A Clinical Nurse Specialist in Home Healthcare.

PURPOSE: Opportunities and challenges in home healthcare are discussed from the perspective of a gerontological clinical nurse specialist who has served as an expert clinician, administrator, and compliance director of a home health agency in the Midwest United States. DESCRIPTION: Home-based nursing care requires a distinct set of knowledge and skills centered on the home environment and the way the home health patient responds emotionally and physically to become confident and self-sufficient. A Theoretical Framework for Home-Based Professional Nursing Practice is presented identifying the 6 concepts (primacy of home, patient authority, patient self-management, caregivers as collaborators, interprofessional clinical team collaboration, nurse autonomy) that are building blocks to describe the experience of patients in their homes and interactions with providers. The quality of clinical care and documentation influence reimbursement for care and the financial survival of the home health agency. OUTCOME: Six management priorities both within the administrative office and the clinical teams are highlighted to improve quality of care, promote efficiency, and retain staff. CONCLUSION: Exciting opportunities are available for the clinical nurse specialist in home-based care.

A Theoretical Framework of Home-Based Professional Nursing Practice.

The purpose of this article is to introduce a descriptive middle-range theoretical framework unique to professional nursing practice provided in the patient's home. The variety of care models provided in the home, ranging from nonskilled home maintenance service to hospital-at-home programs, reinforces the need to clearly define and describe home-based professional nursing practice. This framework includes six concepts (primacy of home, patient authority, patient self-management, caregivers as collaborators, interprofessional clinical team collaboration, nurse autonomy), and four relational statements of the concepts that describe the experience of patients in their homes and home-based providers. The four theoretical statements are: (1) The patient's beliefs, habits, and self-management actions in the home are shaped by the meaning of home and the physical home environment. (2) The patient has ultimate decision-making control and authority over his/her own health-related behaviors in the home. (3) Home-based care includes interprofessional teams to provide holistic care and maximize self-management ability. (4) The home-based nurse is autonomous when working in the home with the patient/caregiver and has primary responsibility for holistic assessment and intervention. Knowledge of this theoretical framework can help nurses maintain the integrity and purpose of the professional nurse's role in home-based care as well as provide guidance for nursing education and organizational structures. Recommendations for research to test and validate the framework are provided.

Becoming an Expert Home Health Nurse.

The purpose of this article is to discuss the five levels of skill acquisition (novice, advanced beginner, competent, proficient, and expert) developed by Patricia Benner and colleagues, within the unique context of home health nursing. Descriptions of practice at each level are provided and can help nurses have reasonable expectations of performance. Recommendations are made for competence-based clinical support programs such as orientation, mentoring, and clinical ladders that identify, measure, and reward clinical knowledge and skill.

Incorporating Virtual Visits Into the Home Health Plan of Care.

Virtual visits, using 2-way real-time remote communication between the patient and the home health clinician, are a valuable adjunct to in-person visits to advance the prescribed plan of care. This article defines virtual visits within the larger context of telehealth and describes how to balance and integrate assessment and teaching modalities across in-person and virtual visits. Protection of patients' rights and privacy and facilitation of face-to-face visits with practitioners are also discussed.

Best-practice intervention for care of clients who self-mutilate.

PURPOSE: To describe the development of a best practice intervention to guide nurse practitioners (NPs) who care for individuals who self-mutilate. DATA SOURCES: The evidence on which the guideline was based includes six descriptive studies and expert clinical opinion articles. The framework for development of the guideline is a systematic process to obtain and analyze the best available evidence, develop a theory-driven intervention, and propose a system for ongoing evaluation of the effectiveness of the intervention. CONCLUSIONS: The guideline is an information sheet, containing the definition of self-mutilation, background of the problem, target population affected, and intervention. The three components of the intervention are (a) the NP's self-evaluation of values, beliefs, and assumptions about individuals who self-mutilate; (b) a focused, in-depth assessment of the client; and (c) therapeutic strategies to address the emotional, social, and biological dimensions of self-mutilation. IMPLICATIONS FOR PRACTICE: This Best-Practice Intervention for Care of Clients Who Self-Mutilate guideline provides direction for NPs to address a preventable, self-injury behavior effectively. Further study is needed to examine the effectiveness of the use of the guideline and the intervention.

Concept analysis of self-mutilation.

AIM: This paper is a report of a concept analysis to define and describe self-mutilation. BACKGROUND: Although there has been an increased interest in self-mutilation, as evidenced by recent publication of opinion literature, anecdotal reports and a few clinical studies, the concept has not been well developed to guide nursing research and interventions. METHOD: Definitions and uses of self-mutilation were obtained in a comprehensive review of the health, psychology and education literature up to April 2007 to identify the defining attributes, antecedents and consequences. Walker and Avant's concept analysis strategy was the organizing framework. FINDINGS: Self-mutilation is the intentional act of tissue destruction with the purpose of shifting overwhelming emotional pain to a more acceptable physical pain. Antecedents of self-mutilation are impaired coping skills and an unhealthy response to situations that cause unbearable emotional stress. Limited research suggests that risk factors for self-mutilation may be White race, adolescent age, female sex and history of sexual abuse as a child. Although self-mutilation allows the individual to gain control over emotions and provides a diversion from emotional pain, a release of endorphins after the physical damage that contributes to the feeling of relief supports an addictive maladaptive coping cycle of pain, relief, shame and self-hate. CONCLUSION: The theoretical definition of the concept of self-mutilation offers the basis for nurses to develop interventions to provide competent care when discovering injuries that are self-inflicted.

Comparison of upper arm and forearm blood pressure.

The upper arm is the primary site used to obtain a blood pressure measurement (BPM); however, when it is not possible to use the upper arm, the forearm is a commonly used alternate site. This study determines if there is a significant difference between upper arm and forearm BPMs among adults and examines the relationship of participant characteristics to the BPM difference. A convenience sample was recruited from a low-income, independent-living, 104-apartment complex in the Midwest. Of the 106 participants, 64% were female and 89% were White. Ages ranged from 20 to 85 years (M = 50.7). The investigators calculated the BMIs (range = 18 to 42, M = 29.3, SD = 5.4) for the 89% (n = 94) of participants who reported their weight. The forearm tended to have higher BPMs than the upper arm (M difference = 4.0 mm Hg systolic, 2.3 mm Hg diastolic). However, site differences were greatest for men, obese adults, and middle aged (36 to 65) adults.

The meaning of time in oldest-old age.

In a phenomenological study that described the lived experience of adults older than 85 years, 19 oldest-old adults' lived time is illuminated by 5 themes: Defining Self Through Experience, Being Situated in Time, Knowing Lifetime Is Limited, Planning for the Future, and Leaving a Legacy.

Student learning with concept mapping of care plans in community-based education.

Concept mapping, a learning strategy used to understand key concepts and relationships between concepts, has been suggested as a method to plan and evaluate nursing care. The purpose of this study was to empirically test the effectiveness of concept mapping for student learning and the students' satisfaction with the strategy. A quasi-experimental pre- and posttest design was used to examine the content of concept maps of care plans constructed by junior-level baccalaureate students (n = 23) at the beginning and end of a community-based mental health course. Additionally, students completed a questionnaire to self-evaluate their learning and report their satisfaction with concept mapping. Findings indicated that concept mapping significantly improved students' abilities to see patterns and relationships to plan and evaluate nursing care, and most students (21/23) expressed satisfaction in using the strategy. This study supported concept mapping as an additional learning strategy and has extended knowledge in community-based nursing education.