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Nurs 6650: Psychotherapy With Groups and Families Study Papers. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Permalink: https://nursingpaperessays.com/ nurs-6650-psycho…ies-study-papers / ? As a future advanced practice nurse, it is important that you are able to connect your classroom experience to your practicum experience. By applying the concepts you study in the classroom to clinical settings, you enhance your professional competency. Each week, you complete an Assignment that prompts you to reflect on your practicum experiences and relate them to the material presented in the classroom. This week, you begin documenting your practicum experiences in your Practicum Journal. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Learning Objectives Students will: · Analyze nursing and counseling theories to guide practice in psychotherapy* · Summarize goals and objectives for personal practicum experiences* · Produce timelines for practicum activities* In preparation for this course’s practicum experience, address the following in your Practicum Journal: Select one nursing theory and one counseling theory to best guide your practice in psychotherapy. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Explain why you selected these theories. Support your approach with evidence-based literature. Develop at least three goals and at least three objectives for the practicum experience in this course. Create a timeline of practicum activities based on your practicum requirements. Required Readings American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Standard 5A “Coordination of Care” (page 54) Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer. · Chapter 11, “Group Therapy” (pp. 407–428) Nichols, M. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson. · Chapter 1, “The Foundations of Family Therapy” (pp. 1–6) · Chapter 2, “The Evolution of Family Therapy” (pp. 7–28) Breeskin, J. (2011). Procedures and guidelines for group therapy. The Group Psychologist, 21(1). Retrieved from http://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2011/04/group-procedures.aspx Khawaja, I. S., Pollock, K., & Westermeyer, J. J. (2011). The diminishing role of psychiatry in group psychotherapy: A commentary and recommendations for change. Innovations in Clinical Neuroscience, 8(11), 20–23. Retrieved from http://innovationscns.com/ Note: You will access this article from the Walden Library databases. Koukourikos, K., & Pasmatzi, E. (2014). Group therapy in psychotic inpatients. Health Science Journal, 8(3), 400–408. Retrieved from http://www.hsj.gr/medicine/group-therapy-in-psychotic-inpatients.php?aid=2644 Note: You will access this article from the Walden Library databases. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Lego, S. (1998). The application of Peplau’s theory to group psychotherapy. Journal of Psychiatric & Mental Health Nursing, 5(3), 193–196. doi:10.1046/j.1365-2850.1998.00129.x Note: You will access this article from the Walden Library databases. McClanahan, K. K. (2014). Can confidentiality be maintained in group therapy? Retrieved from http://nationalpsychologist.com/2014/07/can-confidentiality-be-maintained-in-group-therapy/102566.html U.S. Department of Health & Human Services. (2014). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/special/mhguidancepdf.pdf Laureate Education (Producer). (2015). Microskills: Family counseling techniques 1 [Video file]. Baltimore, MD: Author. Note: The approximate length of this media piece is 32 minutes. Laureate Education (Producer). (2015). Microskills: Family counseling techniques 2 [Video file]. Baltimore, MD: Author. Note: The approximate length of this media piece is 32 minutes. Laureate Education (Producer). (2015). Microskills: Family counseling techniques 3 [Video file]. Baltimore, MD: Author. Note: The approximate length of this media piece is 24 minutes. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Evaluate psychotherapeutic approaches to group therapy for addiction To prepare: · Review this week’s Learning Resources and reflect on the insights they provide on group therapy for addiction. · View the media, Levy Family: Sessions 1-7, and consider the psychotherapeutic approaches being used. · Levy Family Episode 1 Program Transcript [MUSIC PLAYING] FEMALE SPEAKER: You’re not dressed? You’re going to be late for work. MALE SPEAKER: I’m not going to work. I’m sick. FEMALE SPEAKER: Of course you’re sick. You’re hungover. I don’t want the boys to see you like this. Go back to bed. MALE SPEAKER: See me like what? I told you, I’m sick. FEMALE SPEAKER: Well, what do you call it when someone is sick almost every morning, because they drink every night while they sit in the dark watching TV? MALE SPEAKER: You calling me a drunk? FEMALE SPEAKER: What do you call it? MALE SPEAKER: I call it, leave me the hell alone. FEMALE SPEAKER: Baby, you need to stop this. It’s tearing us up. The drinking, the anger– you’re depressed. MALE SPEAKER: You said, for better or worse. FEMALE SPEAKER: My vows don’t cover this. You were never like this before. You’ve changed. I want us back, the way we used to be. MALE SPEAKER: That way is dead. It died when I went to Iraq. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Levy Family Episode 2 Program Transcript FEMALE SPEAKER: I want to thank you for getting me this Levy case. I think it’s so interesting. Just can’t wait to meet with the client. MALE SPEAKER: What do you find interesting about it? FEMALE SPEAKER: Well, he’s just 31. Usually the vets I work with are older. If they have PTSD, it’s from traumas a long time ago. But Jake, this is all pretty new to him. Nurs 6650: Psychotherapy With Groups and Families Study Papers. He just left Iraq a year ago. You know, I was thinking he’d be perfect for one of those newer treatment options, art therapy, meditation, yoga, something like that. MALE SPEAKER: Why? FEMALE SPEAKER: Well, I’ve been dying to try one of them. I’ve read a lot of good things. Why? What are you thinking? MALE SPEAKER: I’m thinking you should really think about it some more. Think about your priorities. It’s a good idea to be open-minded about treatment options, but the needs of the client have to come first, not just some treatment that you or I might be interested in. FEMALE SPEAKER: I mean, I wasn’t saying it like that. I always think of my clients first. MALE SPEAKER: OK. But you mentioned meditation, yoga, art therapy. Nurs 6650: Psychotherapy With Groups and Families Study Papers.Have you seen any research or data that measures how effective they are in treatment? FEMALE SPEAKER: No. MALE SPEAKER: Neither have I. There may be good research out there, and maybe one or two of the treatments that you mentioned might be really good ideas. I just want to point out that you should meet your client first, meet Jake before you make any decisions about how to address his issues. Make sense? Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Levy Family Episode 3 Program Transcript JAKE LEVY: We’d be out on recon in our Humvees, and it would get so hot. We used to put our water bottles in wet socks and hang them right outside the window just so the water would cool off of a bit, and maybe then you could drink it. Man, it was cramped in there. You’d be drenched, nowhere to breathe. Nurs 6650: Psychotherapy With Groups and Families Study Papers. It’s like riding around in an oven. And you’d have your helmet on you, 100 pounds of gear and ammo. I swear, sometimes I feel like it’s still on me, like it’s all still strapped on me. FEMALE SPEAKER: How many tours did you do in Iraq? JAKE LEVY: Three. After that last recon, I just– There were 26 of us. Five marines in the Humvee I was in. I remember I was wearing my night vision goggles. We passed through a village and everything was green, like I was in a dream or under water. And then there was a flash, bright light just blinded me. There was this explosion. I can’t– I can’t– FEMALE SPEAKER: It’s OK, Jake. Take it easy. I understand this is difficult. There’s something I;d like to try with you. It’s called exposure therapy, and it’s a treatment that’s used a lot with war veterans, especially those struggling with anxiety and PTSD. JAKE LEVY: Exposure therapy? FEMALE SPEAKER: Yes. It’s to help someone like yourself to confront your feelings and anxieties about a traumatic situation that you’ve experienced. Nurs 6650: Psychotherapy With Groups and Families Study Papers. It’s a– It’s meant to help you get more control of your thoughts, to make sense of what’s happened, and to not be so afraid of your memories. JAKE LEVY: Put that in a bottle and I’ll buy 10 cases of it. FEMALE SPEAKER: Well, one part of it is learning to control your breathing. And when you practice that, you can learn to manage your anxiety, to get more control of it, not let it control you, to protect yourself. Do you want to try it? JAKE LEVY: Right now? FEMALE SPEAKER: Sure. JAKE LEVY: Why not? Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Levy Family Episode 4 Program Transcript FEMALE SPEAKER: So do you want to try to go back to what you’re telling me before? LEVY: I can try. It was night. We were out on patrol. I remember it was so hot packed in our vehicle. Suddenly there was an explosion. We got tossed into a ditch. And somehow I made it out, and I could see it was the Humvee behind us. It’s whole front end was gone. It had hit a roadside bomb. Our vehicle had just driven past it, just mistriggering it. But not them. Nurs 6650: Psychotherapy With Groups and Families Study Papers. They didn’t make it. FEMALE SPEAKER: Remember how we practiced. Slow your breathing down. Inhale and exhale from your abdomen. LEVY: Thank you. FEMALE SPEAKER: And just take your time. Whenever you are ready. LEVY: So the bomb went off. I managed to get out. I had my night vision goggles on. And I could see the Humvee, the one that got hit. It’s whole front end was gone. And there’s this crater in the road. And inside it I could see– I could see Kurt’s– our platoon Sergeant, he was lying there everything below his waist was gone, blown off. And he was screaming. Screaming like nothing you’d ever heard. And then he was looking at me. And he was screaming for me to kill him. To stop his suffering. Nurs 6650: Psychotherapy With Groups and Families Study Papers. He was yelling, please. Please. And someone tried putting tourniquets on him. But the ground just kept getting darker with his blood. And I was staring into his face. I had my rifle trained on him. I was going to do it. You know. He was begging me to. I could feel my finger on the trigger. And I kept looking into his face. And then I didn’t have to do nothing. Because the screaming had stopped. He’d bled out. Died right there. And all I could think was I’d let him down. His last request, and I couldn’t do it. I couldn’t put a bullet in him so he could die fast not slow. FEMALE SPEAKER: I can see and hear how painful it is for you to relive this story. Thank you for sharing it. Do you think this incident is behind some of the symptoms you’ve been telling me about? LEVY: When I go to sleep at night, I close my eyes, and I see Kurt’s there staring at me. So I don’t sleep too good. That’s why I started drinking. It’s the only way I © 2013 Laureate Education, Inc. 1 Levy Family Episode 4 can forget about that night. So I drink too much. At least that’s what my wife yells at me. We’re not doing too well these days. I’m not exactly the life of the party. I left Iraq 10 months ago. But Iraq never left me. I’m afraid it’s never going to leave me alone. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Levy Family Episode 5 Program Transcript FEMALE SPEAKER: It was such an intense story. I just kept seeing things the way he did, you know. The weird green of his night-vision goggles, his sergeant screaming for Jake to kill him. I just keep seeing it all in my head. [MUSIC PLAYING] MALE SPEAKER: Why, do you think? FEMALE SPEAKER: Why what? MALE SPEAKER: Why do you think you keep thinking about this story, this particular case? FEMALE SPEAKER: I don’t know, maybe because it’s so vivid. Nurs 6650: Psychotherapy With Groups and Families Study Papers. You know, I went home last night, turned on the TV to try to get my mind off it. And a commercial for the Marines came on, and there was all over again– the explosion, the screams, the man dying. Such a nightmare to live with, and he’s got a baby on they way. MALE SPEAKER: Could that be it, the baby? FEMALE SPEAKER: Maybe. That’s interesting you say that. I mean, the other vets I work with are older, and they have grown kids. But Jake is different. I just keep picturing him with a newborn. And I guess it scares me. I wonder if he Levy Family Episode 6 Program Transcript FEMALE SPEAKER: I know three of you did tours of duty in Iraq, and the others in Afghanistan. So I just wanted to follow up on that, talk about how you’re adjusting. [MUSIC PLAYING] MALE SPEAKER 1: You say adjust to, but there’s no adjustment. You’re just thrown back into your life like you’re supposed to pick up where you left off, but that’s a joke. Two years ago, I was dug in, pinned down by 50 Cal sniper fire, just praying the chopper would get me out alive. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Now, the hardest part of my day is standing in the grocery store trying to decide if I want yellow or brown mustard with my hot dogs. JAKE: Nah, two six packs or a case. FEMALE SPEAKER: You find that you drink more than you used to? JAKE: Why not ask him if he finds he’s eating more hot dogs than he used to? BILL: You know why? JAKE: Why is that? Oh great, Buddha. BILL: Because I’ve been where you are. You talk about booze like it’s some joke, but nobody’s laughing. You can’t get adjusted to anything when you’re trying to get loaded. JAKE: I guess you won’t be joining me for a drink at the bar later. I was going to buy. FEMALE SPEAKER: No, that’s a good point, Bill. Sometimes we do things to avoid dealing with unpleasant feelings, like adjusting to life back at home. Nurs 6650: Psychotherapy With Groups and Families Study Papers. JAKE: What do you know about it? Give me a break. Back off, or I’ll make you. BILL: I drink too much too. But I’ve had enough of you mouthing off. JAKE: My wife’s had enough of me too. She’s the reason I’m here. We never used to fight. I never used to drink so much, but now I can’t stop myself from doing either. FEMALE SPEAKER: So why do you drink too much? © 2017 Laureate Education, Inc. 1 Levy Family Episode 6 BILL: It’s the only way I can shut it out, images of what I saw over there, horrible things that no one should ever have to see. I wake up some nights and I hear mortar rounds coming in. And I reach for my helmet and my weapon, but they’re not there. So I freak out. And then I see pretty curtains. TV’S on. And then I remember I’m at home. I realize I’m not going to get blown up after all. FEMALE SPEAKER: Thanks for sharing, Jake. You make a good point. It can seem a lot easier to self medicate rather than face the fears, the bad memories that we have. So what do you think? What are some other things, maybe, you do to avoid the challenge to being a civilian again?’ll be able to deal with it. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Levy Family Episode 7 Program Transcript FEMALE SPEAKER: How did you find out? MALE SPEAKER: There’s a guy who served in our platoon. He didn’t call. Wrote an email. He said it would bother him too much if he talked about it. Sorry to be the one who tells you that Eric committed suicide last night. The last time I saw him, he said he was adjusting to civilian life pretty well. His girlfriend told me it wasn’t true. She said he told everyone he was doing fine. But the nightmares kept after him even when he wasn’t sleeping. It just tore him up. I guess he decided he’d had enough. He ended it with a service revolver. Marine to the end. FEMALE SPEAKER: I’m sorry, Jake. MALE SPEAKER: Thank you. You know, I spend almost every night in front of the TV, drinking until I can’t remember anything else. Nurs 6650: Psychotherapy With Groups and Families Study Papers.But I read that email last night, and I didn’t drink a drop. I just kept thinking about Eric. You know we went through Parris Island together? FEMALE SPEAKER: I didn’t know that. MALE SPEAKER: Yeah. I didn’t turn on the TV, either. I went straight to the computer. And before I knew it, I was reading about veterans and suicide. They say about 22 veterans commit suicide every day, 22. That’s like one every hour. Makes it sound like we’re time bombs. Makes you wonder which one of us is going to go off next. FEMALE SPEAKER: You sound glad that you didn’t drink last night. MALE SPEAKER: Yeah. I’ve been trying to quit for my wife. But that email– you know what else I read online? I checked all over with the VA, but it doesn’t look like they do anything to help prevent suicide. I mean, they offer help if you ask for it, but no prevention. Who’s going to ask for help, right? They train you to be stronger than everyone else, to endure. Asking for help is just not something most men do. FEMALE SPEAKER: Do you need help, Jake? MALE SPEAKER: I need a lot, but not like that. I’m not ready to check out yet. I got a baby on the way. © 2017 Laureate Education, Inc. 1 Levy Family Episode 7 I found out something else. I was reading about this veteran who committed suicide in another state. And they started this program in his memory that brings other vets together to help each other. FEMALE SPEAKER: Peer counseling? MALE SPEAKER: Yeah, that’s it. And I spent the whole rest of the night thinking, why don’t we have something like that? We should be reaching out to all vets, not just those who are already getting mental health services. I’d even volunteer to get something like that going. FEMALE SPEAKER: Well, that’s a great idea. But we’d need to find the money for a program like that. Nurs 6650: Psychotherapy With Groups and Families Study Papers. I mean, our budget is maxed out. We’d have to lobby the state legislature for the funding. MALE SPEAKER: Well, I’ll do it. I’ll write the letter. I want to try. FEMALE SPEAKER: Well, OK. MALE SPEAKER: I can’t let Eric go without doing something for him. For me, too The Assignment In a 2- to 3-page paper, address the following: Identify the psychotherapeutic approach that the group facilitator is using, and explain why she might be using this approach. Determine whether or not you would use the same psychotherapeutic approach if you were the counselor facilitating this group, and justify your decision. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Identify an alternative approach to group therapy for addiction, and explain why it is an appropriate option. Support your position with evidence-based literature. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Required Readings American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author. · Standard 6 “Evaluation” (pages 65-66) Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Chapter 16, “Psychotherapeutic Approaches for Addictions and Related Disorders” (pp. 565–596) Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. · Chapter 13, “Problem Group Members” (pp. 391–427) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Note: Retrieved from Walden Library databases. Gamble, J., & O’ Lawrence, H. (2016). An overview of the efficacy of the 12-step group therapy for substance abuse treatment. Journal of Health & Human Services Administration, 39(1), 142–160. Retrieved from http://jhhsa.spaef.org/ Note: Retrieved from Walden Library databases. Kim, J. W., Choi, Y. S., Shin, K. C., Kim, O. H., Lee, D. Y., Jung, M. H., … Choi, I. (2012). The effectiveness of continuing group psychotherapy for outpatients with alcohol dependence: 77-month outcomes. Alcoholism: Clinical & Experimental Research, 36(4), 686–692. doi:10.1111/j.1530-0277.2011.01643.x Note: Retrieved from Walden Library databases. Allyn & Bacon (Producer). (2000). Motivational interviewing [Video file]. Mill Valley, CA: Psychotherapy.net. Note: You will access this media from the Walden Library databases. The approximate length of this media piece is 102 minutes. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Laureate Education (Producer). (2013d). Levy family: Sessions 1-7 [Video file]. Baltimore, MD; Author. Psychotherapy.net (Producer). (2015). Group therapy for addictions: An interpersonal relapse prevention approach [Video file]. Mill Valley, CA: Author. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Week 6: Foundations of Group Work and Types of Groups Evaluate the following group therapy article below. (See attached article) Bélanger, C., Laporte, L., Sabourin, S., & Wright, J. (2015). The effect of cognitive-behavioral group marital therapy on marital happiness and problem solving self-appraisal. American Journal of Family Therapy, 43(2), 103–118. doi:10.1080/01926187.2014.956614 Applying Current Literature to Clinical Practice The Assignment In a 5- to 10-slide PowerPoint presentation, address the following: · Provide an overview of the article you selected, including answers to the following questions: · What type of group was discussed? · Who were the participants in the group? Why were they selected? · What was the setting of the group? · How often did the group meet? · What was the duration of the group therapy? · What curative factors might be important for this group and why? · What “exclusion criteria” did the authors mention? · Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own client groups. If so, how? If not, why? · Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Note: The presentation should be 5–10 slides , not including the title and reference slides . Include presenter notes (no more than a half page per slide) and use tables and/or diagrams where appropriate. Be sure to support your work with specific citations from the article you selected. Support your presentation with evidence-based literature. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Required Readings Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer. · Chapter 11, “Group Therapy” (Review pp. 407–428.) Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. · Chapter 1, “The Therapeutic Factors” (pp. 1–18) Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. · Chapter 2, “Interpersonal Learning” (pp. 19–52) Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. Nurs 6650: Psychotherapy With Groups and Families Study Papers. · Chapter 3, “Group Cohesiveness” (pp. 53–76) Leszcz, M., & Kobos, J. C. (2008). Evidence-based group psychotherapy: Using AGPA’s practice guidelines to enhance clinical effectiveness. Journal of Clinical Psychology, 64(11), 1238–1260. doi:10.1002/jclp.20531 Note: Retrieved from Walden Library databases. Marmarosh, C. L. (2014). Empirical research on attachment in group psychotherapy: Moving the field forward. Psychotherapy, 51(1), 88–92. doi:10.1037/a0032523 Note: Retrieved from Walden Library databases. Microsoft. (2017). Basic tasks for creating a PowerPoint presentation. Retrieved from https://support.office.com/en-us/article/Basic-tasks-for-creating-a-PowerPoint-2013-presentation-efbbc1cd-c5f1-4264-b48e-c8a7b0334e36 Tasca, G. A. (2014). Attachment and group psychotherapy: Introduction to a special section. Psychotherapy, 51(1), 53–56. doi:10.1037/a0033015 Note: Retrieved from Walden Library databases. Tasca, G. A., Francis, K., & Balfour, L. (2014). Group psychotherapy levels of interventions: A clinical process commentary. Psychotherapy, 51(1), 25–29. doi:10.1037/a0032520 The American Journal of Family Therapy, 43:103–118, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0192-6187 print / 1521-0383 online DOI: 10.1080/01926187.2014.956614 The Effect of Cognitive-Behavioral Group Marital Therapy on Marital Happiness and Problem Solving Self-Appraisal CLAUDE BE?LANGER University of Quebec in Montreal (UQAM), Montreal, Canada, McGill University, Montreal, Canada, and The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse (CRIPCAS), Montreal, Canada LISE LAPORTE McGill University Health Center, Montreal, Canada STE?PHANE SABOURIN The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse (CRIPCAS), Montreal, Canada, and Laval University, Quebec City, Canada JOHN WRIGHT The Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse (CRIPCAS), Montreal, Canada Problem solving self-appraisal affects problem solving performance and marital adjustment. This study investigated the effects of cognitive-behavioral group marital therapy on couples’ adjustment and their self-appraisal of problem solving activities. Sixty-six cou- ples participated in group couples therapy. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Subjects were randomly assigned to an experimental or a waiting list control group. They completed the Problem Solving Inventory and the Marital Happiness Scale. Therapy was effective in improving global couple adjustment and problem solving self-appraisal. The program had a differential effect on the improvement of self-perceived problem solving abili- ties depending on the spouses’ initial self-appraised problem solving ability level. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Address correspondence to Claude Be?langer, De?partement de Psychologie, Universite? du Que?bec a? Montre?al, C.P. 8888 succursale Centre-ville, Montre?al, QC H3C 3P8, Canada. E-mail: [email protected] 103 104 C. Be?langer et al. Marital therapy based on social learning principles aims to enhance com- munication and/or to teach problem solving skills, with the expectation that such behavioral changes will lead to an increase in marital satisfaction (Woodin, 2001). However, increased attention has been devoted to the role of individual cognitive variables in mediating the relationship between communication/problem solving behaviors and marital distress (Be?langer, Sabourin & El-Baalbaki, 2012). The importance of cognitive processes in the development and maintenance of marital dysfunction has been confirmed in several investigations of the implications of spouses’ cognitions in outcome research (Dunn & Schwebel, 1995). Nurs 6650: Psychotherapy With Groups and Families Study Papers. Researchers have evaluated problem solving self-appraisal as a deter- minant of individuals’ adaptational outcomes (Godshall and Elliott, 1997; Heppner, Kampa, & Brunning, 1987). Problem solving self-appraisal refers to a relatively stable attitude toward one’s personal problem solving reper- toire as well as toward the self-regulatory processes at work while a problem is being solved (Heppner & Krauskopf, 1987). Nurs 6650: Psychotherapy With Groups and Families Study Papers. Social problem solving abilities are used in social contexts, and they af- fect interpersonal adjustment (Elliott & Grant, 2008). For instance, family care- givers demonstrating effective problem solving styles reported greater rela- tionship satisfaction (Shanmugham, Cano, Elliott & Davis, 2009). Self-efficacy in response to personal problems is related to the way the person appraises his or her problem solving skills. Accordingly, to develop good coping ca- pacities, it is important for a person to be able to appraise his or her problem solving skills and style (Heppner & Dong-Gwi, 2009). Moreover, Bandura’s work strongly supports the notion that people’s perception of self-efficacy af- fects their motivation to face challenges, their decision-making behaviors and their emotional reactions in difficult situations (Bandura, 1986; Carre?, 2004). Perceived self-efficacy has also been related to many personal difficulties such as depression (Dreer, Elliott, Fletcher, & Swanson, 2005; Rivera et al., 2007; Nezu, Kalmar, Ronan & Clavijo,1986), psychosocial impairment (Shan- mugham, Elliott & Palmatier, 2004) and alcoholism (Elliott, Grant & Miller, 2004); it has also been associated with psychological adjustment (Heppner & Anderson, 1985), physical health (Heppner, Kampa, & Brunning, 1987) and personality (D’Zurilla, Maydeu-Olivares & Gallardo-Pujol, 2011). Nurs 6650: Psychotherapy With Groups and Families Study Papers. The well-established links between problem solving self-appraisal and relationship satisfaction have led researchers to investigate problem solving capacities and self-appraisal in relation to coping skills and the marital relationship. These studies were based on the basic premise that, for most people, the quality of their marital relationship is an important predictor of their general well-being (Hertzog, 2011). When facing stressful life events, partners use joint efforts in problem solving interactions and other coping strategies to reestablish satisfaction and maintain marital adjustment. A failure in these cognitive and behavioral adaptation mechanisms often leads to marital distress. Nurs 6650: Psychotherapy With Groups and Families Study Papers. Impact of Group CBT on Marital Happiness and Self-Appraisal 105 Dyadic coping strategies encompass both the cognitive and behavioral components that influence marital satisfaction. Therefore, it is necessary to understand the relationships between the cognitive strategies and so- cial behaviors that partners adopt during their problem solving interactions. If there is such a link, then what is the exact nature of this interrelation, and in what ways do these cognitive (problem solving self-appraisal) and behavioral (problem solving efficacy) strategies influence marital satisfac- tion? The preoccupation with understanding the cognitive and behavioral problem solving determinants of marital adjustment can be found in a lim- ited number of studies that have addressed these particular issues (Baucom & Kerig, 2004). In line with these questions, an investigation in our lab- oratory showed that problem solving self-appraisal differentiates distressed from non-distressed partners (Sabourin, Laporte, & Wright, 1990). Nurs 6650: Psychotherapy With Groups and Families Study Papers.Distressed spouses expressed less problem solving confidence, a stronger tendency to avoid different problem solving activities, and less control over their behav- ior than their non-distressed partners (Sabourin et al., 1990). Another study that was run by the same team (Lussier et al., 1997) examined the rela- tionship between spouses’ attachment styles, coping strategies, and marital satisfaction. These researchers pinpointed many links between attachment strategies, coping skills and marital adjustment. These results are consistent with Bodenmann et al. (2006), who reported several studies showing that positive dyadic coping significantly correlates with a better quality of mari- tal relationship, lower levels of stress and better physical and psychological well-being, and in some studies, these correlations are stronger for women than for men. Kurdek (1991) tried to conceptualize these

Nursing

Stroke/Cerebrovascular Disease Essay Stroke/Cerebrovascular Disease Essay Transient ischemic attack (TIA) This is a short-term decrease in the amount of blood supplied to part of the brain, which restricts the brain’s oxygen supply. This causes symptoms that are similar to those seen in stroke but they are not as long lasting. The person may slur their speech, have a temporary lapse of movement in the face, their arms may be weak or numb and their vision blurred.Stroke/Cerebrovascular Disease Essay These symptoms usually only last for a matter of minutes and TIA is also referred to as a “mini stroke.” Symptoms that do not resolve after 24 hours, however, indicate a full stroke. A person who has experienced a TIA needs to be evaluated and treated as soon as possible to minimize the chance of a further TIA or full stroke occurring. Stroke or cerebrovascular accident (CVA) This is an event that occurs as a result of restricted or blocked supply of blood to the brain. Most commonly, the blockage is caused by a blood clot. Starved of oxygen and nutrients, parts of the brain cells start to die which can cause brain damage or even death.Stroke/Cerebrovascular Disease Essay Related Stories Permalink: https://nursingpaperessays.com/ stroke-cerebrova…ar-disease-essay / Fermented soy products may help you live longer The main points to be aware of in stroke are represented by the acronym FAST where the letters stand for the following: Face – An eye or corner of the mouth may be drooped on one side of the face. A person may drool and have a lack of expression due to paralysis of the facial muscles on one side of the face. Arms – The person may be unable to raise their arms due to paralysis and weakness of the muscles. Speech – Speech may be indistinct, slurred or completely absent. Time – Medical attention must be sought as soon as possible after symptom onset, as the sooner the patient is treated, the more likely they are to recover and not suffer from brain damage. Subarachnoid hemorrhage This is a form of stroke that occurs when leaking blood accumulates on the surface of the brain. The leak is usually caused by an aneurysm rupturing beneath a membrane called the arachnoid, which leads to the accumulation of blood in the subarchnoid space. A subarachnoid hemorrhage can also be caused by a severe head injury or a birth defect that causes arteriovenous malformations.Stroke/Cerebrovascular Disease Essay Vascular dementia Vascular dementia refers to a decline in mental aptitude linked to slowly dying brain cells. Problems with the blood vessels cause a reduced supply of blood to parts of the brain, which become damaged and may eventually die off. Stroke carries a high risk of death. Survivors can experience loss of vision and/or speech, paralysis and confusion. Stroke is so called because of the way it strikes people down. The risk of further episodes is significantly increased for people having experienced a previous stroke. The risk of death depends on the type of stroke. Transient ischaemic attacks or TIA – where symptoms resolve in less than 24 hours – have the best outcome, followed by stroke caused by carotid stenosis (narrowing of the artery in the neck that supplies blood to the brain). Blockage of an artery is more dangerous, with rupture of a cerebral blood vessel the most dangerous of all. Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community. Stroke is uncommon in people under 40 years; when it does occur, the main cause is high blood pressure. However, stroke also occurs in about 8% of children with sickle cell disease.Stroke/Cerebrovascular Disease Essay High blood pressure and tobacco use are the most significant modifiable risks. For every 10 people who die of stroke, four could have been saved if their blood pressure had been regulated. Among those aged under 65, two-fifths of deaths from stroke are linked to smoking. Atrial fibrillation, heart failure and heart attack are other important risk factors. The incidence of stroke is declining in many developed countries, largely as a result of better control of high blood pressure and reduced levels of smoking. However, the absolute number of strokes continues to increase because of the ageing population. Founded in 1907, the University of Pavia’s Clinica Neuropatologica (Clinic for Nervous and Mental Diseases) was created as an institution for the diagnosis and treatment of neuropsychiatric disorders and, in line with what was happening (or would later happen) to similar institutions, it was built outside the complex of the city’s main hospital (the San Matteo Hospital). In the years immediately following its foundation, the institute’s location was actually to prove its fortune, endowing it with those peculiar characteristics and qualities that still today identify it in the minds of the people of the city and province of Pavia; however, as was to prove the case for all clinics similarly located, this circumstance was to end up leaving the institute in “splendid” isolation, excluded from the organisational, and even cultural, developments of more recent years. The move to the new site in via Mondino, a modern and much more comfortable building, was not to succeed in resolving this problem completely, given the institute’s new orientation as, primarily, a hospital health care facility; indeed, as such, it feels acutely, and at times painfully, its isolation from hospitals in which it could fulfil the role that, correctly, is now starting to be envisaged for neurology, today and in the future.Stroke/Cerebrovascular Disease Essay Over time there has emerged a growing contraposition between two different models, or versions, of neurology. On the one hand, we have “academic” (or classical) neurology, which, while boasting a refined diagnostic approach, remains one of the few disciplines using a semiological framework that has moved on very little, if at all, from the body of knowledge of the past century; furthermore, it also has the severe drawback of offering few or no treatment options. On the other hand, we have “emergency” neurology, which, being primarily geared at the management of critical conditions on admission to hospital or during hospitalisation, is deeply integrated with the other (more or less general) medical specialties, and has an operational approach that is at odds with the erudite, sometimes almost philosophical, case discussion that has become a feature of the first “version” of this discipline. The intensive care hospital is the right setting for the practice of emergency neurolo gy, which involves semi-intensive type care and close contact with other intensive and semi-intensive care units and departments, such as the coronary unit and emergency room or accident and emergency department. Operating in this way, the emergency neurology unit is able to “intercept” the neurological needs of patients on their admission to hospital, or at the onset of specific complications in other units of the same hospital. As such, it can be seen as the natural evolution of the model of organisation represented by the stroke unit, which is given over to the diagnosis and treatment of acute cerebrovascular diseases and is a technologically and culturally advanced area for the management of critical neurological conditions that would otherwise have to be treated in non-specialist settings, with all the attendant drawbacks and problems (low diagnostic specificity, more diagnostic tests, longer hospitalisations, uncertain impact of non-specialistic therapies). In view of these considerations, it can reasonably be asserted that stroke care has been the driving force behind the definitive development of (emergency) neurology, given that it is, precisely, changing ideas on diagnosis and treatment that have allowed the transition from a “nihilistic” to an “interventional” approach, characterised by interventions within the very first hours of the acute event, links with emergency services (but also with rehabilitation services) and, finally, the development of management outlooks that are completely new and, above all, geared at reducing mortality and disability, not only from stroke but also from other acute neurological diseases. At the present time, the “classical model” (high specialty) of neurology is still in operation in the Mondino Institute; but alongside it there is also an emergency neurology unit and a neurorehabilitation unit which has close links with a widespread territorial network. In this way the institute is able to offer a complete range of neurological services in line with the direction this discipline is taking.Stroke/Cerebrovascular Disease Essay At first glance, this whole process may seem to have very little to do with the historical figure of Ottorino Rossi and his activities within the University of Pavia. However, in actual fact, in Rossi’s 1906 essay “L’arteriosclerosi dei centri cerebrali e spinali”, which he wrote while still an assistant at the Clinic of Nervous and Mental Diseases of the University of Pavia (directed by Professor Casimiro Mondino), we encounter a rather unusual, or at least unexpected (i.e. not particularly “contemplative”) approach to the problem of cerebrovascular disease, which he interpreted in an essentially anatomopathological way (the only one possible at the time), also identifying some therapeutic possibilities, which were interesting not least because of their scope for further development (1). What Rossi wrote in 1906 is clearly in line with what, in much more recent times, has been written about the approach to cardiovascular and cerebrovascular risk in the atherothrombotic patient. In short, he showed the benefit of a holistic view of the problem and accepted, in part, the more classically cardiological view of the local acute coronary event as a complication of atherosclerotic plaque rupture.Stroke/Cerebrovascular Disease Essay Atherothrombosis is characterised by an unpredictable and sudden disintegration (rupture or fissure) of an atherosclerotic plaque; this causes platelet activation leading to thrombus formation and occlusion of the vessel where the plaque is located. It is the basic condition that determines the events leading to myocardial infarction, ischaemic stroke, peripheral artery disease and vascular death, and it is the final consequence of atherosclerosis, which, instead, develops over a period of several decades. Indeed, although the atherosclerotic process begins in an individual’s late teens or twenties, with the formation of fatty streaks and fibrous plaques, the clinical manifestations of the disease are rarely evident before the age of 40 years. Atherothrombosis is a progressive process over time that affects the entire vascular system; it is potentially fatal and it is unpredictable (as regards both the timing of the clinical event and the long-term outcomes). Rossi’s essay did not fail to point out the pathological complications (or rather consequences) of atherosclerotic lesions of both extracranial and intracranial vessels, and here again it is possible to discern a modern approach to the problem of cerebrovascular disease, i.e. the one that focuses on altered cerebral circulation, whose role is, even today, still not fully and definitively clarified, especially with regard to the possible therapeutic approaches that it might imply.Stroke/Cerebrovascular Disease Essay Leaving aside the obvious differences from extracranial large vessel disease, it is clearly apparent that intracranial vessels are still little studied (especially in acute settings) and rarely considered candidate sites for recanalisation procedures in ischaemic disease (mechanical or pharmacological thrombectomy); above all, no appropriate long-term therapeutic approaches (as valid as those used to treat the same condition in the major vessels) are known. Finally, appealing as the hypothesis is, the role of genetic factors in the phenotypic expression of intracranial disease has not yet been fully identified (and, with it, possible therapeutic approaches). Leaving aside observations that are still in part sub judice, like those on vertiginous syndromes linked to atherosclerosis, Rossi’s essay also introduces the important topic of vascular cognitive decline, in other words the condition that, many years later, was to be sweepingly labelled (albeit, unfortunately, in the absence of diagnostic-therapeutic certainties) “vascular dementia”. As chapter 16 of the Italian SPREAD stroke guidelines (Psycho-Cognitive Complications) (2) clearly shows, vascular dementia can be seen as a condition in which the cognitive decline may result from a range of very diverse pathological conditions. Indeed, there exist various forms of vascular dementia: the multi-infarct form (i.e., related to multiple infarcts, even in different arterial territories, as in the case of cardioembolic stroke); the form associated with a single strategic lesion – this often involves a single acute ischaemic event –, which is characterised by the occurrence of a (sometimes peculiar) cognitive disorder resulting from an injury that interrupts (sometimes permanently) the cortico-subcortical circuits that underlie the major cognitive functions; the form associated with cerebral small-vessel disease; the acute and/or chronic hypoperfusion form, seen prevalently in conditions of chronic hypotension (iatrogenic hypotension, chronic autonomic failure, chronic heart failure) or acute prolonged hypotension (heart or carotid surgery); finally, the haemorrhagic form.Stroke/Cerebrovascular Disease Essay Of all these, the one that has attracted the most interest on the part of researchers in recent years is undoubtedly the “small-vessel disease” form, previously also described as Binswanger’s disease. In reality, the definition “small-vessel disease” includes cerebral white matter disorder characterised by diffuse changes of vascular origin (leukoencephalopathy), or by the presence of diffuse lacunar or microlacunar lesions (most often asymptomatic), or by an association of the two. From the anatomopathological point of view, these structural white matter alterations are underlain by changes in the walls of small cerebral vessels, which lead to the appearance of lipohyalinosis, microaneurysms, microatheromas and even fibrinoid necrosis. These are conditions that can, of course, translate into a clear susceptibility to hypoperfusion phenomena (occurring, for example, as a response to arterial hypertension that would otherwise be harmful to the microcirculation and the cerebral haemodynamic, possibly leading to leukoaraiosis), haemorrhagic lesions (usually detectable on gradient echo MRI or CT as microbleeds, or larger haemorrhagic lesions, as in the case of typical spontaneous intraparenchymal bleeding), or small focal lesions definable as ischaemic lacunar infarcts, whose physiopathogenetic significance and, particularly, therapeutic implications are still debated today. Additionally, of course, cerebral atrophy alone may be present as a possible anatomopathological picture underlying the clinical manifestations of vascular dementia.Stroke/Cerebrovascular Disease Essay All this adds up to a complex morphological picture, in which the clinical features can have very different, or excessively similar, connotations. The differential diagnosis of vascular dementia may have to be made versus other forms of dementia, such as Alzheimer’s dementia, even though numerous clinical and neuropsychological findings seem to clearly differentiate the latter. However, it should not be forgotten that the phenotypic expression of vascular cognitive impairment, too, appears to result from a genetic background that only in some cases corresponds to a monogenic disease (CADASIL, CARASIL, CAA); in other cases it is likely that it is the combination of gene polymorphisms (in themselves insufficient to cause the disease) with vascular risk factors (hypertension, diabetes, smoking, hypercholesterolaemia), and in general with certain environmental conditions, which gives rise to a wide spectrum of clinical conditions. Ottorino Rossi’s descriptions of cases observed at the Clinic for Nervous and Mental Diseases constitute accounts of phenomena that would, many years later, be observed using more appropriate research tools. At the same time, Rossi provided descriptions, even classical ones, of alterations of sensorimotor function possibly dependent on acute-subacute vascular lesions, located both supra- and subtentorially, or in the spinal cord.Stroke/Cerebrovascular Disease Essay Perhaps because it was following in the wake of a method oscillating between clinical observation (necessary and “compulsory”) and instrumental diagnostic investigation, the Clinica Neuropatologica where Rossi conducted his studies did not fail to equip itself, over the years, with a set (initially simple, even minimal) of instrumental tools. This was enriched in more recent times (early 1970s) with the acquisition of a brain CT scanner (the institute was one of the first in Italy to purchase one); this addition was an important step towards better understanding (and, in part, confirmation) of what had previously been described purely on the basis of anatomopathological observations. Attempts to establish a functional approach to vascular pathology Thus, the whole neurology scenario was set to change and, as proved to be the case for all the branches of modern medicine, to do so in an increasingly rapid and specific manner. Moreover, the Pavia Clinica Neuropatologica had, during the ’70s, brought together, under Prof. Kauchtschischvili, a group of young researchers through whom it was ready to take up, once again, the line of investigation concerning, precisely, cerebrovascular disorders and the haemodynamic, degenerative and functional conditions that can cause them. These young researchers included, among others, Giuseppe Nappi, Marco Poloni, Giorgio Bono, Paola Bo, and Gianpaolo Papandrea. Adopting an approach characterised by openness to collaborations outside the institute, a spirit that would continue in the years that followed, they studied, among other things, cerebral transit time with radioactive tracers (in collaboration with A. Favino of the Institute of Occupational Medicine, University of Pavia).Stroke/Cerebrovascular Disease Essay In the early 1970s, this group published papers (3-8) on the influence of smoking and other “harmful” exogenous factors, such as chronic alcohol abuse, aging and induced hypoglycaemia, on the functional status of cerebral circulation. The latter was evaluated mainly using a rheograph, a rather rudimentary instrument from whose results it was easy to intuit the involvement of purely mechanical factors capable of influencing the characteristics of the sphygmic wave which this technique claimed to depict. This instrument was used to photograph a “functional abnormality” – no longer an anatomopathological one (as in Rossi’s times) – in the context of diseases whose evolutionary pattern was already quite easy to understand. This was also the period of pharmacological studies using vasoactive substances such as ergot derivatives (vincamine) in the “treatment” of chronic disorders of cerebral circulation. These studies, in addition to rheography, also used another method that might today be considered “curious”, namely ophthalmodynamometry, i.e. the determination of blood pressure in the retinal artery through the application, to the orbit, of an inflatable balloon in order to determine the disappearance of the pressure wave, and thus the evaluation of “intracerebral” circulation (as well as of the efficacy of possible mechanisms of compensation in the presence of intracranial and/or extracranial vessel disease).Stroke/Cerebrovascular Disease Essay Thanks to the work of the same group, it was not long before these studies of cerebral haemodynamics were embracing other methods, namely the Doppler method and angiography, allowing the description of cases with dolichobasilar and megadolichobasilar artery abnormalities (and also consideration of their possible role in hemifacial spasm, in an early interpretation of what would later more correctly be identified and described as a neurovascular conflict involving the VII cranial nerve) (9,10). At the same time, a National Research Council study – this study was coded ATS-OD2 and its aim was to conduct an instrumental assessment and follow up of patients with cerebrovascular diseases (TIA or minor strokes) observed in the acute or subacute phase – was using methods now fortunately obsolete and long since abandoned, such as EEG recording during carotid compression. This particular application of electroencephalography was, indeed, not free from risks, associated with the possible presence of unstable plaques in the compressed carotid artery. Furthermore, it was not unusual for the sinus stimulation that could derive from this procedure to cause the appearance of a worrying asystole (fortunately short-lasting). Mainly, however, it rarely expressed, in reality, the state of cerebral circulation, and its compensations, following an acute event (11,12).Stroke/Cerebrovascular Disease Essay Finally, following the acquisition of the cerebral CT scanner, this remarkable tool of investigation also began to be applied to clinical research, particularly research into cerebrovascular diseases, both acute and chronic, through investigations geared mainly at defining clinical pictures related to chronic vascular white matter disease and at describing findings that might be considered topical today, given the fresh interest that has been shown in this disease in recent years, in part thanks to the efforts of a large number researchers, both Italian and foreign (13). For both the institute and the working group created over many years and coordinated by Prof. Giuseppe Nappi (who co-authors this article), which was mainly oriented towards the study of functional disorders of the nervous system, particularly headaches, this period also constituted a valuable opportunity to investigate the possible links between headache and acute cerebrovascular episodes, especially minor strokes and those episodes that, at the start of the 1980s, were still known as RIAs (reversible ischaemic attacks).Stroke/Cerebrovascular Disease Essay These investigations of the presence of headache before and/or during and/or after the onset of the ischaemic cerebrovascular symptoms constituted, for the school of the Mondino Institute of Neurology, the moment that marked a real revival of interest in vascular disease in the strict sense, even though some years were still to gothe importance of the categorisation of headaches as the point of transition between affective and cerebrovascular disorders, which, unlike the former, are hallmarked by the final (ischaemic) damage. Indeed, it is always a predisposition to develop headache that, depending on risk factors that are linked to aspects of the internal and external environment, underlies the appearance of the “complication”, and can be inserted among the comorbidities of the two classes of disorders that lie at the two ends of the spectrum.Stroke/Cerebrovascular Disease Essay There was, in this period, no lack of experimental models simulating the relationship between migraine and vascular disease, a relationship demonstrated, for example, in the response of the cerebral endothelium to nitrates, which are known for their headache-inducing effect and also provide a reliable measure of cerebral vascular reactivity both in physiological and in pathological conditions (diabetes, carotid stenosis, etc.). A similar experimental model allowed the Mondino group to discover the clinical relevance of the use of NO donors, both in acute and in chronic cerebrovascular disease, especially in patients with traditional risk factors, such as diabetes and hypertension (16,17). In short, the study of cerebrovascular diseases by the Pavia neurological school was well under way again, as is shown by the fact that, from its use of models, both clinical and speculative, borrowed from other interesting diseases such as those affecting the autonomic nervous system (investigated at length in this period, also within the context of various forms of primary headache), it succeeded in making connections that are still very much appreciated today; these include the interesting and useful relationship, supported by a more recent review published in Clinical Autonomic Research, between the autonomic nervous system and ischaemic stroke. Discussion of the activity of the autonomic nervous system was still serving to complement and enrich epidemiological, clinical and/or therapeutic data, providing some very interesting interpretations of pathological events that, in some cases, prompted the opening of new lines of research in the field (17,18).Stroke/Cerebrovascular Disease Essay The relationship between the autonomic nervous system and stroke is perhaps best enshrined in a very common and increasingly frequent condition (not only among the elderly), namely, atrial fibrillation which, of course, particularly with advancing age, can cause stroke (cardioembolic). However, there exist many other relationships between ischaemic (or haemorrhagic) cerebrovascular disease and changes in vegetative functions. It was for these reasons that the Pavia neurological group, in conjunction with a group of Pavia cardiologists, founded the Italian Society of Cardioneurology, through which, in 1989, an international meeting was organised in Palmi Calabro (Reggio Calabria) which brought together specialists in both disciplines from every part of the world, and came shortly after another interesting meeting held in Pavia (19). The proceedings of this international meeting were published in the book “Neurocardiology Update” (20).Stroke/Cerebrovascular Disease Essay A stroke unit is established at the C. Mondino Foundation It was in the early nineties, when the institute was still located at the old site in via Palestro, that we began to develop the necessary know-how, cultural, scientific and organisational, to care for cerebrovascular patients, sometimes in the acute phase. The work, in those early years, was done without a dedicated area. In other words, it was carried out, within the various departments, by an “itinerant” medical team (stroke team). In this period, initial ideas began to take shape on the organisation of what, in 1996, was to become one of Italy’s first stroke units. An area for this unit was selected: one of the large rooms (traditionally occupied by as many as 13 beds) located within the department, at the time directed by Prof. Nappi, was transformed into anopen space designed to accommodate six closely monitored beds, a nursing area and a specially equipped bathroom. Outside the department, in what had previously (in the old Clinica Neuropatologica) been the “verandah”, i.e. the space given over communal activities, including meals, a small area was created to house the computer equipment. Its purpose was to collect data from the stroke unit monitors, as well as from the computerised patient records that were gradually being introduced in this period, and from nursing folders. This use of advanced IT solutions and software revolutionised many aspects of the care of cerebrovascular patients in our stroke unit (workflow management, compliance with Italian SPREAD guidelines, assessment of clinical risk, and so on).Stroke/Cerebrovascular Disease Essay The stroke unit was enthusiastically welcomed by the nursing staff, some of whom still work there today (the unit was transferred to the institute’s new site in 2003), as well as by the physicians and all those who, over the years, have made a crucial contribution to the work done there (rehabilitation therapists, physiotherapists, psychologists, social workers and bioengineers). Its inauguration provided the opportunity for a congress, held at the “old” Mondino site, which was attended by the specialists (vascular surgeons, neurosurgeons and others) who, with sacrifice and enthusiasm over many years of joint collaboration, had taken part in all the work on cerebrovascular diseases (21). The stroke unit, thanks to its well-known organisational and management features, was a setting ideally equipped for ensuring accurate identification of a patient’s risk profile, continuous monitoring of vital signs, prompt therapeutic interventions in response to neurological and/or medical complications, standardisation of specific treatment procedures for stroke, and effective and rapid multidisciplinary consultations.Stroke/Cerebrovascular Disease Essay At the same time, it opened the way for the development of management models for improvement of nursing and for initiatives geared at involving, and raising awareness among, the general public; examples in this regard include information campaigns carried out first in the province of Pavia and then at regional level (PRESTO and ASL MI2 projects), and projects developed for the Ministry of Health (on more advanced and effective computer-based models of care). The intensive work carried out in recent years in the sphere of information, aimed both at the public and, in particular, at patients and their families, is illustrated by the publication (in early 2003) of the booklet entitled “The stroke patient: what do I do when he comes home?” This booklet, born of the collaboration between all the professionals who took part in the information campaigns held at provincial level (especially those organised in rehabilitation centres), was published in no less than 100,000 copies and quickly became a “must” from which many other healthcare professionals have drawn inspiration for similar initiatives.Stroke/Cerebrovascular Disease Essay Similarly, the intensive and enthusiastic collaboration with the Department of Computer Science and Systems Engineering of the University of Pavia (in particular with the late Mario Stefanelli, and with Silvana Quaglini and Silvia Panzarasa, among others) allowed us to develop and test some extremely interesting management models (22). The Pavia group came to international renown through its study and demonstration of the important benefits to be obtained from adherence to guidelines (first those of the AHA and then the Italian SPREAD guidelines), namely reduction of mortality and disability as well as of hospitalisation costs. The collaboration with this group led to the development of computerised medical record systems equipped with software, such as that for assisted clinical decision-making (workflow management), whose applications continue to be used in both the nursing and the medical areas. At the same time, the capacity, thanks to the computer systems used, to store numerous data has allowed us to publish some extremely interesting studies, including one on the importance of monitoring in the care of the acute cerebrovascular patient (23). The up-to-date models developed and the results obtained have allowed the centre based at the C. Mondino Institute to be among the first and the most advanced stroke units in Italy, and also to participate (as the only Italian centre) in the Stroke Unit Trialist Collaboration, coordinated by Peter Langhorne.Stroke/Cerebrovascular Disease Essay The experience gained through these projects, as well as through the everyday care of the patients regularly referred to the stroke unit (both at the “new” and the “old” site) – in spite of the absence, already noted, of an accident and emergency department –, contributed, in the early 2000s, to the development of regional health care models. These models were finalised after the important PROSIT project (the first author of this piece was also a member of the scientific committee of that project, coordinated by Livia Candelise, Milan, which demonstrated the superiority of the stroke unit compared with traditional departments: a net reduction [9%] of mortality and disability), and included the stroke unit in the Lombardy Regional Health Plan 2002-2004, in the subsequent regional “Cardiocerebrovascular Plan”, and in the documents of the regional Cardiocerebrovascular Commission. All this led to decisions, at regional level, of great importance from the perspective of the organisation of stoke units and their integration with emergency and rehabilitation services (24-26).Stroke/Cerebrovascular Disease Essay A stroke registry

NURS 6231 – Healthcare Systems and Quality Outcomes Case Study NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Healthcare Outcome Measures Explained There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension to patient-reported outcome measures (PROMs). The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Permalink: https://nursingpaperessays.com/ nurs-6231-health…comes-case-study / #1: Mortality Mortality is an essential population health outcome measure. For example, Piedmont Health care’s evidence-based care standardization for pneumonia patients, resulted in a 56.5 percent relative reduction in the pneumonia mortality rate. #2: Safety of Care Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-acquired infections (HAIs) are common safety of care outcome measures: Skin breakdown—happens when pressure decreases blood flow to the skin. A skin assessment tool can be used to reduce skin breakdown. Patients with skin breakdown are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for example, because their circulation is poor. HAIs—caused by viral, bacterial, and fungal pathogens. For example, Texas Children’s Hospital identified evidence-based bundles to reduce HAIs in children through their partnership with the Solutions for Patient Safety National Children’s Network. Using an enterprise data warehouse (EDW) and analytics applications to identify vulnerable patients and monitor clinicians’ compliance with best practice bundles, Texas Children’s Hospital decreased HAIs by 35 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #3: Re admissions Readmission following hospitalization is a common outcome measure. Readmission is costly (and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions. After increasing efforts to reduce their hospital readmission rate, the University of Texas Medical Branch (UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate, resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by implementing several care coordination programs and leveraging their analytics platform and advanced analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #4: Patient Experience Patient-reported outcome measures (PROMs) fall within the patient experience outcome measure category. According to the Agency for Clinical Innovation (ACI), PROMs “assess the patient’s experience and perception of their healthcare. This information can provide a more realistic gauge of patient satisfaction as well as real-time information for local service improvement and to enable a more rapid response to identified issues.” For example, a patient might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they received. Patient experience may also be used as a balance metric for improvement work. For example, a care delivery process may decrease the LOS, which can be a positive outcome, but result in a decreased patient satisfaction score if patients instead feel they are being pushed out.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #5: Effectiveness of Care Effectiveness of care outcome measures evaluate two things: Compliance with best practice care guidelines. Achieved outcomes (e.g., lower readmission rates for heart failure patients). Given the rapid changes that occur within healthcare, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance with care guidelines; It’s equally important to monitor treatment outcomes and alert clinicians when care guidelines need to be reviewed. Failing to adhere to evidence-based care guidelines can have negative consequences for patients. For example, according to The Dartmouth Atlas of Healthcare, “even though it is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack, many heart attack patients are never prescribed beta-blockers.”NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #6: Timeliness of Care Timeliness of care outcome measures assess patient access to care. Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients. A community hospital system implemented an improvement process to address overcrowding in its ED after determining that approximately 4,000 patients were leaving its ED each year without being seen. They leveraged their analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse, and early access to a qualified medical provider. They achieved significant performance improvements, including an 89 percent relative reduction in the rate of patients that left without being seen, with current performance at 0.4 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The efficient use of medical imaging is an increasingly important outcome measure. According to the European Science Foundation, “Medical imaging plays a central role in the global healthcare system as it contributes to improved patient outcome and more cost-efficient healthcare in all major disease entities.” For example, during Texas Children’s Hospital’s efforts to improve asthma care it discovered a high volume of chest X-rays being administered to asthma patients. Using its EDW to examine real-time X-ray data, it realized clinicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas Children’s Hospital’s IT team traced the problem to a faulty order set within the hospital’s EHR, and rewrote the order set to reflect the evidence-based best practice.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Process Measures Are Equally Important Achieving outcomes is important, but the process by which health systems achieve outcomes is equally important. Process measures capture provider productivity and adherence to standards of recommended care. For example, if a health system wants to reduce the incidence of skin breakdown, then it might implement the process measure of performing a risk assessment using the Barden Scale for reducing pressure ulcer risk in all the appropriate units in the hospital. If health systems are too focused on an outcome, then they lose sight of the process. The following outcome and process measures illustrate how systems can improve healthcare outcomes by improving processes:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Conducting a medication reconciliation system check with heart failure patients at the time of discharge (process measure) can reduce heart failure readmission rates (outcome measure). Performing a fall risk assessment on a patient at the time of admission (process measure) can reduce fall rates (outcome measure). Using a skin assessment tool (process measure) can prevent skin breakdown (outcome measure). Three Essentials for Successful Healthcare Outcomes Measurement Among every health system’s goals is to improve patient outcomes. But outcomes improvement can’t happen without effective outcomes measurement. As health systems work diligently to achieve the Quadruple Aim, they need to prioritize three outcomes measurement essentials: transparency, integrated care, and interoperability. Used in tandem, these essentials improve and sustain outcomes measurement efforts by creating a data-driven culture that embraces data transparency, an integrated care environment that treats the whole patient and improves critical care transitions, and interoperable systems that enable the seamless exchange of outcomes measurement data between clinicians, departments, and hospitals.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #1: Data Transparency Healthcare is on a journey to outcomes transparency. Patients rely on outcomes data to make educated decisions about their healthcare. Quality reporting organizations, such as The Leap Frog Group, evaluate and report on U.S. hospital safety and quality performance. Patients want reassurance that they’re receiving the best care for the lowest cost. Publicly reported healthcare outcomes help do just that. #2: Integrated Care and Transitions of Care The industry is also shifting toward integrated care—hospitals aren’t just treating a hip anymore; they’re treating the whole person. A key component of integrated care is helping patients with transitions: easing patient transitions from the ER, to surgery, to inpatient care, to rehab, and, ultimately, back to a steady, normal state. Transitional points of care are critical for managing consistency of care and providing the right care in the right setting at the lowest cost.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #3: Data Interoperability Sharing data between departments within an integrated system is another important component. Outcomes measurement and improvement depends on the system’s ability to share data across clinicians, labs, hospitals, clinics, pharmacies, and other staff, departments, and settings. EDWs improve interoperability by integrating data and providing a single source of truth. Improving critical care transitions through integrated care and seamlessly exchanging data through interoperability are essential ingredients for better outcomes measurement. For example, as heart failure patients are discharged (depending on the risk stratification), it’s critical for them to see a cardiologist or primary care physician as quickly as possible. Otherwise, they have a higher risk of being readmitted.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The Quadruple Aim: The Goal of Outcomes Measurement Outcomes measurement should always tie back to the Quadruple Aim, so healthcare organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality and improving the care experience at the most efficient cost. Health systems measure outcomes to ensure they are delivering the best care for patients and providing a transparent, efficient, and accessible environment for all healthcare providers. That is outcomes nirvana. Policies to improve population health have often focused exclusively on the expansion of access to basic health services, to the neglect of quality of care. Efforts to increase the demand for priority interventions have implicitly assumed that the care available is of sufficient quality or that, with the expansion of coverage, quality will naturally improve.1 However, such assumptions may be incorrect. There is growing recognition that people may be acting in a perfectly rational way when they avoid using health services of poor quality and that poor quality of care can be a barrier to universal health coverage independent of access.2NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The aim of many strategies to improve health-care quality has been to ensure that essential inputs – e.g. technology, operational facilities, pharmaceutical supplies and trained health workers – are in place.3 Many such strategies have focused on the supply side and been designed to support the provision of services according to clinical guidelines.4 The acknowledgement that quality improvement approaches should be applied within patient-centered models of care is relatively recent.5 In this paper we seek to unpack complexities around quality of care and identify strategies for improving the measurement of such quality. An understanding of these issues could inform pragmatic strategies for the analysis and measurement of quality of care. We draw on research conducted in a variety of low- and middle-income countries and identify areas of inherent complexity that require further in-depth research. In doing so, we reflect on what is meant by quality of care and how perceptions and understanding of quality of care influence health systems and effect the measurement of quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study We have identified and structured our discussion around six conceptual and measurement challenges. First is the recognition that, even though they may not reflect actual quality, perceptions of the quality of care are an important driver of care utilization. Second, a patient’s experience of quality must be conceptualized as occurring over time. Third, responsiveness to the patient is a key attribute of quality. Fourth, so-called upstream factors – e.g. management at facility and higher levels – are likely to be important for quality. Fifth, quality can be considered as a social construct co-produced by different actors. Finally, there are substantial measurement challenges that require the adaptation and improvement of current approaches. The classic framework on quality of care developed by Donabedian makes the distinction between structure, process and outcomes.6 More recently, the Institute of Medicine in the United States of America (USA) has unpacked the concept further and suggested that efforts to improve care quality should be focused around six aims: effectiveness, efficiency, equity, patient-cent redness, safety and timeliness. We do not seek to propose a new framework for understanding quality. Rather, we highlight some key issues that deserve more consideration in debates about enhancing the accessibility and quality of care. Building on our experiences of doing empirical research in low- and middle-income countries, we present several insights that are complementary to existing, comprehensive frameworks of quality of care and may be absent from current debates.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Clinical quality Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes. The care provided should be effective, evidence-based and neither underused nor overused.7 The concept of clinical effectiveness tends to shift attention away from inputs such as drugs and equipment and towards the process of care.6,8 While relatively easy to measure, the availability of inputs cannot generally be used in isolation to determine if a patient’s health is likely to improve as a result of the care received.9 Clinical processes are directly attributable to the behaviour of health-care providers and their measurement can provide a critical starting point in the development of methods to improve care received by patients. Although health outcomes can be informative, they are only likely to be a crude measure of quality because of the inherent unpredictability in patients’ responses to health care.9NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Assessment of the clinical quality of care poses several conceptual and practical challenges. It requires a strong evidence base that can act as a benchmark against which to evaluate interventions. In high-income countries, treatments received can be compared with the treatments recommended in national guidelines. In many low- and middle-income countries, however, such guidelines are either not available or poorly enforced. Even when such guidelines are present, the evaluation of what constitutes the over provision of care is not clear-cut and requires careful judgement. Although harmful care should be distinguished from unnecessary care, such categorization can be difficult in practice. Care for a single patient may be provided over the course of numerous interactions by a large team of health professionals. In such circumstances, measurement of the quality of care often focuses on a small number of distinct interventions with proven efficacy.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study There are several well-known practical challenges to the assessment of the clinical quality of care. For example, it may not be possible to observe the interactions between patients and their physicians and, when they are possible, such observations can generate bias through the Hawthorne effect, i.e. health-care providers change their behaviour when observed.10 In low- and middle-income countries, medical records are often poorly maintained and may not reflect actual practice. The use of so-called undercover or standardized patients in the assessment of clinical care may raise ethical concerns,11 is generally limited to non-invasive conditions12 and is not a practical solution to the routine measurement of quality.9 Despite these challenges, an influential literature on the clinical quality of care in low- and middle-income countries is emerging.2,13NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Perceived quality Attempts to improve the quality of care have often been underpinned by a biomedical understanding of quality – i.e. the conceptualization of a gold standard of quality guided by clinical guidelines – that can lead to a narrow focus. Provider practices tend to vary despite the existence of accountability procedures and guidelines.14 Interventions may not be implemented as intended or easily accommodated within established models of care.15 Clinical quality is important for patient outcomes but perceptions of the quality of care – which may not correlate with actual quality – are likely to be the key drivers of utilization.16,17 Patients may also find it difficult to evaluate the quality of care because they lack their physician’s medical expertise and training.18,19 In South Africa, a key motivating factor in patients’ travel to access health services – including travel across borders – was found to be the patients’ perceptions of the quality of health services.20 Patients may sometimes believe an ineffective and unsafe treatment to be good, even when they have access to effective and safe treatments. In Malaysia, for example, many people with hypertension seek potentially ineffective and unsafe treatments from traditional practitioners.21 Perceptions of the quality of care are based on a mix of individual experience, processed information and rumor. In Uganda, perceptions of the quality of the care that was locally available were found to have persuaded many women to seek maternal care away from their local area – apparently regardless of the availability of transportation and the distances involved.22 In Bangladesh, despite a nationwide expansion in the network of health facilities, facility-based deliveries remained rare and most women still attempted to give birth at home or, in the case of complications, at distant periurban health cent res that the women believed to offer care of higher quality than that available at the community facilities closest to their homes.23,24 Patients’ trust in services has been shown to be an important element of perceived quality.25NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Perceptions of the quality of care may relate entirely to non-clinical factors. For example, criminalized or marginalized populations – e.g. some ethnic or sexual minorities – may judge the quality of care only according to the extent that the care environment is non-discriminatory or supportive.26 In Zambia, many patients considered public-sector clinics supported by one particular nongovernmental organization to be better than other public-sector facilities that apparently provided the same standardized package of care.27 The effect of perceived quality is not limited to delivery models. Among remote rural populations in Armenia, there was disappointingly low participation in community-based health-insurance schemes because the quality of the care provided by the schemes was perceived to be low. Despite the often high out-of-pocket costs, most people in the communities covered by the schemes preferred to use district-based clinics and hospitals – where they believed the quality of care to be higher than in the facilities covered by the schemes.28 Although quality is a construct largely based on individual subjective perceptions, such perceptions are shaped by collective and traditional beliefs and peer influences. While improving or, at least, maintaining the actual quality of the care they provide, health systems need to address – and ultimately close – the gap between perceived and actual quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Quality as a process There is a temporal dimension to both clinical and perceived quality. Although the Donabedian framework recognizes the importance of understanding the process of care,6,8 the quality of care may often be assessed in just a single encounter or illness episode. However, individual treatment for most diseases is not a one-off event but a succession of treatment episodes. Patients’ perceptions of quality may develop over time, as the different attributes of the services available and their outcomes are revealed. Waiting times and staff attitudes may be perceived rapidly. However the patient’s experience of clinical treatment, e.g. surgery, and its implications for subsequent care, e.g. frequent check-ups, and health outcomes, e.g. potential complications, may carry on developing over months or years. Patients may only become sensitized to the benefits of having a dedicated provider and effective follow-up after they experience the absence of such benefits. Easy-to-navigate pathways to care and continuity are critical to how patients perceive the quality of care and choose whether to continue treatment or not.29 Long-term compliance is only likely if the patients involved consider their care to be of good quality. Such compliance is a particular challenge in the monitoring and treatment of chronic noncommunicable diseases and human immunodeficiency virus, especially for the under-resourced health systems of low- and middle-income countries.30–33NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Responsiveness While The World health report 2000. Health systems: improving performance34 defined responsiveness to people’s non-medical expectations as a key health-systems goal, the relationship between responsiveness and quality has rarely been discussed. Although ability to book an appointment, confidentiality, privacy, respect shown by staff and waiting times are not service attributes that are clinically necessary, they may all influence patients’ perceptions and their willingness to return for – or adhere to – treatment. At a broader level, responsiveness involves respect for cultural needs and the preferences of specific patient groups – e.g. ethnic, gender and sexual minorities and migrants. The relationship between health workers and their patients often develops over time and multiple episodes of care. As levels of trust and mutual understanding increase, responsiveness and the patients’ perceptions of the quality of their care often improve.35 Although responsiveness to need is often consistent with good clinical practice, it represents an added layer in the patients’ perceptions of quality. In one South African study, women appeared to have been given greater access to public maternity wards but it was the verbal abuse that the women often suffered on such wards that largely shaped the women’s poor perceptions of the care that they had received.36NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Upstream factors The patient–provider interaction is likely to be influenced by governance and management practices at national, sub national and facility levels. The results of studies in the United Kingdom of Great Britain and Northern Ireland and the USA have demonstrated the key importance of management in ensuring care of high quality.37 In low- and middle-income countries, however, there appears to have been little consideration of the role of management practices – especially at district or facility level – in influencing the quality of care. There is increasing recognition that health professionals do not act in isolation and that governance, management and structural factors also determine the performance of health systems.38,39NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Even when front line providers do have substantial discretion in their interpretation of regulations and freedom to adapt treatment protocols, their actions may still largely depend on upstream factors related to institutional capacity, legal sanctions and professional norms. A study of tuberculosis cases in Samara, in the Russian Federation, revealed that while entry to the care system was relatively easy and formally free and pharmaceuticals were highly subsidized, some cases from marginalized groups – e.g. former prisoners, migrants and people not registered with the authorities – still avoided treatment because of perceived discrimination, loss of social status and stigma.40 Both behavioral and structural factors can be important when assessing perceived quality of care. Quality as a social construct Assessment of quality of care in low- and middle-income countries is frequently conducted at the individual level by using various tools – e.g. clinical observations, exit and in-depth interviews, extraction of medical records, role-playing vignettes and standardized patients, designed to assess both patients’ experiences and technical quality. However, social networks influence perceptions relating to both health services and illness.41 Therefore, for a comprehensive investigation of the development of the general public’s and patients’ perceptions of the quality of care, we need to examine community and family values.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study In many situations, patients may have responses to a health provider’s actions and, similarly, providers may adapt their responses to patients to suit social norms.42 For example, a patient may be recommended a clinical investigation and they may either agree to be investigated – e.g. if the proposed investigation is offered by a provider trusted by the patient’s social network – or they may exit the system and seek care elsewhere, e.g. from a more trusted traditional practitioner. Such responses may be considered as a social relationship that can happen in formal care settings, or elsewhere. Perception of quality can also be shaped by power relationships in society. In a study in the Russian Federation, the women most likely to undergo pregnancy-related procedures were found to be the relatively young and poorly educated. Although such women were relatively poor and therefore found it particularly hard to pay for their care, they appeared to be given little choice – possibly because of their relatively low social status and inability to negotiate care that was commensurate to their needs.43 Similar discrepancies between what health professionals felt would improve the quality of care for non-compliant patients and those patients’ preferences and wishes were observed in a study of tuberculosis cases in India. In that study, the number of treatment choices offered was found to be positively correlated with social status.44NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Measurement challenges In light of the above discussion, there is a case for taking a broader perspective when measuring quality of care. Although this has been recognized by the World Health Organization’s monitoring framework for universal health coverage45 – which considers effectiveness of treatment, patient safety, people-cent redness and the level of integration of health services as key dimensions – the focus of recent assessments of the quality of care has been on indicators of health-service coverage.45,46 We suggest that, for a comprehensive and detailed assessment of the quality of health services, both clinical and perceived quality of care need to be evaluated and then compared (Box 1). Alongside technical measures of quality, attention should be given to manifestations of quality – e.g. acceptability, cultural appropriateness and responsiveness. Strategies to improve clinical quality only have the potential to increase demand for care if the general public’s perceptions of the quality of the care available also improve.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Box 1. Principles for measuring the quality of health care Measure aspects of care that go beyond technical quality, e.g. responsiveness, acceptability and trust. Measure perceived quality and compare with clinical quality. Measure quality at different points in the patient pathway through the health system. Measure the immediate and upstream drivers of quality of care. Measure collective and individually assessed quality and its relationship to power, social norms, trust and values. Any evaluation of the overall quality of care needs to consider a patient’s experience of quality as a cumulative process. Changing patterns of illness and increasing numbers of treatment options mean that an increasing amount of health care involves a sequence of interlinked contacts – with a range of health professionals at different levels of the health system – over a lengthy period.47 A patient’s perceptions may vary widely as treatment follows diagnosis and follow-up follows treatment, with each stage potentially affecting the patient’s subsequent choices. By measuring clinical and perceived quality at each key step in this continuum of care, it should be possible to generate a better, more nuanced understanding of how patients interact with health systems.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study A growing body of work focusing on measures of patients’ perceptions now exists. To understand these perceptions more holistically, qualitative methods need to become an integral part of quality assessments. In such assessments, theory-driven hierarchical models can be useful in generating propositions to guide empirical research or help deepen interpretation.48 Mid-range program me theories48 and open-box evaluations49 have also been useful in examining why and how particular health program mes work. Although the measurement of indicators that are rapidly observed by patients seeking care – e.g. staff attitudes and waiting times – can be useful, it is important to delve deeper and study how upstream factors, such as management practices, matter – e.g. by influencing staff morale. Use of carefully selected proxies for quality of care and comparison of findings generated through different methods may help to inform pragmatic intervention strategies. Finally, assessment of individual perceptions of the quality of care and examination of how such perceptions are rooted in community, family and societal expectations, norms and values may offer a promising way forward. Perceived quality may correlate closely with the expectations and social status of the users themselves, the circumstances in which the users obtain care and/or the levels of community cohesion and resources that enable collective action. Although the inclusion of contextual variables and appropriate units of observation for studying community and social group-level characteristics may be methodologically challenging, it is important for understanding individual choices and perceptions.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Conclusion Recognition of the multifaceted nature of the quality of care is critical for scaling up priority health interventions. If uptake of health services is to be increased, we require not only better technical quality but also better acceptability and patient-cent redness – across the continuum of care. Perceptions of quality are shaped by interconnected community, health-system and individual factors. Moreover, quality of care cannot be understood f

Nursing

NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Permalink: https://nursingpaperessays.com/ nurs-6230-case-s…n-research-paper / ? Few people have had more influence on the science and practical application of process management than Dr. W. Edwards Deming. His impact on the automotive industry is legendary, and many other industries have tried with varying degrees of success to implement his principles as well. For years I have followed and admired those that have tried to bring his quality improvement processes to healthcare. I strongly believe that healthcare has much to gain by successfully implementing key Deming principles. Let me share five principles that I believe can make the biggest difference in healthcare process improvement.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 1. Quality improvement is the science of process management. When Deming and others developed their approach to modern quality improvement in the 1940s, they were basically developing a way for modern organizations to deal with the complex challenges that were confronting them. The approach they developed to improvement was remarkably simple, yet extraordinarily powerful. It’s centered on the fact that quality improvement is really about process management. These quality improvement concepts and techniques have been used to transform almost every major industry in the world with dramatic results. The last holdouts, the last passions of resistance, are primarily healthcare, higher education, and government. Now, it’s happening to healthcare. I believe higher education is imminent; it’s anyone’s guess whether government will ever succumb to these forces.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Now, we all know healthcare is very complex, but it’s not fundamentally different from other industries. Healthcare simply consists of thousands of interlinked processes that result in a very complex system. If we focus on the processes of care one at a time, we can fundamentally change the game and deal with the challenges facing healthcare. Now, this may seem like a tall order, but the Pareto principle tells us that there are probably 20 percent of those processes that will get us 80 percent of the impact. So, the challenge of every organization is to identify that 20 percent, roll up their sleeves, and begin the important work of addressing those challenges.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 2. For quality control in healthcare, if you cannot measure it—you cannot improve it. Deming clearly understood the importance of data. Meaningful quality improvement must be data-driven. This is particularly true for quality control in healthcare. You’re basically dead in the water if you try to work with healthcare providers and you don’t have good data. I think everybody recognizes that. Deming said, “In God we trust…and all others must bring data.” I love this quote because it reflects that reality. I’ve had physicians during my career tell me pretty much the same thing, only they’re not quite so polite. They basically say, “Dr. Haughom, John, get lost! Bring the data. And then we’ll decide if we believe it.” So, data is critical if we’re going to have a meaningful impact in healthcare. 3. Managed care means managing the processes of care, not managing physicians and nurses.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper An important application or clarification of a Deming principle was put forward by my good friend, Dr. Brent James. Managing care means managing the processes of care. It does not mean managing physicians and nurses. What James said is very true. One of the big mistakes made in the 90s with the managed care movement was naively thinking that managing care meant telling physicians and nurses what to do. The reality is that you need to engage clinicians in the process because they understand the care delivery process and they are best equipped to figure out how to improve the process of care over time. And for this reason, I strongly believe that these changes will, in fact, ultimately be very empowering for all clinicians who try to get involved.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper 4. The right data in the right format, at the right time, in the right hands. If clinicians are going to manage care, they need data. They need the right data delivered in the right format, at the right time, and in the right place. And the data must be delivered into the right hands—the clinicians involved in operating and improving any given process of care. 5. Engaging the “smart cogs” of healthcare. If quality improvement is going to work in healthcare—if we are going to realize value—it means we must engage clinicians. To use Deming’s term, clinicians are healthcare so-called “smart cogs.” They are the front line workers who understand and own the processes of care. And as I said in an earlier slide, we’re very fortunate in healthcare because we have a workforce dominated by clinicians who are extraordinarily committed, very intelligent, and highly educated.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper But we live in a pristine time. I once received from an email from a fellow physician leader at a leading national delivery system. I’m going to withhold the name of the delivery system, but I can tell you that if you ask knowledgeable people to list of top 10 delivery systems in the country, almost everyone would put this organization on their list. Despite that, this physician wrote to me lamenting how difficult it was for him to get his peer physicians to see a new future. And in his email, he succinctly described the problem by saying that his physicians were “historically encumbered and demoralized.” And I love the succinctness of his description because what he is basically saying is they’re clinging to the past and are demoralized because they don’t see a new future. And in that short phrase, this very excellent physician leader pretty much encapsulated the problem and points us towards the solution. Basics of Quality Improvement Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper A variety of approaches—or QI models—exist to help you collect and analyze data and test change. While it’s important to choose a reputable QI model to guide your efforts, it’s more important that you fully commit to using the QI process and good QI practices. Benefits of QI Understanding and properly implementing QI is essential to a well-functioning practice, and is necessary for any practice interested in improving efficiency, patient safety, or clinical outcomes. In addition, good QI practices and improved patient outcomes position your practice for success by: Helping you prepare for the transition to value-based payment models. Allowing you to participate in the public reporting of physician-quality data. Giving you the opportunity to participate in the federal Quality Payment Program (QPP) following one of two tracks: the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM). Equipping you with the skills necessary to apply for and complete national recognition programs, such as National Committee for Quality Assurance’s (NCQA) Diabetes, Heart/Stroke, and patient-centered medical home (PCMH)-recognition programs.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Helping you earn Family Medicine Certification-Performance Improvement activity credit (formerly Maintenance of Certification) requirements. The AAFP’s Office Champions Project are an example of QI demonstration projects in which participating family physician practices select staff and physician office champions to lead the implementation of an intervention. Read the results: Child and Adult Immunization(794 KB PDF) Treating Tobacco Dependence Practice Manual Tobacco Cessation 2013(15 page PDF) Quality Improvement Basics The QI process is grounded in the following basic concepts: Establish a culture of quality in your practice. Your practice’s organization, processes, and procedures should support and be integrated with your QI efforts. The culture of a practice—attitudes, behaviors, and actions—reflect how passionately the practice team embraces quality. The QI culture looks different for every practice, but may include establishing dedicated QI teams, holding regular QI meetings, or creating policies around your QI goals.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Determine and prioritize potential areas for improvement. You will need to identify and understand the ways in which your practice could improve. Examine your patient population (e.g., to identify barriers to care, frequently diagnosed chronic conditions, or groups of high-risk patients) and your practice operations (e.g., to identify management issues such as low morale, long patient wait times, or poor communication). Use established quality measures, such as those from the National Quality Forum(www.quality forum.org), Agency for Healthcare Research and Quality(www.quality measures.ahrq.gov), and the Quality Payment Program(qpp.cms.gov) to guide your efforts. Collect and analyze data. Data collection and analysis lie at the heart of quality improvement. Your data will help you understand how well your systems work, identify potential areas for improvement, set measurable goals, and monitor the effectiveness of change. It’s important to collect baseline data before you begin a QI project, commit to regular data collection, carefully analyze your results throughout the project, and make decisions based on your analysis.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Communicate your results. Quality improvement efforts should be transparent to your staff, physicians, and patients. Include the entire practice team and patients when planning and implementing QI projects, and communicate your project needs, priorities, actions, and results to everyone (patients included). When a project is successful, celebrate and acknowledge that success. Commit to ongoing evaluation. Quality improvement is an ongoing process. A high-functioning practice will strive to continually improve performance, revisit the effectiveness of interventions, and regularly solicit patient and staff feedback. Spread your successes. Share lessons learned with others to support wide-scale, rapid improvement that benefits all patients and the health care industry as a whole. Quality Improvement Models and Tools Quality improvement models present a systematic, formal framework for establishing QI processes in your practice. Examples of common QI models include the following: Model for Improvement (Plan-Do-Study-Act [PDSA] cycles)(www.ihi.org): The Institute for Healthcare Improvement’s Model for Improvement combines two popular QI models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI). The result is a framework that uses PDSA cycles to test interventions on a small scale. Six Sigma(asq.org): Six Sigma is a method of improvement that strives to decrease variation and defects.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Lean(www.ihi.org) is an approach that drives out waste and improves efficiency in work processes so that all work adds value. Five top challenges affecting healthcare leaders in the future Healthcare is a big topic which presents even bigger challenges for healthcare leaders. For centuries there has been much debate about how best to implement affordable healthcare coverage for millions of uninsured Americans has taken center stage in the political arena (Wood, 2011). Today’s leaders are hard pressed to find solutions to multiple complex issues which impacts the ability to successfully implement cost-effective programs, maintain efficient operations and services, staff and trained employees, and support other healthcare initiatives. The future of organizational entertainment in healthcare requires skilled leaders to plan for any potential problems. Over the next five to ten years, healthcare leaders should expect to encounter a plethora of challenges including regulatory and policy changes; medicinal and technological advancements; funding; education; and ethical issues. Leaders must realize a combination of these challenges could quickly consume time and money for medical research, facility upkeep, equipment overhaul, and operational training. Research suggests technological advancements will present additional challenges with programming, control, and support issues. Indoctrination of new systems requires leaders to educate themselves, their staff and the vulnerable public on the use of new systems, processes, and programs. This article provides foresight information about the future challenges healthcare leaders will face and suggestions to help them overcome.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Healthcare rising costs As more people strive to live longer, healthier and more active lifestyles, healthcare concerns increase and so does the costs. Research reveal healthcare costs and spending often rise at rates exceeding inflation, and is expected to increase in the future. The Society for Human Resource Management present that the Office of “1 the Actuary at the Centers for Medicare and Medicaid Services estimates that aggregate health care spending in the United States will grow at an average annual rate of 5.8 percent from 2015 through 2025, or 1.3 percentage points higher than the expected annual increase in the gross domestic product.” This causes a huge concern for leaders as they seek to provide coverage for their employees. Leaders must find alternative methods to combat the rising costs of care. They must do the research to find funding, grants and contributors to help them conduct research, set up programs and implement processes at the pace of change. The Health Services Research Information Central (HSRIC) provides a list of “grants, funding and fellowships” leaders might consider helping them train staff members, open up public information sites or labs for processing paperwork and other initiatives.2NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Healthcare regulatory challenges Healthcare has taken center stage in the political arena under the Trump administration. As tension and uncertainties mound regarding Trump’s threats to repeal and replace Obamacare, insurance and medical executives scramble to determine “what business is going to look like in the years ahead” (Gomes, 2016). Larry Levitt, a senior executive with the Kaiser Family Foundation emphasized any transition from one program to the next will require time for insurers to adjust to the “reverse disruption” and “overhaul to how individuals buy policies” (Gomes, 2016). Healthcare leaders must inform themselves, and staff on how to handle the changes in coverage. Currently, there is a “noticeable gap between the belief that change is necessary and actual support for specific reform plans designed to achieve that change” (Wood, 2011). Leaders will be challenged to counter frustration and confusion from Americans, once deemed otherwise uninstallable, who have formed a sense of security their current coverage, argues Wood (2011).NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Regulatory challenges drive up the cost of providing services and care. As the Trump administration strive to regulate Medicare and Medicaid eligible healthcare providers are overwhelmed by regulated “changes and new reporting requirements” (Brown, n.d.). Research provide that healthcare leaders are further burdened to comply with a variety of newly revised standards including the Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare and Medicaid Services (CMS), and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). To combat these challenges, the healthcare provider needs actively engage in awareness and information sharing regularly. Studies suggest leaders must implement document control programs, compliance training, routine audits and address non-conformance incidents immediately utilizing integrated healthcare platforms.3NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Medicinal and technological advancement challenges The practice of medicine and technology has created opportunity and challenges in the way providers practice medicine today and in the future. Today’s health organizations are facing physician shortages and need “low-cost alternatives to office visits” and in-patient care (Austin, Beethoven, & Chait, 2016). Five to ten years from now, leaders can expect more of a shift from the traditional office visits and prescribing in favor of virtual and cyber doctor patient interactions. Sanicola (2016) argue “medicine” – the use of “electronic communication” such as “two-way video, phone, email, wireless tools, and other forms of telecommunications technology.” Telemedicine “works well for treating common conditions such as colds, flu, pink eye and sprains” and “more easily manages patient care for chronic illnesses that require daily interventions” adds Sanicola (2016). The rapid change requires leaders to acquire and develop methods for maintaining and accessing private sessions and data of patients. Saslow (2016) argue the pressure and “growing influx of patient data, legal requirements for strict privacy and security, rapidly advancing clinical technology increases costs, and other factors. At a minimum, leaders should explore innovative ways to manage and store the information adequately adds Saslow (2016). Heathfield, Pitty and Hanka (1998) posit leaders must “understand and predict the behavior of systems and provide important knowledge to inform further developments.” Once the leader understands the system, they can prepare training strategies for the staff and the patient. The leader’s training efforts must be a continuous initiative to keep up with the continual change of technology and medicine in the future.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Training and education challenges Professional development is the key. Healthcare leaders must take steps to assess, develop and fine tune key personal and professional skills to remain proficient (Northouse, 2013). Most training initiatives, per Dunn (1995) remain centered around “traditional clinical interview with its focus on acute illness,” but healthcare providers will be challenged to change that dynamic. The future will require healthcare leaders to take more of a hands-off approach; involve patients more in personal care; offer alternatives to current practice and make themselves and staff available to forms of communicating with the patient without a trip into the office (Gomes, 2016). Ethical challenges Ethical challenges in healthcare is a big deal. Recent news stories support this claim with headlines about ethical violations of healthcare providers. In 2016 the British Broadcast Center (BBC) reports Dr. Paolo Macchiarini, was accused of providing misleading medical research which led to the deaths of seven patients (Kremer, 2016). More recently an Olympics Physical Therapy doctor, Larry Nassar was found guilty and sentenced for sexual misconduct. These incidents hurt the character and trust of the medical leaders. In addition, it creates legal costs and rise in malpractice insurance coverage for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Giving the very serious ramifications, healthcare leaders must ensure their behavior and their employees are above reproach. Bruning and Baghurst (2013) suggest “reform requires ethical decision-making from leaders” because these leaders influence “various relationships” and “creates fundamental successful changes in healthcare.” Sound “ethical principles to transformational leadership improves healthcare relationships and alleviates stress and tension produced by change” (Bruning & Baghurst, 2013). Leaders must understand the success of the organization; heavily rely on their ethical behavior. Building trust earns money and funding and reduces unnecessary liability costs for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Conclusion Healthcare managers must be able to provide direction and guidance to organizations about roles, responsibilities, and functions (Gomes, 2016). The leader must devise and revise strategies everyone can understand and follow. Thompson et al. (2011) argue “decisions made by healthcare managers not only focus on ensuring that the patient receives the most appropriate, timely, and effective services possible, but also address achievement of desired performance targets.” Ultimately, decisions made by an individual manager affect the organization’s overall performance (Northouse, 2013). Leaders should not take on the many challenges “posed by complex health care systems” therefore, it takes “a shared, distributed, or collective approach to address complex problems with diverse perspectives, talents, and skills” (MacPhee et al., 2013). Leaders must build a collaborative environment whereby everyone is involved in the process of developing strategies to help overcome the challenges as they arise. Staying abreast of the changes and implementing a plan of action will create successes for healthcare leaders and their organization for years to follow.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Why Quality Improvement in Healthcare is Important? Healthcare, safety, efficiency and equability are few of the concerned facts which every human must remain aware about. With the improvement of technology and science, improving quality in healthcare has become important. The institutions dedicated to medical practices need to give high effort for healthcare services. Implying specialized methods for healthcare settings, the doctor office need to stream measurable improvement in the quality of healthcare services. As said, quality improvement is meant for enhancing safety, effectiveness, and efficiency which is achieved by deploying various methods. Both qualitative and quantitative healthcare improvement has become imperative. Healthcare features are becoming complex with time and the requirement of new and enhanced methods is becoming inevitable. This would reduce costs as well offer access to new technology.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Changes in Healthcare System Would Improve the Level of Performance The main reason behind the quality improvement of healthcare is that, if the healthcare practice institutions are stuck with the traditional concepts with no further enhancements, it will fail in generating better results. Streamlining the changes into the system, a new level of performance can be achieved. Replacing the inefficient parts of the structures with new inventions can prove to be worthy. For the proven efficiencies, improved methodologies are implemented in healthcare on a global scale. Digital version of patient’s health record or simply the EHR- Electronic Health Records software renders real-time records that are patient-centered. The EHR contains medical and treatment histories of a patient. EHR system is prepared at the doctor office that goes beyond standard clinical data and features a broader view of the health standard of a patient.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper What Are The Aims Of Healthcare Improvement? Safety- It renders a protective shield that avoids the patients from injuries for the care. Effectiveness- Basing on the knowledge of science, the healthcare services are rendered as would be beneficial for the patient and avoid the services that are not profitable. Patient-Focused- The provided health-care is as per preferences of any individual patient. The requirements and values of healthcare ensure the patients with precise clinical decisions. Real-time- Quality improvement in healthcare reduces the time of lingering which may sometimes are harmful when delayed. Efficiency- It avoids certain wastes that include effort, idea, supply as well as equipment. Equability- Basing on personal characteristics, the rendered healthcare quality mustn’t differ. Benefits of Continuous Quality Improvement (CQI) Continuous Quality Improvement (CQI) is a systematic approach to achieving ongoing improvements in a product or service. CQI users define the problem, map the process, identify improvement opportunities, implement the improvements and continually monitor the results for improvement opportunities. There are several benefits of using CQI.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Use of data CQI uses quantitative information (e.g., output, defects) instead of subjective information to improve the process. Monitoring the data identifies ongoing opportunities for improvement. Improved morale The use of CQI helps improve employee morale by not blaming the employee for the problems in the system. Instead, it focuses on the problems in the process, not the people performing the process. Better customer service Because CQI focuses on continuously improving the organization’s performance and removing problems from the system, customer satisfaction increases. Increased productivity Removing errors from the process results in fewer errors and less repeat work on the part of the employees. Less repeat work means increased productivity. Increased revenue By removing errors and increasing customer service, the organization has the opportunity for increased sales.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Principles Of Quality Improvement In Healthcare Principle 1: Promote hands-on improvement projects. High-level strategy discussions and ideas aren’t enough to promote quality improvement in healthcare. Hands-on work aids the adoption of quality improvement projects because staff and physicians can see the direct impact in real-life situations. It also incentivizes internal teams when the organization identifies an area that needs improvement, and encourages staff and physicians to play an active part in the strategy. Principle 2: Get buy-in on what “quality” means. Part of the difficulty in defining quality improvement stems from the word “quality” itself. It’s subjective, and organizations sometimes suffer from internal clashes on how to characterize those seven letters. It’s important to get buy-in across the organization on exactly what quality means so you can objectively determine if it’s improving. However you decide to define quality, it should be measurable and revolve around patients. Healthcare organizations are guided by a mission to improve the lives of patients, so your definition of quality should overlap with how you care for them.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Principle 3: Focus measures on improvement vs. accountability. Since quality improvement in healthcare revolves around the patient, performance measures should focus on improvement rather than accountability. When accountability is overemphasized, the needs of the patient are superseded and quality improvement can’t be applied. For example, a typical accountability measure might collect data on the percentage of ER patients who waited more than 30 minutes, and hold management accountable for keeping wait times under 30 minutes. A better tactic would focus on the system and collect actual wait time data in minutes to measure performance, instead of just focusing on the person who’s held accountable for those wait times. By taking this approach, a process can be improved. The concept of quality has been contemplated throughout history and continues to be a topic of intense interest today. Quality presently is addressed in numerous academic and trade publications, by the media, and in training seminars; it is perhaps the most frequently repeated word among managers and executives in contemporary organizations. In a recent survey, executives ranked the improvement of service and product quality as the most critical challenge facing businesses [1]. Quality has been described as “the single most important force leading to the economic growth of companies in international markets” [2]. Quality in healthcare is also a determinant issue as healthcare accomplishes a work of life perpetuation and quality in healthcare sector is getting thorough attention. So far, different approaches have been introduced to improve healthcare service quality. Therefore, this research aims at reviewing the methods and approaches with their improvement models used for service quality improvement in a healthcare and gives alternatives insights for further research in the area.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The need for service quality improvement Both public and private organizations exist to serve their customers. The service quality particularly in the public sector has become ever more important in improving customer satisfaction. Organizations, especially in the public sector agree that customer satisfaction is one of the most vital factors that contribute establishment of reputation and credibility among the public. The public complaint of long queues, poor service delivery and insufficient physical facilities affect the image and level of service quality in the public sector. Service quality that customers receive must be reliable, responsive and emphatic involving service product, service delivery and service environment. Service quality has been documented as one of the key driving forces for business sustainability and is crucial for firms’ accomplishment. Hence, research on service quality has been carried out worldwide.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper Earlier studies have focused on service quality construct by Paranormal et al. [3-5]. The development of the original 22-item SEMIQUAVER instrument signifies one of the most extensively used operation of service quality. It has provided researchers with the possibility of measuring the performance-expectations gaps composed of five determinants namely, reliability, responsiveness, empathy, assurance and tangibility. Existing studies focus on measuring the service quality level by these five dimensions in a holistic manner without considering the independent focus that should be given for each dimension through prioritization and their integrated impact to other improvement activities.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The apparent reluctance of service organizations to utilize quality improvement based strategies and practices are difficult to understand, especially in light of the increased significance of the service industries and the demand of customers. The trend signifying the increasing importance of the service sector is expected to strengthen in the foreseen future. This trend, coupled with an increasing emphasis on the customer-focus strategic orientation makes the reluctance of some service organizations to implement quality improvement initiatives difficult to fathom. Some attribute this apparent reluctance of service organizations to implement quality improvement initiatives to the difficulties associated with defining service quality. Despite apparent difficulty, some practical research has attempted to practically address issues related to service quality in different service operational settings such as rapid asses

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