Running Head: ADVANCED PRACTICE MODEL

Advanced Practice Model 1

Running head: ADVANCED PRACTICE MODEL

Multidimensional Factors Affecting Wellbeing:

A Model for Multi-level Nursing Practice

Mary P. Bennett DNSc, RN

IndianaStateUniversity, School of Nursing

Advanced Practice Model 1

Introduction:

This paper presents my personal model for nursing practice which describes the various levels of nursing practice, gives some examples for model implementation at the advanced practice level, and proposes some outcome objectives for model evaluation. The model incorporates concepts from Psychoneuroimmunology (PNI) theory, whichI have used to guide my overall research program for some time. PNI started from a multifactorial model of illness which included stress, coping and disease formation (Engel, 1962). This theory was further developed by Solomon (1964, 1985, 1987) to include the effects of stress on the immune system in disease formation. Later, the term "psychoneuroimmunology" was coined by Ader (1981) to describe the basic phenomena of this theory - interactions between the nervous system and the immune system and the subsequent effects upon disease development and progression. Because PNI theory acknowledges the holistic nature of wellness and illness, it is particularly useful as a guide for nursing research and practice (Birney, 1991).

Practice Framework Assumptions

1. There are multidimensional factors which affect well-being, and not all of these factors are physical or genetic.
2. Psychosocial factors such as stressful life events, personality traits, and behavioral / lifestyle factors all have an effect upon the person's well-being.
3. Socio-environmental factors, such as income, occupation, religion, common social culture, and family all influence a person’s health related options and choices that they make.
4. Many of these multidimensional factors are capable of being modified by a variety of Therapeutic Nursing Interventions.

Advanced Practice Model 1

The graphical representation below gives an example of various factors which can affect health outcomes, and the general type of nursing interventions that can act to modify the effects of these factors on health outcomes. This framework attempts to take into account a wide variety of nursing actions, from traditional nursing interventions, to use of complementary therapies to relieve stress, to use of political activism to improve environmental conditions for an entire community. I find the model helpful, because it is broad enough to cover many of the activities nurses in general engage in.

Advanced Practice Model 1

Advanced Practice Model 1

For persons who are graphically inclined, the figure may explain it all. For those who are textually based and find such models overwhelming, keep reading. The basic premise behind my model is that there are many factors which affect well-being, and the effects of many of these factors on wellbeing can be modified by the appropriate use of Therapeutic Nursing Interventions (TNI). Another basic premise of this theory is that clients must not be viewed in isolation. Each client has various life events, socio-cultural, psychosocial, behavioral, and environmental factors which impinge upon his/her well-being, in addition to physiological factors. Individualization of nursing interventions in order to meet holistic needs of specific clients is a key factor.Another important part of this model is how therapeutic nursing interventions act to modifymultidimensional factorsto improve well-being.

The first set of therapeutic nursing interventions are the Holistic Interventions. These interventions act to modify the effect of negative stressful life events, psychosocial factors, and behavioral factors upon the PNI network, and thus upon well-being. For instance, research has documented that holistic factors such as stressful life events, psychosocial factors, and behavioral factors, all have an effect upon the person's well-being. Whether this is a negative effect or a positive effect depends upon the event or the behavior. Holistic factors affect physical functioning through changes in the PNI network. The PNI network is an interconnection of reactions, involving neurotransmitters, neuropeptides, hormones, and the immune system (Pert, Ruff, Weber & Herkendam, 1985; Pert, 1986). Studies supporting PNI theory and the communication network between the CNS and the immune system have been reviewed in the nursing literature (Birney, 1991; Houldin, Lev, Prystowsky, Redei & Lowery, 1991; Nguyen, 1991; Zeller, McCain & Swanson, 1996). A research project was designed to test this part of the model. In this project we were able to document that a therapeutic nursing intervention (use of humor) decreased stress and improved immune function in a sample of health women (Bennett, Zeller, Rosenberg & McCann, 2003).

The next set of interventions listed are the Environmental Interventions. These endeavors, such as professional activism for quality of care and safe staffing levels, or political activism to improve access to health care, are aimed at improving the health care environment.

The third set of interventions are the Traditional Interventions. These are aimed at directly improving a client’s physical functioning. Of course, physiological factors play an integral part in holistic well-being, and are one many nurses are most comfortable in dealing with. This may be because most traditional health interventions have been aimed at modifying these physiological factors directly.

The final set of factors are those not subject to modification. There are only a few of these, but in some persons they profoundly affect well-being. However, while a person's genotype and past are not modifiable, how these things affect their current physical and mental well-being may well be modifiable by any of the three general sets of interventions in this model.

Lastly, it should be acknowledged that many interventions may fall into more than one category. For example: individualized pain management, might be considered primarily a holistic intervention. Pain usually is considered a stressful life event, and can affect various psychosocial factors, behavioral factors and the PNI network. However, pain can also directly affect physiological functioning, so some may consider pain management as a traditional intervention. There is certainly room for flexibility and growth in this model.

What is nursing? What do nurses do? Each of us knows inherently what we are and what we do, yet when asked to define it for the public we find ourselves speechless. It's like trying to tell someone how to tie a shoe. The knowledge and ability are there on a level that is not just cognitive or verbal, but lies in the very connection between your mind and your fingers. Yet, we meet with people who really do not know or understand what nurses do, let alone understand how the different educational levels relate to one another.

A hospital controller once related a story about a nurse practitioner who recently opened up her own office, after working in a clinic for a couple years. The controller wanted to know if it was legal, let alone ethical, for a nurse to go into “practice for herself, especially after Dr. X just finished training her". This scenario highlights how poor a job we have done in educating others about our various levels of practice, when even those in the health care arena are confused.

Advanced Practice Model 1

Definitions of Key Concepts and Interrelations between Concepts:

In Nursing, as a whole, there are four main concepts that are viewed as essential to any nursing theory. They are: environment, nursing, health and client. The concepts of family, complementary therapy and therapeutic nursing interventions are also important for this particular framework .

Definition of Health: According to the World Health Organization, health is a complete state of mental, physical, and social well-being and not merely the absence of disease (World Health Organization, 1948). However, for many people, health by this definition would never be obtainable, because there are few who ever obtain a complete state of mental, physical and social well being. My definition of health is somewhat broader. For me, health is the optimal level of physical, mental, emotional and spiritual wellbeing that the client/s is capable of at this point in his/her life.

Definition of Client: I believe that a client is a person or persons with whom the nurse interacts with, and develops therapeutic nursing interventions for, in order to improve that person/s health or health environment. The client and his/her environment (including family) have a major impact on both the client’s concept of health, and his/her ultimate health outcomes.

Definition of Environment: For me, environment is the “world” in which a client/s lives, as they themselves view it. I think that this can vary from person to person, even for people living in the same household. As demonstrated in the graphical model, health environment is affected by multi-dimensional factors, many of which can be modified by therapeutic nursing interventions.

Definition of Family:For many people, health and health related behaviors are strongly influenced by their family. I feel that family membersplay a critical role in influencing a person’s genetics, lifestyle choices, values (including health related values), home environment and other factors that are related to health. However, the term “family” has many meanings. The tradition definition of a nuclear family has implications where relationships are not recognized, such as for same sex couples, where families are not confined to one household, such as with extended families, and where parents of dependent children live apart. Some people use a household focus, which results in terms such as “two parent family” and “one parent family”, with only household members being considered to be family members. Children whose parents live apart and who spend time with both parents would be more accurately termed “two home children”. It can be quite misleading to use households as the basic unit for analysis. People can be active members of more than one household, and there can be sharing of resources and income between households (Birks, 2001). Since the issuethat is important for this model is wellbeing, I use the term “family”here to refer to any one that the client identifies as being part of his/her family, and that have the ability to influence the client’s wellbeing and/or factors related to wellbeing. It isnot limited to biological relatives, and it can encompass the broad array of kinship and living patterns around the world.

Definition of Nursing: For me, nursing in general can be defined as the art of using therapeutic nursing interventions to improve well-being in persons, families and communities. According to Buchanan (1994), therapeutic nursing interventions are:

Nursing actions and interactions, executed as part of the nursing process, with or for individuals and families, that are directed at influencing a measurable change in health status and quality of life. Interventions are directed at: treating acute illness; alleviating illness related symptoms; promoting human adaptation to acute illness during acute and transitional phases of recovery; rehabilitation during chronic illness and disability over the life span; preventing illness; and supporting individuals and families during terminal or end of life transitions (p. 190).

Putting it all together: I plan to use this framework to guide how I interact with clients. In order to help clients obtain their optimal level of well-being or health, it is necessary to find out how they view their own personal situation. People make the choices they do because of a variety of factors, such as family values, personal resources and their own environmental situation. All of these factors need to be taken into account when working with the client to develop appropriate therapeutic nursing interventions to meet their specific needs. No one (or very few people) stand alone. It is important to incorporate family history and values into the assessment process, not only because you are looking for risk factors for certain diseases, but also because family values and interactions play such an important part in the lifestyle choices a client makes. And the environmental assessment is very important. People make the choices they do, partly because of their own personal assessment of their environment. If they do not feel they have the resources needed to make a lifestyle change, they will not even attempt to make the change.

Use of this Theory in Role of the Advanced Practice Nurse:

In order to help a client obtain their optimal level of well-being, health care can not be intermittent, sporadic, unorganized treatment of various sets of symptoms. If you only treat symptoms, you will simply perpetuate the chronic disease process. Most clients want to be well, but frequently feel that if something not hurting or making them sick enough to miss work, they can safety ignore the disease. Then, once the disease process reaches the level of symptoms, they want the health care provider to “fix it”. Many people give more thought to providing the appropriate care and maintenance for their cars than for their bodies. Part of this is because we have complicated and elevated the process of “health care” to the point that many people feel that they can not do anything to help themselves. They think that health care is a matter best left to “the professionals”. My mother-in-law is a classic example. She is to have a “test” done this week. She did not ask the MD what the name of the test was,or what it was for. After finding that she was to have something done, my husband then asked me to tell her what the test was. All she could tell me about the test was that it would take about 4 hours and that she could not eat prior to the test. She thought it had something to do with the blood vessels in her leg, or maybe her heart. When I asked why she had not gotten more information from the MD about the test, she replied that she figured he knew what he was doing and therefore she would do whatever he told her she needed to do. Of course, with so little understanding of her own health and treatment, she can’t make any informed decisions about what activities might actually help her maintain her health.

As you can see, the focus of advanced nursing care needs to be on health surveillance (promotion and maintenance of wellbeing), in addition to providing for management of acute and stable chronic illness. In addition, continuity of care is critical. The optimal level of health care can not be provided unless the health care provider and the client work together over time to develop a coordinated approach to health promotion and maintenance.As you can see from my mothering-law, if the health care provider had assessed the client’s level of understanding, he would have found out that she has no idea what is going to be done to her or why it is being done. This type of client assessment is as important as taking a blood pressure, but is frequently overlooked by the medical model of health care that prevails in our current health care system. Part of this is based on the reward structure. We are paid to do tests, not to talk to people. Therefore, the incentive is to do more tests, not make people better informed about their health care, etc. In addition, people who go into medicine are those who were able to do well in college and pass the entrance exams. These exams are highly quantitative and objective, based mostly on science, math and chemistry. While knowledge of these subjects is important, they are probably not the most important skills needed to work with and communicate effectively with clients about their health care. What is really needed is a health care provider who can work from both areas of knowledge, quantitative and qualitative. We need providers who can make accurate diagnoses and order the correct tests, etc. but also ones who can assess the client’s level of knowledge and help them understand their own health care needs.

Use of the Practice Model within the Nursing Process Framework

In order to demonstrate how my model could be applied using the nursing process, I selected a case study of a client with a chronic disease process, life style issues, environmental issues, family factors and cultural factors. Most clients we deal with will have all of these types of issues. Even with clients from our own “culture” the culture itself has an effect on what clients believe they can do to obtain or maintain their own health.

The client case for this demonstration of my model within the nursing process framework is as follows: In Morgan Water's community (an Indian reservation), one fourth of her tribe had diabetes. Morgan had a few family members who had developed diabetes, heart disease, or other serious conditions later in life, but at the age of 27, she never imagined she was at any risk. However, she overlooked the fact that environmental factors as well as genetic factors play a crucial role in the development of diabetes. Morgan is obese and leads a sedentary lifestyle. Like most of the younger members of her tribe, much of her diet consists of food that is cheap and fast, such as pizza and burgers. In the past few months, she had been experiencing unusual thirst, dizziness, blurred vision, and an awkward feeling of numbness in her right foot. Following her parents' advice, she finally visited the local nurse practitioner. She was worried, but never suspected that she had Type 2 diabetes. Usually this disease doesn't occur until after the age of 45, but the sedentary lifestyle, family gentics and her current diet have increased her risk. Morgan is wondering will she have to take insulin shots for the rest of her life, like the other people in the tribe with diabetes? So many of her friends, so many of her people, had suffered from this terrible disease. Adapted from Morgan: A Case of Diabetes(Rubin & Herreid, 2002).

I selected this case study to demonstrate howI plan to use my model with the nursing process to assess, implement, and evaluate client health outcomes (See nursing care plan below).The multidimensional model for nursing practice encourages nurses to use a holistic view of wellbeing, and to explore a variety of interventions in order to assist clients in their journey towards wellbeing. Holistic wellbeing is achieved by working with clients to devise appropriate and individualized therapeutic nursing interventions, and by helping clients evaluate their own progress towards their goals.