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Professional Learning Portfolio

Kara Elkins

Ferris State University

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Table of Contents

I. Personal Information

A. Background Summary

II. BSN Program Outcomes

A. Collaborative Leadership

B. Theoretical Base for Practice

C. Generalist Nursing Practice

D. Scholarship for Practice

E. Health Care Environment

F. Professionalism

III. Professional Accomplishments and Credentials

IV. Appendix

A. Health Belief Survey

B. Faculty Check Point Signatures

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Personal Information

In this section of my portfolio I will explain the many areas of nursing that I have done over the past six years of my nursing career. I will also explain my career goals, and a summary of my professional accomplishments.

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Professional Background Summary

I graduated in 2006 with an Associate’s Degree in Nursing from Grand Rapids

Community College. After graduation I was offered a job with Spectrum Health Hospital in a

med/surg neurology specialized unit. There I cared for patients with strokes, seizure disorders,

post head injuries, and many other ailments. I became NIH stroke certified, and also became a

charge nurse. I then realized that my passion was to care for critically ill patients.

I took a job in the medical ICU at Spectrum and it was there that I found my passion for

nursing. I became certified in many things such as, caring for patients with IntraArterial Balloon

Pumps (IABP), and patients on continuous dialysis known as CVVH. I was ACLS and PALS

certified and became a critical care nurse rounder in which I was a part of the code team, stroke

team, chest pain team, and RAP (rapid response) team. I developed excellent critical thinking

skills, and was able to help others learn as well.

Due to changes in my family situation, I decided to take a job in an outpatient surgical

center as a PACU nurse. Here I am learning many things as well.

After I finish my BSN, my goal is to continue my education for my master’s degree

specializing in anesthesia. Becoming a CRNA is something that I have always wanted to do.

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II. BSN Program Outcomes

In these next sections I will provide several examples of assignments that I have completed

during my education here at Ferris State University. These assignments will be categorized

based on the outcome requirements of the BSN programs at Ferris. These requirements are

Collaborative Leadership

Theoretical Base for Practice

Generalist Nursing Practice

Scholarship for Practice

Health Care Environment

Professionalism

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A. Collaborative Leadership

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B. Theoretical Base for Practice

This section includes examples of my work in nursing theory, and using theory to

develop a foundation for my own nursing practice.

The first example I have provided is a personal self-assessment of reasoning

paper. This paper has not only given me the opportunity to research the large issue of barriers to

healthcare that patients face outside of the hospital, but also has helped me to examine and relate

it to a very important nursing theory, Dorthea Orem’s self-care theory.

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Kara Elkins

Self-Assessment of Reasoning

Ferris State University

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Abstract

In this paper I will describe content that has been most significant to me throughout this semester. I have chosen to write about the barriers to self-care that patients face out of the hospital setting. I have given myself a letter grade of B for this assignment related to the elements of reasoning and critical thinking. I will describe why I have chosen this in the following sections.

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Self-Assessment of Reasoning

One problem that many patients face today is how to successfully administer self-care

while considering the outside factors that can become significant barriers. Patients need our help

and support as health care providers to notice which barriers affect them, and provide them with

the correct resources.

Significant Content

The content that was most significant to me in this semester’s discussion came from week

4. In this week we discussed the barriers that many face related to self-care. These barriers

include not having adequate finances, not having the level of education needed to understand

medical regimens, or not having the support of family or friends.

Thoughts and Feelings

This issue makes me very upset. There are people who just can’t afford their meds, and

some who don’t understand exactly what they need to be doing with medication regimens and

diet restrictions, and they are continuously in and out of the hospital with all kinds of health

problems or exacerbations which results in poor quality of life.

Point of View or Assumptions

I have worked in a medical ICU for 5 years and during this time have come across many

patients who suffer from chronic illnesses such as Chronic Obstructive Pulmonary Disease

(COPD), Congestive Heart Failure (CHF), Diabetes, etc. Many of the patients that are in and out

of the ICU are ones who either choose not to take care of themselves, or ones that don’t have the

means to appropriately care for themselves at home. I struggle with helping these patients find

resources, and also with watching them deteriorate from their illness all because of lack of

support or finances. Because of my experience in the ICU, I already had preconceived notions

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on this topic before the discussion or reading from this week, however, the discussion and

reading did offer further incite on the topic.

Analysis of Thinking

This topic is extremely relevant to my practice. I constantly have patients coming in and

out of the ICU setting with exacerbations of their chronic illnesses because they can’t afford

medications, or they don’t have the family support at home to keep them on track with their

medications, diets, and exercise routines. When a person doesn’t have the motivation

themselves, family support is important. My opinion on this topic has been greatly influenced by

the patients that I work with. We need to help these patients and provide them with the resources

they need to help them have a good quality of life, otherwise they have nothing to live for or

motivate them to life healthier lifestyles. I think the question that needs to be asked is how can

we as health professionals better screen our patients for potential barriers for self-care? Coming

up with an appropriate screening tool that is also effective is important. Patients don’t always

want to tell us about their financial problems, and more often than not out of embarrassment our

patients don’t tell us that they don’t understand something. We can usually tell how much

family support they have by the amount of people coming to visit, but can’t always tell other

barriers. We also need to be aware of different cultures and their standards or ways of dealing

with chronic illnesses so as not to offend our patients, and equally as important to make sure that

education and language barriers aren’t interfering with education.

The model that is most used in this area of self-care is Dorthea Orem’s self-care model.

Orem describes three types of self-care requisites in her model: universal, developmental, and

health deviation requirements. Universal includes air to breathe, water, food, elimination, and

the balance between activity and rest. Developmental includes maintenance of life processes that

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promote progression of maturation, and provision of care to prevent or overcome conditions that

effect human development. Health deviation requirements include developing a system to

maximize quality of life for those who suffer with chronic illness or other problems that effect

development (Pender, 267-268). By using Orem’s self-care theory we can categorize our

patients to better assist them with finding resources specific to their needs and illnesses. We

aren’t always going to be able to help everyone, and that becomes the consequence for not

having an appropriate assessment tool for patients, but there is a lot of information that can be

learned to assist patients such as learning about Medicare and Medicaid programs and also

learning about other drug programs offered by local pharmacies to assist in lowering costs.

Other things to get to know are support groups in the area we can refer people to, or even

exercise classes to get them moving.

I have chosen to give myself the grade of B for this assignment. I feel that I have grasped

the concept of critical thinking related to this class, but I also feel that I still have weaknesses in

areas regarding the elements of reasoning. I still have biased opinions and find it difficult to

truly listen to the opinions of others. This is something that I need to continue to work on. I feel

like my critical thinking skill have improved over this semester and being a part of discussions

has helped. I also feel that I have good problem-solving skills. Working in an ICU has helped

me to learn how to problem-solve as well as helped me to develop my critical thinking skills.

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Sources

Pender, N., Murdaugh, C., Parsons, M. (2011). Health Promotion in Nursing Practice. Upper

Saddle River, New Jersey. Pearson Education.

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C. Generalist Nursing Practice

In this section, I have provided examples of papers that show different health care needs

of different populations. The first example is a paper written on childhood obesity, and what we

as nurses and a community can do to help this at risk population.

The second example is a paper written based on evidence-based practice. This paper

researches the different problems faced by patients in the ICU based on ventilator assisted

pneumonia (VAP). In this paper I have researched different evidence-based ideas on how to

lower the incidence and risk for patients on ventilators.

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Childhood Obesity: How can we help our overweight kids?

Janice Schmuckal and Kara Elkins

Ferris State University

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Abstract

Kids these days are spending the majority of their free time in front of the television or computer

instead of outside. This is causing a huge rise in rates of childhood obesity all around the nation,

which is also increasing the risk of cardiovascular disease and diabetes in our young population.

There are state and federal laws that are hoping to mandate physical activities and healthier

nutrition in our public schools, and many other programs to get involved in to help educate and

teach our kids healthy habits. In the following pages there is an explanation of ways that are in

place to help and ways that we as members of the community can help our kids with this

growing problem.

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Childhood Obesity: How can we help our overweight kids?

Everywhere we look it is easy to find information on the rise of obesity in the United

States. Our kids are becoming more inactive and eating a much higher calorie, lower nutritional

value diet. Activities that kept earlier generations up and moving, like playing outside, dancing,

or sports are being replaced with a very sedentary lifestyle brought on by computers and

technology. We need to encourage children to be physically active and for them to take us

seriously we need to become active too. If we get out there and do it, so will our kids!

In a prospective cohort study, information is gleaned on the impact of obesity in

childhood having an effect on cardiovascular risk factors in adulthood. In the study, several

measurements were used on the children to decide the high risk factors of the participants. The

measurements used were BMI, waist circumference, fat mass, systolic and diastolic blood

pressure, fasting glucose, insulin levels, triglycerides, LDL, HDL, and cholesterol levels. There

were 7725 kids in the 9-10 year group, 7159 in the 11-12 year group, and 5509 participants in the

15-16 year group (Lawlor, 2010).

The results of the study showed that childhood BMI will identify those at increased risk

of cardiovascular disease later in life. This means that kids ages 9-12 that have higher adiposity

levels have a higher cardiovascular risk factor by the time they reach age 15-16. High BMI, fat

mass, and waist circumference are all associated with a higher risk for cardiovascular disease.

The good news is that in this study it also showed that if the kids go from obesity in the 9-10 age

to normal weight in the 15-16 age group, their cardiovascular risk improve. The kids that remain

overweight during that period stay at a higher risk for cardiovascular disease (Lawlor, 2010).

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Physical Education in School

Michigan law mandates that all students attending school in Michigan are required to

participate in physical education program, however, our state does not require a certain amount

of time per week the kids must be participating in the class. It is possible for a child to be

exempt from gym class if a waiver from a doctor is obtained, like the children that have health

problems such as exercise induced asthma. Michigan has provided our schools with the standard

requirements that every district must adhere to, and that includes the same teacher to student

ratio in a physical education class as in a regular class room of a given school (National

Association for Sport and Physical Education, 2010). We have state requirements in place to

assist in getting our kids moving, but the controversy remains whether it is the responsibility of

the school to end the rising obesity in children or is it up to the parents to set the rules at home

when a child’s weight is rising out of control.

During the first three years of school children are very energetic and eager to learn skills

in mobility and locomotion taught in P.E. class. They are taught to hop on one foot and then the

other, skip and jump. These skills teach them spatial awareness and balance. They are taught to

gallop, throw and catch a ball both over hand and underhand, kick a ball, and dribble a ball. At

this age children usually have more motivation and energy than is required for the activities at

hand. They are happy just to participate in physical activity. The benchmark skills are evaluated

by Level 1 through Level 4 standards. Level 1 is an incomplete or inconsistent level of a skill

meaning the child can do this skill some of the time, but is not very coordinated in doing it well.

Level 2 is a complete mature skill performance meaning the child does the activity well and

consistently. Level 3 is a mature form of the skill meaning the child can perform the skill in a

controlled setting. Level 4 is an advanced skill performance meaning the child can perform the

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skill effortlessly. By the end of second grade the child is expected to perform mature

manipulative skills of this caliber (Michigan Department of Education, 2007). At this age kids

are on average very close to a normal weight and BMI, and are not being impacted by gross

obesity in their physical education.

During grade three through five these simple skills previously described become more

mature and fine-tuned. The skills taught to this age group are to be able to hit a target or to

channel their energy. Hitting a ball with a bat, playing basketball, and playing tennis are some

examples of the skills taught to this age group. This age group must step up the pace to play

against an opponent, and they are being taught to become more competitive. Running, jumping,

and speed begin to come in to play for this age group. When a skill requires speed and agility,

the slower, heavier kids are quickly filtered out by not being able to keep up with the light on

their feet athletic kids. Obesity of children has impacted their physical activity at a very early

age. The same standards are used for evaluation of these skills throughout school. By the end of

fifth grade a child is using their skills in a complex environment. They are now able to use their

skills in an organized sport, moving the way they need their body to move. This is the age group

that begins the decline of an obese child not being able to keep up with their peers, giving them

negative feedback and even less desire and motivation to be physically active.

When a child enters the junior high level the patterns and lifestyle are in place for the

child to either be physically active or headed toward obesity if not already there. Positive

reinforcement and personal gratification will help teach a child to continue physical fitness as

they age. Funding and cutbacks in our schools is a big part of how much the schools put into

teaching the kids to be physically active. When we look at the cost of obesity and all the health

issues it causes later in life, it only make sense to spend that money on prevention in the early

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years of school. These kids need to learn the importance of physical education, so that they can

carry that knowledge with them as they grow older and are at a greater risk for developing

diseases like diabetes and heart disease.

Many kids in grades kindergarten through 3rd do not have the opportunity to participate in

an organized sport for the benefit of exercise. During this time period kids rely on what they do

in gym class and what they do on recess to get their exercise. It seems as though recess is the

first thing threatened to be shortened or cut as schools are focusing more and more on test scores

and academic achievement, but it really is important for our kids. Recess allows for kids to have

active play time where they can run around and get their heart rates up. This physical activity at

recess is very helpful in fighting childhood obesity. It will also benefit the child in school as

healthy kids will have fewer absences from school (Frost, 2010).

When a child is entering middle school they are at a very awkward period in their life.

They are trying hard to fit in with their peers and their social life is of great importance to them.

With computers and video games beckoning their attention, it is easy to understand that only a

few minutes each day are being spent doing physical exercise. This is a crucial time in a child’s

life to get them involved in sports and activities because it will help them develop a healthy body

and healthy habits that will stick with them for a lifetime. Involvement in a sport at this age will

provide many benefits such as improved cardiovascular health, weight management, and

improved self-esteem. All of those benefits will improve how these kids feel about themselves.

Some examples of sports this age group would enjoy are basketball, soccer, volleyball, and

football. A child’s commitment to a team gives them a sense of belonging that will reinforce

them wanting to continue the sport, and it will also teach them a good life lesson of responsibility

and commitment to others (Frost, 2010).

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Nutrition in Schools

Have you ever wondered what exactly your children are eating when they are at school?

Many schools have vending machines full of candy and sugary drinks, but what is being served

at lunch time? What choices do the kids really have? According to the Federal Register and

nutrition standards for schools in the United States, schools are required to “provide at least

minimum calorie and nutrient levels for protein, calcium, iron, vitamin A, and vitamin C”

(Federal, 2011) which are the key nutrients that promote growth and development. They also

must decrease the levels of sodium and cholesterol in the food they serve, and increase the

amount of dietary fiber. Meals must also be limited to no more than 30% of total calories from

fat and less than 10% of total calories from saturated fat (Federal, 2011). This plan is intended to

provide students with meals that are nutritious and not full of fat and calories. This plan also

hopes to provide several positive outcomes such as: increasing the availability of key food

groups, improving students’ eating habits and providing them with nutritional education while

updating the meal requirements in accordance with the latest nutritional science. (Federal, 2011)

In the Dietary Guidelines for Americans, 2010 recommends less than 7% of total calories in

saturated fat consumption and less than 1500mg of sodium consumption per day. (Federal, 2011)

So what does this all of this mean for your school lunch menu? It means that nutritional factors

are being monitored in the public schools across America, but as parents we still need to make

sure our kids are getting the appropriate nutrition for their growing bodies.

Activities

There are many activities that obese children can do that will also provide them with

support from other children in their position, and the education to lose weight in a healthy way.

Examples of these activities are camps focused on overweight kids, after school programs, and

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support groups. One program available is called Wellspring. This organization has 11 locations

around the United States and the UK. They offer camping opportunities, a year round boarding

school, or just afterschool programs to help educate obese children. They provide the students

with fitness programs, and nutritional education. They claim that their campers lose an average

of 4 pounds a week, and also gain the knowledge to keep off the weight when they return to their

normal lives at home (Wellspring, par.3). Wellspring also provides the parents with the

education they need to make sure their child stays healthy at home.

Some of the top activities to keep kids active are also inexpensive. Start with a game of

tag. This will get the kids running around the yard and their heart rates up. Most kids only want

to run for short bursts which is what is required of tag. Get children involved in gardening. This

would require them to do some kneeling, digging, and raking. Having kid sized tools will help

the child feel more coordinated with this activity. Biking, hiking, swimming, and walking a dog

are also activities to get kids moving that are not very expensive. If you do not own a pet you

could encourage your child to walk a neighbor’s dog. Most kids love animals and would enjoy

talking a pet down the street. Both the dog and the child can benefit from the exercise.

The place to start to help out these overweight kids is to educate both the kids and their

parents. Education on what they can do to lose weight and keep it off, and also the importance

of keeping the weight off like lowering their risk for life altering morbidities. Many people don’t

truly understand the risk of being overweight, or even how or where to start to begin losing

weight. They need our help, and it is our responsibility as health care professionals, educators,

or just members of the community to get them the education and motivation they need to get

started.

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References

Federal Register ,Department of Agriculture (Jan 13, 2011). Nutrition Standards in the National

School Lunch and School Breakfast [Vol 76 number 9]Retrieved from:

http://www.fns.usda.gov/cnd/governance/regulations/2011-01-13.pdf.

Frost, S. (2010, June 11). The Benefits of Recess in School for Children in Grades K-3. Retrieved

March 16, 2011, from http://www.livestrong.com/article/

146098-the-benefits-of-recess-in-school-for-children-in-grades-k-3/

Lawlor, D. A. (2010, November 25). Retrieved March 2, 2011, from BMJ 2010;341:c6224.

2010

National Association for Sport and Physical Education and the American Heart Association .

(2011). Retrieved March 15, 2011, from National Association for Sport and Physical

Education website: http://www.naspeinfo.org/shapeofthenation

PHYSICAL EDUCATION. (2007, January). Retrieved March 16, 2011, from Michigan

Department of Education website:

http://www.michigan.gov/documents/mde/PE_Stnds.Bench_FINAL_2.14.07_186997_7.

pdf

Wellspring. (n.d) Retrieved from: http://www.wellspringweightloss.com/.

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Evidence Based Practice Proposal (EBPP)

Kara Elkins

Ferris State University

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Article annotation 1

Cutugno, C. (2007). Sedation in Mechanically Ventilated Patients. American Journal of Nursing, vol.107, issue 11, 72AA. doi: 10.1097/01.NAJ.0000298070.42596.0b

Christine Cutugno is an assistant professor at Hunter University School of Nursing. She has her PhD in nursing and is also CCRN certified. This article aims to show that even though the goal for ventilated patients is as little sedation as possible, these patients still require minimal sedation to reduce stress and anxiety due to invasive and life saving devices. Christine says that using a universal sedation assessment tool is extremely important so that the nurses and all Drs. are consistent in giving their patients sedation medication. She also points out the difference of judgment when it comes to assessing a patient between varying nurses, and this is another reason why using an easy, universal assessment tool is crucial.

Article annotation 2

Pun, B.T, Dunn, J. (2007). The Sedation of Critically Ill Adults: Part 2: Management. American Journal of Nursing, vol. 107, issue 8, 40-49. doi: 10.1097/01.NAJ.0000282293.72946.1f

Brenda Punn, MSN,RN,ACNP is a project manager at Vanderbuilt Univeristy Medical Center and is a member of its ICU Delirium and Cognitive Impairment Study Group. Jan Dunn MSN, RN is a research coordinator at Saint Thomas Hospital and also works for Hospira (manufacturer of certain sedation medications). This article shows that under sedation is just as harmful for ventilated patients as over sedation. They say that without having agreed upon sedation goals between Drs. and nurses there is a risk of complications regarding over or under sedation which could possibly impede recovery. The recommended medication for long term sedation is Propofol because of its short half-life. This drug allows daily awakening trials without much discomfort for the patient. Versed, Ativan, Haldol, and Fentanyl are recommended more for rapid sedation of extremely agitated patients. Picking the appropriate drug for patients is important along with trialing non-pharmacological techniques first such as low stimulation guidelines. This article is written by an employee of a drug manufacturing company and may be biased.

Article annotation 3

Jackson, D.L. , Proudfoot, C.W , Cann, K.F., Walsh, T. (2010). A Systematic Review of the Impact of Sedation Practice in the ICU on Resource Use, Costs, and Patient Safety. Critical Care, vol.14, issue 2, 59. doi: 10.1186/cc8956

Timothy Walsh is a Professor of Anesthetics and Critical Care at Edinburgh University. Daniel Jackson is Head of Health Economics, EMEA at GE Healthcare. Clare Proudfoot is a Consultant at Heron Evidence Development Ltd, a health outcomes research consultancy. Kimberley Cann is a Health Outcomes Analyst at Heron Evidence Development Ltd. This article is a research experiment that shows that there is strong evidence supporting sedation improvement of ventilated patients and reduced length of ventilation and ICU stay. This article supports daily

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sedation breaks to perform spontaneous breathing trials (SBTs), crucial for weaning vent support. These authors also state that adequate sedation of these patients could not only benefit the patients with better control of pain and anxiety, but improve health care costs because of shortened hospital stays and lengths of time on life saving invasive devices. Their research determined the use of specific protocols was influential in giving the patients the amount of sedation needed without giving too little or too much.

Evidence of Reasoning Proposal (EOP)

The problem that I am hoping to address is the inconsistency of following sedation protocols, and sedation assessments between nurses and Drs.

Purpose: Appropriate sedation measures keep our patients at a lower risk for anxiety issues and in long term a lower risk for ICU psychosis. It also keeps our patients from experiencing the pain and discomfort of invasive life support devices such as mechanical ventilation by endotracheal tubes (ET tubes).

Questions: Why do we use protocols with so much leeway on sedation goals? Why are Drs. shying away from sedating our ventilated patients even when they are extremely anxious? How can we help family members understand the importance of minimal stimulation for their loved one?

Point of View: When taking care of these critically ill patients I see all kinds of unnecessary stimulation that results in extreme anxiety and increase in respiration and blood pressure for my patients. We have simple rules to minimize this stimulation such as 1-2 visitors in the room at a time, dim lights, lights out with no television or radio at night, and low volume on the monitors. I also see vented patients who are anxious and need to be restrained to prevent extubation or removal of important lines who aren’t sedated. Why do Drs. feel that these patients are ok without any type of anxiety medication even after we try non-pharmacological techniques first? These patients are suffering from unnecessary discomfort.

Information: Many things contribute to anxiety and eventually ICU psychosis. Some of these things cannot be helped in the ICU setting, but some can. Things that can be fixed are adequate sedation, minimizing noise in the patient’s room, and limiting family noise. Family members are an important part of the healing process, but too much can be detrimental to the patient’s health. Mechanical ventilation and invasive lines and procedures are extremely painful, and restraining patients is very uncomfortable. We have a policy that all ventilated patients need to be restrained to prevent extubation, but where is the policy for appropriate sedation for these patients?

Concepts and Ideas: We need to be using the types of sedation that even when used long term are easy to come off of such as Propofol or Precedex instead of the use of large doses of

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narcotics and benzodiazepines. This way it will be out of the patient’s system faster and shouldn’t decrease chance of getting off ventilator support. When the patient is admitted the family needs to know the rules of the ICU to keep their loved one safe, and we as staff need to enforce these rules consistently to protect the wellbeing of our patients. We need to develop a better assessment tool and protocol for when to sedate a patient, and it needs to be agreed upon by nurses and Drs. so that we all can stay consistent.

Assumptions: There will always be those tough family members who will fight until they get what they want, and no one will stand up to them to enforce the rules, or the Drs. who will refuse to give the patient any sedation regardless of the patient’s anxiety level. Being a teaching hospital we constantly have new Interns and Residents caring for these patients, and not all of them have the same point of view in sedation techniques. Nothing will be perfect, we just need to strive to do our best for our patients.

Implications and Consequences: I think we all know what the consequences will be. Worse case our patients could ultimately suffer from PTSD or ICU psychosis. This will lengthen the hospital stay or at the very least be a huge setback for the patient and their family with possibly years of symptoms related to their experience. Our patients could have anxiety attacks, blood pressures could spike resulting in other health problems, or their respirations could become rapid resulting in blood gasses that need to be normalized.

Inference and Interpretation: We, as a unit, need to do something as a team to help our patients so they aren’t at an increased risk for these problems. We also need to collaborate with our physicians so that we are all on the same page regarding sedation for our patients. Our attending physicians need to teach our sedation protocols to all new Interns and Residents coming in to the program so that sedation can remain consistent regardless of new Drs. moving in and out of the unit.

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D. Scholarship for Practice

In this section, I have provided research examples on two separate issues. These papers

have helped me to gather current evidence to better my nursing practice, which is very important

in this career. Evidence-based practice is very important to continue to provide the best care for

our patients.

The first example is a group critique on a mobility protocol for patients in the hospital

setting. The second example is an evidence-based research on catheter assisted urinary tract

infections (CAUTI), and how we can decrease the prevalence in patients at risk. This paper also

shows how by reducing the prevalence, we can reduce health care costs.

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Nurse Driven Mobility Protocol Critique

Sue Vansteel, Kara Elkins, Benjamin Kasper

Ferris State University

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Abstract

The critique of research by Padula, Hughes, Baumhover (2009) on: “The impact a nurse driven

protocol on functional decline of hospitalized older adults” was conducted by a group of Ferris

State nursing students. An analysis by the group determined that the overall study was weak.

Despite the weakness noted “findings suggest that early and ongoing ambulating in the hallways

may be an importune contributor to maintaining functional mobility” (Padula, Hughes,

Baumhover 2009 p.330).

Areas of weakness in the study were evident in the purpose and problem, which lacked clarity,

conciseness. The literature revealed that it did not include opposing views. The Barthel Index

(BI) and a Get up and Go test identify the individual ability to perform self care are subjective

with an interrater agreement of r + 0.793 for BI score.

Strengths include the hypothesis which state “independent variables was mobility protocol and

dependent variables were functional status and length of stay” (Padula, Hughes, Baumhover

2009 p.325). The quasi research design was a “nonequivalent control group design” (Padula et

al., 2009 p. 327). Which appears to be appropriate for the study.

Institution may implement mobility protocols that are nurse driven despite the weakness of this

study. However additional research in needed to validate the guidelines and outcomes of these

protocols and studies.

Keywords: functional decline, mobility, older hospitalized adults, protocols, critique

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Nurse Driven Mobility Protocol Critique

Nursing research evolved from the days of Florence Nightingale which focused on a “healthy

environment promoting patients’ physical and mental well-being” (Burns & Grove 2011, pg. 10)

to the evidenced based clinical research of today (Burns & Grove 2011, pg. 10). Evidence based

nursing research reports the strongest empirical findings that are significant to understanding

health and illness experiences. Based on the relevance of the study clinical implication is

estimated for therapeutic interventions in nursing practice.

The purpose is to critique the quantitative research article: Impact of a Nurse-Driven

Mobility Protocol on Functional Decline in Older Adults, published in the Journal of Nursing

Care Quality in October -December issue 2009. Using Groves and Burns (2011) text:

Understanding nursing research: Building an evidence-based practice and the Niewiadomy’s

guidelines provided by Hoisington to evaluate the strengths and weakness of the research.

Padula, Hughes, Baumhover (2009) states “maintaining mobility in acutely and even critically ill

people is a key component in achieving positive outcome” (p. 326). This study addressed the use

of a mobility protocol that would be nurse driven to have an impact functional that is commonly

seen in hospitalized older adults.

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Purpose

Evidence

Padula, Hughes & Baumhover (2009) states “the purpose of the study to determine the

impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults (p.

326)

Support

According to Burns and Groves (2011) the purpose should contain clear and concise

steps in-order to reach specified goals or outcomes. The process for identifying the purpose of a

study according to Burns and Groves (2011) may include these elements “identify, describe, or

explain a situation; predict a solution to a situation; or control a situation to produce positive

outcome in practice” (p. 41). The purpose is a descriptive statement which includes a focus or

concept to be studied (Burns and Groves 2011 p.148). In addition the variables are outlined such

as population and relationships that may exist among the variables. Differences among the

groups or variables need to be outlined in the purpose statement (Burns and Groves 2011 p.148).

Analysis

Padula et al. (2009) purpose statement is reflected in the title and restated in the abstract,

as a goal in the first paragraph and after the literature review. The purpose statement describes

the variables being hospitalized which includes older adults, mobility protocol (independent

variable) and functional decline (dependent variable). This is a strong purpose statement.

However, reduction in length of stay was discussed in the abstract as an outcome, and was noted

in the area of research during the study but was not addressed in the purpose statement. The

addition of LOS would have increased the strength of the purpose statement

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ProblemEvidence

The problem statement given by the authors in this article is: “Maintaining mobility is

paramount in preserving independence in activities of daily living (ADL) for older adults, yet

research has demonstrated that low mobility and bed rest are common during acute

hospitalization” (Padula et al., 2009 p.325). Padula, Hughes, and Baumhover (2009) also state

that “maintaining functional status forms the foundation for continued independence and health

and encompasses behaviors necessary to actively engage in daily life,” (p. 325) which is why this

study is so important. The author’s also state that “a stay in the hospital often results in

complications that lead to functional decline in older adults, which occurs in 34% to 50% of

hospitalized older adults, and impairment in functional status is a strong predictor of poor

outcomes" (Padula et al., 2009, p. 325).

Support

According to Burns and Grove (2011) a research problem is “the area of concern where

there is a gap in the knowledge base needed for nursing practice”(p. 146). With a research

problem there needs to be a research problem statement, which is made to identify the “specific

gap in the knowledge needed for practice” (Burns and Grove, 2011, p. 146). According to the

Nieswiadomy critique guidelines, the problem statement must be clear, and the population

should be included. The reader should be able to see how feasible the study will be as well as

the significance of the study based on the problem statement (Hoisington, 2007).

Analysis

The problem statement in this article seems incomplete. The writers also placed the

problem statement in a paragraph meshed together with the purpose of the research, which made

PORTFOLIO 34

it more difficult to distinguish. The problem statement is weak. The writers state a problem that

is both ethical and feasible, but they are very broad. By just stating that bed rest is common

during hospital stays may not be seen as a problem for readers who are not in the health care

field. It would have been stronger with some examples of some solutions or specific problem

areas, or by putting the problem statement in a section by itself and expanding on it. This way it

would be better understood by every reader regardless of background. Padula et al. (2009) state

the common problem during hospitalization is low mobility and bed rest (p. 325) and this is a

problem because maintaining mobility in older adults is important. The point of this study seems

feasible with the support of trained professionals a hospital setting to help mobilize the patients.

Patient mobility is important in for positive patient outcomes..

Review of Literature

Evidence

A literature review section is not identified in this article. However, in the introduction

section, this article has nineteen sources which were cited. There was minimal critique of the

literature review cited in the article. The sources were paraphrased with no direct quotations. The

reference section of this paper does contain all listed citations with source dates ranging from

1986 to 2008.

Support

According to Burns & Grove, “A review of literature provides you with the current

theoretical and scientific knowledge about a particular problem, enabling you to synthesize what

is known and not known” (Burns & Grove, 2011, p. 189). Nieswiadomy outlines a guideline for

critiquing the literature review of a research article. The guideline includes the following

questions to ask while doing a review of literature. The group of questions are as follows: is the

PORTFOLIO 35

literature review comprehensive and concise? Does the review flow logically from the purpose(s)

of the study? Are all sources relevant to the study topic, are the sources critically appraised, are

both classic and current sources included? Are paraphrases or direct quotes used most often, are

both supporting and opposing theory and research presented? Are most of the references primary

sources, can a determination be made if sources are primary or secondary? Are all sources that

are cited in the article found on the reference list and do the references appear free of citation

errors?

Analysis

The literature review by Padula et al. (2009) is a section that is untitled; however, the

authors covered nineteen sources and gave many examples of studies in their introduction. The

included sources and subsequent review of citation of these sources appear to be comprehensive

supporting the authors study. Nevertheless, the author’s appear to be lacking information

opposing their study. The literature review in this article is rather brief and it is not concise, to

be concise, there needs to be a lot of information conveyed in a brief yet comprehensive section.

“The purpose of the study was to determine the impact of a nurse-driven mobility

protocol on functional decline in hospitalized older adults” (Padula, Hughes, & Baumhover,

2009 p. 326). The literature does flow logically from the purpose; the review of literature was

conducted on older adults. There was some information lacking in regards to the age population

of the study participants in previous studies. The literature review which was done by the

author’s flows nicely into the fact that little research was found specific to mobility and changes

to mobility during hospitalization (Padula et al. 2009, p. 326, para. 3).

While it appears that some possible sources have been excluded, all of the sources used in

the literature review are relevant to the topic and based on functional decline in the hospitalized

PORTFOLIO 36

older adult population. It does not appear that the authors have critically appraised their sources

and there is a lack of critique. According to Burns & Grove, “a critical appraisal of research

involves careful examination of all aspects of a study to judge its strengths, limitations, meaning,

and significance” (Burns & Grove, 2011, p. 28).

It appears that the authors did include current and classic sources. However, due to lack

of familiarity with this topic; appraisal of sources can be quite difficult. According to Burns &

Grove, “Sources should be current up to the date the paper was accepted for publication” (Burns

& Grove, 2011, p. 194). Current sources should be published within five years of the authors

study. Based upon the five year criteria, there are many sources included in the study published

within five years and many in the years previous to that. In a search on CINAHL using

keywords of acute hospitalization functional decline forty related articles where found between

the years 1998 -2009.

Padula et al. (2009) did not use any direct quotations in their review of literature. It

appears that paraphrases were used by the authors with the possibility of synthesis of sources

being used. “Synthesis of sources involves compiling the findings from all of the selected

studies and analyzing and interpreting those findings” (Burns & Grove, 2011, p. 220). The

authors presented many supporting theories and research studies for their article. Conversely,

there does not appear to be any opposing research present in the literature review. A search of

CINAHL found articles demonstrating oppositional research.

Academic Journal

Exercise program implementation proves not feasible during acute care hospitalization.

Full Text Available (includes abstract); Brown CJ; Peel C; Bamman MM; Allman RM;

Journal of Rehabilitation Research & Development, 2006 Nov-Dec; 43 (7): 939-46

PORTFOLIO 37

(journal article - clinical trial, research, tables/charts) ISSN: 0748-7711 PMID:

17436179

Subjects: Frail Elderly; Home Physical Therapy; Therapeutic Exercise; Aged: 65+

years; Female; Male

Database: CINAHL

Theoretical/ Conceptual Model

Evidence

The author’s mention functional status, baseline functional status, mobility, activities of

daily living, self-care, and cognitive function as components of various theories of nursing and

conceptual frameworks. For the research study a Geriatric Friendly Environment through

Evaluation and Specific Interventions for Successful Healing (GENESIS) program was utilized

as a model of nursing care delivery for geriatric patients (Burns &Grove 2011). Incorporated into

this mode of care is a nurse-driven mobility protocol. Features of the mobility protocol require

the nurse to evaluate and eliminate barriers to ambulation. This includes addressing orders for

bed rest, necessity of catheters, drains and intravenous therapy. Mobility of patient includes

ambulation three to four times per day, up in chair for meals and bathroom or bedside commode

encouraged.

Support

According to Burns and Grove (2011) “conceptual models are similar to theories but are

more abstract than theories” (p.228). A conceptual model assists the researcher to provide details

about the phenomena articulate any assumptions and reveal any philosophical positions (Burns &

Grove 2011). To provide clarity and consistency for the direction of the research, it is important

to identify the theory and theorist framework. An accurate understanding the concept and the

PORTFOLIO 38

theorist’s definition of the concept is often clarified in the study. Concepts may be an idea, word

or object in which the meaning is defined by the theorist (Burns &Grove 2011). Concepts have

more implication than a dictionary definition and need to be understood so they can be linked to

the method of measurements and implementation in nursing practice (Burns & Grove 2011).

Connecting the concept to the theory provides a foundation for how the findings will be used in a

practice setting.

Maps or models can be used to graphically display the correlation between a concept and

a relationship statement (Burns & Grove 2011). When maps and models are utilized as a

framework the theorist must include references as support (Burns & Grove 2011). Most

important concepts in a theory or study framework are often expressed in a graphic manner and

assist with identifying the gaps in the theory (Burns & Grove 2011)

According to Burns & Grove (2011) frameworks are the guide by which a research study

is developed. The framework provides a reasonable method for collecting and organizing data,

information or problems being investigated. It is through this framework the researcher is able to

examine the result of the study and link them to an existing body of knowledge. Research uses

study frameworks to explain the theory that is being examined. Often the term conceptual

framework or theoretical framework are used to identify the framework and may be used

interchangeably in the context of a research study (Burns &Grove 2011).

Some frameworks are not always clear and expressed in a manner which is difficult for

the reader to locate. Burns and Grove (2011) describe these frameworks as rudimentary ideas

that are explained through literature review or in the introduction. Often the ideas are not

developed but rather implied from the readings. These are considered to be implicit frameworks

(Burns & Grove, 2011, p. 239).

PORTFOLIO 39

Analysis

Padula et al. (2009) do not clearly identify a theory or theorist within the context of the

study. The review of the literature speaks to several previous studies which mention functional

status, self-care, and mobility but they are not specifically identified as concepts. These words or

ideas are found in the introduction but they lack definition, clarity and are not linked to a theory.

The reader lumps together many components that tie into functional status to older adult health

and quality of life, but these components also lack clarity or reference to a theory. An example

would be the introduction of the article which states “Functional status, the ability to perform

basic self-care activities, in a significant component of older adults’’ health status and quality of

life” (Padula, Hughes & Baumhover, 2009, p.325). For clarity, a reference to Orem’s self-care

theory would provide a specific framework in which to base the study. The study variables were

identified as mobility protocol, functional status and length of stay (Padula, Hughes &

Baumhover, 2009, p. 325) but explicit definitions and or framework were not defined.

Padula et al. (2009) use the literature reviews as the method for making relationship

statements that link mobility to functional status and length of stay. Several references are used

to demonstrate that lack of mobility resulted in functional decline (Padula, Hughes & Baumhover

2009). Other references demonstrate that mobility and frequent ambulation improve functional

outcomes for many patients (Padula, Hughes & Baumhover, 2009). It is therefore implied that

there is a relationship between mobility and functional decline through various literature reviews.

However, this relationship is vague because the definitions for mobility and functional status are

not provided. Functional and cognitive status instruments are identified for their research.

PORTFOLIO 40

Without a specified conceptual framework, map or model identified there is a lack of context for

the study. This makes the study weak but still feasible.

Hypothesis and Research questions

Evidence:

In this study, two hypotheses were clearly stated. The first hypothesis given is “older

adults who participate in a mobility protocol will maintain or improve functional status from

admission to discharge”, and the second hypothesis given is “older adults who participate in a

mobility protocol will have a reduced length of stay (LOS)” (Padula et al. 2009, p. 327). Both

hypotheses identify the population, which in this case is older adults, and the dependent and

independent variables. The independent variable in each of the hypotheses is the mobility

protocol. The dependent variable in the first hypothesis is functional status, and in the second is

length of stay (Padula et al. 2009, p. 327).

Support

According to Burns and Groves,( 2011) “a hypothesis is a formal statement of the

expected relationship between two or more variables in a specified population” ( p.167 )A

hypothesis is the researchers “educated guess” on what they believe will be the outcomes of the

study. Hypotheses are valuable components of research because they influence the study design,

sampling method, data collection and analysis process, and the interpretation of the findings by

the author (Burns and Groves, 2011 p.167). A hypothesis guides the entire research process.

A well-written hypothesis should include the variables that are to be measured, as well as

the population that is to be studied, and the proposed outcomes (Burns and Groves, 2011, p.

167). There are a few different types of hypotheses that are used in research, and they are

described in four different categories. 1) associative versus causal, 2) simple versus complex, 3)

PORTFOLIO 41

non-directional versus directional, and 4) null versus research (Burns and Groves, 2011, p.167).

A hypothesis can be associative or causal based on the relationship among the variables being

studied. “Associative hypotheses identify relationships among variables in a study but do not

indicate that one variable causes an effect on another variable” (Burns and Groves, 2011, p. 167-

170). A causal hypothesis “proposes a cause-and-effect interaction between two or more

variables” (Burns and Groves, 2011, p. 167-170).

The difference between a simple and complex hypothesis is how many variables are

being used in the study. A simple hypothesis has two variables, whereas a complex hypothesis

has three or more variables being measured (Burns and Groves, 2011, p.172). Non-directional

hypotheses state a relationship between the variables, but does not predict the exact nature of the

relationship, and this is different than a directional hypothesis because in a directional hypothesis

there is a relationship stated along with the nature of the relationship using terms such as

positive, negative, increase, decrease, etc. (Burns and Groves, 2011, p.174). The last category of

hypotheses is null verses research. “A null hypothesis is used for statistical testing and for

interpreting statistical outcomes,” and “this type of hypothesis is used when a researcher believes

there is no relationship between two variables and when information is inadequate to state a

research hypothesis” (Burns and Groves, 2011, p.174). A research hypothesis actually states the

relationships and provides adequate information (Burns and Groves, 2011, p175).

Analysis

Padula et al. (2009) clearly worded their hypotheses. The population, dependent and

independent variables are clearly stated. This information helps to fully understand the author’s

opinions the outcomes of the study. Both hypotheses stated are simple in that they compare two

variables. They are also both research hypotheses in that there is a relationship stated in each.

PORTFOLIO 42

The first hypothesis which stated that “older adults participating in the mobility protocol will

improve functional status, and in the second hypothesis they state that older adults participating

in the mobility protocol will have reduced length of stay” (Padula et al. 2009, p. 327).

Because of the use of the terms to describe the nature of the relationship, they are both

considered directional hypotheses. This section of the research article is strong and the

hypotheses directly relate to the purpose of the study.

Research (Study) Design

Evidence

In the research methods section of their study, researchers Padula, Hughes and

Baumhover state what the research design for their study will be. “This study used a

nonequivalent control group design” (Padula et al., 2009, p. 327).

SupportBurns & Grove define a research design as a blueprint for conducting a study (Burns &

Grove, 2011). Research design comprises the type of data that will be collected and what

resources will be used to obtain the data. The researcher must also decide if their goal is to

determine causative factors, explore associations between variables or study historical data from

previous research. A research design must be appropriate to test the hypothesis or answer the

research questions. “Quasi-experimental design facilitates the search for knowledge and

examination of causality in situations in which complete control is not possible” (Burns &

Grove, 2011, p. 270). Quasi-experimental study designs vary widely, according to Burns &

Grove, “the most frequently used design in social science research is the untreated comparison

group design with pretest and posttest” (Burns & Grove, 2011, p. 271).

PORTFOLIO 43

Experimental designs are very similar to the quasi-experimental design with the exception of the

control groups and the test groups which are randomized. Non experimental groups like

descriptive and comparative designs are used to examine relationships between variables or

examine a single unit in the context of real like environments (Burns & Grove, 2011, p. 262-

264).

Nieswaidomy has set forth guidelines for critiquing quantitative research designs, they

are as follows. Is the design clearly identified in the research paper and is the design appropriate

to test the study hypothesis or answer the research question. If the study used an experimental

design, was the most appropriate type of experimental design used and what means were used to

control for threats to internal and external validity. Does the research design allow the researcher

to draw cause-and-effect relationship between variables? If the design was non-experimental,

would an experimental design have been more appropriate and what means were used to control

for extraneous variables, such as subject characteristics if a non-experimental design was used

(Hoisington, 2007).

Analysis

The research design is clearly stated in the research report. The researcher’s state that

their research study is a “nonequivalent control group design” (Padula et al., 2009, p. 327). This

type of research design is considered a form of quasi-experimental.

Is the design appropriate to test the study hypothesis or answer the research questions? It

appears that the research design that has been chosen will be appropriate for the study. The

researchers used a convenience sample which can lead to internal validity problems. By using a

convenience group, it is difficult to make certain that the control group and treatment groups

begin at the same level. The researchers describe their use of a pretest and posttest called Barthel

PORTFOLIO 44

Index to measure the groups beginning, middle and ending statistics. With the use of a pretest

the hope is that the researchers could tell if the groups were equal before the treatment was

administered. It does appear that this research design is appropriate for this study.

What means were used to control internal and external validity? Attempts to control

validity were poorly made with this study; however, it does not appear that they were strong

enough to prevent bias. According to Padula et al. (2009) criteria used to create groups were

ability to understand English, no physical impairment to limit mobility, and cognitively intact. A

research nurse screened potential patients and enrolled subjects. There was no discussion of the

qualifications of the research nurse, which could lead to bias in which group a patient was placed

(control or treatment) (p. 327). There was also mention of an advanced practice nurse employed

on the control unit, with no mention of what, if anything was done to prevent internal validity

concerns. There was no discussion on how the researchers controlled external validity such as

the Hawthorne effect, reactive effects, and experimenter effect.

Does the research design allow the researcher to draw a cause and effect relationship

between the variables? Somewhat, the researchers were able to demonstrate by the use of

Barthel scoring that there was a significant increase in the scores for the treatment group, in fact,

according to Padula et al. (2009) the treatment group improved from baseline by +11.5 with the

control group improving by 6.9 which was deemed ‘not significant’ by the researchers. The

researchers also used an Up and Go test which showed scores which were of no significance to

their study (p. 329).

In summary, the research design which was selected seems to be appropriate to test the

hypothesis and answer the research questions. The nonequivalent control group design which

PORTFOLIO 45

was chosen (pretest and posttest control group design) seems to be appropriate for this study. An

area of weakness in this study was mainly the lack of controls for internal and external validity.

The researchers did not discuss or identify how they could control internal and external validity.

Sample and Sampling Methods

Evidence

       For this study, “the researchers used a convenience sample of fifty adults (N=50) ages 60

and older, who were admitted with medical diagnoses to 1 of 2 nursing units” (Padula et al.

2009, p. 327).  They took 25 patients from each unit being studied.  Other criteria that was

included when choosing the population for this study was a length of stay that was at least three

days, English speaking, no prior physical impairment that would greatly limit mobilization, and

those who were cognitively intact.  Patients completed a Mini-Mental exam prior to the study

and needed a score of 24 or more to qualify (Padula et al., 2009, p. 327). 

            Before choosing the sample, a “research nurse screened 453 patients for eligibility, from

those 84 subjects were enrolled, and from those patients 34 were withdrawn from the study for

various reasons” (padula et al., 2009, p. 327). 

            The study took place in a private hospital with 247 beds.  Two nursing units in this

hospital were a part of the study.  The two units that were used were both “equal in size, cared

for similar patient populations, and were characterized by similar nursing staff composition. 

They were both predominantly registered nurses and certified nursing assistants” (Padula et al.,

2009, p 327). 

Support

            Sampling is defined by Burns and Grove (2011) as, “selecting a group of people, events,

behaviors, or other elements with which to conduct a study” (p. 290).  Padula et al. was very

PORTFOLIO 46

precise when choosing the population they would study. A criteria was established to screen the

patients, and also made sure the population was accessible to them.  An accessible population is

very important for a research study, and is the portion of the target population (or entire set of

individuals that meet the criteria of the study) that the researcher has reasonable access to (Burns

and Grove, 2011, p. 290).

Padula et al. used a convenience sample for their research study.  Burns and Grove

define a convenience sample as “a sample where subjects are included in the study merely

because they happen to be in the right place at the right time” (Burns and Grove, 2011, p. 305). 

This way of sampling has been known as being a weak approach, only because there isn’t as

much opportunity to control bias (Burns and Grove, 2011, p. 305).   Researchers are not able to

be as meticulous when choosing their subjects. 

            On the positive side of using convenience sampling, “it is inexpensive, accessible, and

usually less time consuming to obtain the samples” (Burns and Grove, 2011, p. 305).  This type

of sampling is very common in healthcare research.  This is because the sampling frames that

meet specific criteria are not always available and the researcher has to use what is available at

the time or area where they are conducting their research study.  The more criteria set when

choosing the sample, the better the power and validity of the study.  Power is “the capacity of the

study to detect differences or relationships that actually exist in the population.  The minimal

acceptable level for power in a study is 80%” (Burns and Grove, 2011, p. 308). This means that

the study has reasonable findings that can be used in the future. 

Analysis

            The sampling procedures that were used by the researchers in this study were very well

thought out.  They used a convenience sample, but had very specific criteria that gave the study

PORTFOLIO 47

the validity it needed.  The researchers chose to use only medical patients in this study because

then they were able to avoid potential limitations that are associated with post- surgical patients

(Padula et al., 2009, p. 327).  Along with this, there were several other criteria that made the

sampling portion of the study very strong and valid.  They had a very specific target population,

and then took the initial 453 people and eventually narrowed them down to the final 84 patients

that would take part in the study (Padula et al., 2009, p. 327).  From the 84 patients chosen, 34

were withdrawn for many reasons which included discharge, transfer from the units being

studied, having disqualifying procedures, or personal reasons (Padula et al., 2009, p.327).

            The researchers did an excellent job choosing their sample group.  They clearly identified

their target population, and had great criteria to narrow the population size.  Because of the

smaller location and sample of the study, a comparison study may need to be done in other

hospitals with a similar population to prove the validity of this particular study.  This study,

however, will provide enough information to either prove or disprove the hypothesis that “older

adults who participate in a mobility protocol will maintain or improve functional status from

admission to discharge” (Padula et al., 2009, p. 327).

Data Collection Methods

Evidence

Data was collected by

“an advanced practice nurse with expertise in gerontology and geriatrics was hired to collect data and was trained by the geriatric clinical nurse specialist and the principal investigator. Training included human subjects’ protection and achievement of high level proficiency with the protocol and data collection instrument (Padula et al. 2009 p 328)’

The data was collected at Miriam Hospital in Providence, Rhode Island. This facility has 247

beds and 2 nursing units were assigned to the study. These units were of “equal size, cared for

PORTFOLIO 48

similar patient populations and were characterized by similar nursing staff composition” (Padula

et al. 2009 p. 327). Nurses on the treatment unit had been trained and supported a geriatric

program called Geriatric Friendly Environment through Nursing Evaluation and Specific

Intervention for Successful Healing (Genesis). Incorporated into this model is a nurse driven

mobility protocol (Padula et al. 2009 p. 328). The control unit had not implemented the geriatric

program and the nurses did not receive the training. The nurses did not float between theses two

units.

These data points focus on key elements that help to determine current heath status and

future results of the mobility protocol. The data was collected to determine if the implementation

of a mobility protocol would “maintain or improve an older patients functional status from

admission to discharge” (Padula et al. 2009 p. 326).

A demographic data collection sheet was developed specifically for this research.

Eligible subjects for the study were screened by the research nurse and the data was collected

within 48 hours of admission.

A ratio-scale was used to measure the nursing staff characteristic by unit for the study

period. The elements of this data included RN hours per patient day, unlicensed assistive

personnel hours per patient day, total nursing hours per patient day, % total nursing hours by RN,

and % total nursing hours by unlicensed assistive personnel.

Key demographic data was collected on the eligible subject for the study. The level of

measurement used for this information is a nominal-scale. Information obtained included “age;

gender; primary diagnosis; use of assistive devices; fall risk assessment; presence of any

restriction to mobility; use of occupational or physical therapy; LOS; first and number of times

PORTFOLIO 49

out of bed” ( Padula et al., 2009 p. 328). However, the fall risk assessment uses an ordinal-scale

measurement.

The modified Barthel Index, level of independence and the get up and go test are

examples of ordinal-scale measurement. Each of the scales are described below.

According to Padula et al. (2009) data was collected from the patients perception of their

functional mobility 2 weeks before admission and at admission. The data was collected using a

modified Barthel Index (BI). It measured 10 items with a 5 point rating scale to enhance the

sensitivity (p 328).

The level of dependence was measured using a numeric scale 0 (totally dependent) to 100 totally

independent.

A get up and go test with specific criteria measured the ability to stand, walk and return

to sitting (Padula et al. 2009 p. 329). Data for this study was collect at “admission and at

discharge on a 1 to 4 scale, 1 being able to rise in a single movement and to 4 being unable”

(Padula et al. 2009, p. 329).

Measurement of cognitive status was conducted routinely using a mini-mental

state examination score. The rating of this test was not provided. Charts were reviewed to collect

the data for ambulation, number of times in the chair and other activities.

Support

In 1946 Steven “organized the rules for assigning numbers to objects so that hierarchy in

measurement was established”(Burns and Grove 2011 p.329). These levels describe as being

nominal, ordinal, interval and ratio.

Nominal-scale measurement is the lowest in which data is organized in categories of

defined property but they cannot be ranked in any kind of order. There are several rules to this

PORTFOLIO 50

measurement in that there is no order to the categories, they are exclusive and exhaustive (Burns

and Grove 2011 p. 329).

Ordinal-Scale measurement are the level most used in nursing assessment. The data “are

assigned to categories that can be ranked” (Burns and Grove 2011 p. 330) with rules governing

how the data is ranked. These rules indicated an equal distance does not exist between the

rankings and the categories must be exclusive and exhaustive (Burns and Grove 2011 p. 330).

The third level is an interval-scale measurement in which there are “equal numerical

distance between the intervals” (Burns and Grove, 2011 p. 329). According to Burns and Grove

(2009) these scales follow the rules of mutually exclusive and exhaustive categories and ranking

ordering are assumed to represent a continuum of value” (p. 330).

The last and highest level of measurement is the ratio-scale. This measurement has

categories that are mutually exclusive, exhaustive, order ranked, equally spaced intervals and a

continuum of values (Burns and Grove 2011 p. 329).

The type of test can pose a threat to internal validity. This is especially true with pretest and post

test with the same questions. The threat comes from a subject already knowing the questions

(Hoisington 2012 Cycle 3). External Validity may be threatened by the subject answering the in

a manner that could sway results.

Analysis.

The author’s give a good description, comparison and reason for the selection of these

two nursing units. The data collection was completed by hired trained professionals which

decreases the possibility for error and strengthens the measurement process. However the

author’s do not provide information if others were involved in data collection. A vast amount of

data is collected at admission and discharge using the different assessment scaled. The article

PORTFOLIO 51

does not explain when other data is collected and how it is collected. In addition the author’s rely

on information being documented in a chart. One cannot be sure if all elements of the data

collectionwere documented in the chart.

The researchers goal was to provide data that would demonstrate a nurse driven protocol

would have an impact on a patient’s functional decline in a hospital setting. The modified BI tool

to measure functional status is standard in the clinical and research setting with demonstrated

inter-rater agreement. This strengthens the reliability of the results. The get up and go test also

has been tested for reliability which also strengthen the validity. These were weak in that the test

were subjective and based on patients or significant other perception. The threat to internal

validity is high because the subjects were asked the same question at the start of the study and at

discharge. Despite the weakness of the tool the results appear to be promising and may warrant a

more in-depth follow up study.

Instrument

Evidence

Padula et al. (2009) discussed four instruments which were used in their research. The

instruments used are as follows, demographic data collection sheet, functional status via Barthel

Index, Get Up and Go test, and Mini-Mental State Examination (MMSE) (Padula, Hughes, &

Baumhover 2009, p. 328). The demographic data collection sheet falls under a nominal-scale

measurement, no reliability or validity information was provided. The Barthel Index (BI) falls

under an ordinal-scale measurement, the authors state that, “researchers have proposed the BI as

the standard for clinical research purposes” (Padula et al., 2009, p. 328), and provided an

interrater agreement of r = 0.793. The Get Up and Go test is also an ordinal-scale measurement,

which accordng to the authors has been reported to be reliable and valid with a correlation rating

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of r = -0.78 in comparison to the BI (Padula et al., 2009). The MMSE also falls under ordinal-

scale, however, no reliability or validity measures were included by the authors.

Support

Reliability of an instrument is of great importance to a study. According to Burns &

Grove, “reliability is concerned with the consistency of the measurement method” (Burns &

Grove, 2011, p. 332). If an instrument is not reliable, researchers cannot know what it is really

measuring or if it is really measuring what they want it to measure. Reliability testing measures

the extent of random error in the measurement method (Burns & Grove, 2011, p. 333). There are

three types of reliability testing, which according to Burns & Grove, are stability, equivalence,

and homogeneity.

Stability is described as a “concern with the consistency of repeated measures of the same

attribute with the use of the same scale or instrument” (Burns & Grove, 2011, p. 333). Stability

is also known as the test-retest reliability. Equivalence is also used as a form of reliability

testing, according to Burns & Grove equivalence, “involves the comparison of two versions of

the same paper-and-pencil instrument or of two observers measuring the same event” (Burns &

Grove, 2011, p. 333). Also mentioned by Burns & Grove is interrater reliability which is a

comparison of two observers of two judges in a study (Burns & Grove, 2011, p. 333).

Homogeneity is the third form of reliability testing described by Burns & Grove, this type

of testing is used primarily with paper-and-pencil instruments or scales which addresses the

correlation of each question to the other questions within the instrument (Burns & Grove, 2011,

p. 334).

Validity of an instrument according to Burns & Grove is a, “determination of how well

the instrument reflects the abstract concept being examined” (Burns & Grove, 2011, p. 334). An

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instrument may be valid for one study and that same instrument may not be valid for another.

Researchers need to know if the instruments they are using are valid for what they are

measuring, or their study may be in jeopardy. According to Burns & Grove, there are three types

of validity, which are contrasting groups, convergence, and divergence (Burns & Grove, 2011, p.

335).

Validity from contrasting groups can be determined by, “identifying groups that are

expected (or known) to have contrasting scores on the instrument” (Burns & Grove, 2011, p.

335). Validity from convergence is determined, “when a relatively new instrument is compared

with an existing instrument(s) that measure the same construct” (Burns & Grove, 2011, p. 335).

According to Burns & Grove (2011), the instruments are used concurrently, and then the results

are evaluated using correlational analysis. Measures which are positively correlated strengthen

the validity of the instrument (Burns & Grove, 2011, p. 335). Lastly, validity from divergence

can be measured, which is using an instrument of opposite effect than what is actually being

measured. According to Burns & Grove, “correlational procedures are performed with the

measures of the two concepts. If the divergent measure is negatively correlated with the other

instrument, validity for each of the instruments is strengthened” (Burns & Grove, 2011, p. 335).

Analysis

Padula et al. (2009) provides clear descriptions of the instruments used for data collection

performed in this study. The instruments are described; their purpose and function are included

with how the data was collected. The authors created a demographic data collection sheet for

this study; however, they did not include any form of reliability or validity for this tool.

The function and purpose of the BI and Get Up and Go tests were described by the

authors. The BI was listed as having an interrator score of r = 0.793 which according to Burns &

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Grove is a low score for reliability, an interrator score should be greater than 0.80 to avoid

reliability concern (Burns & Grove, 2011, p. 333). The Get Up and Go test was reported to

correlate to the BI with a score of r = -0.78. This score is negative due to the fact that the Get Up

and Go test is a divergent test from the BI. This score also falls below the recommended score

set forth by Burns & Grove of 0.80.

The authors include excellent information on the instruments. However, they are

deficient in explanation of the suitability of the tools used for their study. There are significant

threats to internal validity of this study. The authors did not identify the possibility of skewed

information, for example, the patients are being given the same test over and over again, and

there is a possibility of repeated testing bias.

Descriptive Analysis

Evidence

            Padula et al. (2009) did not use many descriptive statistics in their research presentation. 

They have given two tables in their work, one that shows nursing staff characteristics by unit

during the study period in hours between the treatment and control group, and another that shows

Barthel scores (which reflect the subjects’ perception of functioning) preadmission, admission,

and discharge between the treatment and control groups (p. 327 and 329). 

Support

            Burns and Grove (2011) defines descriptive statistics as “statistics that allow the

researcher to organize the data in ways that give meaning and facilitate insight; such as

frequency distributions and measures of central tendency and dispersion” (p. 536).  Ways that

this information can be given in a research article are in tables, charts, and graphs.  There are

many types of charts and graphs that can be used.  The goal of descriptive statistics is to show

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the reader different examples of how the variables reflect and relate to each other (Burns and

Grove, 2011, p. 389). 

            Frequency distribution, a type of descriptive statistics, is “used to organize the data for

examination.  In this case tables are developed to display the values” (Burns and Groves, 2011,

p. 384).  Measures of control tendency, the average of the data, consist of the values for mode,

median, mean, and midpoint (Burns and Groves, 2011, p. 385-387).  Measures of dispersion,

measures of individual differences of the members of the sample,  include the variance, range,

and standard deviation, which are usually shown in graphs (Burns and Groves, 2011, p. 388). 

“The purpose of this analysis is not to define causality, but to describe the difference in the

variables and groups being studied” (Burns and Groves, 2011, p. 389). 

Analysis

            Padula et al. presented their data using limited descriptive statistics.  As mentioned

previously only two tables were used.  The inclusion of additional graphs would have been more

helpful to the reader and made it easier to understand their data and findings.  This was a very

weak section in their analysis.

Inferential Statistics

Evidence

            “Inferential statistics were used in this study to calculate the probability theory and the

differences between the treatment and control group on the dependent variables” (Padula et al.,

2009, p. 329).  The majority of their probability testing gave results that were “non-significant”. 

The researchers calculated probability between the treatment and control groups on fall risk

scores on admission.  “The p score, or probability score, was documented as P=.07 (about 7%),

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and the treatment group did have slightly lower scores than the control” (Padula et al., 2009, p.

329). 

            Barthel scores were also calculated for probability.  “Discharge scores improved for the

treatment group from admission to discharge (P=.05), while the control group numbers were

insignificant and actually had a slight increase by P=.006” (Padula et al., 2009, p. 329).  “The

treatment group did have a shorter length of stay on average than those in the control group with

a probability score of P<.001” (Padula et al., 2009, p. 329).  T scores were not given in this data

analysis.

Support

            Inferential statistics are calculations and other ways to show the relationship between the

groups and variables being studied.  Many different tests are used in this area.  “The probability

test is used to explain the extent of the relationship, and the probability that an event will occur

in a given situation, or can be accurately predicted” (Padula et al., 2009, p. 376).  Probability

values are expressed as p and given in decimals to be translated into percentages. 

The chi-square test is another example of a statistic that researchers use.  “The chi-

square test determines whether two variables are independent or related, and can be used with

nominal or ordinal data” (Padula et al., 2009, p. 401). 

“The t test is a very common analyses that tests for significant differences between two

samples” (Padula et al., 2009, p. 404).  “This test is used to examine differences in groups when

the variables are measured at the interval or ratio level” (Padula et al., 2009, p. 404). 

“ANOVA and ANCOVA are used to help the researcher examine the f statistic and the

effect of a treatment apart from the effect of one or more potentially confounding variables”

(Padula et al., 2009, p.407-408). 

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Analysis

            Padula et al. (2009) only gave probability test results, and did not provide any t tests. 

They gave a few different probability values that gave the reader a good picture of the data that

was being presented, but could have offered more testing results to provide additional clarity of

the outcomes.  Their use of inferential statistics was greater than their descriptive statistic use,

and therefore was stronger, but they could have used more variety in their testing and

calculations to provide the reader with a broader picture of their data analysis.

Study Findings

Evidence

The research study by Padula et al. (2009) contains a discussion section in which the

study findings are also presented.  In the discussion section, Padula et al. (2009) presents their

two hypotheses and relates their findings accordingly.  The discussion section contains statistical

data to support their findings.  Padula et al., discussed that their first hypothesis that, “older

adults who participate in a mobility protocol will maintain or improve functional status from

admission to discharge was supported” (Padula et al., 2009, p. 330).  Also stated by the

researchers was that their second hypothesis, “older adults who participate in a mobility protocol

will have a reduced LOS, was also supported” (Padula et al., 2009, p. 330).  The researchers

came to the determination that their study showed a significant decline in functioning between

preadmission and admission and that prolonged immobility is a contributor to functional decline.

Padula et al. (2009) also included a conclusion section in which they tied together their findings

in one short paragraph.

Support

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            This section contains support for study findings, study discussion and study conclusion. 

According to Burns & Grove (2011) the findings section of a study contains results which are,

“translated and interpreted to become study findings, which are a consequence of evaluating

evidence from study” (Burns & Grove, 2011, p. 410).  Next is the discussion section, according

to Burns & grove (2011), “The discussion section ties together the other sections of the research

report and gives them meaning” (Burns & Grove, 2011, p. 59).  The discussion section should

contain items such as, “major findings, limitations of the study, conclusions drawn from the

findings, implications of the findings for nursing, and recommendations for further research”

(Burns & Grove, 2011, p. 59). Limitations should be discussed so the reader will understand

what restrictions were encountered during the study so a determination can be made about the

credibility of the findings (Burns & Grove, 2011, p. 48).  Then, lastly is the study conclusion

section which should include a “synthesis of the findings” (Burns & Grove, 2011, p. 412).

Analysis

            While Padula et al. (2009) presented their findings, the researchers placed their findings

and discussion into the same section which makes it difficult for the reader to separate between

the two at times.  The researchers did not include information on where the study results could be

used in actual nursing practice, nor did they accentuate how this study makes an important

difference in the lives of people.  The researchers did give limitations and mentioned that

“further study with quantification of the impact of diseases is indicated” (Padula et al., 2009, p.

330).  The researchers also made mention that the control group and treatment groups had

identical out of bed times during the study, which indicates that even on the non-trained

GENESIS unit that the patients were getting similar care. 

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            Padula et al. (2009), discusses in their conclusion that their findings suggest that “early

and ongoing ambulation in the hallway may be an important contributor to maintaining

functional status during hospitalization and to shortening LOS” and that “ambulation should be

viewed as a priority and as a vital component of quality nursing care” (Padula et al., 2009, p.

330).  The researchers seem to be making an all-inclusive statement that all patients will benefit

from their study, when in fact they did not include all patients in their study. They also do not

make any suggestions for further research in this area with different design or samples.

Conclusion

Padula et al. (2009), made a great case for needing a mobility protocol. They had a

strong hypothesis that clearly stated the variables, and gave strong support for why they felt a

mobility protocol was needed, but unfortunately, their research was weak. They only did their

research in one facility, using one unit as a control, and another as a treatment group which made

their sample very small. “The research nurse screened a total of 453 patient records for

eligibility; of those, 84 eligible subjects were enrolled, but 34 were then withdrawn from the

study (Padula et al., 2009, p. 327). They used specific criteria to screen the patients which

allowed for less bias and more validity in their research, but they did not recognize the external

validities of the certain diseases and acuity of the patient participating in the treatment, and

therefore, did not take into account these factors and how they may have themselves contributed

to the LOS.

“Prolonged immobility is clearly demonstrated to be an important contributor to

functional decline, and ambulation is a priority and a vital component of quality nursing care”

(Padula et. al., 2009, p. 330). These researchers have proven that a mobility protocol of some

sort is needed, and does help in reducing length of stay, but further research must be done in this

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area with a bigger sample to compare results. Only older adults over 70 were used in this study,

and the research could be used to assist all ages in reducing LOS in all types of units. Overall,

this research was weak, but with a little more detail and larger and broader samples, this research

could be used to change practice all over the world.

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References

Burns, N. & Groves S. K. (2011) Understanding nursing research: Building an evidence-based.

Maryland Heights, MO: Elsevier

Padula, C.A., Hughes, C., & Baumhover, L.(2009). Impact of a nurse-driven mobility protocol

on functional decline in hospitalized older adults. Journal of Nursing Care Quality. 24(4),

Nieswiadomy Guidelines ….

Revised 6/27/2012

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INDWELLING URINARY CATHETERS: PREVENTION OF CATHETER-ASSOCIATED

URINARY TRACT INFECTIONS (CAUTIs)

April Beresford, Benjamin Kasper, and Kara Elkins

Ferris State University

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Abstract

Catheter-associated urinary tract infections (CAUTI) are of big concern today. They can

leave patients with increased amount of unnecessary pain and discomfort, lead to

increased length of stay in hospitals, and large amounts of money that could be better

used elsewhere. We will review and critique three articles relating to CAUTI and the

steps that are being researched to decrease the incidence of it, while also discovering if

the research itself is strong enough or too weak to make a case for change in practice.

Keywords: Urinary tract infection (UTI), foley catheter, straight catheter, hospital

acquired, healthcare acquired, cystitis, CAUTI

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Indwelling Urinary Catheters: Prevention of Catheter Associated Urinary Tract

Infections (CAUTIs)

Catheter associated urinary tract infections (CAUTI) are the cause of many

hospital acquired infections. According to Andreessen et al. (2012), “CAUTIs are the

most common type of nosocomial infection, accounting for 40% of all infections in the

hospital per year” (p. 209). Because of the increase in these numbers, nurses,

physicians, and others in the medical field, have decided to come together to research

the issue.

In this document, we will discuss three different studies that have been

conducted to find the root cause of this problem, and to come up with plans to reduce

the cause, and therefore decrease the incidence of CAUTI.

Description of Research Articles

Article One

This first article written by Andreessen et al. (2012), focuses primarily on

changing the current practice of nurses and doctors by giving them a tool to help

prevent catheter associated urinary tract infections (CAUTI). The researchers have

developed a bundle plan that will aid the nurses in insertion techniques and

maintenance of urinary catheters. This plan will also include daily assessment of need

by both the nurse and physician, and will require a q24 hour order to continue use of

catheter in a patient. By changing practice, adding meticulous computer

documentation, and reducing use and duration of catheters, these researchers hope in

the long run to reduce the percentage of CAUTIs experienced by patients. This is

proven to be an important study because it has been noted that “CAUTIs are the most

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common type of nosocomial infection.” This causes increased pain and discomfort felt

by the patient, and also increases healthcare costs for both the patient and the medical

facility (Andressen et al., 2012, p. 209). Medicare and Medicaid are no longer paying

for treatment of CAUTI because it is something that the hospital is unnecessarily

causing the patient to have (Andressen et al., 2012, p. 209). Because of this, hospitals

are now required to pay out of pocket for the additional expenses related to CAUTI,

which include but are not limited to antibiotic treatment and increased length of stay.

Article Two

Oman et al conducted a primary research study in 2011 to establish the

effectiveness of nursing initiated interventions in regards to the incidence rate of

catheter associated urinary tract infections (CAUTI). Because bladder catheterization is

common in the hospital setting, and nursing professionals are utilized to manage these

urinary drainage systems, Oman et al studied the effectiveness of specific nursing-

initiated interventions in relations to urine elimination management within a hospital

system. This study was conducted on two adjacent medical/surgical units at a Colorado

hospital using a formally constructed nursing education program and measured CAUTI

rates in a daily average census of 18 patients for a period of over one year. The goal of

this study, which was carried out by five registered nurses and a physician, was to

“decrease CAUTI rates through implementation of hospital-wide nursing interventions

that emphasized education for inpatient nurses and specific unit-based nursing practice

actions on a pulmonary medical and a general surgical inpatient unit” (Oman et al,

2011, p. 4).

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Article Three

While indwelling catheter use remains a necessity on the medical intensive care

unit (MICU), catheter associated urinary tract infections (CAUTIs) continue to be an

ongoing battle. This study has shown that with use of guidelines for indwelling catheter

use CAUTIs can be reduced or eliminated in MICU inpatients (Elpern et al., 2009, p.

535).

A vast majority of the data presented in the article, “Reducing use of indwelling

urinary catheters and associated urinary tract infections,” written by Elpern et al. (2009),

was obtained from quality improvement indicators which were used to determine CAUTI

rates in inpatients of the MICU which was studied. Other data collected during this

study was duration of catheterization, appropriateness of catheterization and reason for

inappropriate catheter use. This study focuses on appropriate indwelling catheter

usage and CAUTI rates within a 6 month focus range in a 21 bed MICU.

Critical Appraisal

Article One

Review of literature

The authors of this research article spent two months before beginning the study

reviewing the literature for procedures and policies that would assist them in decreasing

CAUTI incidence (Andreessen et al., 2012, p. 211). The several sources that are

referenced are current and relevant to the study and the goals of the study. In this area,

they did not provide much of the information that they gathered from their review, but it

is considered strong in that their sources are up to date, and the information used was

shown to be a strong background for beginning the study. The “bundle” that they

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created to decrease percentage of CAUTI was put together based on the information

gathered in the review of literature, and this bundle was the basis for the study. This

would show that the researchers were very thorough and confident with the review.

Hypothesis

Andreessen et al. (2012) did not actually make a problem/purpose or a

hypothesis statement that was recorded in the article. They did however ask the

question “is a urinary catheter bundle with computerized documentation and ordering

templates (including the daily assessment of continued need for a catheter) effective in

reducing the use and duration of indwelling urinary catheterization in acute hospitalized

patients” (Andreessen et al., 2012, p. 211). They also made a statement earlier in the

article saying “The strongest predictor for CAUTI is the duration of catheterization, and

catheterization lasting more than six days increases the risk for CAUTI seven times”

(Andreessen et al. 2012, p. 210).

Framework

In this question they did introduce the following variables dependent variable:

duration of urinary catheterization, and independent variables: urinary catheter bundle,

which included proper insertion and assessment techniques to be utilized, computerized

documentation, and ordering templates. The population was also defined which in this

case is “acutely hospitalized patients” (Andreessen et al., 2012, p. 211). This is a strong

hypothesis because all of the variables were defined and the question asked is relevant

to the goals for the study.

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Research design/data collection

This article is out to prove that the independent variables named (urinary catheter

bundle, computerized documentation, and ordering templates) have a direct relationship

with the dependent variable of catheter duration, which they feel, will influence the long-

term research goal of decreasing CAUTI incidence. Because of the cause and effect

noted in the relationship of these variables, The researchers have used causality in their

research design for this study. The study that they performed was an experimental

using the pretest and posttest design. According to Burns and Grove 2011),

experimental pretest and posttest design focus on the study of causality between

variables and look at the relationship before and after the manipulation of variables (p.

276). Andreessen et al. did an evaluation before and after the introduction of the

urinary catheter bundle.

The total amount of time it took these researchers to complete their project was

eight months. During this time, they were collecting data daily from computerized

charts. The initial three weeks included evaluation of 1,200 charts to collect baseline

data, followed by many months of collecting data after the urinary catheter bundle and

other policies were put into place. They ended with another three-week post program

evaluation process that required the review of 1,385 computerized medical charts to

collect the outcome data (Andreessen et al., 2012, p. 211). These charts were

reviewed many times to find all patients with indwelling urinary catheters. They would

then follow these patients to make sure the bundle and new policies were being

adhered to with the hopes of the catheter duration for these patients would be

decreased, and in turn resulting in less incidence of catheter acquired urinary tract

PORTFOLIO 69

infections Andreessen et al., 2012, p. 211). Registered nurses, physicians, and

infection control nurses, along with the others that were involved in the research team,

reviewed the documentation (Andreessen et al., 2012, p. 211).

The research team put a lot of effort into their data collection process. This area

of the research was strong, but could have been better with more detailed information

as to what they were recording in their data collection and not just that they were

looking for patients with indwelling catheters.

Sample/setting

“The research project took place at a VA (veterans affairs) medical center, and

included patients with acute placement (less than thirty days) of an indwelling urinary

catheter” (Andreessen et al., 2012, p. 211). Only male patients were included because

the majority of the patient population at this center was male. All charts were reviewed

for those male, and eighteen and older (Andreessen et al., 2012, p. 211). Those

patients who needed long-term catheterization, or were diagnosed with a urinary tract

infection within 24 hours of admission were excluded from the study to protect from

misinformation in the data collected (Andreessen et al., 2012, p. 211).

This sample a convenience sample. Burns and Groves (2011) define

convenience sampling as “choosing subjects because they happen to be in the right

place at the right time” (p. 305). The researchers chose the location of the study to be

the VA hospital, and then chose the target population out of those who were admitted to

the hospital during the time of the study. They didn’t have full control over those who

were available when they were collecting data.

PORTFOLIO 70

The researchers did what they could to control outside variables that may

construe the data, and therefore made this a strong sample for their research. Their

choice to only include male patients also decreased the amount of bias in their study as

well since there were not many female patients available for study. They will have to

conduct another study with female patients to see if in fact the same the same results

are achieved, or if different tools need to be utilized.

Limitations

This study was conducted at a single site which causes limitation in that the

results may be limited to hospitals of similar size and type to the VA medical center

where the study took place. “The project also lacked CAUTI rates for comparison

because the hospital had not collected this rate before this project began” (Andreessen

et al., 2012, p. 211). Even though this study contained these limitations, the

researchers did everything they could to control biases and chose their target

population the best they could.

Analysis/results

A total of 90 charts were used in this study after all ineligible patients were

removed. “In the pre-intervention stage of the study 2% of the charts had complete

documentation on urinary catheter insertion dates, removal dates, and catheter

maintenance, and in the post-intervention stage, the nurses had documented

appropriately 98% of the time” (Andreessen et al., 2012, p. 214,). “The new catheter

bundle template was being used 40% of the time, the new order template was being

used 35% of the time, and only 2% of the charts were missing a documented order”

(Andreessen et al., 2012, p. 211). The nurses were also following CDC guidelines

PORTFOLIO 71

regarding appropriate catheter size more frequently after the catheter bundle was

introduced.

Discussion

According to Andreessen et al. (2012), “the most important criteria was the daily

questioning of the continuing need for catheterization (p. 215). This portion was

included in the ordering criteria. After the post-intervention data was gathered, it

showed that the use of the guidelines from the care plan bundle along with the need for

daily assessment and order for a urinary catheter, assisted in reducing catheter use

(Andreessen et al., 2012, p. 215). Proper education was given to the staff and residents

regarding proper use of urinary catheters, including care when inserting and

maintenance, proper assessment and appropriate uses, and detailed documentation.

The researchers made it so that even after the data was collected, the staff would have

the appropriate tools and knowledge to continue to work towards the goal of CAUTI

rates decreasing. This proves that this study is important to them and they wish to see

the rates continue to decrease.

Conclusion

It was discovered at the end of the study that “the implementation of a set of

guidelines (the urinary catheter bundle) for catheter use and care resulted in a reduction

of catheter use by 57% and a significant decrease in catheter duration by 70%”

(Andreessen et al., 2012, p. 216). The researchers that conducted this study felt that in

the long-term, if this new plan of care continued, would contribute to the reduction of

CAUTI, but in order to really research the reduction of incidence of CAUTI, the

researchers would have to continue to watch and collect the data from the medical

PORTFOLIO 72

center. The effort lies with the staff and practitioners to keep up the newly introduced

protocols, and then the researchers are confident that this will lead to decrease in

CAUTI (Andreessen et al., 2012, p. 216).

The researchers in this case did an excellent job with their study. The study was

well thought out and the interventions were simple changes that nurses were able to

execute easily. Even though there were limitations, and the information wasn’t able to

be compared to previously recorded percentages of CAUTI, the conclusions validated in

this study could be used in broader settings to assist in the prevention of CAUTI.

Article Two

Problem and Purpose

Oman et al began by describing the background and history of catheter

associated urinary tract infections (CAUTIs). “Cather-associated urinary tract infections

are common, morbid, and costly. Nearly 25% of hospitalized patients are catheterized

yearly, and 10% develop urinary tract infections” (Oman et al, 2011, p. 1). They also

state that CAUTIs create a financial burden, and attribute to hospital-acquired

bacteremia on a large scale and point out that significant populations at risk are

postoperative patients and inambulatory patients who “do not have a clear indication for

indwelling urinary catheters” (Oman et al, 2011, p. 1). After building a strong concern

for addressing the problem of CAUTI in the patient population, they state “Catheters

may be inappropriately retained for days because of convenience, misunderstanding of

their necessity/appropriateness, or lack of clear orders for removal. Therefore, efforts to

reduce CAUTI prevalence must focus on evidence-based use of IUCs during insertion,

maintenance, and removal” (Oman et al, 2011, p. 1). This can be considered as the

PORTFOLIO 73

problem statement, as it reflects the concerns regarding CAUTI that were reflected in

the background review. The purpose statement is clearly identified on page two, and

states “The purpose of this quality improvement process study was to develop and

implement evidence-based, multifaceted, nurse-driven interventions to improve urine

elimination management in hospitalized patients and to measure the impact of these

interventions on the duration of indwelling urinary catheterization (dwell time) and the

CAUTI incidence among patients on the target inpatient units” (Oman et al, 2011, p. 2).

This accurately reflects the reason for the study. It is clear and concise and easy to

understand, and clearly includes ties to nursing practice and builds on existing nursing

research.

Review of Literature

Oman et al did not do a formal presentation of the literature reviewed in

preparation for or in process of their study. Instead, they used facts and other

information during the study to assist in explaining or conceptualizing their data. The

literature cited and the information included was all current with the exception for only

four of their 23 sources cited, and for those citations it was framed that the data was

historical. None of the literature presented was thoroughly or critically appraised, nor

was there a method to determine which research mentioned was primary or secondary

research. No quotations were utilized but information stated from outside sources was

properly cited. There was no contradictory theory or information presented. All of the

sources cited were appropriately listed at the end of the study with no citation errors

found.

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Study Framework

Oman et al were very clear in their description of this study framework.

Relatively early in the study description, they state “This project used the following

framework for implementation: Recruit a multidisciplinary team; Examine the evidence;

Identify and understand product(s); Measure outcomes” (2011, p.2). The concepts

contained within the framework were all clearly stated, and included “A pre/post

intervention design….to test the impact of nurse-driven interventions based on current

evidence to reduce CAUTIs in hospitalized patients on 2 medical/surgical units” (Oman

et al, 2011, p.1). Variables in this study were numerous. The dependant variables in

this study were incidence rates of CAUTI, catheter duration, LOS, bladder scanner

usage, and product streamlining. The independent variable was solidified as “nursing

interventions” but was broken down into a series of interventional options presented to

nurses who were participating in the study. Oman et al also described additional

technology provided to the unit, such as bladder scanners, as well as numerous

methods of educational support provided to nurses and nursing assistants on the

sample unit. Because there were multiple variables at work within the sample unit

simultaneously, it was it was impossible within this framework to identify which nursing

intervention was most effective or which were not highly effective, nor was the

educational component of the study evaluated from the standpoint of effective education

of the nursing staff. Although there were several variables to consider in this study, each

was clearly outlined and identified by the researchers. The relationships between the

concepts were presented in very clear terms.

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Hypothesis and Research Questions

This study was based on a quality improvement approach, and Oman et al

describe a gap between the evidence-based nursing practices current to our nursing

practice and the availability of these concepts to disseminate within the nursing

population. “The goal of this quality improvement study was to decrease CAUTI rates

through implementation of hospital-wide nursing interventions that emphasized

education for inpatient nurses and specific unit-based nursing practice actions on a

pulmonary medical and a general surgical inpatient unit” (Oman et al, 2011, p. 4-5).

The hypothesis was not written in a single declarative sentence, but can be derived

indirectly by referencing the framework and assessing the reflection at the end of the

study, which state that “The findings of this project support the effectiveness of

implementation of a CAUTI program that encompasses nursing education, competency

training, products, and surveillance to positively impact patient outcomes. Re-

examining a common nursing procedure resulted in improved practice with IUC care

and improved patient outcomes” (2011, p. 5).

Quantitative Design

The Oman et al study was a quantitative study, which sought to systematically

describe variables, test their relationships, and examine the cause-and-effect of nursing

interventions on CAUTIs in hospitalized patients. Oman et al used a quasi-experimental

pretest/posttest design which was specifically identified as their chosen method, and

further subdivided this study into three phases (baseline data collection; house-wide

intervention; second data collection) which were all critically evaluated. This was a

quasi-experimental and not a true experimental study because complete control over all

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of the variables was possible. The design of the study was very effective in examining

the results of the study because the variables were clearly identified and the

relationships between those variables was clearly constructed. Threats to the internal

validity of the study were controlled by explaining in detail each of the nursing

interventions encouraged in the intervention group, and how each one correlated to a

reduction in the use of or the infection rates of urinary catheters. One threat that could

not be controlled was the sample population; although two units were utilized (one

medical and one surgical) the population diversity among the patients was minimally

described, and the nursing staff was not described, including but not limited to years of

experience within the nursing staff. This study was conducted using only that single trial

at a single hospital which creates a study bias. Definition of the ‘Student T’ test was not

cited and not explained or summarized which left a gap in the study instrumentation

which is important also to internal validity.

Sampling Procedure

The target population is identified several times throughout the study, including

an introduction to this population in the very first sentence of the study which reads

“Hospital-acquired, catheter-associated urinary tract infections (CAUTIs) are a common

and costly health care concern” (2011, p.1). The target population is later clarified in the

purpose statement, which was “The purpose of this quality improvement process study

was to develop and implement evidence-based, multifaceted, nurse-driven interventions

to improve urine elimination management in hospitalized patients…” (2011, p. 2). The

population included within the selected nursing units was not adequately described

within the study: ages, backgrounds, comorbidities, etc. Although it is necessary to

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acknowledge that Oman et al did include a table to identify the mean age and the

breakdown of the male/female proportions on each unit, no correlation between that

data and the context of the study was made. The sampling procedure was not

descriptively identified, and it was only briefly mentioned that the average daily census

of each nursing unit was 18 patients per day for a sum of approximately 150 patients

per month. It was not specified whether or not all of part of the patient population on

these units was included in the study, and the reader was left to assume that this was a

convenience sampling of the accessible population. A convenience sampling is a weak

approach to enforcing the internal validity of a study because it “provides little

opportunity to control for biases; subjects are included in the study merely because they

happen to be in the right place at the right time” (Burns & Grove, 2011, p. 305). This

accounts for both the population of the patients as well as the population of the nurses

who were included in this study. Because this study was only conducted in two nursing

units at a single hospital, the potential biases are numerous and it is too narrow to

consider it a complete and accurate representation of both the nursing and the patient

populations at large. “Our assessment of the focused interventions within 2 units may

have provided only a snapshot of the overall effectiveness of the education, policy and

product changes implemented in this study as a more comprehensive assessment of

the impact of the intervention were not undertaken” (Oman et al, 2011, p. 5). The issue

of subject dropout was completely omitted.

Data Collection

Data collection and measurement was explored extensively in this study.

“Demographic patient data, CAUTI rates, and IUC duration were collected at baseline

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(phase 1) and after the two intervention phases” (Oman et al, 2011, p. 3). Oman et al

describe the data collection intervals for the incidence rate of CAUTI, and indicate that

demographic data was compiled but the group fails to include any of that information in

the study. Catheter duration, length of stay (LOS), bladder scanner usage, and product

streamlining were also measured and correlated as part of the study outcome (Oman et

al, 2011, p. 4). The descriptions of these, as well as the instruments of measurement

used to evaluate each variable was included and adequately described each so that the

effectiveness of the interventions as a whole could be validated. There were no

extensive analytical models presented as a component of any of the variables; instead

“All variables were summarized using descriptive statistics appropriate for the level of

measurement. Statistical analyses were conducted to compare the differences between

the baseline and the 2 post-intervention catheter-days… CAUTI rates were not

compared because of the low numbers of incidences and rates” (Oman et al, 2011, p.

3). This statement is a bit confusing, and does not precisely identify which rates were

compared (or not compared) at the conclusion of the study to validate the effectiveness

of the nursing interventions as an independent variable. Thorough attention was paid to

describing the educational methods used to train nursing staff including attendance

rates, defining characteristics of catheters used, variances in the LOS among the

patient population, and bladder scanner usage. The data collection component of this

study was thorough and only minimally biased, but would have benefitted from a

definition of the Student t test (Oman et al, 2011, p. 3), a population description of the

nursing staff including years of experience.

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Study Findings

The study findings at the end of the research study report directly reflect the

problem and the purpose statements at the beginning. “The findings of this project

support the effectiveness of implementation of a CAUTI program that encompasses

nursing education, competency training, products, and surveillance to positively impact

patient outcomes” (Oman et al, 2011, p. 5). Because of the study framework and the

methods of data collection, it was not determined which of the nursing interventions

included in the study (education of patients and families, questioning physician orders,

education of nurses and supportive care staff, bladder scanner use, alterations in

catheter equipment, charge nurse catheter rounds, and increased availability of bedside

commodes) were most effective. Determining which interventions were most effective

were not a part of the hypothesis or scope of this study. “It was beyond the scope of

this quality improvement project to determine which of the individual components of this

comprehensive intervention were the most effective in changing practice. However, our

results suggest an important impact of the house-wide intervention on catheter duration

apart from the focused intervention” (Oman et al, 2011, p. 5). Additional limitations

within this study were disclosed, and included a concern regarding external validity. “In

addition, the number of CAUTIs on the intervention units during the study period was

low, and the confidence intervals around the CAUTI rates were relatively large, making

it difficult to assess the impact of the intervention on the outcome of interest” (Oman et

al, 2011, p. 5). Table 3 on page 4 describes per-patient catheter duration measured in

days, and shows an improvement on both the pulmonary and the general surgery units

by indicating a decrease in the number of days patients remain with an indwelling

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urinary catheter. The researchers also individually address each of the primary patient

outcomes: catheter duration (per table 3), incidence of CAUTI (decreased from 3.4

patient days to 2.2 in the third period), length of stay (from 6.91 to 6.55 days on the

surgical unit and from 7.39 to 6.72 on the pulmonary unit), bladder scanner usage (50

recorded uses total with only 2 patients out of those 50 who required a catheter

reinsertion), and product streamlining (removal of silver alloy indwelling catheters in a

cost-savings effort did not negatively affect the CAUTI rates). After reviewing the

evidence presented in an objective manner, it seems logical to conclude that these

interventions did have a positive effect on decreasing the CAUTI rates.

Implications for Practice

Because this study was directly aimed at assessing the effectiveness of nursing

interactions within the population of hospitalized patients who require an indwelling

urinary catheter, assimilation of the results of this study are relatively simple. “Focusing

on nursing-driven interventions to improve the nursing care of ICUs was found to

positively impact CAUTI rates. Re-educating on the importance of a perceived ‘basic’

skill and infusing best evidence into current practice were important to raise awareness

of simple interventions that positively impacted patient outcomes” (Oman et al, 2011, p.

5). It is not possible to select which intervention was the most successful or effective,

but to provide emphasis on a larger scale that best practice methods in nursing do have

positive effects on patient outcomes. The researchers caution, though, that nurses are

not completely independent. “To effectively change practice, multifaceted efforts are

necessary to reduce CAUTI in hospitalized patients. IUCs are often indicated in the

management of patients in acute care hospital facilities, and efforts that re-examine

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practice and strategies for care management based on best evidence are needed and

must be continuously revisited” (Oman et al, 2011, p. 5).

Article Three

Review of Literature

Elpern et al. did not include literature review in their study. Greater than 50% of

their sources are current; however, there was no indication of databases used for

acquisition of sources. They also did not include a critical appraisal of their sources.

No quotations were used in the article, however, the sources which were used

appeared to have proper citation throughout.

Study framework/theory

Elpern et al. did not identify a specific framework used for this study. However, the

authors appear to have used intervention theory. According to Burns & Grove, “Such

theories direct the implementation of a specific nursing intervention and provide

theoretical explanations of how and why the intervention is effective in addressing a

particular patient problem” (Burns & Grove, 2011, p. 238). In the case of this study, the

intervention is removal of inappropriate catheters, assessment for need of catheters and

early removal of indwelling catheters.

Hypothesis

The hypothesis used was, “days of use of urinary catheters and number of

CAUTIs would decrease during the intervention months compared with the 11 months

before the intervention. Total days of use of catheters and monthly CAUTI rates before

and during the intervention were compared using unpaired t tests. Significance was set

at P <.05” (Elpern et al., 2009, p. 537).

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Elpern et al. defined a CAUTI as “an infection in a patient with a urinary catheter

who met National Healthcare Safety Network definition of a urinary tract infection”

(Elpern et al., 2009, p. 537). The authors also used a formula to calculate CAUTI rates.

CAUTI rates were defined as, “the number of CAUTIs divided by the number of urinary

catheter device days multiplied by 1000. CAUTI rates were computed monthly” (Elpern

et al., 2009, p. 537).

Research design/data collection

Elpern et al. (2009) state that, “this study was a before-and-after evaluation of a

low-technology intervention to reduce duration of urinary catheterization and occurrence

of CAUTIs in an MICU.” Subjects included in the research study consisted of all MICU

patients admitted from December 1, 2007 to May 31, 2008 who had indwelling catheters

as part of their unit stay (Elpern et al., 2009). The data collected during the intervention

phase of this study was duration of catheterization, appropriateness of catheterization,

and reasons for inappropriate catheter use. Surveillance for CAUTIs was completed by

nurse epidemiologists from the medical center’s infection control department (Elpern et

al., 2009, p. 537).

There are many threats to the external validity of this study. Some of the threats

are discussed by the authors, such as the subjectivity which was involved in daily

evaluations, appropriate catheter use was consensus based and not evidence based,

and differences of opinion on catheter use were deferred to the judgment of the nurses

providing direct patient care.

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Study Findings

Elpern et al. provided detailed statistical information to support their research

findings. The data analysis is included with the results of the study. It is reported that,

“during the 6-month intervention, 337 patients had indwelling urinary catheters for a total

of 1,432 days. Before the intervention, the mean number of urinary catheter days was

311.7 device days per month (d/mo)”(Elpern et al., 2009, p. 538). Continuing on with

the data analysis, Elpern et al. stated that the comparison of data pre and post

intervention has demonstrated a decrease in the mean catheter days to 238.6 d/mo, for

a total reduction of 73.1 d/mo. “In the 11 months before the intervention, 15 CAUTIs

occurred during 3,429 device days or 4.7 per 1000 days. In the intervention phase,

zero CAUTIs occurred in 1,432 device days” (Elpern et al., 2009, p. 538). The stated

statistical findings are significant.

Implications for Practice

It is very apparent that by assessing the actual need for indwelling urinary

catheters and using guidelines which allow catheter use for specific purposes only, the

CAUTI rates had been completely eliminated in this study. It is not a feasible idea for

complete elimination of CAUTIs due to the nature of the invasiveness. Elpern et al.

stated that, “despite strict adherence to indicators, some CAUTIs will inevitably occur.

Reasonable goals are to avoid overuse of indwelling urinary catheters and reduce

CAUTI rates” (Elpern et al., 2009, p. 540).

Recommendations

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Urinary catheterization is a necessary component of patient care in many

different types of patient situations, yet overuse of catheters has been demonstrated in

all three articles to be a significant contributor to high infection rates. In addition to

possessing a questioning attitude with catheter use, there are other actions that can be

taken by a nurse to assist in the reduction of CAUTI for those that do require prolonged

catheterization: daily reassessment of the need for the catheter, intentional catheter

selection based on individual patients and not nurse preference, detailed patient care

documentation, charge nurse rounds on every shift, education of patients and family

members about proper catheter care, and ongoing competency training for both nurses

and nursing assistants. Because CAUTI can become a significant comorbidity, and is

not a reimbursable medical condition for some major insurance payers, careful attention

to this condition is vital. As a group, we recommend careful consideration of the need

for each and every indwelling catheter that is placed, and for hospitals to develop

practice policies that reflect the recommendations listed above.

Conclusion

Each of these three articles was chosen because they appeared to be strong

studies that directly reflected the potential for nurse-specific interventions related to

CATUI. Although each quasi-experimental study had its own challenges and areas of

bias, each was constructed differently enough from one another to cover those gaps, at

least in part. There is enough evidence included within the three studies to make a

strong recommendation for changes in nursing practice and to validate the importance

of doing so.

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References

Andreessen, L., Wilde, M., Herendeen, P.,(2012). Preventing Catheter-Associated

Urinary Tract Infections in Acute Care. Journal of Nursing Care Quality. 27(3),

209-217. Retrieved from http://www.nursingcenter.com/lnc/JournalArticle?

Article_ID=1355891

Burns, N. & Grove S. K. (2011) Understanding nursing research: Building an evidence-

based practice. Maryland Heights, MO: Elsevier Saunders.

Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009).

Reducing use of indwelling catheters and associated urinary tract infections.

American Journal of Critical Care, 18(6), 535-541. doi:10.4037/ajcc2009938

Oman, K., Makic, M.B., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2011).

Nurse-directed interventions to reduce catheter-associated urinary tract

infections. American Journal of Infection Control. doi:10.1016/j.ajic,2011.07.018

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E. Health Care Environment

This section includes examples of how I can advocate for healthcare in many different

environments of health care.

One example that I have included is a personal health assessment that I developed based I

what I felt I was important to me. By doing a personal health assessment it helps me to think

about the needs of each individual person, so that I can help them with their personal

assessments as well.

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Personal Health Assessment and Health Promotion Plan

Kara A. Elkins

Ferris State University

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Abstract

I have decided that losing weight is an important health promotion activity to incorporate

into my daily routine. I have setup a plan throughout this paper guided by the steps of the

Transtheoretical model (TM), and also by using the NANDA wellness diagnosis of readiness for

enhanced power to show that I am ready. I have taken a health belief survey showing that I feel I

am in control of my own health and health care decisions, and I also took an American Heart

Association “my life check” survey which showed me the areas that I need improvement in my

lifestyle relating to diet, exercise, and all around health care management. These surveys and my

calorie logs for the first two weeks are located in the Appendix portion of this paper.

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Personal Health Assessment and Health Promotion Plan

The area of my life that I have decided to work on for health promotion is to lose weight.

I will do this by incorporating more exercise into my daily routine, and by eating healthier. I feel

that this is a very important step in my life because if I am healthier, my family will be healthier

too. I plan on counting calories, and tracking my daily activities. This way I will know if I am

doing what I need to be doing to meet the short-term and long-term goals that I am setting for

myself.

Transtheoretical Model

The transtheoretical model is used “to describe how individuals progress toward adopting

and maintaining behavior change” (Pender, 51).

According to Pender (2011) there are five stages in the transtheoretical model (TM).

These stages are: pre-contemplation, contemplation, planning or preparation, action, and

maintenance (pg. 51). In the pre-contemplation stage the individual isn’t even thinking about

taking action on a particular behavior that they may need to change for health benefit (Pender,

51). This stage occurred quite a while ago for me in my journey to lose weight. I have wanted

to do this for so long and have tried many times recently to start a daily routine. Therefore,

because I think about starting this journey every day, I really have not used the pre-

contemplation stage. The next stage is the contemplation stage. This is when the individual is

thinking seriously about quitting or adopting a particular behavior in the next six months

(Pender, 53). This is the stage that I am in now with my plan to eat better and exercise more so

that I will lose weight. I intend to change my unhealthy eating habits and become more active in

my everyday life. Next is planning and preparation which I am beginning right now by writing

this paper and putting an actual plan in place. In the planning and preparation stage the

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individual is planning to change the behavior in the next month and is taking steps in the

direction of change (Pender, 51). The action stage is what I hope to accomplish next. During the

action stage the individual has made the behavior change and it has persisted for less than six

months, which means that you are actively engaged in the behavior change (Pender, 51). A few

days ago I began my exercise routine that I will be doing 3-4 times a week to help with my

journey of weight loss. The final stage of the TM is the maintenance stage. During maintenance

the change has been in place for at least six months and is continuing so that you are sustaining

the change over time (Pender, 51). This stage will be incorporated in my long-term goals of my

weight loss journey.

There are many factors that can cause barriers to the TM. Self-efficacy and temptation

are two of those barriers. Self-efficacy has to do with the individual’s attitude and behavior

towards the goal that is being obtained, and temptation is the urge to engage in a specific

behavior in the midst of a difficult situation such as cravings for a certain food that isn’t on the

diet plan for weight loss (Pender, 52). As you can see the individual has to be in the correct state

of mind to succeed at any goal or adoption of any behavior change.

NANDA Wellness Diagnosis

I have chosen a NANDA diagnosis that I feel fits me the best in this situation. That

diagnosis is the Readiness for Enhanced Power. Readiness for enhanced power is defined as “a

pattern of participating knowingly in change that’s sufficient for well-being and that can be

strengthened” (Sparks, pg. 860). My NANDA statement is as follows: Readiness for enhanced

power related to a new found motivation to change and create new lifestyle habits such as: a

healthier diet, increased amount of exercise, and being more observant of daily calorie

count/burn. As evidenced by a personal BMI that considers me overweight by 10 lbs. and

PORTFOLIO 91

horrible eating habits mostly due to the fact that I am a busy mom and don’t always have the

time to cook healthy meals. I also don’t always have time in my day to exercise, but I also know

that I don’t really try to find the time either. Because of the changes that I know I need to make,

readiness for enhanced power seems appropriate. My expected outcomes are that I will be in

control of my life, I will make good choices based on diet and exercise, and I will develop a plan

of action to help me meet these goals. I will keep my calorie intake to around 1500 calories/day,

while also controlling portion sizes so that I have an intake that won’t cause me to gain any more

weight. My exercise goal is to exercise for at least one hour three times a week. Next step is to

show how I will evaluate my progress. I will monitor my weight loss by weighing myself

weekly. I will also track amount of exercise I do weekly and amount of calories I take in daily

by using the calorie journal that is shown in the appendix portion of this paper. I also plan to do

develop an exercise routine with my husband so that I will have someone to hold me

accountable, and most importantly so I won’t give up. I feel that with all of the support that I

have from my family, and with the tools that I have in place to keep track of everything, I am

ready to go and I will be successful in my lifestyle change.

Goals

Short-term: My short-term goals include finding recipes for healthy food that my family will

love, developing an exercise routine that will work around my work schedule and family

schedule, and getting a weight loss of at least 10 pounds so that based on my BMI I will be

considered “a healthy weight”. I really think that these goals are attainable, and that I am not

setting myself up to fail by trying to achieve them. I truly believe that people tend to fail at diet

and weight loss programs because they set goals to high and they aren’t able to meet them. I

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have learned that if you set small attainable goals you have more motivation to continue as you

achieve them, even if they are only weekly goals. This is my plan so that I am successful.

Long-term: My long-term goals include changing diet habits for not only myself, but for my

entire family. I also hope to find more foods that are healthy so that my kids are happy and there

is enough variety, so that we don’t get bored with the food choices. I also hope to have an

exercise routine down that will be easy for me to continue, and finding more activities to do with

my kids. My kids love to be outside and it is my goal to find fun and active things to do that fit

in our budget. I also hope to lower my body fat percentage to a level of around 20% (I am

currently 25%), and then maintain my weight and lifestyle. The biggest part of long-term goals is

maintenance just as was talked about with the transtheoretical model in previous sections.

Maintenance is truly the measure of success when evaluating a change.

Conclusion

I am really excited about this change in my life, and especially excited for the healthy

changes that it will provide for my husband and kids. We aren’t always making unhealthy

choices and we do stay pretty active, but in the long run a change is necessary. I really want to

show my kids by example what it means to live a healthy life. I want them to try new foods, and

develop healthy habits so that the habits stick as they grow older. I also want to change my

lifestyle in hopes of adding more healthy years on to my life. Adding more healthy years that my

husband and I will have to travel, or spend time with grandkids. Based on my personal health

belief survey shown in Appendix A, I believe that I am in control of my personal health and

well-being. This proves that I have a very good chance of being successful because this is a

change that I want for myself and I know that I am the only one that can make this change. I am

in control of the decisions that affect my health, and now is as good of time as any to begin a

PORTFOLIO 93

lifestyle change. I can’t wait to have more energy, have better self-esteem, and just all around

feel better!

Evaluation of Progress: So far since I have started this process of change two weeks ago, I have

lost a total of 5 pounds, and I feel absolutely amazing. I have found that the food journal I

created to keep track of the amount of calories that I consume daily has been a great help. It

helps because I can see and compare every meal to see the best way to divide the calories

between meals so that I can stick to my goal of around 1500 calories/day. So far I have done

very well with maintaining the calorie number, but I am already starting to get bored with the

food that I am eating. I still have to find more recipes that everyone in my family will like. I

have not been exercising 3 times a week because I have been so busy, but I am working on that

change. I have decided that this change is so important so starting slow and being successful is

better than starting all out and getting burned out because it doesn’t fit in my schedule. I can

already tell that my self-esteem is growing and I am a happier person. I have more energy as

well. I am so excited to see this journey already paying off after only two weeks!

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Sources

American Heart Association. (2011). Life’s Simple 7. Retrieved from www.mylifecheck.org/

Pender, N. J., Murdaugh, C. L., Parsons, M. A., (2006). Health Promotion in Nursing Practice

(5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

Sparks, S., & Taylor, C. (2008). Nursing Diagnosis Reference Manual (7th ed.). USA. Lippincott

Williams & Wilkins

Ursuy, P. (January 2011). NURS 310 Class Syllabus.

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F. Professionalism

This section will provide information for my professional career. It will explain how I

demonstrate a level of professionalism based on values, ethics, and specific behaviors.

I first have provided a copy of my resume, so that you could see all of the different areas

of nursing I have been involved in, and also the certifications that I have obtained throughout my

nursing practice.

I have also included the service learning project that I did in the course NURS 325. This

project allowed me to volunteer at a pregnancy center. By doing this, I gained so much

knowledge of what young girls actually face when they have an unplanned pregnancy, and I was

able to counsel and help many of these women through their fears.

I also have provided a paper that I wrote about my professional development. It was a

plan that I developed and includes five and ten year goals in practice.

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Kara Elkins10861 68th Ave.

Allendale, MI 49401(616)218-8371

kelkins612@yahoo.com

JOB EXPERIENCE: 2010- Present RN – Metro Health Hospital (Midtowne Surgical Center

Specializing in the care of pre and post-op orthopedic surgical patients. Assisting in getting patients ready for surgery, and management of patients in the recovery phase immediately post-op. Management of airways, and potential airway complications. I also participate in making pre-op phone assessments of our future patients.

2007- 2010 RN - Spectrum Health Hospital (Medical ICU)

Specializing in the care of critically ill patients with a variety of chronic illness such as Diabetes, COPD, Cancer, and Heart disease. Also specializing in the care of patients with severe sepsis and other unexpected illnesses. Participation in “new-age” protocols such as the cooling protocol for post-arrest patients. Currently hold the position of a critical care nurse rounder in which I assist med-surg and progressive care units in transferring patients to the ICU and doing more detailed assessments on very sick patients. I am a member of the rapid response (RAP) team, part of the stroke assessment team, and the STEMI (for patients having a myocardial infarction) team.

2006- 2007 RN - Spectrum Health Hospital (4 South Neuroscience Unit)

Specializing in the care of patients with seizure disorders, head injuries, stroke, traumas/spinal injury, post op craniotomy and back/neck surgeries,and patients on telemetry monitors.

2005 – 2006 Pharmacy Technician - Saugatuck Drug Store Responsible for customer service, and assisting with filling prescriptions.

2001 - 2004 Unit Assistant - Holland Community Hospital Responsible for assessing vital signs, and performing all patient care including, but not limited to; bathing, feeding, ambulating, and dressing the patients under my care. At this time worked in an Oncology/Hospice unit as well as Critical Care.

1997 - 2001 Customer Service - Saugatuck Drug Store

Responsible for accounts payable and receivable, and customer service.

EDUCATION:

2002 Hamilton Community High SchoolHigh School Diploma

2003 - 2006 Grand Rapids Community CollegeADN – RN

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2010 – Current Ferris State UniversityBSN

SPECIAL SKILLS:

Care of patients (adult and pediatric) with complicated airways post-surgery

Care of patients with an Intra-Aortic Balloon Pump

Member of the RAP, stroke, and STEMI team for the hospital

6 years experience reading telemetry, and other monitoring devices such as the BIS monitor for sedation, and SWAN monitors for cardiac function testing.

3 years experience with patient care as a unit assistant including 1 year in pediatrics, and 2 years in med-surg and telemetry.

Computers: Windows XP, Internet Explorer, and hospital information systems such as: Cerner, Patient 1, and Ulticare. Experience with Endotool and CPOE programs.

1 year experience in retail management

CERTIFICATIONS:PALS certified by American Heart AssociationBLS (Health Care Provider) certified by the American Heart AssociationACLS certified by the American Heart AssociationIABP (Intra-Aortic Balloon Pump) nurseStroke Assessment nurse (NIH stroke scale)

REFERENCES:Provided upon request

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RN to BSN Service Learning Project

Kara Elkins

Ferris State University

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Abstract

For my service learning project I have chosen to volunteer at Lakeshore Pregnancy Center

(LPC). This organization strives to support women in need who are expecting or have a child

under one year of age. During my time at LPC I will be counseling women and supporting them

through one of the biggest changes in their life, having a baby. This organization provides many

resources and a lot of support for the women of the community who may not have anywhere to

go. I hope to make a difference in many women and children’s lives while at LPC, and I hope to

learn a lot about this area of health care so that I may use this experience in my current field of

nursing practice.

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RN to BSN Service Learning Project

The Learn and Serve America National Service-Learning Clearinghouse describes

service learning as:

A positive, meaningful and real experience to the participants, an experience involving

cooperative rather than competitive experiences and thus promote skills associated with

teamwork and community involvement and citizenship, and they address complex

problems in complex settings rather than simplified problems in isolation. Service

Learning offers opportunities to engage in problem-solving by requiring participants to

gain knowledge of the specific context of their service-learning activity and community

challenges, rather than only to draw upon generalized or abstract knowledge such as

might come from a textbook. Service-learning offers powerful opportunities to acquire

the habits of critical thinking; i.e. the ability to identify the most important questions or

issues within a real-world situation. (National, 1)

This service learning project, that is to be completed in our last course of the RN to BSN

program, is important for students so that we may “enhance our professional development”

(Treschendorf, 1). By enhancing our professional development we will aid in our advancement

in the nursing profession, and be able to provide insights from our experiences. This project will

also be very beneficial in broadening our nursing scope of practice by giving us new experiences

and learning opportunities that we may not currently have in the area of nursing that we currently

practice in. The purpose of this initial assignment is to discuss the location that I have chosen to

complete this project, and to describe what I will learn and do throughout this service learning

experience.

Agency

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The agency that I have chosen to complete my service learning project with is the

Lakeshore Pregnancy Center (LPC). The LPC is a Christian organization that “offers hope to

women facing unplanned pregnancies by providing practical help and emotional support”

(Lakeshore, 2010, 3). Some of the services that LPC provides to their clients are pregnancy

tests, ultrasounds, prenatal care, prenatal and parenting classes, counseling for expectant

mothers, and distribution of material baby items that may be needed. This organization is an

active part of the pro-life movement and strives to counsel and provide material and emotional

support to new moms. This organization also provides information on adoption if that is what

the parents choose for their unborn child. (Lakeshore, 2010)

Volunteer Role

My role at LPC will include many different things. I will be talking to expectant mothers

and answering questions about the things their bodies go through during pregnancy and labor. I

will be helping to distribute baby care items such as diapers, clothes, formula, and baby food to

clients based on their needs. I also hope to help assist in teaching classes on prenatal topics

relating to health of mom and baby, pre and postnatal care, and assisting the ultrasound tech on

the days that she is there.

I feel that my service will benefit the community in many ways. LPC offers all of their

services free of charge, and therefore needs volunteers to keep the organization running. LPC

has provided support to many women and children in the community. They provide clothing,

food, and diapers for all of their clients up until their babies are one year old. If the family still

needs support after the child turns one, the LPC provides them with other resources so that they

can continue to receive the support that they and their children need. This is so important to

those families that may not have the money or resources to care for their child or themselves. By

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being a part of this organization I have the opportunity to help and make a difference in many

women’s lives, and in doing so help their child to grow up in a good Christian home. There are

many testimonies listed on the LCP website describing what the LPC has done for many of their

clients. Here are a few testimonies to prove that LPC offers great outcomes in their organization:

"I felt hurt, ashamed, and betrayed. But God has a way of bringing people into your life

to make a change and give you guidance and resources that you need. That’s what LPC did for

me and my life and my children’s lives."

"Initially the abortion idea did come to mind…I was scared and these people really care,

they feel for you. They helped through the process and helped me reach my final decision to

keep my baby. Actually seeing the ultrasound was the first step, carrying him and feeling him

kick was another step, then actually holding him was like ‘Wow, this is it! I’m a mom now and

this little person depends on me.’ It’s just amazing! I was so happy I couldn’t stop smiling."

"I was considering having a second abortion but what LPC did was listen to me and gave

me options. They helped me think about my health and my baby’s health.”

"If it wasn’t for Lakeshore Pregnancy Center my baby, my little baby girl would not be

here."

“I have gained a friend in LPC, they have helped me turn my life around. I am where I

am now because of their help. I am going back to school, I have friends now, I have a church, I

have a new life” (Lakeshore, 2010).

By “service learning” in this organization I will be teaching classes, talking with new

moms, and helping to distribute material support items to families in need. In talking to the

clients I will be providing them with education about pregnancy, and pre and postnatal care,

nutrition, and also other resources outside of the scope of LPC that may benefit them. Most of

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the women that become clients at LPC are young (average 17-20), and have little or no support

from family, boyfriends etc. Some of them come from abusive relationships, some are addicts.

Regardless of the circumstance, these women come to LPC for help in their situation, and LPC

provides this help and support through the grace of God. LPC is a wonderful organization that

has helped many women out of their horrible circumstances, and helped them bring their

beautiful children into this world.

Learning Goals

In this experience at LPC I really hope to broaden my skills as a nurse. I currently work in

the adult medical ICU and have seen young pregnant women in my unit as patients. I hope that

this experience will provide me with additional knowledge of what this patient may be going

through outside of their illness, and the skills to be able to talk to the patient about any concerns

they may have regarding the pregnancy. While at LPC I will also become more familiar with

support groups and resources for these women and their families, and I will be able to provide

that information to my patients as well. In short, I hope to learn many things including:

1. Broaden my nursing skills to be able to provide better care to the pregnant patients I see

2. Become familiar with support groups and other resources for these types of patients

3. Be able to better counsel these patients and better understand what they may be going through

mentally and physically.

Evaluation Plan

The only real way to evaluate the effects that you have had on the community is by the

response you get from your clients. If the clients are happy and feel that they have everything

they need, you are doing your job. These women and their babies depend on LPC and all of its

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volunteers and counselors. Without success in the organization these women wouldn’t have

anywhere to go for help.

The way I can evaluate my learning is to look at how I talk to these clients. I feel the

more I learn the easier it will be for me to talk to the clients. I will be able to foresee the needs

of not only the clients of LPC, but also the patients that I come across in the ICU.

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References

Teschendorf, M. (June, 2010) Ferris State University School of Nursing Service Learning Policy.

Department of Nursing. Ferris State University. Big Rapids, Michigan.

Lakeshore Pregnancy Center (2010) Retrieved from www.lpcenters.com.

National Service Learning Clearinghouse. (n.d.) Retrieved from

http://www.servicelearning.org/what_is_service-learning/characteristics.

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Professional Development Plan

Kara A. Elkins

Ferris State University

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Abstract

Putting together a professional development plan for myself has helped me to put in perspective

my practice behaviors, and has helped me compare them to the standards of professional practice

that the American Nurses Association (ANA) have set forth. I have learned areas in which I

need improvement, and areas that I am succeeding in. Goals have also been set for my

professional development. This has helped me to organize my life and have a plan, so that I will

have the best possible chance to meet these goals.

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Professional Development Plan

When I look into my future, I can see what my goals are, but I have no idea how I

am going to reach them, or how long it will take. I have a wonderful family, and I love being a

mom more than anything, but I also want to be able to conquer my goals before I get to much

older. I feel that making a professional development plan for myself will help me to put things

in perspective, and will help me to reach those goals much faster.

Current Professional Practice

I believe overall that my professional practice behaviors are very good. When caring for

my patients I also make sure that I am following the hospital’s policy and procedures because

maintaining my patient’s safety is my number one priority. Patient safety is of utmost

importance to me. This is not only with my patients, but also with the other patients on the floor.

Because of this, I always make myself available to help other nurses when they are busy, and I

also belong to a committee that helps to voice the opinions of the nurses to management and

keep the moral on the unit high. I feel this is important because happy nurses make for better

patient care, and better patient safety scores.

I also like to make sure that my patients are receiving an adequate amount of my time.

This way there is enough time for teaching, or for the patient to ask questions. This helps to

build a trust, and provides the patient with understanding of their illness, and the treatment plan.

It is also my job to find answers to the questions that I may not know by finding other resources

that are available.

Ethics is a big part of nursing, and it is very important. Treating every patient

with respect regardless of their age, illness, or background is crucial. Every patient deserves the

best care you can give which means having the appropriate supplies and resources. Trust

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between the client and nurse is also very important. It is my belief that a good relationship

between nurse and patient, or nurse and family allows them to relax. This is crucial to the

healing process, especially in the ICU.

Working in collaboration with other members of the health care profession is also

something that I feel is very important. I work with all different types of professionals in the

ICU. For example: respiratory therapists (RT), PAs, Physicians, chaplains, PT/OT, etc. There

are many situations that would be detrimental to the patient if we didn’t work together. A code

situation is the prime example. Without RT controlling the airway, the nurse pushing

medications, the tech doing CPR, and the physician or PA giving orders and doing procedures,

the patient is at a great risk of dying.

There are many ways to evaluate nursing practice. Feedback from colleagues or

managers, and also by patient’s reactions to your care are only a few. I take it personally when a

patient or family member is dissatisfied with the care that I have given, and I feel that I didn’t do

the best job that I could.

ANA Standards of Practice

The ANA (American Nurses Association) outlines fifteen different standards of practice

and professional performance. Following these standards of practice will assist in becoming a

great nurse who will be respected for their professionalism and caring attitude. For my

professional development plan I will just be talking about standards seven through fifteen as

these are aimed more towards professionalism.

Standard Seven: Quality of Practice

In this standard the ANA lists specific ways to help improve the quality of your practice,

such as “using creativity and innovation to improve care delivery, or participating in quality

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improvement activities” (ANA, 2004, pg. 33). Participating in quality improvement activities is

important as an RN because not only can you voice your own opinions and ideas, but you can

also understand more of what is going on in your specific unit. I am a part of the shared

leadership committee. In shared leadership we discuss and make decisions based on many of the

points the ANA states is important for quality of care such as, “recommendations to improve

nursing practice or outcomes, participation in efforts to minimize costs, and analyzing factors

related to safety, satisfaction, and effectiveness” (ANA, 2004). We make decisions on a variety

of issues and are the leaders on the unit when it comes to initiating new products or policies on

the floor. We take the concerns of our coworkers and bring them to the meeting with a goal to

come up with a way to improve overall moral on the unit, and boost patient safety and the

satisfaction of both staff and client.

Although I feel that I meet a lot of the criteria that the ANA has described in this

area, there are some things that I could work on when it comes to my practice. According to the

ANA, obtaining a professional certification is important (ANA, 2004). I currently do not have

my CCRN (certification for critical care), but I am working hard to study for it, and hope that

soon I will be CCRN certified. I am also not as involved as I would like to be when it comes to

research. I could do more when it comes to being involved in research studies on the unit. This

research is what makes the unit better as a whole, and being a part of it would be a great

opportunity.

Standard Eight: Education

As far as the education stand point, I feel that in my practice I am meeting the ANA’s

expectations. I am a member of the AACN (American Association of Critical Care Nurses) and

they offer a lot of educational opportunities having to do specifically with critical care nursing. I

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obtain my required continuing education credits by reading articles and attending classes or

conferences that are based on specific critical care issues. I am a certified Intra-Aortic Balloon

Pump (IABP) nurse, and I am also certified in Advanced Cardiac Life Support (ACLS). Along

with this education I am neuro/stroke certified (meaning I can perform stroke assessments based

on the standards of the National Institute of Health, and their specific stroke scale (NIH stroke

scale). I am also part of the OB core team on my unit. This requires classes and continuing

education every year, and is a team of nurses that are more specialized in taking care of pregnant

or post-partum women in the ICU.

There are always ways to improve in anything, and for me to improve in this area I need

to obtain my CCRN certification. I also could become a certified CRRT (continuous renal

replacement therapy) nurse, along with becoming trained to care for patients with an Impella, or

for patients who are on ECMO (extracorporeal membrane oxygenation).

Standard Nine: Professional Practice Evaluation

The ANA states that in this area of professional performance the important points are

“self-evaluation, peer evaluation, and ethical and age appropriate care” (ANA, 2004, pg. 36). In

the adult ICU we see different age groups. We see younger adults around the age of 18, to older

adults over 100 years old. As a nurse I need to understand these different age groups, and the

needs of all of my patients in these age groups. I am able to change my practice for each

individual patient, so that I can connect with them no matter what their age or needs may be. I

also am involved in peer evaluations. Not only do I do written evaluations for my peers every

year, I am there to deliver constructive criticism or to praise my co-workers for the work they

have done.

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I could work on my self-evaluation. I don’t always take the time to really look deep into

my professional behaviors, or practice habits. Sometimes I take shortcuts when I am busy, and

that isn’t the best thing to do. These shortcuts may not be harmful to my patients, but in the long

run could be harmful to my practice. Better evaluation and organization of my own practice

would be beneficial to my career.

Standard Ten: Collegiality

I get along great with all of my colleagues, and really enjoy going to work. We are all

one big work family, and are always willing to help one another out. I share knowledge with my

peers, but also take in as much knowledge as I can from them. I am a preceptor for new nurses

to the unit, and with this role I am responsible to educate new nurses. Not only do I teach them

what I know, but help them to get to know their resources. I think something to work on would

be to give more feedback to my peers. I feel that I do this, but there are always more

opportunities to share feedback, good or bad.

Standard Eleven: Collaboration

In the ICU setting, collaboration is key. We work side by side with many other

professions such as PAs, physicians, respiratory, physical therapy, nurse techs, and even

chaplains sometimes. Each of us has a role in the patient’s care, so without one of us, the patient

isn’t receiving the best care possible. A part of this is being able to step up and make

suggestions when you don’t feel that the patient is being cared for properly. For example: if you

think a physician is ordering a medication that may be harmful to them, or if a procedure is being

done incorrectly you need to be able to voice your concern to the ordering physician. It is the

nurse’s job to maintain patient safety at all times even if that means having to question a

physician’s order. Thankfully on my unit all of our staff is open to suggestions, and willing to sit

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down and talk about the plan of care. I think this is very important for patient safety and

satisfaction.

Standard Twelve: Ethics

“Delivering care in a manner that preserves and protects patient autonomy, dignity, and

rights, and maintaining a therapeutic and professional patient-nurse relationship with appropriate

professional role boundaries” (ANA, 2004) are a few of the important criteria in this standard

listed by the ANA. In my practice, the relationship that I form with my patient or with their

family is one of the first things that has to be established. Without the client’s trust the best care

cannot be given. When a patient is unable to make decisions for themselves, it is the nurse’s job

to maintain their rights. I take my responsibility as a patient advocate very seriously. There is

always room for improvement though. I could improve by digging deeper with my patients to

make sure that all of their needs are being met, and look further in the future for needs they may

have later on.

Standard Thirteen: Research

I am not very involved with many research projects in my job. The part of the research

that I am involved in is to review it, and change my practice based on it to better patient care.

The ANA says that “participating in a formal committee” (2004) is an important aspect of

professional performance. I am involved in shared leadership. Through this committee we are

not conducting any research studies, but talking about a need for research to be done in certain

areas of our practice. Being more involved in the research being done on my unit will be very

beneficial to my career. It will allow me to help increase patient safety rates, and make things

better for staff and patients in the ICU setting.

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Standard Fourteen: Resource Utilization

In the ICU we utilize many resources whether it is other professionals or literature on

certain issues. As the nurse, our patients and their family members look to us for the answers, or

at least the knowledge to know where to find those answers. Being a part of a committee on my

unit has enabled me to be more aware of more cost effective techniques and has given me many

opportunities to better our unit. The longer I am a nurse the easier it is for me to find the

answers. I think getting to know where to find your resources comes with time. I continue to

learn new resources all the time, and utilize them to the best of my ability to help my patients.

Standard Fifteen: Leadership

Showing your passion for the job, encouraging teamwork, and teaching and mentoring

others are just a few of the criteria listed by the ANA in this area of performance (2004). As a

critical care nurse rounder I am responsible for being a resource for nurses outside of the ICU. I

go to progressive care and med-surg units to assist other nurses with patients that are unstable. I

am there to teach other health care providers and help them with things that may be out of their

comfort zones like pulling central lines, drawing blood gasses, assisting in a code or RAP (rapid

assessment of an unstable patient). When a nurse is questioning that something may be wrong

with their patient, the nurse rounder is called to perform a more detailed assessment. In this area

I need to improve on the time I take to teach others. Sometimes I just don’t take as much time

with other staff for teaching as I should. Also, I need to make sure that I am never too busy to be

a resource for others.

Goals for Professional Practice

Five Year Goal

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In five years I want to have my BSN, and be on my way to becoming a nurse practitioner.

I hope to be attending Michigan State University (MSU) and working on my Master’s degree.

MSU’s website for the college of nursing has outlined a program that can be completed in two

years by going to school full time (12 plus credits), and three years part time (6-7 credits a

semester). (MSU, 2010). According to the American Academy of Nurse Practitioners (AANP)

“many years of research has established that NPs provide high quality, cost-effective, and

personalized care” (Quality, 1). “The care that nurse practitioners provide is equal, and NP

patients are more satisfied with their care” (Quality, 1). Because of the education and cost-

effectiveness of the nurse practitioner, they are becoming more popular with the health care

industry. “Nurse practitioners have been playing a bigger role in the nation's health care,

especially in regions with few doctors. With 32 million more Americans gaining health

insurance within a few years, the health care overhaul is putting more money into nurse-managed

clinics” ( Johnson, 2010, paragraph 2) I am excited to continue my dream in becoming a nurse

practitioner, and I think this is a great time to get involved in this area of health care.

Ten Year Goal

In ten years I hope to be through graduate school and be a nurse practitioner. I hope to be

settled in a job that I love and making a difference in many patient’s lives. I am really excited to

think that in ten years I could be doing my dream job! I haven’t yet decided what area of

medicine I would like to specialize in, however, working in cardiology or pulmonology offices

would be my first choices. I work with pulmonologists in the ICU and they have nurse

practitioners that work in their office and run the programs for COPD and CF patients. This

sounds like a great and rewarding job that I would really enjoy doing.

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Plan

I really don’t have a specific plan for meeting these goals other than to stay focused and

work hard. I have a lot of family support and a lot of people willing to help with anything they

can, and I am so grateful for this. I just hope to get through school as fast as I can while making

sure that I am spending enough time with my family. I want my dream of being a nurse

practitioner. I know that in the long run this will be beneficial to my family, but I don’t want to

miss out on great opportunities with my children.

According to my RN-BSN plan, I will have my BSN by May of 2013, and I hope to start

my Master’s degree in the fall of 2013. I also hope to be able to go down to part time at work

while working on my Master’s degree. With the life that I have I need to remain flexible, but

also stay focused on my personal career goals to make my dreams come true.

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References

ANA, (2004). Nursing Scope and Standards of Practice. Silver Spring, MD: American Nurses

Association.

Johnson, C. K. (2010, September 30). Doctor Shortage? 28 States may expand Nurse

Practitioner’s Role. The Huntington Post. Retrieved from

http://www.huffingtonpost.com/2010/04/13/doctor-shortage-28-states_n_536402.html.

MSU Nursing. (2010). Sample Schedules. Retrieved September 30, 2010, from

http://nursing.msu.edu/msnurse_samplesched.asp.

Quality and Cost-Effectiveness of NP Care. (n.d.). American Academy of Nurse Practitioners.

Retrieved from

http://www.aanp.org/AANPCMS2/AboutAANP/QualityandCostEffectivenessOfNPCare.

htm.

 

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APPENDIX

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Health Beliefs Survey

The questionnaire is designed to determine the way in which different people view certain important health-related issues. Each item is a belief statement, with which you may agree or disagree. Beside each statement is a scale that ranges from strongly disagree (1) to strongly agree (6). For each item, choose the number that represents the extent to which you disagree or agree. This is a measure of your personal beliefs; obviously, there are no right or wrong answers.

Please answer these items carefully, but do not spend too much time on any one item. As much as you can, try to respond to each item independently. When making your choice, do not be influenced by your previous choices. It is important that you respond according to your actual beliefs and not according to how you feel you should believe or how you think we want you to believe.

1 - Strongly Disagree; 2 - Moderately Disagree; 3 - Slightly Disagree; 4 - Slightly Agree; 5 - Moderately Agree; 6 - Strongly Agree

1 2 3 4 5 61. If I get sick, it is my own behavior that determines how

soon I will get well again. x

2. No matter what I do, if I am going to get sick, I'll get sick. x

3. Having regular contact with my physician is the best way for me avoid illness.

x

4. Most things that affect my health happen to me by accident.

 x

5. Whenever I don't feel well, I should consult a medically trained professional.

x

6. I am in control of my health.  x

7. My family has a lot to do with my becoming sick or staying healthy.

 x

8. When I get sick, I am to blame.  x

9. Luck plays a big part in determining how soon I will recover from an illness.

 x

10. Health professionals control my health.  x

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11. My good health is largely a matter of good fortune.  x

12. The main thing that affects my health is what I myself do. x

13. If I take care of myself, I can avoid illness. x

14. When I recover from illness, it's usually because other people have been taking good care of me. (doctor, nurses, family)

x

15. No matter what I do, I'm likely to get sick. x

16. If it's meant to be, I will stay healthy. x

17. If I take the right actions, I can stay healthy. x

18.  Regarding my health, I can only do what my doctor tells me to do.

 x

 These three subscales, and the items included in each, are as follows:

Internal Items: 1, 6, 8, 12, 13, 17 Chance Items: 2, 4, 9, 11, 15, 16 Powerful-others items: 3, 5, 7, 10, 14, 18

 The score on each subscale is the sum of the values for each item in that subscale multiplied by 2. Scores within each subscale can range from 12 to 72. The higher the score on the internal subscale, the more personal control clients believe that they exercise over their own health. The higher the scores on the chance subscale and power-others subscale, the higher the beliefs in the importance of chance and others respectively in controlling personal health. Normative means for adults on each subscale are as follows:

 

Internal, 50.4

Chance, 31.0

Powerful-others, 40.9

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.