Cultural Competency
and Social Issues in
Nursing and Health Care
Engage Experience Excel
Boston February 6, 2009
What are outcomes?
End result of care
Measurable change in health status or
behavior
A desired condition
A measurable patient goal
Nursing Outcome
The measure or status of a nursing
diagnosis at points in time after a
nursing intervention
ICNP® 2001
Why do we need
outcome data?
Accountability
Regulatory bodies
Evidence Based Practice/ Guidelines
Consumer demand
Policy driven
Societal perspective
2 important questions
What is to be measured and why?
What result are you seeking and when?
What?
Issues in Defining Nursing
Benchmark data

Not sensitive to nursing care
Team practice

Whole vs individual
Bundling costs and resources

All inclusive
Next : How do we define
advanced practice?
Definition:
Advanced Practice Nursing
Nurse Practitioner/Advanced Practice Nurse is a
registered nurse who has acquired the expert
knowledge base, complex decision-making skills and
clinical competencies for expanded practice, the
characteristics of which are shaped by the context
and/or country in which s/he is credentialed to
practice. A master's degree is recommended for entry
level.
International Council of Nursing Nurse Practitioner/Advanced Practice
Network (ICNNP/APN)
The Problem
A recent survey among 18 countries, conducted by
the International Nurse Practitioner/ Advanced
Practice Nursing Network (INP/APNN) of the
International Council of Nursing identified:

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14 different titles existed for the APN role
Majority (75%) had formal recognition of the APN role
58% had formal APN education programs
52% had licensure requirements, showcasing developing
acknowledgement of the APN as an official advanced role
for nursing practice
Examples of Early
Advance Practice Nursing
Outcome Research
• Florence Nightingale: Modern Nursing
• First outcome data
• First nurse managed
Hospitals
• First environmentalist
• First public health
nurse
Do No Harm
Cheaper to keep well than cure illness!
Early Nursing
Outcome Research
Informs Policy
• Lillian Wald (1867-1940)
•
Visiting Nurses Service 1893
•
Henry Street Settlement House 1895
•
Nursing Insurance Partnership 1909
•
Federal Children’s Bureau 1912
• Esther Lucile Brown ( 1898-1990)
• Social Anthropologist PhD Yale 1929
• Russell Sage Foundation 1930
• “The Brown Report”
• 1948, ''Nursing for the Future''
Mary Adelaide Nutting
1858-1948
World's First Professor of Nursing 1910
Teachers College at Columbia University in New York City
1918 Shared with the Rockefeller Foundation her dream of
seeing basic education for nurses established in universities
Resulted in formation of the Committee for the Study of Nursing
Education, which released the 500-page study Nursing and
Nursing Education in the United States in 1922. (aka The
Goldmark Report for its author, Josephine Goldmark)
Authored with Lavina Dock, 4 volume History of Nursing
All before the Vote!!!!!
American Nurses Association
(ANA) Congress of Nursing
Practice, 1974
Definitions of Advanced Practice Roles:
• Nurse Anesthetist
• Nurse Midwife
• Clinical Nurse Specialist
• Nurse Practitioner
Historical Review
• Sister Mary Bernard St.
Vincent’s Hospital Erie,
PA
1st Nurse Anesthetist
1877
• Mary Breckenridge
British-Trained
Nurse-Midwife
Frontier Nursing School
and Service
1925
AANM 1929
Agatha Hodgins
1st NA program Ohio
1914
AANA 1931
Frances Reiter
• 1943
• “Nurse-Clinician”
• Designated a nurse with advanced
clinical competence
Clinical Nurse Specialist
• Adelaide A. Mayo, editor
• American Journal of Nursing
• 1944
1st Clinical Nurse
Specialist Program
• Hildegard Peplau
• Rutgers University, New Jersey
• 1954
• Psychiatric Nursing- Master’s Level
• NACNS 1995
1st Nurse Practitioner
Programs
• Pediatric Nurse Practitioner
• Loretta Ford & Henry Silver
• University of Colorado 1965
• NAPNAP
• Adult/Family Nurse Practitioner 1971
• AANP
• ACNP
• Neonatal Nurse Practitioner 1977
• Acute Care Nurse Practitioner
• 1995 Adult
• 2005 Pediatric
APN Outcome Studies
CRNAs
Alice MaGaw 1899
1st outcome study Northwestern Lancet
CNMWs
UCSF PEW Health Professions 1998
14 recommendations to improve practice
CNS
Dayhoff & Lyon 2001 CNS defined by role
1st NP Outcome Study
• The University of Colorado PNP
Demonstration Project 1965
• Purpose: To prepare professional nurses to
provide comprehensive well-child care as well
as manage common childhood health
problems.
• Emphasis: Family dynamics and community
cultural values.
• Focus: Shift from care of medical illness to a
strong family oriented health promotive
approach.
Factors Influencing US Nurse
Practitioner Development
• Nurse Training Acts
• Needs within the
• Public Health Nursing
population
• Nursing profession
• Health-care delivery
system
• Emphasis on primary
health care
• Primary Care Physician
Shortage
• Trend Toward Medical
Specialization
• Consumer Movement
• Women’s Movement
Landmark Outcomes
Study
Committee of the Secretary of
Health, Education, and Welfare
Report, 1971
Purpose:
• to study extended roles for nurses
• to evaluate feasibility of expanding
nursing practice
Significant Conclusions
• Extending the scope of the nurse’s role was essential
to providing equal access to health care for all
consumers.
• Need to establish innovative curricular designs in
health science centers with increased financial
support for nursing education.
• Need to advocate for commonality of nursing
licensure and certification, including a model nursing
practice law suitable for national application.
• Need for research related to cost-benefit analyses
and attitudinal surveys to assess impact of new role.
Loretta Ford 1991
“The nurse practitioner movement is
one of the finest demonstrations of how
nurses exploited trends in the larger
health care system to advance their
own professional agenda and to realize
their great potential to serve society.”
Challenges in Outcomes
Research 40 years later
• Ambiguity over role definition still exists
• Historically lack of unity in requirements for
entry into programs
• Variations in degree received
• Debate over setting for and length of program
•
Certificate, MS, now DNP
• Scope of practice (State vs Federal in US)
Standardization of
Educational Preparation
for Nurse Practitioners
1979 - 124 certificate programs, 74 master’s
1990 - 11 certificate programs, 84 master’s programs
2005 - 2 certificate programs 400+ master’s
2007 - 11 DNP programs
2015 - DNP all NP programs
Standards & Guidelines
`
AACN Masters Essentials
(1996)
To establish a unifying
framework for APN curricula
through the identification of a
“common educational core”
Advanced Nursing
Practice:Building Curriculum
for Quality NP Education
(2002)
Common Features of
APN Graduate Education
• The Graduate Nursing Core: generic to
all master’s nursing degrees
• The Advanced Practice Nursing Core:
generic to all advanced nursing practice
• The specialty role core specific to each
APN role
Graduate Core Curriculum
Content
I. Research
II. Policy organization and financing of health care
a. Health care policy
b. Organization of the health care
delivery system
c. Health care financing
III. Ethics
IV. Professional Role Development
V. Theoretical Foundations of Nursing Practice
VI. Human Diversity and Social Issues
VII. Health Promotion and Disease Prevention
APN Core Curriculum
• Advanced Health/Physical Assessment
• Advanced Physiology/Pathophysiology
• Advanced Pharmacology
Specialty Curriculum
• Process of Clinical Decision Making
• Complex or Advanced Nursing
•
•
•
•
Interventions
Health Promotion/Disease Prevention
Epidemiology
Role Differentiation
Interpersonal and Family Theory
APN Curriculum Framework
and Competencies
National Organization of Nurse
Practitioner Faculties (NONPF) 2006
Seven Domains of Practice
1.* Management of Client Health/Illness Status
2. The Nurse-Client Relationship
3. The Teaching-Coaching Function
4. Professional Role
5.* Managing and Negotiating Health Care
Delivery Systems
6. *Monitoring and Ensuring the Quality of
Health Care Practice
7. Cultural and Spiritual competency
Sample NP Skills & Functions
• screening
• physical and psychosocial assessment
• management of common health problems
• follow-up
• continuity of care
• health promotion
• problem-centered services
• identification and mobilization of resources
• health education
• client and group advocacy
* All are aspects of Primary, Secondary, Tertiary Care
Avedis Donabedian’s
Quality of Care Model
Structure
Process
Outcomes
Supports federal government’s sponsorship of
Professional Standards Review Organizations
(PSRO's) & Continuing Quality Improvement (CQI)
Science, Vol 200, Issue 4344, 856-864
Copyright © 1978 by American Association for the Advancement of
Science
Quality of Care
The degree to which health services
increase the likelihood of desired health
outcomes and are consistent with
current professional knowledge

Institute of Medicine (IOM) 1990
Challenges to Nursing
Outcome Research
Patient autonomy
Multiplicity of individual’s health problems
Nonclinical characteristics
Multiplicity of providers
Unknown time between interventions and
outcomes
Lack of baseline measurements
Complexity of variables
Additional Problems
Relative insensitivity of outcomes
Final outcomes not known until too late
Outcomes can be influenced by outside
factors
Information about outcomes not readily
available
Few lists of valid effectiveness criteria and
measurements
Nugent & Lambert 1997
Variance in Outcomes
Not met at all
Met later than expected
Met ahead of time
Variance
 Positive
 Negative
Classification of Variance
 System
 Provider
 Client
Murray & Anderson 2000, Murray & Lindgren 2001
Questions to guide
outcome research
Which outcomes are most important?
To whom are they important?
How are they defined?
How should they be measured?
Who is accountable for achieving them?
Minnick 2001
Outcomes Measures
(Indicators of Outcomes)
Observation
Description
Quantification
Types of Outcomes
Physiological


Heart rate
Weight
Perceptual

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Satisfaction
Symptom control
Quality of life
Well being
Psychosocial
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Attitude
Mood
Cognitive
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Knowledge
Understanding
Functional

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ADLs
ROM
Fiscal

Cost
Behavioral
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Compliance
Motivation
General Outcomes
Length of stay
Resource use
Costs
Patient satisfaction
Technical skills
Inventory of Patient Outcomes
Symptom control and change in symptom severity.
Functional status.
Knowledge of condition and treatment.
Patient satisfaction with care.
Unplanned emergency department visits.
Unplanned hospital readmissions.
Strength of treatment alliance.
International Council of Nurses (2001) International
Classification for Nursing Practice
Clinical Outcomes
Need to adjust for risk factors
Baseline status
 Clinical status
 Treatment
 Setting
 Environment

Variables affecting
patient outcomes
Socioeconomic factors
Family support
Age and gender
Quality of care provided by other
professionals and support workers
Continuum of Outcomes
Too global or
general

Difficult to measure
or link them to prior
action
Too specific or
specialized

Limited meaning or
generalizability
Principles in
Determining Outcomes
Must be measurable
Must relate to care process/intervention
Must be realistic
Must be measured within accessible time
span
Must describe risk
Must consider cost
Chosen parameters must be accurate and
specific to care
Consider Cost
Minimization
Benefit analysis
Consequences
Utility
Underutilization
Direct
Indirect
Opportunity
Gold Standard in Early
APN Outcome Research
Comparative
outcomes
Measured against
physician care


Equivalent
Superior
US Comparative Studies
Brooten et al 1986
Mundinger 2000
Health Resources and Service
Administration (HRSA) Bureau of Health
Professions (2000) CNS & NP
workforce reports
US Congress Office of Technology
Assessment 1986
International
Comparative Studies
Australia
Horrocks, Anderson & Salisbury (2002)
 Chang et a (1999)

United Kingdom
Kinnersley et al (2000)
 Sakr et al (1999)

Netherlands

Laurant et al (2004)
Reviews of categories of
indicators for outcomes
Hegyvary 1991
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Clinical
Functional
Financial
Perceptual
Irvine et al 1998
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Complication
Prevention
Clinical outcomes
Knowledge
Functional health
Cost of care
Patient satisfaction
Classification of
Outcomes
Lang & Marek 1990
Physiological
Psychological
Functional
Knowledge
Symptom control
Home maintenance
Pt satisfaction
Safety
Nursing diagnosis
resolution
Frequency of
service
Cost &
rehospitalization
Well being
Goal attainment
Sources of
Measurement:
Common Data Sets
Administrative data
Medical records
Discharge summaries
Surveys
Electronic medical records
Patient/family reports
Clinical practice
guidelines/critical pathways
Standardized Data Sets

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JCAHO
CONQUEST
AHRQ
HEDIS
APN Outcomes and
Acute Care Setting
Large body of
literature
>disease/medical
based
> physiological
measures
>skill/function based
Systematic Reviews of
Nursing Outcome
Research
Bourbonniere & Evans 2002
Cunningham 2004
Kleinpell 2001
Limitations in APN Studies
Lack of methodological rigor
Use of variable measurement strategies
Lack of specific health related outcomes
Use of physician as comparative group
Heterogeneous outcomes
Lack of economic analysis
All Conclude: Need
Nursing/APNSensitive
Outcomes
Changes in health status upon
which nursing/APN care
has had a direct influence
Nursing Outcome Goals
Often directed toward cost containment
>hospital based, < community based
Rarely directed toward understanding
scientific basis for clinical practice
Rarely examine underlying relationship
between outcomes and care
Beyond comparative
value outcomes of APNs
Unique contributions
of APNs
Income
“Value added”


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Mundinger 2000
Ryden et al 2000
Wong et al 2000
Example APN value
added skills
Health education integral to care
Disease prevention/health promotion
Teaching/counselling/listening
Coordination of care
Community resource access
Partnerships with patients/families
Holistic care in a family social context
Added ‘nursing ingredient’ to APN care
(Plager & Conger 2007)
Nurse Sensitive
Outcomes of Practice
ANA 1996 Set of Nursing Indicators
Johnson & Maas 1997
Nursing Outcomes Classification
Generic Nursing
CNS Literature
Ingersoll et al (2000)
Nurse Sensitive Outcomes of
APN Practice
10 indicators
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Pt satisfaction
Symptom
resolution/reduction
Compliance/
adherence/
cooperation
Knowledge of
patient/family
Quality of life
Perception of being
well cared for
Trust in provider
Collaboration
among providers
Care provider
recommendations
Frequency/type
procedures ordered
How do we capture both
the art and the science
of high level caring at all
levels of nursing?
The Blended Art &
Science of APN
Cunnngham (2000) posits, “How to measure,
as Benner (1984) suggests, the exquisite skill
in clinical judgment that comes from
‘knowledge embedded in practice’ which may
be a deciding variable in APN care
Bourbonniere & Evans (2002) use the term
‘contextual thinking’ to denote the APN’s high
level of data synthesis
Conclusion:
What is the importance of
Nurse Sensitive Indicators &
Outcomes?
.
Demonstrate that nurses at all levels provide safe,
quality, and cost effective care.
Provide strong support for appropriate
allocation of health care resources.
Continue to measure the Art of Nursing as well as the
Science of Nursing.
Make Nursing Visible.
Future Challenges and
Opportunities
APRN Regulatory Model
2008
4 roles
6 population foci
Education, certification, and licensure must
be congruent in terms of role & population
foci.
Specialties can provide depth in one’s
practice within the established population
foci.
Doctorate in Nursing
Practice (DNP)
Although the current masters and PhD programs in nursing are
critical to the future of the profession and are evolving to keep
pace with new demands, they do not fill the growing need for
expert clinical teachers and clinicians.
Informational shifts, demographic changes, growing disparities
in healthcare delivery and access, and stakeholder expectations
are all creating new demands on the nursing profession.
The practice (also called clinical and professional) doctorate,
with a focus on direct practice and healthcare leadership, offers
nursing an exciting opportunity to meet these demands.
22 National Nursing
Organizations Join Together
to Commission a Study of
the Impact of Advanced
Practice Registered Nurses
on Healthcare Quality, Safety,
& Effectiveness since 1990
24/9/2008 The Tri-Council for Nursing
Robin Newhouse, PhD, RN, CNAA, BC, CNOR
University of Maryland & Johns Hopkins University.
“Nursing is not second
class medicine but
first-class health care”
Loretta Ford