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Nursing Care Advanced Practices and Aspects

Relationship-Based and Patient-Centered Nursing Care

Patient-centered care refers to the approach to care which empowers the patient and engages them the process. This perspective on care is driven by the improved understanding of patients’ agency and respect towards them (Tak, Ruhnke & Shih, 2014). Some of the attributes of this kind of care include the focus on patient education and their physical and emotional comfort, as well as the respect towards the patient’s opinions, values, preferences, and so on.

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All these attributes are very pertinent to my workplace, which is a correctional institution. Nurses often have to advocate for the patients’ access to care in these settings, especially given the fact that correctional officers often mistake certain symptoms for aggression, depriving patients of the much-needed interventions. Similarly, in my personal practice, I have always sought to provide customized interventions that take into account the needs and preferences of the patients; I find that the expected outcome of such approach is improved psychological and emotional state of a patient.

As for the efforts to empower patients, it is a crucial component of our attempts to rehabilitate the individuals residing in our institution: an empowered person is more likely to be able to perform self-care and avoid recidivism, and for the nurses of the institution, it is the ultimate goal of our work.

As for relationship-based care, it is a form of patient-centered approach that reviews the relationships of a care provider with patients, coworkers, and oneself (Hunt, 2014). With respect to these attributes, my institution predominantly focuses on teamwork, which is a requirement for effective work and care. However, the nurses also recognize the importance of the relationships with patients and build them in order to support patients and their families and promote healthcare-related activities. As for the relationships with self, they are instrumental in remaining capable of providing high-quality care. Thus, the process of relationship-based care is driven predominantly by the need to ensure high-quality care, and the expected outcome is the improved well-being of the patients.

Intra-/Interprofessional Collaboration and Advanced Nursing Practice

Intra- and interprofessional collaboration is a major aspect of advanced nursing practice, and DNP education programs view this feature as an important competency of healthcare professionals (Dowling, Beauchesne, Farrelly, & Murphy, 2013). Indeed, advanced nursing practice is inevitably connected to teamwork. For example, at my workplace, the interaction between psychiatrists and nurses is a typical form of interprofessional collaboration. Among other things, it involves direct work on patient cases, as well as collaborative educational and quality improvement efforts.

The process is driven predominantly by the acknowledgment of the importance of collaboration for the quality of care and safety of the patients, but apart from that, the organizational culture, which promotes mutual support and fosters effective workplace relationships, is an important factor. The expected outcomes of the collaboration efforts are improved quality of care, patient safety, quality improvement, and some other positive results that depend on the specifics of collaboration.

Another aspect of interprofessional collaboration at my workplace is rather specific because it occurs between healthcare providers and correctional specialists. Unfortunately, the latter often lack essential knowledge on health concerns (Brown et al., 2017), which occasionally can lead to misunderstandings, in which, for example, certain behavioral symptoms of dementia can be mistaken for aggression. Interprofessional collaboration with healthcare providers can help to resolve this issue.

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This form of collaboration appears to be driven, among other factors, by the specifics of the environment, the vulnerability of the patients, and our aim of the continuous improvement of care. Thus, by fostering collaboration and communication between the members of these professions, we can hope to achieve the eventual outcome, which is the improved well-being of incarcerated patients.

Emotional Intelligence in Advanced Nursing Practice

There are five elements or attributes of emotional intelligence (EI) that are typically reviewed. They include self-awareness, which refers to one’s ability to recognize one’s emotions, self-regulation, which refers to one’s ability to handle these emotions, and motivation, which refers to one’s ability to motivate oneself with non-monetary rewards. The remaining attributed include empathy, which refers to one’s ability to understand the emotions of others, and social skills, which refers to one’s ability to successfully interact with others and manage social interactions (Banschbach, 2016). It is noteworthy that three of the elements seem to refer to intrapersonal skills, and only two of them focus on the interpersonal ones.

Personally, I have always focused on social skills when developing my leadership qualities, but I recognize the significance of the intrapersonal ones: they can serve as a source of knowledge on human emotions, which implies that they might be predictive of the interpersonal attributes. Apart from that, intrapersonal skills ensure the leader’s ability to be critical and analyze the interactions between oneself and their followers. As a result, the benefits of being aware and in control of one’s emotions are apparent.

Regarding motivation, this attribute is described by Banschbach (2016) as interpersonal. However, it also appears to be predictive of a leader’s ability to understand motivation as a concept and employ this knowledge to motivate others, although it is important to remember that the motivational preferences of individuals can vary. Finally, the benefits of interpersonal attributes are apparent: empathy is instrumental to understanding one’s followers (and patients), and social skills help to manage the relationships that are necessary for practice. Thus, the significance of EI for leaders is well-established (Northouse, 2015, p. 28). In my future DNP practice, I will proceed to develop my abilities in the field of EI to be able to lead my colleagues and care for my patients effectively.

Transformational Leadership in Advanced Nursing Practice

The advantages of transformational leadership as compared to the transactional one are relatively well-established in multiple fields, including nursing (Ross, Fitzpatrick, Click, Krouse, & Clavelle, 2014; Spano-Szekely, Quinn Griffin, Clavelle, & Fitzpatrick, 2016). Transformational leadership can be defined as a form of leadership that focuses on the leader’s ability to empower the followers and inspire them; it is opposed to the transactional leadership that limits the relationships between leaders and followers to the exchange of work and rewards or reprimands (Ross et al., 2014).

Some of the activities that a transformational leader needs to perform include human resource development and support, goal alignment, vision communication, organizational culture adjustment, and so on. It is also noteworthy that a transformational leader is typically expected to possess emotional intelligence; research indicates that it has a significant positive correlation with transformation leadership, resulting in positive outcomes (Spano-Szekely et al., 2016). Ross et al. (2014) state that transformational leadership can reduce rates of burnout and improve job satisfaction while also contributing to the improvement of the quality of care. All these outcomes are very important for nursing practice.

I believe that I have not experienced the transactional leadership approach in its classical form; at my workplace, transformational leadership has always been the norm. Similarly, I have always perceived transformational leadership as the appropriate way of leading employees. In future, as a DNP-prepared nurse, I will be more likely expected to apply my leadership abilities to leading my colleagues, and I intend to employ my knowledge of transformational leadership to enjoy its benefits.

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Appropriate Application of Epidemiological Terms in Determining Risk

As established by the assignment, the average lifetime risk of developing breast cancer equals 13.2%, but the women who have relatives that suffer from the condition face noticeably higher risks. In particular, the risk for the women with one first-degree relative with breast cancer doubles (resulting in 26.4% risk), and that for women with two first-degree relatives with the condition is five times higher when compared to the norm (66%). These two cases illustrate the use of certain epidemiological terms that help in determining high-risk populations. From this perspective, low- and high-risk populations are defined by their exposure to risk factors.

In epidemiology, attributable risk can be defined as the “additional” risk which is experienced by a person from a higher-risk population as compared to an average person (Fletcher, Fletcher, & Fletcher, 2013, p. 68). For example, in the two above-mentioned scenarios, the women from the two higher-risk populations have the attributable risks of 13.2% and 52.8% respectively. Relative risk, on the other hand, refers to the relative likelihood of developing a condition, which is expressed as the ratio of the incidence of the condition in low- and high-risk populations (Szklo & Nieto, 2014, p. 80). For example, in the mentioned cases, the ratios are stated in the instructions: in the first case, the risk doubles, which means that its ratio is two, and in the second one, it increases fivefold, which means that its ratio is five.

The two terms (attributable and relative risks) should be used for their respective questions. According to Fletcher et al. (2013), in discussion with a patient, it is typically sufficient to state the absolute risks. However, the relative and attributable ones can be helpful to either highlight the additional risks or to indicate the ratio of the risks for different populations.

The Healthy People 2020 initiative aims to prioritize health concerns and specific areas that require improvement and can be improved based on available evidence (Office of Disease Prevention and Health Promotion, n.d.). Apart from that, the initiative works with the statistical data pertinent to the prioritized areas of public health, developing measurable goals for their improvement. For example, in breast cancer, Healthy People 2020 sets the objectives of reducing breast cancer rates and the rates of late-stage cancer while increasing the use of guideline-based screening (Office of Disease Prevention and Health Promotion, 2017).

In the prioritization of health issues and the development of its objectives and guidelines, the initiative apparently uses the epidemiological approach. For example, Healthy People 2020 recommends breast screening to be used with the women who have risk factors (that is, have relatives with breast cancer) (U.S. Preventive Services Task Force, 2013a). Similarly, the use of preventive chemotherapy is approved for women with high risks of breast cancer (U.S. Preventive Services Task Force, 2013b). Thus, Healthy People 2020 illustrates the use of epidemiological studies for public health.

Applying Epidemiological or Biostatistical Terminology

My evidence-based promotion class project focuses on the risks experienced by incarcerated people with mental issues. Incarcerated populations generally suffer from higher risks of multiple health concerns, including those related to mental health (Kendig, 2016). The latter factor can be attributed to the fact that mental disorders are believed to contribute to the behaviors that result in incarceration (Rich, Allen, & Williams, 2014).

According to Rich et al. (2014), the prevalence of mental issues in prisons amounts to 50%, which is five times greater than the prevalence of the conditions in the non-incarcerated population. However, there exists little information on the incidence of mental issues in incarcerated population, which is why it appears that the prevalence may be the best epidemiological term to describe the magnitude of the problem.

As for the assessment of the population, Rich et al. (2014) suggest focusing on causation and risk factors, especially substance abuse: over 70% of the incarcerated population with mental issues also report addiction issues. Apart from that, the author highlights the fact that incarceration offers an opportunity for therapeutic intervention for both problems, which suggests that screening and secondary and tertiary prevention are of great importance to the population and the nurses working with incarcerated adults.

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Frameworks for Assessing High Risk Factors in Populations

The Head Start (2016) Program offers reports that focus on certain statistics, including the health status and access to relevant healthcare services of the participants. Apart from that, there is a continuous effort to assess the outcomes of the application of the program to various populations. For example, Karoly, Martin, Chandra, and Setodji (2016) offer a comprehensive review of the program’s effectiveness in several regions. Some of the outcomes that they cover include those related to the development and learning in children (for instance, literacy, pre-writing, and so on), children’s health and behavior, school readiness, and parenting practices. These outcomes demonstrate the extensive scope of the program and its importance for public health.

When funds are constrained, it is necessary to focus the screening efforts on the populations that are at a higher risk of developing a condition. For example, the U.S. Preventive Services Task Force (2013) suggests that screening for breast cancer is a requirement for the women who have a family history that might indicate heightened risks. Therefore, such prioritization is supported by current evidence and approved by governmental healthcare bodies.

When developing screening programs, it is essential to take into account the cultural specifics of the targeted population. For example, Shirazi, Shirazi, and Bloom (2013) demonstrate that some of the variables that are significant for culturally sensitive approaches include the varied perspectives on health and healthcare, different social roles, and religious beliefs. The authors use these variables to develop a culturally appropriate program for Islamic women: they demonstrate that the role of the men as the gatekeepers who often control the women’s access to healthcare can be employed to instead facilitate it through a faith-based education of both men and women.

Professional Accountability

The professional and ethical accountability during the screening process incorporates multiple features, including those related to the information and services provided to the patient, which should be in line with the current evidence-based guidelines.

In this connection, Battié and Steelman (2014) highlight the significance of the nurses’ responsibility to continually educate themselves, which is why it is important for the nurse to remain aware of the evidence that supports the need for screening and the specific activities related to it. Apart from that, nurses are expected to protect the confidentiality of the information pertinent to screening unless they are legally required to report an issue (as is the case with, for example, child abuse). Nurses’ accountability is an important element of patient safety.

An example of a momentary lapse in professional accountability that I have personally witnessed was a prescription mistake made by the psychiatrist that I work with; I may have been the reason for the error since I had distracted her. Fortunately, after responding to me, she re-read the prescription and immediately corrected the mistake, making a comment on the issue, which is why I remember the case. Distractions are common in the relatively hectic environment of healthcare-related institutions, which is why I am used to double-checking documents, recognizing that I might make a mistake because of it.

Scarce resources are indeed a problem at my workplace, which is a correctional institution, and we predominantly resolve it through collaboration and continued efforts to improve our efficiency. The events in which the resources differ from those required by the policies of my institution must be rare because I have not encountered them. However, I believe that this problem should be addressed by making the administration aware of the problem and, if quick action is required, using one’s understanding of relevant guidelines (including codes of ethics) to find an appropriate solution.

Incarcerated Adults as a High-Risk Population from the Perspective of Developing Mental Health Issues

In epidemiology, a high-risk population is defined as a group of people that exhibit certain characteristics or are exposed to a particular phenomenon, which results in an increased risk for a particular condition or behavior in them (Fletcher, Fletcher, & Fletcher, 2013). An example of a high-risk population is incarcerated people who are proven be more likely to experience a variety of health concerns, including mental issues, when compared to non-incarcerated people (Kendig, 2016).

A Doctor of Nursing Practice (DNP) is expected to have the sufficient competence to be able to identify high-risk populations and provide relevant screenings and interventions based on their needs. The present paper reviews the concerns that a DNP working with incarcerated populations may need to be aware of in order to provide appropriate care to their patients.

Identification of High-Risk Population

In my workplace, which is a correctional institution, I predominantly work with incarcerated adults. These adults, especially the elderly, are a population that can be viewed as a high-risk one from multiple perspectives. It is noteworthy that the idea of “elderly” population is relatively flexible and depends on the settings that are being considered. For example, while people older than 65 years are typically viewed as elderly in the US, incarcerated Americans are regarded as elderly at the age of 50 years (Feczko, 2014, p. 640).

According to Feczko (2014), the primary reason for this distinction consists of the fact that the health of incarcerated people decreases faster, which is partially attributed to the health conditions that they tend to have, including mental ones. This factor demonstrates that incarcerated adults can be viewed as high-risk from the perspective of healthcare.

Mental issues, including, for example, dementia and Behavioral and Psychological Symptoms of Dementia (BPSD) (Feczko, 2014), are a major concern for incarcerated adults (Martin, Colman, Simpson & McKenzie, 2013). At the same time, prisoners with often mental issues remain undertreated (Feczko, 2014), and, in fact, this population and appropriate interventions for it remain understudied (Rich, Allen, & Williams, 2014). It appears that the problem can be viewed as a macro-system one (Caldwell & Mays, 2012). However, in my personal practice, this issue is represented at a microsystem level by the fact that patients with mental conditions often remain undertreated because correctional officers are not sufficiently educated on the matter, which results in the patients receiving reprimands for their behavior rather than care that they require. Thus, there is an apparent interaction between the issue and the environment in which the patients find themselves.

From the perspective of the epidemiological triangle, the situation can be described in the following way. The host (an incarcerated adult) experiences increased susceptibility to the agent (which is mental health issues) within the environment of a correctional institution (Guidotti, 2015; Stanhope & Lancaster, 2014). The environment may be directly conducive to the agent, but apart from that, it hinders the screening and treatment efforts.

In particular, it has been established, for example, that patients with mental issues are rarely referred for treatment services (Martin et al., 2013). In turn, this fact may be related to the evidence which indicates that it is typical for correctional institutions to provide screening services only during the intake, after which the population is hardly screened despite it being a high-risk one (ECRI Institute Evidence-Based Practice Center [EIEBPC], 2013). However, Rich et al. (2014) highlight the fact that incarceration may provide stability, structure, and sobriety required for a successful mental health intervention, which implies that the effects of the environment can be modified, for example, by a DNP professional.

Adverse Health Outcomes

Given the fact that incarcerated adults are exposed to multiple health risks, multiple health outcomes should be mentioned. In general, mental health issues tend to affect the behavior of patients, increasing their vulnerability, especially in the settings of a correctional institution, in which they may attract the unfavorable attention of offices or other inmates. The related outcomes include injury, victimization, and death (Feczko, 2014; Rich et al., 2014).

Moreover, specific mental issues result in their specific outcomes; for instance, the adverse outcomes of dementia and BPSD include an increased rate of falls (and subsequent injury), infections, and, eventually, mortality; also, patients with dementia experience a higher risk of developing cardiovascular problems (Feczko, 2014). Finally, as it has been stated, the adverse health outcomes of the incarcerated population are noticeable in the accelerated aging process, which reflects their poor general health and its rapid deterioration.

In turn, this factor results in multiple negative outcomes, including multimorbidity, disability, various forms of sensory impairment, as well as increased risks of injury and victimization (Rich et al., 2014). In summary, the adverse effects of mental issues are multiple, and the issue requires the attention of care providers, including DNP professionals.

Utilization of Epidemiological Principles and Terminology

In this section, the notions of risk, incidence, prevalence, morbidity, and mortality are going to be applied to the case as major epidemiological terms (Fletcher et al., 2013). The specific estimates of the risks of the incarcerated population in developing mental illnesses vary. A systematic review by Prins (2014) suggests that there have been made attempts at producing such estimates, and some of them can be viewed as high-quality studies, but there are still notable variations in the results, which prevents one from making conclusive statements.

The author suggests that this fact may be explained by different operationalizations of mental illness and other methodology specifics. However, Prins (2014) still reports that the difference between incarcerated and non-incarcerated populations in terms of the prevalence of mental issues are very consistent, which allows making certain conclusions.

According to Rich et al. (2014), the prevalence rates of mental issues in the incarcerated population amounts to 50%. Apart from that, according to the author, it can be suggested that in the US, the relative risks of an incarcerated adult in developing a mental issue are up to five times higher as compared to non-incarcerated adults. As for the development of serious mental issues in offenders, their prevalence has been assessed to be from three to five times greater when compared to non-incarcerated population (EIEBPC, 2013, p. 1). Thus, the variance of the estimates is visible in the presented prevalence rates, but they indicate the differences between incarcerated and non-incarcerated adults, supporting the fact that the former can be viewed as a high-risk population from the perspective of epidemiological analysis.

However, the present study has failed to locate a recent source that would describe the incidence of mental health issues in incarcerated adults. As opposed to prevalence, which describes the portion of the population that is affected by a condition, incidence refers to the new cases of the condition that are discovered in the population (Fletcher et al., 2013). Similar problems can be encountered when searching for the incidence or prevalence rates for specific mental concerns; for example, Feczko (2014) reports that no attempts at defining the prevalence of dementia in the incarcerated adults of the US have been made.

Additionally, despite the fact that deaths can be attributable to mental issues in incarcerated adults (Feczko, 2014; Walker, McGee, & Druss, 2015), no direct information on the mortality rates in the population has been found. As a result, the primary source of information on the condition is related to morbidity, which is limited predominantly to prevalence and is not available for all the individual mental issues.

Regarding the risk factors for the development of mental issues, some of them seem to be relatively prevalent in incarcerated adults. One of the most important risk factors is substance abuse. Rich et al. (2014) point out the fact that addiction is another issue that incarcerated adults are increasingly susceptible to, which emphasizes the significance of this risk for the population. Other notable risks include stress, financial problems, and traumatic experiences during various periods in life (for example, childhood abuse), which are also relatively common in incarcerated adults (EIEBPC, 2013).

Finally, it has been established that genetic factors may be a cause of a mental issue, but no direct evidence on the prevalence of this factor in incarcerated adults has been found. Thus, the analysis of the relevant influences and the causation of mental issues in the population can be used to support the fact that it experiences high risks as compared to the non-incarcerated people.

It should be pointed out that, according to Rich et al. (2014), the incarcerated population receives a temporary opportunity to withdraw from substance abuse and receive medical treatment and other interventions depending on their needs. As a result, the incarcerated population, while vulnerable, can be subjected to positive influences from its environment. Among other factors and actors, these influences depend on the nurses who work in the settings, which highlights the significance of taking into account the above-mentioned risks when caring for the population.


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