global connections: integrating theory and practice in professional

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Item type Presentation

Title Global Connections: Integrating Theory and Practice inProfessional Nursing: The Artinian Intersystem Model inEducational Settings

Authors Artinian, Barbara M.; Cone, Pamela H.

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Link to item http://hdl.handle.net/10755/201893

GLOBAL CONNECTIONS: INTEGRATING THEORY AND PRACTICE IN PROFESSIONAL NURSING USING THE ARTINIAN INTERSYSTEM MODEL Barbara M. Artinian, PhD, RN Katharine S West, MPH, MSN, RN, PHN Margaret M Conger, EdD, MSN, RN Pamela H Cone, PhD, MSN, RN

BARBARA M. ARTINIAN PHD, RN Professor Emeritus Azusa Pacific University

KATHARINE S WEST MPH, MSN, RN, PHN, CNS Kaiser Permanente, Nurse Clinical Systems Analyst University of Phoenix, Facilitator

MARGARET M CONGER EDD, MSN, RN Professor Emeritus Northern Arizona University

PAMELA H CONE PHD, MSN, RN Associate Professor Azusa Pacific University (APU)

OVERVIEW I. Introduction to the Artinian Intersystem Model

(AIM) II. Integrating theory & practice in professional

nursing III. Teaching healthcare interactional skills using the

AIM IV. Teaching the concepts of AIM in educational

settings V. Using the AIM to teach health promotion &

disease prevention in public health nursing VI. Applying the AIM in professional practice VII. Q&A

INTRODUCTION TO THE ARTINIAN INTERSYSTEM MODEL (AIM) Katharine S. West, MPH, MSN

SALZBURG STATEMENT ON SHARED DECISION MAKING - DECEMBER 2010 We call on clinicians to: • Recognise that they have an ethical imperative to share important

decisions with patients • Stimulate a two way flow of information and encourage patients to

ask questions, explain their circumstances, and express their personal preferences

• Provide accurate information about options and the uncertainties, benefits, and harms of treatment in line with best practice for risk communication

• Tailor information to individual patient needs and allow them sufficient time to consider their options

• Acknowledge that most decisions do not have to be taken immediately, and give patients and their families the resources and help to reach decisions

BMJ 2011; 342:d1745

SALZBURG STATEMENT ON SHARED DECISION MAKING - DECEMBER 2010 We call on clinicians, researchers, editors, journalists, and others to: • Ensure that the information they provide is clear, evidence based,

and up to date and that conflicts of interest are declared We call on patients to: • Speak up about their concerns, questions, and what’s important to

them • Recognise that they have a right to be equal participants in their

care • Seek and use high quality health information We call on policy makers to: • Adopt policies that encourage shared decision making, including

its measurement, as a stimulus for improvement • Amend informed consent laws to support the development of

skills and tools for shared decision making

BMJ 2011; 342:d1745

AIM M

OD

EL

DESCRIPTION OF THE ARTINIAN INTERSYSTEM MODEL

Guides the nurse or provider to incorporate patient/client values into the

Mutual Plan of Care

Assesses patient’s own knowledge, values, and

behaviors about the main concern before engaging in interaction to resolve the concern.

FOUNDATIONAL TO THE ARTINIAN INTERSYSTEM MODEL

Each person is an intrasystem biological self psychosocial self spiritual self

Mutuality of interaction between the patient/client

and nurse/provider intrasystems

Fosters mutual problem solving

APPLICATION OF THE ARTINIAN INTERSYSTEM MODEL

Applied to individual clients aggregate populations communities as clients or institutions as clients

Supports

Shared Decision Making in all aspects of health care

AIM CARE PLAN TEMPLATES

1. AIM Block Care Plan Template for Undergraduate Students

2. AIM Community Health Care Plan Template

3. AIM Standard Care Plan Template

4. AIM Narrative Care Plan Template for Graduate Students

INTEGRATING THEORY & PRACTICE IN PROFESSIONAL NURSING USING THE AIM Barbara M. Artinian, PhD

MODEL VS. THEORY

Represents the structure or concept of an object

Example: Ararat Resident-

Centered Care Program

Explains the “How” or “Why” of a phenomenon

Example: Theory of Identity

Preservation

MODEL THEORY

THE PROCESS OF THE AIM

Figure 1.8

THE THEORIES OF THE AIM

Developed by integrating and extending into the model Chin (1969) Kuhn (1974) Antonovsky (1987) Blumer (1969) Stallword & Stoll (1975) Hill (1949)

INNOVATIONS IN NURSING RESEARCH USING THE AIM: PRESERVING IDENTITY THEORY

Copyright © 2009 B.Artinian. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INNOVATIONS IN NURSING RESEARCH USING THE AIM: PREPARATIVE WAITING THEORY

Copyright © 2009 T. Giske. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INNOVATIONS IN NURSING RESEARCH USING THE AIM: LETTING GO THEORY

Copyright © 2009 L.Pash. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INNOVATIONS IN NURSING RESEARCH USING THE AIM: CONQUERING OPERATIONAL SPACE THEORY

Copyright © 2009 E. Hjälmhult. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INNOVATIONS IN NURSING RESEARCH USING THE AIM: CAREGIVING BEHAVIORS DESCRIPTIVE STUDY

Copyright © 2009 M.Friesen. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INNOVATIONS IN NURSING RESEARCH USING THE AIM: RECONNECTING THEORY

Copyright © 2009 P.Cone. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

TEACHING HEALTHCARE INTERACTIONAL SKILLS USING THE AIM Margaret M Conger, EdD, MSN, RN Professor Emeritus Northern Arizona University

EVIDENCE BASED PRACTICE (EBP)

IOM recommends all practice be based on research evidence

EBP must become part of all professional practice Needed to

Enhance quality care Lead to reduced costs

EBP APPLIED TO THE INDIVIDUAL

Identify best practice for a situation Must be research based Useful for the aggregate

Must be adapted to the individual This is where AIM is needed How does provider knowledge/ values fit with client

knowledge/values? What adaptations are needed?

INTERSYSTEM INTERACTION

INDIVIDUALIZING EBP USING THE AIM

Use available evidence from research

Consider client concerns / abilities

Adapt interventions to meet specific client needs

Developmental environment Collect client data

Situational environment Score on SSOC Adapt interventions to

specific client need/ values

EBP AIM

CRITICAL THINKING

Important component of nursing practice

Critical thinking skills used in the AIM

• Inquisitiveness - exercise intellectual curiosity • Systematicity – use orderly process • Analyticity – use research to find answers to

questions • Open mindedness – be tolerant to divergent views

CLINICAL REASONING

Clinical reasoning needed to • Frame • Juxtapose • Test match client’s

present state and desired outcome state”

Assess client present state Score on SSOC

Requires clinical reasoning Work mutually with client to develop plan for interventions

Puset & Herman( 1999)

AIM

USE OF AIM IN DELEGATION DECISIONS

Delegation to assistive personnel (AP) is needed skill in today’s health care environment

Most tools developed to teach delegation focus on tasks

Tool needed that also includes needs of the individual client

Nursing Assessment Decision Grid (NADG) developed

NURSING ASSESSMENT DECISION GRID (NADG)

Assess client subsystems Score on SSOC Delegate care based on

Tasks Client needs Knowledge of AP

Assess client subsystems Analyze information Evaluate client/provider

Knowledge Values Behaviors

NADG AIM

NURSING ASSESSMENT DECISION GRID

Source: Conger, M (1993). Delegation decision making: Development of a teaching strategy. Journal of Nursing Staff Development, 9(3). 131-135.

NURSING ASSESSMENT DECISION GRID

Source: Conger, M (1993). Delegation decision making: Development of a teaching strategy. Journal of Nursing Staff Development, 9(3). 131-135.

USE OF AIM IN INSTITUTIONS

Institution - “two or more partners engaged in intersystem interaction” (Kuhn, 1974)

Leadership styles changing

INSTITUTIONAL SUBSYSTEM ASSESSMENT

Biological Health policies Work schedules Gender issues

Spiritual

Religious affiliations Use of chaplains

Psychosocial Unwritten rules Employee groups Leadership styles Organizational ethics/

values

SITUATIONAL ENVIRONMENT

Knowledge How is information communicated?

Values What are the organizational cultural values ?

Behaviors What is the power structure? How is power shared?

SSOC

Institutions can be scored using the SSOC

Problems identified

Mutually develop plans for changed behavior

Institute changes

Can result in organizational improvement

ARARAT EXAMPLE

Ararat Nursing Facility – long term care residential facility

Staff assessed problems Leadership style – autocratic, crisis focused Client care – not individualized Staff morale – very low

SSOC – very low

ARARAT EXAMPLE

Situational Environment Knowledge

Primary staff – CNA Little knowledge of client care needs

Values Little pride in work

Behavior Fragmented client care Noisy uncaring environment Power applied from top down

ARARAT EXAMPLE Management/Staff negotiated for changed environment Power shared among staff/ management Results

Unprofessional behaviors eliminated Communication with client/families improved Staff appearance looked more professional Increased satisfaction of staff, clients, & families

Client care changed Reduced client falls Improved documentation

Education encouraged All staff had opportunity to increase level of education

CONCLUSIONS

AIM can be applied in a variety of situations Not limited to nurse/client interactions Nurse student education

Enhance application of EBP to individuals Enhance critical thinking/clinical reasoning skills

Institutional change Refine delegation decision making Promote institutional leadership change

USE OF THE AIM IN EDUCATIONAL SETTINGS Pamela H Cone, PhD, MSN, RN

AIM IN NURSING EDUCATION

Congruence with school mission & philosophy

Usefulness in curriculum development

Sense of Community & Mutuality

Centrality of Language

Curriculum with Coherence

Development of Care Plans

Climate for Creative Learning

(Boyer, 1996)

AIM IN UNDERGRADUATE (UG) NURSING PROGRAMS

Early work on AIM focus – UG care plans

Adoption of AIM at APU

Care plans leveled across four years from simple to complex Definition of Person (Stallwood & Stoll, 1975)

Sense of Coherence (Antonovsky, 1987)

Nurse-Patient interaction (Kuhn, 1974)

Mutual Negotiation of Plan

Case Study Vignette

BLOCK CARE PLAN FOR UG STUDENTS

AIM IN GRADUATE NURSING PROGRAMS

Introduction of Theories & Models

Focused discussion of AIM

Student Sample Philosophies

Congruence with the AIM

LESSON PLAN FOR INTRODUCING MODELS AND THEORIES

Discuss student experiences in providing nursing care

Introduce use of models in practice

Selected models, including the AIM

Acquaint students with the concepts of the AIM

Use the AIM diagram

Demonstrate the narrative care plan

LESSON PLAN FOR INTRODUCING MODELS AND THEORIES

Discuss examples of care plans written in varying formats Truncated

Full text

Annotated

Referenced

Group care plans

Care plans based on Glaserian Grounded Theory Research (Artinian, Giske, & Cone, 2009)

NARRATIVE CARE PLAN FOR GRAD STUDENTS

Copyright © 2011 B. Artinian, PhD. From The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing. May use with permission.

NARRATIVE CARE PLAN FOR GRAD STUDENTS, CONTD.

Copyright © 2011 B. Artinian, PhD. From The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing. May use with permission.

NARRATIVE CARE PLAN FOR GRAD STUDENTS, CONTD.

Copyright © 2011 B. Artinian, PhD. From The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing. May use with permission.

AIM IN STAFF NURSING PROGRAMS

Budding RN Program – staff education Designed for current ancillary nursing who have not

completed boards Assist with other mentoring programs

Develop Care Plan using AIM Provider = RN Staff Developer Client = RN board-eligible staff members

INSTITUTIONAL CARE PLAN

Developmental Environment Validation of Main Concern

Need for more RN staff Unsuccessful attempts of board-eligible staff to pass RN

boards Situational Environment

Score on SSOC = 1, 2, 1

Intersystem Interaction to Resolve Main Concern Negotiate, develop, implement, evaluate Re-score on SSOC = 3, 3, 3

AIM IN STAFF NURSING PROGRAMS

Ararat Nursing Facility Participatory

Leadership Reinforce Identity of

Staff Continuous Quality

Improvement Building Positive

Relationships with Families

EMBRACING HEALTH: USING THE AIM FOR HEALTH PROMOTION AND DISEASE PREVENTION EDUCATIONAL PROJECTS IN RN-TO-BSN PUBLIC HEALTH NURSING COURSES Katharine S West, MSN, MPH, RN, PHN, CNS

ADVANTAGES OF USING AIM IN PUBLIC HEALTH NURSING PRACTICE Process-oriented Content-free Use in any health care setting with any client Focuses on interplay of various systems Participation of community client in decision-

making process

USING MODELS TO GUIDE COMMUNITY & PUBLIC HEALTH NURSING PRACTICE

Assessment Assurance Advocacy

Community joint goals & strategies

Definitions & knowledge of health (comprehensibility)

Values regarding health (meaningfulness)

Behaviors carried out to promote health (manageability)

Core Functions of Public Health AIM

HIERARCHY OF INTRASYSTEMS BY COMMUNITY CLIENT

Copyright © 2011, K.West. In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INTRASYSTEM FUNCTIONS OF COMMUNITY HEALTH CLIENTS

In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INTRASYSTEM FUNCTIONS OF PUBLIC HEALTH CLIENTS

In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

INTRASYSTEM FUNCTIONS OF PUBLIC HEALTH CLIENTS, CONTD.

In The Artinian Intersystem Model: Integrating Theory and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing.

POPULATION-FOCUSED PLAN OF CARE

CASE STUDIES ILLUSTRATING USE OF THE AIM IN PUBLIC HEALTH NURSING

DATING SAFETY EDUCATION FOR A CATHOLIC YOUTH GROUP ABIGAIL EVANGELISTA, BSN, RN

Negotiating Values with a community client and adapting the educational objectives of the nurse to match those of the client.

Needs Assessment:

Catholic youth group, ages 12–16

Main concern of sex and sex safety

DATING SAFETY EDUCATION FOR A CATHOLIC YOUTH GROUP ABIGAIL EVANGELISTA, BSN, RN

Church was diametrically opposed to approving a topic that violated the church’s values of celibacy before marriage

Nurse met with Youth Leaders to negotiate values for an appropriate topic that would nonetheless satisfy the identified main concern. Not birth control or safe sex practices Could teach about date rape, date abuse, and physical

violence against women

DATING SAFETY EDUCATION FOR A CATHOLIC YOUTH GROUP ABIGAIL EVANGELISTA, BSN, RN

Joint goals were developed for a mutual educational plan of care on the topic of safe dating

Positive rescoring on SSOC One teen acknowledged an abusive relationship &

requested help.

“It felt so restrictive at first. But then I realized that the PHN needs to be creative and inventive and honor the client’s preferences that I could say this but not that.”

ADVOCACY FOR FOOD SECURITY: THE WIC PROGRAM IN A FARMER’S MARKET KATERINA PEREZ, BSN, RN

Use of the AIM in facilitating the PHN Core Competency of Advocacy Healthy People 2010 Objective 19–5: Increase the proportion of persons

aged 2 years and older who consume at least two daily servings of fruit

Objective 19–18: Increase food security among US households and in so doing reduce hunger

ADVOCACY FOR FOOD SECURITY: THE WIC PROGRAM IN A FARMER’S MARKET KATERINA PEREZ, BSN, RN

Community assessment revealed 4 of 5 health food stores & local farmer’s market,

did not accept the California Electronic Benefit Transfer (EBT) debit cards for the Women, Infants, Children (WIC) food supplement program.

Food stamps households had increased 25.8% between February 2009 and February 2010 (California Department of Social Services, 2010)

Participants limited in access to fresh food and farmer’s market using WIC funds

ADVOCACY FOR FOOD SECURITY: THE WIC PROGRAM IN A FARMER’S MARKET KATERINA PEREZ, BSN, RN

California provides a “token” economy for farmer’s markets to accept EBT cards

Booth set up at market WIC client swipes EBT card in exchange for tokens. Tokens used to purchase produce from the farmer

merchants.

At market close Farmers exchange tokens back into cash at the booth.

ADVOCACY FOR FOOD SECURITY: THE WIC PROGRAM IN A FARMER’S MARKET KATERINA PEREZ, BSN, RN

Unilateral community nurse goal to raise awareness about the lack of acceptance of food stamps/EBT cards by the local health food stores or local farmer’s market.

Solution proposed to the city council Adopt “token” exchange at the farmer’s market “First step” toward food accessibility. Supportive printed materials & references

ADVOCACY FOR FOOD SECURITY: THE WIC PROGRAM IN A FARMER’S MARKET KATERINA PEREZ, BSN, RN

City Council Response: Comprehensibility: credentials as an RN and as a

public health nursing student Manageability: State “token” booth Meaningfulness: Access to local produce, improved

access to healthy food “When I was presenting my EBT card idea in front of council members, I was little shy and felt that perhaps I did not have the authority or credentials to do so. But [advocacy] gives a voice to those in the community who cannot speak for themselves.”

USING THE AIM IN OTHER SETTINGS IN PROFESSIONAL NURSING Katharine S West, MPH, MSN, RN, PHN, CNS

TAYLOR’S RECOMMENDATIONS FOR DEVELOPING A SALUTOGENIC PROGRAM

RESIDENT-CENTERED CARE PROGRAM

POPULATION CARE MANAGEMENT: HEART FAILURE PROGRAM COORDINATOR MAKES CONNECTION

POPULATION CARE MANAGEMENT: CONNECTS TO FAMILY & SOCIAL NETWORK

POPULATION CARE MANAGEMENT: CONNECTS PATIENT TO AGENCY

POPULATION CARE MANAGEMENT: COORDINATOR AS CONNECTOR LESSENS

POPULATION CARE MANAGEMENT: COORDINATOR STAYS CONNECTED

COSMETIC SERVICES - AMBULATORY NP

Cosmetic Services Nurse Practitioner Non-covered service Not medically necessary

Patient’s views = Focus of care

AIM used for Negotiating values between client and NP Developing a mutual plan of care to enhance the sense

of coherence (SOC) of the client

IN CONCLUSION

AIM GUIDES SHARED DECISION MAKING

Even power distribution Attentive to

knowledge values behaviors

Patient & Nurse

Identify Main Concern Negotiate plan of care Quantify nursing effect

Score on SSOC Rescore on SSOC

THE PROCESS OF THE AIM

Figure 1.8

Q&A

REFERENCES Antonovsky, A. (1987). Unraveling the mysteries of health: How people manage stress and stay

well. San Francisco, CA: Jossey-Bass. Artinian, B., & Conger, M. (1997). The intersystem model: Integrating theory and practice.

Thousand Oaks, CA: Sage. Artinian, B., Giske, T., & Cone, P. (2009). Glaserian grounded theory in nursing research:

Trusting emergence. New York, NY: Springer Publishing. Artinian, B., West, K., & Conger, M. (2011).The Artinian Intersystem Model: Integrating Theory

and Practice for Professional Nursing, 2nd ed. New York, NY: Springer Publishing. Blumer, H. (1969). Symbolic interactionism. Englewood Cliffs, NJ: Prentice Hall. Boyer, E. L. (1996). 5 priorities for quality schools. Education Digest, 62(1), 4–8. Chin, R. (1969). The utility of system models and developmental models for practitioners. In W.

Bennis, K. Benne, & R. Chin, The planning of change (pp. 297–312). New York, NY: Holt, Rinehart and Winston, Inc.

Kuhn, A. (1974). The logic of social systems: A unified deductive, system-based approach to social science. San Francisco, CA: Jossey-Bass.

Hill, R. (1949). Families under stress. New York, NY: Harper & Row. Martin, & R. Matheney. Patient-centered approaches to nursing. New York, NY: The Macmillan

Company. Stallwood, J., & Stoll, R. (1975). Spiritual dimensions of nursing practice, Part C. In I. Beland &

J. Passos (Eds.), Clinical nursing (3rd ed., pp. 1086–1098). New York, NY: The Macmillan Company.

Taylor, D. (1997). The implications of sense of coherence for the early treatment of people who have had a traumatic spinal cord injury. Doctoral dissertation, University of Wollongong, Wollongong, Australia.

CONTACT bartinian@earthlink.net kwestscal@gmail.com pcone@apu.edu mpmconger@gmail.com