Essay: Current research activities related to concepts

Current research activities related to concepts
1. Health History
In 2002 the CDC launched the Family History Public Health Initiative, founded upon the principle that family history although a simple and inexpensive form of genetic assessment is an under used but effective tool for identifying patients risks. It has long been taught as one of the core foundations of the medical interview, yet over the years these skills have been lost or overwhelmed by the pressures and time constraints of day to day practice (Orlando et al. 2011). Two of the stated goals of the CDC initiative are to develop tools to enhance family health history (FHH) collection and to evaluate whether family history-based strategies work. Primary health providers partner in studying the implementation of family history collection into the medical decision making process.
In an article published in BMC Health Services Research, the authors stated that bringing family history back into the realm of medical decision making is important for multiple reasons. First, disease prevention has the potential to reduce the ever escalating costs of medical care and relies entirely upon accurate disease risk prediction. Family history has been shown to improve disease risk prediction for colon cancer (Park et al 2009), breast cancer (Gail et al, 1989), and cardiovascular disease (Scheuner 2003). Second, using family history to predict disease requires several skills: understanding what family history is saying about risk, understanding how to communicate risk to patients, and using risk information to motivate behavior change. The authors suggested that by developing an electronic family history collection and decision support tool to assist providers, researchers anticipate that providers will be able to reincorporate family history based decision making into their medical practice.
Dr. Lori Orlando, associate director for Duke Center for Applied Genomics and Precision Medicine, is leading this study funded by the National Human Genome Research Institute. The study that streamlines the process for obtaining family health history information from patients and then uses it to help identify conditions patients might be at risk for. Central to this study is the Duke-developed MeTree software program.  MeTree is being studied in five national health care systems, including Duke. It is a web-based family and personal health history collection and clinical decision support program that gathers information directly from patients. It collects personal history on medical conditions, diet, exercise, smoking, vital signs and laboratory data in addition to family health history to calculate various health-risk scores and assess risk for 20 cancers, 14 hereditary cancer and cardiovascular syndrome and 21 other conditions. The software has been an innovation in assessing genetic risk and is able to provide this information to both patients and providers in order for focused health promoting interventions to take place at the time of the visit.
2. Health Promotion
According to an article published in American Journal of Health Promotion, 2015, almost half of all premature deaths in the United States and other developed countries are caused by lifestyle related problems. Many of these deaths has been found to be preventable  and enhance quality of life for millions of people if they exercise regularly, eat nutritious foods, avoid tobacco and excess alcohol, learn to manage stress, enhance social networks and economic conditions, clarify lifestyle values, and help patients achieve a sense of fulfillment in their intellectual pursuits.
The results of 5 qualitative research studies suggest that nurse’s definition of health promotion is ambiguous and uncertain (Rash2008, Kelley and Abraham 2007, Irvine 2007, Casey 2007, Burman 2009). On analysis it was observed that a common definition of health promotion among nurses, in a variety of health care settings, refers to providing health education and advice about healthy lifestyles (Rash2008, Kelley and Abraham 2007, Irvine 2007, Casey 2007) For example, nurses believed that health promotion is telling someone why he or she should change his or her behavior or life to protect or improve his or her health (Rash 2008). Nurses with more experience commonly perceived health promotion as empowerment (Kelley and Abraham 2007, Irvine 2007).  Although health promotion should have positive influences on the population at large, barriers to its use and effectiveness do exist. Nurses perceived that the most common barrier to promoting health in nursing practice is time, followed closely by not enough education and training (Kelley and Abraham 2007, , Casey 2007) Some nurses believe that they needed more evidence that health promotion is an effective method for helping patients improve their health and some even perceive patients as barriers to promoting health. According to Casey (2007), some nurses believe that patients are unwilling to accept health promotion. More than half of nurses who perceived that patients should not have a choice to receive health promotion, believed that patients frequently ignore advice given to them (Kelley and Abraham 2007). Some nurses believed that nursing management does not empower nurses to promote health and daily nursing tasks are burdensome and prevent them from practicing health promotion (Casey 2007).The percentage of nurse practitioner students who perceived the work environment as a barrier to practicing health promotion increased at the completion of a health promotion course (Rash 2008). Patients’ knowledge deficit about healthy lifestyles and patients’ unwillingness to change also emerged as health promotion barriers for nurses (Rash 2008).
3. Self- Actualization
Apart from Maslow, many more researchers have developed definitions for self-actualization as cited in by, Hall and Hanse (1997). Gowan (1972), for example, defines self-actualization as… ‘a profound sense of commitment.” Kerr (1991) sought those who challenged the limits of intellectual potential and used their gifts to the fullest were self-actualized. Reis and Callahan (1989) favored achievements in recognized fields of endeavor as key to achieving self-actualization.
In 1972, John Gowan applied Maslow’s Hierarchy to a group of men 35 years after their graduation from an Ivy League College, finding what he perceived to be disappointing results for the men. He concluded that the men remained in lower levels of Maslow’s Hierarchy, specifically motivated by selfish interests in parenting, or in hobbies, art, and travel, and did not advance to self-actualize their talent. Unlike Maslow who identified 17 % of the population as self-actualized, Gowan found only five percent of the Ivy League men reached moderate professional accomplishment, and only four percent reached self-actualization.
Because the concept and modes of acquiring self-actualization are quite abstract and complex, it may be difficult although not impossible for a particular nurse to embark on a journey of self-actualization. This process requires skills training, and scientific knowledge acquisition so that the nurse can be empowered to alleviate and overcome the dissatisfaction and frustration with current health care system and move to nursing practice that manifests strongly held believe and values (Kleinman 2005). Literature indicates that self-actualized nurses  have a mitigating effect on important issues such as nursing shortages, nurses’ job satisfaction, and patient and nurses safety issues(Kleinman 2005).These can impact positively on society as quality health care can be given to clients as well as decrease in nurse absenteeism or sick out reducing cost of health care for all.
4. Therapeutic relationship
The American Psychological Association (APA) in 1991, created a task-force to research characteristics of effective therapeutic relationships and concluded that the techniques employed by the therapist are not determinant in this process, but the quality of the relationship that he/she establishes with his/her client (Norcross, 2001).
In a theoretical article Horvath 2000 reviewed the concept of therapeutic relationship and its impact on the client in the counseling process. He stated that establishing good relationships with client is essential to successful treatment outcome and that clients reports of the quality of the relationship were more reliable than therapist reports. He further suggested that the early phase of therapy is crucial in the development of strong therapeutic relationship.
Marziali and Alexander (1991) reviewed the literature on the therapeutic relationship and its role in the therapy outcome. They observed that a gap exist in empirical research regarding process variables that help explain variance in the treatment outcome and that the majority of studies that investigate the treatment relationship are psychotherapy. Marziali and Alexander also outline the role of the therapeutic relationship in the outcome of treatment calling it ‘a potent curative factor in all forms of treatment” (1991, p 388).
There is considerable evidence supporting the assertion that counselling relationship is essential to successful counselling outcome (Hill and Corbett, 1993, Horvath &Symonds, 1991): however these studies have merely described the connection between relationship and outcome. Further research is necessary to examine how and why the therapeutic counselling relationship influences client change.
5. Client Centered Care
Research has found that person-centered care can have a big impact on the quality of care. It can improve the experience people have of care and help them feel more satisfied, encourage people to lead a more healthy lifestyle, such as exercising or eating healthily, encourage people to be more involved in decisions about their care so they get services and support that are appropriate for their needs, impact on people’s health outcomes, such as their blood pressure, reduce how often people use services. This may in turn reduce the overall cost of care, but there is not as much evidence about how confident and satisfied professionals themselves feel about the care provided.
Reviews of research about this topic found that offering care in a more person-centered way usually improves outcomes (Olsson, Jakobsson, Swedberg, and Ekman 2013). Some of the most common ways that have been researched to improve person-centered care include helping people learn more about their conditions, prompting people to be more engaged in health consultations and training professionals to facilitate care that empowers people to take part (McMillan et. al 2013, Lewin, Skea, Entwistle, and Zwarenstein 2001).
Offering care in a more person-centered way can even improve outcomes for professionals. A review of seven studies about professionals delivering person-centered care in nursing homes found that this approach improved job satisfaction, reduced emotional exhaustion and increased the sense of accomplishment amongst professionals (van den Pol-Grevelink, Jukema, and Smits 2012).
6. Critical thinking
In a clinical study, conducted to measure 62 staff nurses’ accuracy of nursing diagnoses in three New York/New Jersey hospital demonstrated that nursing diagnoses of patient’s psychosocial response varied from high to low with 153 newly admitted patients and that the highest level of accuracy in diagnosing was achieved when nurses collaborated with patients and each other providing evidence that critical thinking can improve patient outcomes. The author suggest that in order to improve this scores crictical thinking should form part of all nursing cirliculum.
Scheffer and Rubenfeld (2000) identified seven cognitive skills and ten habits of the mind essential for nursing practice and thinking critically. These cognitive skills are: analyzing, applying standards, discriminating, information seeking, and logical reasoning, predicting and transforming knowledge. The habits of the mind identified in order to think critically are, confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open mindedness and perseverance. Because the clinical situations where nursing interpret are diverse and complex, making and formulating accurate nursing diagnoses can be a challenging task. Therefore in order to become competent at such a task nurses must therefore develop cognitive skills and habits of the mind as identified by above research findings.
7. Patient Advocacy
The concept of patient advocacy can be traced to the Crimean War that occurred between 1853 and 1856 (Foley, Minick and Kee2002). During that time, Florence Nightingale described the importance of creating a healthcare environment that promoted ventilation, cleanliness, comfort, and sanitation. According to Nightingale promoting these conditions provided patient care settings that led to improved health outcomes. (Ronnebaum and Schmer 2015).
The concept of patient advocacy has become an important topic in healthcare. In 1976, the American Nurses Association’s (ANA) Code for Nurses was changed to emphasize the need for nurses to become more autonomous in their provision of patient care and less as extensions of physicians.  Code alterations included the statement: In the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical or illegal practice(s) by any member of the healthcare team or the healthcare system itself, or any action on the part of others that is prejudicial to the client’s best interest (ANA 1985). Since these changes, nurses have continued to refine their patient advocate role to include responsibilities such as protecting patient rights, informing patients about healthcare options, and respecting their patient’s healthcare decisions.
Several articles regarding analyses of the patient advocacy concept were identified in this literature review. Baldwin completed a concept analysis of patient advocacy and identified three defining attributes of this concept: 1) providing a therapeutic nurse-patient relationship in which to secure the patient’s freedom and self-determination; 2) promoting and protecting the patient’s rights to be involved in decision-making and informed consent; and 3) acting as an intermediary between patients, their families or significant others, and as a liaison between patients and healthcare providers. Baldwin summarized these three attributes as: 1) valuing: described as a nurse empowering a patient’s freedom and self-determination; 2) apprising: promoting the nurse’s role of informing, advising, and providing education; and 3) interceding: a term that described the nurse’s role in assisting patients to overcome barriers for healthcare needs [12].
Mallik (1997), discussed the need for definitions and models that involve the patient advocacy concept, how this concept is an integral role of the professional nurse, and how nurses are in a pivotal position to advocate. The author suggested further research should be directed toward empirically examining the role of the patient advocate from both a healthcare leader and practicing nurse perspective (Mallik 1997). Mac Donald (2007) analyzed literature associated with relational ethics and advocacy in nursing. She performed this qualitative review to better understand advocacy in the nursing profession. Results of this research suggested that nurses must continue to learn more about relational contexts as these may influence nursing advocacy interventions (Mac Donald 2007)
In a quantitive study done to evaluate nurses’ attitude and perception towards patient advocacy Negarandeh, et al. (2003) demonstrated a positive correlation between attitude and perception of nurses. Certain Barriers and facilitators to advocacy were also identified.
Barriers to nursing advocacy identified include:
• Powerlessness (lack of law and code of ethics)
• Lack of support for nurses (no support of advocacy actions by managers which lead to lack of support for patients too)
• Physicians leading – one of the most important barrier factor identified by nurses. Nurses believed that even after having good knowledge of the matter it is very hard to talk to doctors)
• Time constraint (force nurses to revise work pattern to complete many tasks in a limited time)
• Limited communication with client and health care team
• Loyalty to peers
• Lack of motivation
Facilitators of advocacy as identified by nurses included
• Nurse patient relationship
• Recognizing and paying attention to patient needs and conditions (comprehensive nursing assessment enables nurses to be more effective in patient advocate)
• Nurses responsibility- believed that nurse conscience commitment to professional code of ethics and respect of patient rights could facilitate patient advocacy
• Physician as colleague- team approach to coordinating patient care was a crucial factor
• Knowledge and skills
Kohnke (1980) believed that the greatest obstacle to advocacy is the health care institution itself because client advocacy is basically in conflict with the culture of the hospital system. Mallik (1977) stated that the concept and role of patient advocacy are open to a variety of different interpretations and in practice the power of outside professional groups especially those of doctors and managers make it difficult for the individual nurse to operationalize the concept. Nurses perceived the main facilitators to patient advocacy were physician support, utilizing a team approach, and rapport with insurance company and other agencies (Hellwig, Yam, and Di Giulio 2003)
8. Delegating
Although there is considerable variation in the language used to talk about delegation, American Nursing Association (ANA) and National Council of State Board of Nursing (NCSBN) both defined delegation as the process for a nurse to direct another person to perform nursing tasks and activities. NCSBN describes this as the nurse transferring authority while ANA calls this a transfer of responsibility. Both mean that a registered nurse (RN) can direct another individual to do something that that person would not normally be allowed to do. Both papers stress that the nurse retains accountability for the delegation. Effective delegation is paramount in nursing. Due to the shortage of staff especially at the high order, some of the duties that managers were in charge of such as assignments, meeting, work schedules, are now being carried o delegated to lower level staff. These staff nurses at this end of the hierarchy are now forced to develop competency in the field of mangers to fulfil their duties.
9. Wellness
The words health and wellness have been used to mean the same things for a number of years. According to the World Health Organization (1948) health is defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” It also pointed out that the ‘enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
No consensus has been given about the nature of health and therefore this according to Bircher & Wehkamp (2011) health care and medicine in most countries were in a state of crisis. They author noted that this short coming inhibited constructive, interdisciplinary dialogue about health values. In the famous definition of health given by WHO, Bircher and Wehkamp noted that it is considered idealistic  to an extent that almost no one can be considered to be healthy and therefore agreement with this definition has become limited and at present it can no longer serve as a central concept for the implementation of health care system.
The authors suggested that physician have lost control of health care in favor of economists and politicians and as a result leadership is no longer based on medical but on economic and political values. To redirect health care system the authors suggest that a new concept of health and wellness is needed, one ‘that respects the dignity of each person, distinguishes between health and disease, provides essential elements for the process of diagnosis, reimbursement and clarifies the relationship between individual and society”. Bircher and Wehkamp proposes the use of new definition of health known as the Meikrich Model can help correct this deficiency. In this model health is define as ‘a dynamic state of wellbeing characterized by a physical, mental and social potential, which satisfies the demands of a life commensurate with age, culture and personal responsibility.” The models further states that if the potential is insufficient to satisfy these demands the state is disease. In this definition health potential consist of two components, a biological component given and a personal acquired potential. At birth the biological given component has a finite value but thereafter it decreases throughout life and at the time of death it is zero. The personal acquired potential is quite small at the time of birth but increases rapidly during childhood and adolescence. It may rise throughout life providing that an individual cultivates it and may be damage by neglect, alcohol, drugs etc., be hurt by social surroundings that are not supportive enough, over demanding, or destructive. Therefore social support for health is crucial. The demands of life are those we have to respond to in order to lead a healthy life and vary continuously with age. These demands can be modified by the culture of the society. In each person the decision about health or disease depends on the balance between the total potential and the demands of life. If the two partial potential outweighs the demands of life a person is healthy and if they weigh less the person is diseased. This model provides person with chronic illness hope and support because they realize that they can do something about their condition even when improvement of the physical state can no longer be expected.
10. Pain
Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods. The cornerstone to adequate pain treatment in this population is the availability of adequate pain assessment methods (Stevens, Johnston and Grunau 1995, Finley and McGrath 1998).The subjectivity of pain causes enormous difficulties in evaluating neonatal pain. Several physiologic parameters have been used to evaluate, measure and qualify the pain stimulus in the neonate. Their specificity, sensitivity and workability are variable, but in general they are easily available in Neonatal Intensive Care Units (NICU). These parameters include: heart rate, respiratory rate, blood pressure, O2 arterial saturation, transcutaneous oxygen and carbonic dioxide pressures, vagal tone, palmar sweating, intracranial pressure and hormones associated with the endocrine-metabolic response to stress. Most of them do not change specifically in response to pain. These physiologic parameters can help to determine the presence or absence of pain, but generally they do not help to qualify the pain.
Study of neonatal behavior seems a promising way of evaluating pain in pre-verbal patients, (Grunau and Craig 1987, Guinsburg et al. 1997, Lawrence 1993 and Hadjistavropoulos, Craig, Grunau, and Johnston 1994) and such behavior includes crying, motor activity, and the facial expression of pain. The cry is considered to be the primary way of communication for newborn infants. (Levine and  Gordon 1982) with a single, practical and easy-to-apply tool.
Several studies have tried to relate pain to different characteristics of the cry (Golub and Corwin 1982, Johnston and Strada 1986)    But the main problem in using the cry as a measure of pain is that approximately 50% of newborn infants do not cry during or after a painful procedure.( Stevens, Johnston and Grunau 1995, Guinsburg et al. 1997, Johnston, Stevens, Craig and Grunau 1993).  Moreover, crying is not a specific pain assessment tool and can be elicited by other non-painful stimuli, such as discomfort and hunger.
Both term and preterm newborn infants have an organized repertoire of movements in response to a painful stimulus(Craig, Whitfield, Grunau, Linton, Hadjistavropoulos 1993).Motor activity is a sensitive method of pain assessment and its specificity is enhanced by the concurrent use of other physiologic and behavioral pain evaluation tools. Several studies have indicated that the observation of facial expression seems to be a non-invasive, sensitive, specific and useful method of pain evaluation in term and preterm newborn infants.