The nursing process according to Orem. A concrete very simple example explains how to follow this nursing process]

The author shows how Orem's theory, based on self care, can be applied to the nursing care of a patient with severe cardiac illness. To do so, she explains in detail what is looked for in the patient's history to delineate problems, and then uses a systematic care plan approach to solve them. In the patient's history, the nurse looks for information on each need, and on the specific factors in the patient's life and health history that will have an impact on the patient's capacity to meet Orem's goal of self care. Inabilities are labelled self care deficits. When the self-care deficit is well understood, it is important then to determine the source of the patient's difficulty. Orem states that there are two main phases to self-care: the decision and the action. The author illustrates this through a discussion of the patient's difficulty to stop smoking. She then explains a particular method to write a nursing diagnosis that directs the nurse to work, not on the deficit itself, i.e. in this case smoking, but rather on the patient's lack of knowledge. The "SMART" approach to writing nursing care objectives (specific to the patient and the current situation, measurable, attainable by the client in a reasonable period of time, realistic for the current situation, and truthful or having clear significance for the patient at the moment) is detailed along with interventions that respect Orem's concept of nurse-patient contracts. The nursing process based on Orem's conceptual framework is not difficult to manage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nurse staffing models as predictors of patient outcomes

BACKGROUND: Little research has been conducted that examined the intended effects of nursing care on clinical outcomes. OBJECTIVE: The objective of this study was to evaluate the impact of different nurse staffing models on the patient outcomes of functional status, pain control, and patient satisfaction with nursing care. RESEARCH DESIGN: A repeated-measures study was conducted in all 19 teaching hospitals in Ontario, Canada. SUBJECTS: The sample comprised hospitals and adult medical-surgical and obstetric inpatients within those hospitals. MEASURES: The patient's functional health outcomes were assessed with the Functional Independence Measure (FIM) and the Medical Outcome Study SF-36. Pain was assessed with the Brief Pain Inventory and patient perceptions of nursing care were measured with the nursing care quality subscale of the Patient Judgment of Hospital Quality Questionnaire. RESULTS: The proportion of regulated nursing staff on the unit was associated with better FIM scores and better social function scores at hospital discharge. In addition, a mix of staff that included RNs and unregulated workers was associated with better pain outcomes at discharge than a mix that involved RNs/RPNs and unregulated workers. Finally, patients were more satisfied with their obstetric nursing care on units where there was a higher proportion of regulated staff. CONCLUSIONS: The results of this study suggest that a higher proportion of RNs/RPNs on inpatient units in Ontario teaching hospitals is associated with better clinical outcomes at the time of hospital discharge.     

Nursing care on post-traumatic responses of a fire survivor

This paper describes the experience of nursing a fire survivor in the intensive care unit (ICU). The survivor was sent to the ICU because of an inhalation injury combined with acute respiratory failure. Together with dyspnea, the patient was also experiencing post-traumatic responses. Care providers collected the data through observation and hand-written communication. It was after analyzing the data that we confirmed the patient to be experiencing the health problems associated with post-traumatic responses. The problem was the major focus of our caregiving. A good relationship was fostered with the patient through support and understanding while the patient's physical condition was stabilized. With appropriate nursing intervention and professional medical consultation, the patient's condition improved. In accordance with the physical condition of the patient, which they continued to monitor after the patient's return to the ward and subsequent discharge, the nurses provided continuous, holistic care. The patient recovered from the physical pain and psychological damage, as well as the depression and was able to resume a normal life.     

Mobilizing nursing skills.

The author argues that the practice of nursing should be based on the "nursing model" related to care not the "medical model" related to cure. Using the nursing model entails making an assessment of the patient's needs and an individualized nursing care plan to meet them. It is conceded that the historical development of nursing practice as a series of stereotyped, ritualized activities within a hierarchical profession militates against implementing the nursing model; but the author illustrates how to Royal Marsden Hospital, a specialist hospital for the treatment of cancer patients, has innovated and developed the concept, as well as creating specialist roles for nurses who maintain continuity of patient care from the first appointment in the hospital's outpatients' clinic through to this after-care following his discharge home.     

The consultative process used in outreach: a narrative account

Aim:  The aim of this paper was to provide a narrative account of the communication skills used in an effective outreach consultation utilizing Neighbour's consultative model. Other consultation models were considered; however, because of their overly comprehensive approach or emphasis on behaviour modification, these were deemed inappropriate.
Background:  The nursing profession has endured significant changes of late and as a result is developing more autonomous roles in both the community and the acute health care settings. In the past, the term consultancy was used within the medical context; nowadays, there are advance nurse practitioners for whom consultancy is an integral part of their role. Although every nursing interaction is in essence a consultation, the fact that nurses are taking up on new advanced roles highlights the necessity for nurses to develop their consultation skills even further. Therefore, it makes sense to explore what aspects of that consultancy role needs special consideration in order to ensure that positive outcomes are achieved.
Conclusions:  This paper has used a narrative account to uncover those salient skills needed to enhance the therapeutic relationship with a patient requiring the services of outreach. Furthermore, the application of a recognized consultation model was used to elucidate the underpinning knowledge of systematic history taking and assessment as well as demonstrating the communication skills and strategies needed to increase the patient's participation and empowerment throughout the consultation.
Relevance to clinical practice:  Effective communication skills encompassed in a consultative model are integral to the success in safeguarding the well-being of patients requiring advanced levels of care. Prejudging or pre-empting information being conveyed can be detrimental to patient safety and may prolong or complicate treatment plans.     

Psychiatric consultation and referral

Over half of patients with psychiatric problems are seen by primary care physicians. Many of these patients will benefit from psychiatric consultation when the diagnosis is unclear or when the patient is not responding to treatment. Good communication between referring physician, consulting physician, and patient are essential to ensure a good result. Specific problems that should lead to consultation include: patient's request, unclear diagnosis, poor results from treatment, and crisis situations such as suicide attempts. Consultation-liaison psychiatry services in the primary care setting are becoming more popular and are an excellent way of improving communication between primary care physicians and psychiatrists. Further development of this role of the psychiatrist in the primary care setting has great potential of improving the quality of care delivered patients with psychiatric problems who seek care from their primary care physician. It appears that the majority of patients continue to seek care for their psychiatric symptoms from their primary care physician. Open communication and ease of consultation with psychiatrists can make the care of these patients even more rewarding to the primary care physician.     

Mirizzi综合征59例围手术期护理

目的:探讨M irizzi综合征的围手术期护理。方法:回顾性分析59例M irizzi综合征患者的病例特点及围手术期护理。结果:本组均采用手术治疗,其中46例术后随访1~5年,痊愈39例,效果良好6例,欠佳1例。结论:M irizzi综合征围手术期精心护理对患者身体康复和预后具有重要意义。     

Nursing workload, medical diagnosis related groups, and nursing diagnoses

Patient conditions associated with the relative amount of time nurses spent caring for patients were identified in this study. The patient conditions examined were: nursing condition using 37 nursing diagnoses, medical condition using diagnosis-related groups (DRGs), and demographic characteristics of age, sex, and race. Nursing time was estimated using the Rush-Medicus patient classification workload measurement tool. Data were gathered from checklists of nursing diagnoses and the discharge records of 2560 adult inpatients of an acute care community hospital. Using multiple regression analysis nursing condition explained twice the variation in daily nursing workload (52.4%) than medical condition (26.3%). The finding that nursing care time is predicted better by a patient's nursing condition than by either medical condition or demographic characteristics indicates that nursing care is not physician prescribed.     

Virtual rapid response: the next evolution of tele-ICU

The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center's tele-intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a "virtual handshake" by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19's medical centers.     

Care of a patient with breathing difficulties.

Use of the Roper model of nursing care enabled the patient's physical, social and psychological needs to be met. Identification of actual and potential problems in each activity of daily living enabled goals to be set and care plans to be implemented to alleviate the problems. It is important that nursing care addresses not only the physical side of nursing, but also the psychological needs of the patient and the patient's family. By identifying the patient's fears in each activity of daily living, we could offer practical help and reassurance which greatly facilitated her return to independent living.     

The use of therapeutic touch in the management of pain

Nursing by definition is in part nurturing. It is the care of human beings--people who should be viewed and treated as a unified whole, people who interact with the environment and those around them on many levels. Nursing as a profession offers a unique service to those who are ill and in pain. That service takes form in many ways, among them a deep caring for the patients. The caring component in nursing is one of the most valuable intangibles, and TT is one of the most basic of the caring skills. TT provides the patient with extra care and puts the "art" back in nursing. But TT is also something much more than that. TT is a very personal act of caring, of giving to another person. To the patient with pain, TT affirms that you care and that you are acknowledging their pain. That, in and of itself, can be a source of great comfort to someone with pain. The management of pain is a complex and inexact science at best. The pain experience is a complex and often frustrating one. Patients look to various members of the health care profession for assistance and affirmation of their pain. But there are no "magic bullets" in the treatment of pain; even TT is not a universally effective therapy. There is a great deal to learn about pain, about the treatment of pain, and about TT. The challenge now is to continue the research to better understand pain, to understand the human response to pain, and to explain the phenomenon of TT, one modality in the treatment of pain. In implementing this research effort, it is important to recognize that objective scientific information is a necessary but insufficient component in understanding pain. Subjective information, the pain experience, is just as necessary for fully understanding the problem of pain. Until research provides better approaches, the treatment of the patient with pain, regardless of modality, demands multiple approaches, a commitment to keep trying, engaging the patient in the treatment plan, and moving at the patient's pace, not that of the care giver or health care team.     

How Japanese nurses provide care: a practice based on continuously knowing the patient

AIM: Criticisms of the nursing process as a problem-solving approach have emerged recently. This study aimed to identify and describe a way of nursing based on the clinical practice of selected nurses in Japan. METHODS: Data were collected using semi-structured interviews and observations at one 300-bed Japanese hospital in 1999. The purposive sample consisted of 24 female nurses. Data analysis occurred simultaneously with data collection, and questioning and constant comparison were used for data analysis. Codes were clustered into categories and relationships among these were identified. In the final stage of the analysis, two group interviews with participants were carried out to enhance credibility. FINDINGS: This study identified a Japanese way of nursing intended to help patients explore and realize meanings and values of their experiences with illness. When nurses first contacted a patient, they quickly formed a patient image, but altered it each time they obtained new patient information. A patient image consisted of the patient's subjective world (the patient's perspective) and the holistic patient (nurses' perspectives of the patient). The nurses sometimes pursued strategies to know the patient's subjective world. The target, direction, conditions and ways of nursing care were decided based on continuously knowing the patient. The nurses related their knowledge and thoughts to the patient, and by talking with the patient promoted the patient's consideration and participation, and empowered the patient. Nurses continued attending to patients even when they could not provide specific nursing interventions. CONCLUSIONS: Knowing the patient was found to be especially important in determining nursing care. The model described in this study does not contradict the nursing process as a systematic approach to problem-solving. Rather, it has some alternatives that might be useful in providing individual care in Japan.     

The primary care physician's role in nursing facility care

As more care is shifted from the acute care hospital and other sites to nursing facilities, and as the complexity of nursing facility care increases, more is expected of attending physicians. Physicians play an important role in helping patients and their families in this setting and in working with the facility staff in caring for these patients. Structuring visits to address patient and family needs and staff concerns; reviewing resident assessment instruments, care plans, and orders for care; and carefully documenting and coding those visits in such a way as to represent the purpose and complexity of the visit and the patient's clinical circumstances not only helps to improve the overall care provided to the patient but also helps others such as payors and regulators who are concerned about quality of care to have a better understanding of the patient's situation and future plans and expectations. Thus, as nursing facility care becomes more complex, the role of physicians in the nursing facility becomes even more essential.     

Structure and duration of consultations in Estonian family practice

OBJECTIVE: To study the influence of age, gender and the nature of the patient's problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. DESIGN: Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). SETTING: Primary health care. SUBJECTS: 405 consecutive consultations were video-taped in the practices of 27 family doctors. MAIN OUTCOME MEASURES: Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. RESULTS: The average consultation lasted 9.0 min (+/- 4.9). Physical examination was 2.0 min (+/- 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. CONCLUSION: Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.     

Nurse/patient dependency — is it iatrogenic?

It is often assumed that nursing care is given in response to the patient's degree of incapacity. This study indicates that rather than nursing care arising as a response to patients' dependency, nursing care is producing dependency. A considerable proportion of the measured dependency of 168 elderly patients arose from the type of nursing care they received--it was iatrogenic. Task allocation nursing was found to be positively unhealthy for elderly long-stay patients, whilst individualized care (nursing process) was associated with lower patient dependency, a shorter hospital stay and a better chance of surviving the hospital stay. The findings demonstrate the inadequacy of nurse staffing formulas which are based on patient dependency. It is suggested that despite the rising numbers of very old people in the population, the elimination of nurse-induced dependency could reduce the level of dependency in geriatric wards.     

Predictors and outcomes of feeling of insufficient consultation time in cancer care in Korea: results of a nationwide multicenter survey

Background

Shared decision making and an integrative approach is expected to result in better outcomes, but might require more time. While ensuring that sufficient consultation time is essential to quality cancer care, it is not clear whether cancer patients feel that the amount of consultation time with their oncologists is sufficient.

Methods

Data were collected from 2,556 cancer patients on their perceived and preferred consultation time, and included potential predictors, such as socio-demographics, clinical, behavioral, and quality-of-life factors, as well as potential outcomes, including unmet patient needs, trust in doctor, and satisfaction. The feeling of insufficient consultation time was defined as the perception that consultation time is less than the preferred consultation time; multivariate analyses were used for identification of predictors and comparison of outcomes.

Results

Overall, 37.1% felt that consultation time was less than preferred. Younger age, female sex, higher education level, having national health insurance, having been diagnosed with less common cancers, and having anxiety/depression were significantly associated with feelings of insufficient consultation time. Subjects with a feeling of insufficient consultation time reported higher current needs for information, physical symptoms, and psychological problems. They also reported less trust in their physician, lower overall satisfaction, and lower intention to continue treatment at the current cancer center.

Conclusion

This study illustrated that high-quality cancer care, characterized by shared decision making and an integrative approach, seems to be related to sufficient consultation time that meets the individual’s subjective needs, and measures should be taken to ensure sufficient consultation time.     

Ethics: issues of concern.

Awareness of the aforementioned issues (confidentiality and privacy, deception and debriefing, and publication of study results and data analysis) is a major step in preventing the violation of a patient's dignity as a human being during a research study. Also, with patients themselves in unison with patient advocates demanding "humane" care and voicing the patient's "right to know" about alternative procedures, we must not assume our study participants to be naive and blindly trusting of nursing. On the other hand the public perception of nursing as a profession of "care givers" and not "harm doers" is one that we should perpetuate in good faith.     

Nursing home staff's views on quality improvement interventions: a follow-up study

Ongoing problems with nursing home care mandates understanding nursing home staff's perspectives on innovative quality improvement programs. This follow-up study used focus groups to examine the experiences of staff who participated in a clinical trial that involved Quality Indicator (QI) feedback reports, quality improvement training, and APN consultation. The authors found that QI reports provided staff with a benchmark to judge their care and a means to track problems; APN consultation was essential for staff to learn best practices; and staff questioned the validity of the QI reports, which hindered them from seeking new solutions to problems identified in the QI reports. Findings indicate that innovative QI programs and APN consultation can positively influence nursing home quality improvement efforts and improve care.     

The life of a new long stay patient: a reflexive experience

The care received by one patient in an acute psychiatric ward setting is described and analyzed by examining the relevant literature and the patient's perspective through a therapeutic relationship with a psychiatric nursing student. The patient is described as the new long stay patient and the reasons for the existence of this group are discussed. The paper concludes by stating the need to provide for those patients who are inappropriately occupying acute beds because there is no available alternative. This is found to cause problems for the individual, for psychiatric services and for nursing care.     

The mental health nurse: a valuable addition to the consultation-liaison team

Nurses, particularly those working in non-psychiatric settings, report that they do not feel adequately prepared to meet the mental health needs of patients. The psychiatric consultation-liaison nursing role has arisen in part, as a response to these difficulties and aims to facilitate access to mental health nursing expertise for general hospital patients and staff. The impact of the introduction of a nursing position into an established consultation-liaison psychiatry service was evaluated using an activity audit, a staff attitude survey, and staff focus groups. The findings demonstrated that the addition of the nursing role to the consultation-liaison psychiatry service improved access of general hospital patients to specialist mental health care. It also provided valued expert assistance to staff in the provision of care to this patient group, particularly those with complex problems and significant psychiatric comorbidity. The study found that the nursing consultation was particularly helpful because of its focus on practical and care-orientated interventions. The model of practice that evolved out of this project is described and the findings support the use of both direct and indirect patient interventions as important psychiatric consultation-liaison nurse activities.