so preventing medical errors and benefiting the patient. This effective teamwork and pooling of computerized evidence-based information promotes new and more efficient ways of treatment for patient care but always having the patient in the center of their medical plan.

Conclusion

In conclusion, EHRs are invaluable in the care and treatment of our patients and their families. EHRs are patient-centered, providing a unique way to tell the individual’s story, utilizing teamwork, excellence and evidence-based practice into an individualized package.

References

Center for Medicare and Medicaid Services. (2012) Electronic Health Records. Retrieved from https://www.cms.gov/Medicare/E-Health/EHealthRecords/index.html

HealthIT.gov. (2013). What is an electronic health record (EHR)? Retrieved from https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr

Institute of Medicine of the National Academics. (2001). Crossing the quality chasm: a new health system for the 21st century. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

Knickman, J. R., & Kovner, A. R. (2015). Health care delivery in the United States (11th ed.). New York, NY: Springer Publishing.

Kowitlawakul, Y., Chan, S. W. C., Pulcini, J., Wang, W. R. (2015). Factors influencing nursing students’ acceptance of electronic health records for nursing education (EHRNE) software program Nurse Education Today. Retrieved from http://www.sciencedirect.com.ezp.waldenulibrary.org/science/article/pii/S0260691714001944

Discussion 3

Improving Quality: Patient -Centered Care.

According to the Institute of Medicine (2012), in order to improve health care, the goal should be to provide safe, effective, patient-centered, timely, efficient and equitable care. Health care needs to be patient-centered and all though most places claim to base their practice around patient’s, it does not always happen that way. As providers feel pressured to see more patients in less time, care has shifted to the needs of the system rather than the patient. According to Knickman and Kovner (2015), even though many tools, techniques, and measure have been implemented to evaluate and improve quality in the U.S, patient-centered treatment is still an ongoing problem in the US.

Quality Improvement Strategy

According to The Institute for Health Care Improvement, 2016 “care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient an integral part of the care team who collaborates with care providers in making clinical decisions. Patient-centered care puts responsibility for important aspects of self-care and monitoring in patients’ hands long with the tools and support they need to carry out that responsibility”.

Aims for Improvement

Knickman

Improving Quality with Interpersonal Communication

“Communication is an integral part of life; without it, we would not survive. Verbal and non-verbal communication begins at birth and ends at death. We need communication not only to transmit information and knowledge to one another, but more importantly, to relate to one another as human beings around the world in the context of relationships, families, organizations, and nations” (American Nurses Association,2012). Bedside reporting is a great example of implementing interpersonal communication, it allows the patient to meet the on coming nurse and it allows the patient to be part of their care. Also the doctor setting up a follow up appointment for the patient before they discharge is a way to keep an open line of communication between patient and doctor and it provides patient center care. I see both of these examples done at my place of employment.

Summary

Although there has been much improvement to patient-centered health care, there is still much more work to be done. I have heard the expression, we are guests in our patients lives, instead of hosts in our health care organization. This is a great motto to live by and to use as we grow to be the kind of health care organization that patients do not mind revisiting as their health needs permit.

Reference:

American Nurses Association. (2012). Improving health care in your state. Retrieved from

http://nursingworld.org/MainMenuCategories/ Policy- Advocacy/Advocacy Resources Tools/ Looking-for-Solutions.pdf

Institute of Medicine of the National Academies. (2012). Crossing the quality chasm: The IOM Health Care Quality Initiative. Retrieved from http://www.nationalacademies.org/hmdl/~/media media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

Institute for Health Care Improvement. (2016). Across the Chasm Aim #3: Health Care must be Patient centered. Retrieved from: http://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmAim3HealthCareMustBePatientCentered.aspx

Knickman, J. R., & Kovner, A. R. (Eds.). (2015). Health care delivery in the united states (11th ed.). New York, NY: Springer Publishing.

Health care professionals play a crucial role in helping to prevent and control infectious disease. Nurses are an important factor in helping to prevent the spread of infection. As a nurse it is extremely important to understand the infection process, the chain of infection, and prevention techniques.

In the TWO scenarios below, describe in paragraph form what you as a health care provider would do in these situations. Describe what was done right, what was done incorrectly, and what education needs to be discussed in each scenario.

Scenario 1

A man is recovering from a minor surgical procedure. His son, daughter-in-law, and grandson come to visit him. His daughter-in-law is suffering from what appears to be a bad cold and, although hospital policies prohibit children under the age of 10 from visiting patients in this ward, the 3-year-old grandson still came up.

You notice that the woman is sneezing and coughing into her hands. You also notice that the child keeps moving from his mother’s lap to the patient’s lap in the hospital bed. In addition, you observe that the woman is changing the television stations on the remote control to find something the child can watch.

Scenario 2

A charge nurse on a medical/surgical unit approaches a computer and notices that the keyboard is visibly soiled. She goes to a supply closet to get some disinfectant wipes to clean the keys. When she returns, she notes that a nurse is sitting at the computer using the soiled keyboard. As she watches, the nurse picks up a patient chart, makes a note, and then returns to the keyboard. When she is finished typing, the nurse walks away from the computer and heads for one of the patient rooms.

Details:

Conceptual models, theories, and empirical indicators are linked and provide a nursing knowledge system to apply the model or theory to nursing practice, research, and education. Advanced-practice nurses are required to understand the linkages as applied to nursing and translate the components into practice. To continue development of nursing knowledge, advanced practice nurses can create structure to test theory.

General Guidelines:

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

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
This assignment requires that at least two additional scholarly research sources related to this topic, and at least one in-text citation from each source be included.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
Directions:

Write a 1,000-1,250 word paper examining how the Conceptual – Theoretical – Empirical (CTE) structure translates into nursing practice based on one of the middle range theories that has been formulated or derived from your preferred conceptual model of nursing. Translate and apply the selected theory to nursing practice using actual examples. Evaluate the theory using the CTE steps below:

Evaluation of the conceptual-theoretical-empirical linkages.
Evaluation of the selected theory.
Evaluation of the empirical indicators.
Evaluation of research findings.
Evaluation of the utility and soundness of the practice theory.

Each state has laws that differ in regard to the role of the Nurse Practitioner. They also may significantly impact the NP’s practice. Legislative changes may occur annually, bi-annually, or during an emergency legislative meeting at the state or federal level. These legislative sessions and any subsequent changes may significantly impact your scope of practice as a Nurse Practitioner. Remaining current with the laws in your state is essential. For example, the recent change at the federal level changing hydrocodone-containing drugs from a Schedule III drug to a Schedule II drug has impacted NPs in some states. For states that allow for Nurse Practitioners to write Schedule III-V drugs, these NPs are now unable to write for hydrocodone- containing medications, which significantly impacts their ability to provide care for their patients. The Pearson Report, which is updated almost annually, provides a national overview of each state’s current legislature. As a future NP, you should become familiar with The Pearson Report and stay abreast of state and federal legislation.

For this Discussion, you will post an explanation that defines the legal implications for standard of care, the key components of a malpractice policy in regard to a case study. Additionally you will explain the collaborative agreements and rules for your state in regard to your NP practice and the case study you select.

To prepare:

Review the following case studies and select one to research in depth:

Case Study One: Dismissing the non-compliant patient.

Gwen, a 52 year old Caucasian LPN, recently joined your practice as a new patient. She currently has a BMI of 32, B/P of 142/88. Pulse is 89, Respiratory rate is 22, Pulse Ox is 96% on Room Air. She is taking Lisinopril 10mg po daily (when she can remember), Metformin 1000mg po BID and refuses lab work. Her physical exam is unremarkable and foot exam is normal. She refuses all vaccinations including Prevnar and Influenza. Gwen’s last mammogram and pap smear were “years ago.”

Case Study Two: Preventive care, why is it so important to document?

John, a 62 year old attorney, who has been a long-term patient of yours, comes to you to discuss his erectile dysfunction. You note that he has refused lab work for the past two years. He is a 30 pack/year smoker, and has not had a chest x-ray or ECG in three years. He does take his HCTZ 25 mg po daily. His BMI is 29 and all vital signs are within normal limits. He does agree to his Prevnar Vaccine today.

Case Study Three: Patient and professional relationships.

Jennifer, a 45 year old Caucasian returns to your clinic for a refill of her hydrocodone. She was diagnosed with Ovarian Cancer last year, followed by successful removal and treatment. All vital signs are stable and preventive care is up to date. She wants to discuss filing a lawsuit against the surgeon that initially turned her away and told her she had gastritis and needed to eat healthier.

Review the following articles found in this week’s Learning Resources:

Miller, K. P. (2013). The National Practitioner Data Bank: An Annual Update. The Journal for Nurse Practitioners, (9)9, 576-580.

Stelmach, E. I. (2015). Dismissal of the Noncompliant Patient: Is this What We Have Come to? The Journal for Nurse Practitioners, 11(7), 723-725.

Review endocrine disorders and erectile dysfunction in your Primary Care Medicine text (Gorrol, Ah. & Mulley, A.G., 2009).

Consider strategies and treatment options that would be most effective for these patient scenarios to improve compliance and health outcomes.

Reflect on how to approach the non-compliant patient and the importance of a separate preventive care visit.

By Day 5

Post an explanation that addresses the following for the Case study you selected:

Identify and briefly summarize the case study you selected

Explain any legal implications for standard of care related to the case study you selected

Identify and explain the key components of a malpractice policy related to the case study you selected

Explain the collaborative agreements and knowledge the rules for your state in regards to NP practice the case study you selected