NR 505 ADVANCED RESEARCH METHODS MIDTERM STUDYGUIDE, Exams of Nursing

Download NR 505 ADVANCED RESEARCH METHODS MIDTERM STUDYGUIDE and more Exams Nursing in PDF only on Docsity! 1. How does social justice and health inequities influence population health care provision? Why is this critical information for the provision of evidence-based care? a. Social justice speaks to equal health care and the quality of healthcare to all individuals. If social justice is not performed then population health care will not be adequate. If all individuals are not provided with equal opportunity to. 2. Are you able to both define and apply key terms, such as: vital statistics, morbidity, mortality, cases, social justice, epidemiology, population health, incidence, prevalence, outcomes, interprofessional collaboration, HP2020, determinants of health, risk analysis? 3. What is the Campaign for Action? a. The Campaign for Action was established as a movement to utilize medical professionals, specifically nurses, within an interdisciplinary network to increase overall satisfaction with their medical care (Campaign for Action, n.d.). This campaign was initiated to mobilize the concept of interdisciplinary care within the healthcare realm to assist patients in a holistic approach to ensure positive patient outcomes. One initiative of this campaign is to double the number of nurses with their DNP by the year 2020 (Campaign for Action, n.d.). By utilizing DNPs, this increases the overall reach of medical professionals to the public as well as diversify the field, encourage leadership within nursing, and assisting with continued nursing education (Campaign for Action, n.d.). By reaching the public through various means, this increases the well-being of the overall population’s health and establishes primary care to assist with preventative measures. Through education, patients will be able to take control of their personal health and take the appropriate steps for themselves and their family to maintain a healthy, robust life. 4. Explain the differences between primary, secondary, and tertiary interventions? a. Primary prevention refers to preventing disease before it occurs. (prevention and planning) Usually, primary prevention occurs through application of epidemiological concepts and databases to assess risk factors and then target those populations in which there can be the greatest impact on outcomes to ward off impending disease or unhealthy outcomes. For example, if the APN has assessed epidemiological data and observes that there is a high incidence and prevalence of lung cancer in those individuals and populations who smoke before the fifth grade, then this epidemiological data can be the basis for planning a smoking cessation educational program for school-age children before the fifth grade. b. Secondary - Secondary prevention consists of screening and diagnosis of disease. Secondary prevention is one of the most cost-effective strategies to improve current health status and prevent chronic, debilitating disease states through screening of individuals and populations. For example, screening helps APNs detect a disease once it is present and assist and facilitate the patient or population to get care for the disease that has been detected. The APN must be knowledgeable and apply standards of care and accepted national clinical guidelines to advise the individual or population to undergo preventive screening that is age appropriate and developmentally appropriate. The target population needs to be identifiable and accessible and the disease should affect a sufficient number of people to make screening cost-effective. The preclinical period should be sufficient to allow treatment before symptoms appear so that early diagnosis and treatment make a difference in terms of outcome. Finally, it is necessary for the screening test to be sensitive enough to detect most cases of the disease and to be specific enough to limit the number of false-positive tests. Screening tests should also be relatively inexpensive, easy to administer, and have minimal side effects. c. Tertiary intervention - Tertiary prevention consists of interventions aimed at interventions to facilitate the rehabilitation of the patient to the highest level of functioning while addressing the risk factors that could further result in the deterioration of the patient's health. For example, an APN would counsel a patient who has had a myocardial infarction about the risk factors that could elicit further debilitation. The client may be encouraged to lose weight and commit to an appropriate exercise program while being closely monitored for cholesterol levels, and so on. Certainly a cardiac rehabilitation program could be of value to this patient. As stated above, accepted national clinical guidelines should be utilized as a benchmark for this follow-up care 5. Is screening a tertiary intervention? If yes, why, if not, what is it? a. no. 6. How does a provider determine the usefulness, appropriateness, of a screening test? Where would a NP look to find a screening test? What determines if a screening test should be used? a. Screening and diagnostic tests are important, but are not always 100% accurate in confirming a diagnosis. How do we distinguish which tests are good to use? Even if a test identifies a disease, we must ask the following. b. Is it valid? i. The validity of any screening test is the ability of that test to distinguish correctly who has a disease. ii. Validity is based in both the specificity and sensitivity iii. specificity (the ability of a test to correctly identify those who do not have the disease) and iv. sensitivity (the ability of a test to correctly identify those who have a disease). v. SENSITIVITY = Those who are TRUE POSITIVES/ TRUE POSITIVES + FALSE NEGATIVES vi. SPECIFICITY = Those who are TRUE NEGATIVES/TRUE NEGATIVES + FALSE POSITIVES c. Is it reliable? d. Is it cost effective? e. Does it assist us in improving outcomes for the patient (i.e., improved quality of life, more life years lived, etc.)? f. Continuous variable screenings are those that are not either positive or negative, but occur on a continuum of values, such as blood glucose or hemoglobin levels. In that case, a population "normal" is often established as a range of normal values. People with a disease are often considered positive when they have a specific value or level to their screening tests, such as the diagnosis of diabetes with a hemoglobin A1c of > 6.5%. Often, the first test is more sensitive, and the second test is more specific. g. Positive predictive value (PPV) is a proportional value of the proportion of people in any given population who are screened as positive and who actually have the disease. i. PPV is the number of true positives divided by everyone who tested positive. h. Negative predictive value (NPV) is also a proportion, but is the opposite (and the probability that a result is a true negative). i. It is the number of true negatives divided by all of those who tested negative. i. Where would an NP look to find a screening test? What determines if a screening test should be used? i. Determining whether a screening test is appropriate requires the APRN to address several aspects of the disease of interest. The target population needs to be identifiable. There should be enough people to make the study cost effective. The preclinical period should be proficient to allow treatment before symptoms appear so that early diagnosis and treatment make a difference in terms of outcomes. The NP could look at the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, and SAMHSA-HRSA to find a screening test. Sensitivity and specificity measure the validity of a test. Sensitivity is the number identified/ the number affected. Specificity is the number identified in the screening of not having the disease/ the actual number who do not have the disease. 7. Can you explain what "descriptive epidemiology" means? What is the purpose? How is it used? The 5W's of descriptive epidemiology: a. What = health issue of concern b. Who = person c. Where = place d. When = time e. Why/how = causes, risk factors, modes of transmission 8. How are causation and descriptive epidemiology related, how do they work together to aid evidence-based care? a. Causation helps look at the cause of the issue or disease process. Descriptive epidemiology focuses on the person, place, and time. An example of how they are intertwined might be a person who was sick from E. Coli. The physician might look at what the individual ate to determine what made them sick. For instance, they may have decided to eat from the salad bar at a local restaurant. 9. What does "causation" mean? Can you relate causation to primary, secondary and tertiary interventions? a. Causation is an increase in a casual factor or exposure causes an increase in the outcome of interest (disease). Causation related to primary intervention could be the use of flu vaccines yearly to prevent the flu from causing an illness. A secondary intervention would be to test for the influenza virus in a patient. A tertiary intervention would be giving Tamiflu to a flu positive patient. Since we know that the influenza virus causes the flu when can help to perform actions against it. 10. What is a case-control study and how does it differ (or how is it the same) as the cohort study design? ii. To learn about characteristics such as knowledge, attitude and practices of individuals in a population iii. To monitor trends over time with serial cross-sectional studies 17. What is meant by "scientific misconduct"? a. Scientific misconduct is the violation of the standard codes of scholarly conduct and ethical behavior in the publication of professional scientific research. Its an action that willfully compromises the integrity of scientific research, such as plagiarism or the falsification or fabrication of data. It includes gift authorship, data fabrication and falsification, plagiarism, and conflict of interest. 18. Differentiate: random error, systematic error, confounding error. a. Random error measurements tend to be too high or too low in equal amounts do to random factors. And are less serious than bias. They can occur from an unpredictable change in an instrument used for collecting data. b. Systemic error- This can include selection bias based on the individuals selected for a study and the way groups in the study are selected. It can also include information bias were information tends to be incomplete or inaccurate and tends to lead a study in a certain direction. c. Confounding error- occurs when it appears that a true association exists between and exposure and outcome, but in reality , this association is confounded by another variable or exposure. 19. What is the highest level of data findings? How is evidence appraised? a. Level I- Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. 20. Can you describe the various levels of studies and how they are rated in terms of their use for integration into practice? 21. What factors determine quality of care? a. Effectiveness, patient safety, timeliness, and patient centeredness. 22. How is a website's credibility determined? a. The medical library association, the Health on the Net Foundation, and the US National Library of Medicine provide guidelines for evaluation online information. b. Who runs the site? Why have they created the site? Who is sponsoring the site? Does the information favor the sponsor? Where did the information come from? Is the information sponsored by experts? Is it up to date? What is the privacy policy? 23. What are key indicators when assessing a model of care? a. Pain Management b. Consistency of communication c. Staff Mix d. Client satisfaction e. Prevention of Tobacco Use f. Cardiovascular disease Prevention g. Caregiver Activity h. Identification of Primary Caregiver i. Activities of Daily Living j. Independent Activities of Daily Living k. Psychosocial interaction 24. How would you explain the Triple Aim initiative (model) to a colleague? a. The Triple Aim for Populations seeks to reduce the cost per capita of care, improve the health of population, and enhance patient experience and outcomes 25. What are methods to measure health outcomes? 26. What are elements of the Action Model? 27. Terminology, such as: morbidity, mortality, incidence, prevalence, cases, epidemiology, population health, social justice, period prevalence rate, sensitivity, specificity, positive predictive value, epidemiological triangle, confounding (variables), study methods The epidemiological triangle is a model that has historically been used to explain causation. The model consists of three interactive factors: the causative agent (those factors for which presence or absence cause disease—biologic, chemical, physical, nutritional), a susceptible host (such things as age, gender, race, immune status, genetics), and the environment (including such diverse elements as water, food, neighborhood, pollution). 28. Levels of Evidence 29. Website reliability 30. Rapid cycle improvement model a. Rapid-cycle improvement is a "quality improvement method that identifies, implements and measures changes made to improve a process or a system."1 Rapid-cycle improvement implies that changes are made and tested over periods of three or months or less, rather than the standard eight to twelve months. It consists of fours stages: i. Plan: Identify an opportunity to improve and plan a change or test of how something works. ii. Do: Carry out the plan on a small number of patients. The test period may be as short as one day for small PDSA cycles. iii. Study: Examine the results. Did you achieve your goals? iv. Act: Use your results to make a decision, incorporate changes into your workflow, and establish future quality improvement plans What Is Epidemiology? Epidemiology is the study of disease distribution within populations and the risk factors that affect increases or decreases in distribution. These factors might be genetic, environmental, social, cultural, or based on some direct action by the individual. The science of epidemiology serves first to find out the "why" of disease and then to analyze these factors for recommendations in disease screening, treatment, prevention, and monitoring. Understanding population disease lends to the clinician being able to enact proper screening, prevention, diagnostic, and therapeutic plans for patients. Epidemiology is one of the most important bases for all healthcare research and evidence-based decision making. For example, how does the ANP answer a patient who smokes and has hypertension when asks about the risk of myocardial infarction or stroke? Where would information to support the APN's response be found, and what type of research was undertaken to determine that answer? Is the source of evidence reliable, and was the research conducted appropriately to find the correct population and disease data to support the answer? Epidemiology serves as the foundation for the answers to these questions and begins, in its most simple format, as astute observation. Disease Occurrence and Transmission Disease always has an origin. Often, multiple factors (and not just a single factor) create the optimal environment for any disease, not just infections. The triad of any disease includes the host, agent, and environment. Environmental factors include factors such as individual's home, stress level, diet, and more. Genetics also plays a strong role in disease occurrence. Disease can be transmitted either directly or indirectly. Infected individuals can have outright symptoms or subclinical disease, making the transmission of the disease more difficult to detect. Immunity within the population depends on many factors, including individually acquired immunity, incubation periods, isolation of the community, immunization, and overall health of the community. Diseases with a very long incubation period, such as hepatitis C or those brought about by exposure to a chemical, may increase rates of transmission due to repeated or numerous exposures or spread by patients without symptoms. Thus, epidemiological tracking of disease may take years, and retrospective investigation is often needed to statistically tie risks and exposures to actual development of disease. Determining the occurrence of disease requires careful measurement and tracking in disease surveillance (both active and passive), identification of stages of the disease within an individual and the population, measures of incidence, attack rate, prevalence, mortality rates, case-fatality rates, and years of potential life lost. Healthy People 2020 Healthy People 2020 is a national document with agreed-upon national objectives that guides and assists APNs to focus on and identify levels of population healthcare for persons across the life span. There is clearly a strong and compelling linkage between epidemiological concepts, the three levels of prevention, and the goals of Healthy People 2020. The study and application of epidemiological principles enables the APN to make comprehensive, evidence-based clinical decisions for patients and populations. Define Epidemiology Community health Population-based research Epidemiology: The science of public health Population Health: Focuses on risk, data demographics, and outcomes Outcomes: The end result that follows an intervention Aggregates: Defined population Community: Composed multiple aggregates Data: Compiled information Prevalence: Measures the existence of all current cases within a time frame Incidence: Measures the appearance of new cases Surveillance: Collection, analysis, dissemination of data High-risk: Increased chance of poor health outcome Morbidity: Presence of illness in population Mortality: Related to the tracking of deaths Week 2 Screening and Prevention of Disease Last week the three levels of prevention were discussed. To recap: Primary Primary prevention refers to preventing disease before it occurs. Usually, primary prevention occurs through application of epidemiological concepts and databases to assess risk factors and then target those populations in which there can be the greatest impact on outcomes to ward off impending disease or unhealthy outcomes. For example, if the APN has assessed The tests’ ability to yield a positive result when the person actually has the condition, disorder, or disease Specificity The test’s ability to yield a negative result when the person does not have the condition Gold Standard Tests with 100% sensitivity and specificity Positive Predictive Value The probability of the person actually having the disease when the screening test or diagnostic test is positive Negative Predictive Value The probability of the person being free of disease the disease when the screening test or diagnostic test is negative Clinically Significant Referring to results that have clinical significance Likelihood Ratio Combines sensitivity and specificity data to help the clinician quantify how much the odds of disease change based on a positive or a negative test result Epidemiology Descriptive epidemiology is the first step in any epidemiology investigation or in analyzing any health problem from a research perspective. It is sometimes called the natural history of a disease and begins with defining the differences, similarities, and correlations of key areas of any health problem. This information is gathered in an active surveillance on a case-by-case basis where each specific person's information is entered into a database. In passive surveillance, this information is pulled from a database. Although you often hear of descriptive epidemiology for outbreaks, this information is gathered on any (acute or chronic) disease over time to track who is at risk. The three key areas of information gathered include person, place, and time. Why do we need it? It is not just something discussed in a class or text, or even completed by scientists in some far-off pharmaceutical lab. Healthcare research is based in epidemiology and is needed so that we can change the natural history of a disease. How do we improve survival time or quality of life? How do we cure? How do we prevent? All of this rests in epidemiological research. The 5W's of descriptive epidemiology: 1. What = health issue of concern 2. Who = person 3. Where = place 4. When = time 5. Why/how = causes, risk factors, modes of transmission Hierarchy of Evidence The amount of information can often seem overwhelming for those of us who do not possess a strong statistics background. But as with other skills, the more you read and evaluate research, the better you become at it. An important concept is the hierarchy of evidence. As we know, some research designs carry more credibility than others. Keep the evidence hierarchy in mind as you review epidemiological data. Transmission of Agents Infectious diseases are caused by microbes that can spread very quickly, sometimes within a matter of hours or days. The most common infectious agents responsible for disease are bacteria, viruses, fungi, and protozoa. The various modes of transmission for each of the infectious agents impacts which interventions are most effective. Some modes of transmission follow. Airborne—rubeola, rubella, polio, tuberculosis (TB), diphtheria, hantavirus, smallpox, and so onFecal—oral ingestion (contaminated water and/or food), hepatitis A and E, and so onDirect contact—impetigo, scabies, lice, smallpox, and so onSexual contact—Chlamydia; gonorrhea; hepatitis B, C, and D; human immunodeficiency virus (HIV); HSVDirect inoculation—syphilis; hepatitis A, B, C, and D; HIV infectionInsect or animal bite—malaria, rabies, Lyme disease, bubonic plague Other communicable diseases that have come to the forefront include sudden acute respiratory syndrome (SARS), West Nile virus, ebola, HIV/acquired immunodeficiency syndrome (AIDS), hantavirus, E. coli 0157:H7, and Lyme disease. As a note, human papilloma virus (HPV) was also on this list of emerging infectious diseases. Most advanced practice nurses (APN) are familiar with the development of an immunization that protects females against the types of HPV that cause most of the cervical cancers and genital warts. As immunization of the population continues, there is every indication that HPV and the subsequent cancers it causes will decrease. To be effective, APNs and infectious disease staff must integrate the epidemiological concepts of incubation period, colonization period, and infectious or communicable period with the modes of transmission, including reservoirs, to effectively intervene in the epidemiologic triad to break the infectious cycle. Epidemiological Triad and Communicable Disease A key factor to consider with respect to communicable disease control is the chain of infection and knowing how to apply clinical guidelines and standards of care to interrupt disease transmission. The chain of infection is a framework used as a basis to interrupt or prevent transmission of disease and/or an epidemic. Each of the links in the chain must be favorable for transmission of the disease to occur. Breaking any link in the chain can disrupt the transmission and/or prevent an epidemic. Which link it is most effective to target will depend on the organism. For example, the chain of infectivity may be broken in a case of infectious disease simply by hand washing, which is the best way to reduce the spread of harmful organisms in any environment. As the APN plans interventions, the attributes of the host, agent, and environment are all considered. Surveillance The significance of epidemiologic surveillance of infectious disease in the general population and healthcare delivery settings cannot be overemphasized. There is no doubt that without surveillance and oversight by the public health system, infectious disease would be rampant, with numerous deleterious outcomes. Surveillance also plays a critical role for the monitoring of agents of bioterrorism, such as anthrax and smallpox. There is no doubt that careful and thoughtful application of epidemiologic concepts when treating infectious disease can improve patient safety and quality of life in a global society, whether in acute care or community- based healthcare environments. Nurses can be empowered to apply epidemiologic concepts through assessment, planning, implementation, and evaluation via the application of the epidemiologic triad. Through application of the epidemiologic triad, patient outcomes can be greatly enhanced. Nurses can also assist in patient and staff education and policy setting at the institution or higher levels to protect patient safety and enhance patient outcomes. Centers for Disease Control and Prevention In the struggle with infectious or communicable disease, the APN has a formidable ally in the Centers for Disease Control and Prevention (CDC). This governmental powerhouse has multiple resources based on the epidemiological principles and evidence-based research. You only need to type in a communicable disease and a myriad of information is presented. This includes fact sheets for the client; fact sheets for the professional; statistics on incidence, prevalence, immunization status, and trends; testing guidelines; treatment guidelines; and much more. The CDC is one of the best sources for population-based relevant information for the APN to determine appropriate interventions. Also, there is vital information included in Healthy People 2020 to guide practitioners in achieving our national health goals of identifying, treating, controlling, and eliminating communicable diseases. Week 3 Causal Relationships There are four types of causal relationships. 1. Necessary and sufficient: A factor is both necessary (i.e., disease will occur only if the factor is present), and sufficient (i.e., exposure always leads to disease). This type of relationship is rarely encountered. For example, consider infectious diseases. One hundred people can be exposed to an infectious disease, but not everyone develops the disease because there are other variables involved (e.g., immune status, low infectivity rate, etc.). 1. Necessary but not sufficient: More than one factor is required, usually in a temporal sequence. The initiation and promotion stages associated with carcinogenesis models examples of this type of causal relation. For example, when considering tuberculosis, the tubercle bacillus is a necessary factor, but even its presence may not be sufficient to produce the disease in every individual. 2. Sufficient but not necessary: A specific factor can cause a disease process, but other factors by themselves can cause the same disease. For example, vitamin B12 deficiency can cause anemia, but other factors can result in anemia as well. 3. Neither sufficient nor necessary: A specific factor can be combined with other factors to produce disease. However, the disease may be produced even in the absence of the factor. This is a causal model observed frequently in chronic disease. Risk Factor A condition that may adversely affect an individual’s health Absolute Risk The incidence of a disease in a population Relative Risk The ratio of the risk of disease in exposed individuals to the risk of disease in non-exposed individuals Odds Ratio The ratio of the odds of development of disease in non-exposed person Attributable Risk How much of the risk (incidence) of the disease we hope to prevent if able to eliminate exposure to the agent in question Incidence Rate The number of new cases of a disease that occurs during a specified period of time in a population at risk for developing the disease Prevalence Rate The number of affected persons present in the population at a specific time divided by the number of persons in the population at that same time Resources There are many resources available addressing chronic disease. Under the auspices of the CDC, the National Center for Health Statistics (NCHS) is considered the nation's principal health statistics agency. According to the NCHS, the agency compiles statistical information to serve as a basis of public health interventions and a basis for health policy. The goals of the agency include the following: Another agency under the auspices of the CDC is the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). The CDC's National Center for Chronic Disease Prevention and Health Promotion consists of nine divisions that support a variety of activities that improve the nation's health by preventing chronic diseases and their risk factors. Program activities include supporting states' implementation of public health programs, public health surveillance, translation research, and developing tools and resources for stakeholders at the national, state, and community levels. The Center's surveillance activities provide data and statistics relevant to each of its program areas. This week there was a web site exploration activity involving the IHI, Campaign for Action and IHI Triple Aim. These web sites presented information regarding population health outcomes and health care economics. Inter- professional collaboration was addressed in the Campaign for Action site. ● What is the Research Pyramid demonstrating the levels of evidence? Where does the RCT fit? Why? ● Quality of Care Outcomes: Examples: Decrease in incidence (new cases), reduction in mortality rates, access to primary care measures, satisfaction measures, daily demand and supply The 5W's of descriptive epidemiology: What = health issue of concern Who = person Where = place When = time Why/how = causes, risk factors, modes of transmission Week 5. Introduction to Culture "According to the current demographic and epidemiological trends there is an indication that the number of Americans who are vulnerable to suffering the effects of heath care disparities will rise over the next half century. Current census data indicate that many culturally diverse patient populations, as well as low-income families of whatever race or ethnicity, tend to be in poorer health than other Americans. It can therefore be assumed that people will be sicker and have poorer health outcomes if the demographic trends are not reversed soon" (CDC, 2008). The moral of this story is that there are substantive health issues for many in our society; our current methods of dealing with the issues mentioned above are not working. For example, health coverage does not appear to be the answer although it is a very relevant issue indeed. A key strategy is to focus on meeting primary and secondary health promotion initiatives to keep our populations healthy no matter their ethnic background. We must also carefully and thoughtfully examine sociodemographic trends to truly make a positive impact and reverse negative health outcomes now for the future. It is not enough to keep putting more and more money into health insurance. As a global society dealing with diverse populations, we must also focus on epidemiological recognition of disease states in high-risk, culturally diverse populations to prevent disease and promote health. We must also concomitantly work to provide health coverage and insurance for those services needed when a person enters the healthcare delivery system. According to Clark, culture is, "the practices, beliefs, values, and norms which can be learned or shared, and which guide the actions and decisions of each person in the group" (2008 p. 182). Being a culturally competent advanced practice nurse (APN) is no longer an option but a necessity. One only needs to consider the 2008 census data, which indicate that all minority populations are increasing and that the Hispanic population will increase 47% by 2042. The increasing numbers will result in Hispanic people becoming the majority population group in the United States. In addition to the shift in population, it is well known that populations of diverse racial, ethnic, and cultural backgrounds suffer from disproportionate adverse health outcomes. Population of the United States by Race and Hispanic/Latino Origin, Census 2000 and 2010. Race and Hispanic/Latino OriginCensus 2010, Population Percentage of Population Census 2000, Population Percentage of Population To assist healthcare providers in achieving competency in providing culturally appropriate care, the APN must take the responsibility to acquire the necessary skills. The five constructs of cultural competence form the foundation of the practice model discussed in "Process of Cultural Competence in the Delivery of Healthcare Services" (Campinha-Bacote, 2002). Self-examination of one's own prejudices and biases toward other cultures. An in-depth exploration of one's own cultural/ethnic background. Cultural Awareness A lifelong commitment to self-evaluation and self-critiques, redressing the power of imbalances in the patientphysician dynamic, developing mutually. Beneficial relationships. Cultural Humility Obtaining a sound educational foundation concerning the various worldviews of differences cultures. Obtaining knowledge regarding biological variations, disease and health conditions and variation in drug metabolism. Cultural Knowledge Ability to collect culturally relevant data regarding the client's health history and presenting problem. Ability to conduct culturally based physician assessments. Conducting these assessments in a culturally sensitive manner. Cultural Skill Motivation of the healthcare provider to "want" to engage in the process of cultural competence, characteristics of compassion, authenticity, humility, openness, availability, and flexibility, commi tment and passion to caring, regardless of conflict. Cultural Desire The very essence of what health and disease denotes can vary from culture to culture. Therefore, there is a wide spectrum of what are considered appropriate interventions, which may not be compatible with Western medicine. Based on the cultures' perceptions of disease causation, symptomatology, and pathology, appropriate interventions may diverge from Western medicine's approach (Gesler & Kearns, 2002). The textbook provides many examples of the beliefs of direct cultures and the influence they play in healthcare. There are some long-standing health disparities in minorities. Minority health is often viewed as a variant form of Anglo-Protestant culture, with the scientific foundation and the principles of cause and effect as the basis of our healthcare. Madeline Leninger's groundbreaking transcultural nursing theory (1978) addresses several areas that encompass culture, including values, beliefs, customs, and traditions. These are held by a specific group of individuals and are passed down from generation to generation through language. Leninger (2002) describes cultural competence as the ability of the practitioner to bridge cultural gaps in caring and to work with cultural difference, enabling the family and patient to receive meaningful and supportive care. She also describes culturally congruent care as care that is centered on a person's values and meaning as opposed to care that has been predetermined by other criteria. Paisley defines ethnicity as "the aggregate of cultural practices, social influences, religious pursuits, and racial characteristics shaping the distinctive identity of community" (Paisley et al., 2002, p. 138). This differs from race. Race is defined as a biological designation whereby group members share features (e.g., skin color, bone structure, genetic traits such as blood groupings) (Purnell & Paulanka, 2005, p. 452). Nationality usually refers to the country of birth, or the ancestors' country of birth. Cultural competence in nursing consists of four principles. Care is designed for the specific client. Care is based on the uniqueness of the person's culture and includes cultural norms and values. Care includes self-employment strategies to facilitate client decision making to improve health behaviors. Care is provided with sensitivity and is based on the cultural uniqueness of clients. Cultural nursing assessment is a systematic identification and documentation of the cultural care beliefs, meaning, values, symbols, and practices of individuals or groups using a holistic perspective. The APN may also use the Kleinman Explanatory Model of Illness (1978). Below are the questions that can be utilized. What do you call your problem? What do you think caused your problem? Why do you think it started when it did? What does your sickness do to you? What do you fear most about your sickness? What are the chief problems your sickness has caused you? What kind of treatment do you think you should receive? What is the most important result you hope to receive from the treatment? According to Giger and Davidhizer (2000), although cultures differ, they all have the same basic organizing factors that must be assessed in order to provide care for culturally diverse patients. These factors include communication (verbal and nonverbal); personal space; social organization; time perception; environmental control; and biological variations. The explosion of new genetic information has had a profound impact on healthcare. It is essential for the advanced practice nurse (APN) to be able to integrate this new information to effect positive outcomes. In recognition of the added responsibilities, the following APN core competencies have been developed. Definitions Definitions Genetics – The study of individual genes and their impact on relatively rare single gene disorders (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009) Genomics – The study of all genes in the human genome as well as their interaction with other genes, the individual’s environment, and the influence of cultural and psychosocial factors (Consensus Panel on Genetic/Genomic Nursing Competencies, 2009) Genetic epidemiology – The link of epidemiology and genetics (Khoury, Bety, & Cohen, 1993) Family History Conducting an accurate family history for three generations can reveal a wealth of information on which to base prevention strategies. If the information collected is used to counsel individuals on how to decrease risk with lifestyle modifications (before the patient has the disease) then the utilization of the family history would be considered a primary intervention. For example, if the family history identifies an increased risk for breast cancer, the patient is counseled to modify lifestyle choices to minimize risk. The information should also result in screening strategies that result in the early identification of the disease. The screening strategies would be considered secondary prevention strategies (Spector et al., 2009). Risk Interpretation Consider the following pieces of information: (1) A history of malignant melanoma in a first-degree relative has been associated with an eightfold increase in risk (Glanz, Saraiya, Wechsler, 2002); (2) having a sister with a BRCA1 mutation gives a woman a 50% risk of having the same genetic mutation (Jacobellis et al., 2004); and (3) similarly, there is a nearly 9% chance or risk for children with relatives who have epilepsy to develop the disease (Epilepsy Foundation, n.d.). As an APN, how do you translate this information to best inform a family faced with a life-altering decision? As the APN discusses risk with his or her patients, it is important to reflect on the meaning of the various ways risk is expressed. Without a clear understanding of the terminology that describes risk, no meaningful discussion or decision making can take place. As noted under the core competencies, one of the roles the APN assumes is interpreting the risk for patients to ensure informed decision making. Although risk terminology has been discussed previously, certain aspects bear repeating. Absolute risk is the probability of an event, such as illness, injury, or death Absolute risk gives no indication of how its magnitude compares with others. The odds ratio closely approximates the relative risk if the disease is rare. Odds ratio and the relative risk are used to assess the strength of association between risk factor and outcome. Attributable risk is used to make risk-based decisions for individuals. Population-attributable risk measures are used to form public health decisions (Nordness, 2006). In addition, the APN must consider the possibility that home testing, for a variety of genetic conditions, is available. Due to easy access on the Internet, patients may present the APN with results from home testing that they do not understand, and with no concept of the implications of validity and reliability (Wolfberg, 2006). Patient Education The APN has a responsibility in the role of genetic counselor to patients. Of course, the interdisciplinary aspect of providing optimal healthcare must also be considered. Referrals to a genetic counselor may be appropriate. However, the APN must be willing to carry out the competencies as described previously, such as informing the patient of the importance of accruing accurate, detailed information about their family history. In 2004, a survey indicated that 96% of people felt that family history was important to their health but less than 30% actually had relevant family history to share (Awareness of family health history as a risk factor for disease--United States, 2004). The healthcare provider must recognize that all aspects of elucidating, teaching, counseling, and supporting need to be done considering the patients’ cultural context. Cultural aspects can influence comprehension and interpretation of genetic testing, treatments, and implications (Hamilton & Bowers, 2007). Pharmacogenomics One of the additional responsibilities when possessing prescriptive authority is the necessity of having a thorough knowledge of pharmacogenomics. It has been acknowledged that the effect of medications has a range of therapeutic and nontherapeutic responses. Age, weight, ethnic background, and physiologic impairments associated with disease processes were often concomitant with these variations. Due to the recent genomic research, it is now acknowledged that genetic variations can affect mediation efficacy, toxicity, and drug interaction outside of the drugs themselves (National Institute of Health, 2009). Certainly the specifics and implications of these variations will be discussed, in detail, in pharmacology.ek 6 Resources Centers for Disease Control and Prevention Genomics and Health It is not surprising that the Centers for Disease Control (CDC) offers the most comprehensive information on genetics and genomics. The Office of Public Health Genomics (OPHG), established in 1997, promotes the integration of genomics in public health research, policy, and practice to prevent disease and to improve the health of all people. The aim of the OPHG is to integrate genomics into public health research policy and programs, which could improve interventions designed to prevent and control the country’s leading chronic, infectious, environmental, and occupational diseases. The CDC home page lists a plethora of information to help the practitioner keep current on the newest information, with evidence-based guidelines for implementation in clinical settings. Below are some existing resource categories. How Do You Define the Following? EGAPP Evaluation of Genomic Applications in Practice and Prevention. GAPPNet Genomic Applications in Practice and Prevention Network (established in 2009) is a collaborative initiative involving partners from across the public health sector working together to realize the promise of genomics in health care and disease prevention. GEDDI Genetics Early Disease Detection Intervention project (GEDDI) (established in 2009) developed a model strategy for using clinical, genetic, and family history information to reduce the risk of disease, death, and disability in affected individuals, family members, and populations. HuGENet Human Genome Epidemiology Network (HuGENet) (established in 1998) helps translate genetic research findings into opportunities for preventive medicines and public health by advancing the synthesis, interpretation, and dissemination of population-based data on human genetic variation in health and disease. HuGENet reviews are systematic, peer-reviewed synopses of the epidemiologic aspects of human genes, including prevalence of allelic variants in different populations, population-based information on disease risk, evidence for gene-environment interaction and quantitative data on genetic tests and services carried out according to specific guidelines. NHANES III CDC’s Office of Public Health Genomics (established in 2002) formed a multidisciplinary working group with members from across CDC. It developed a proposal to measure the prevalence of selected genetic variants of public health significance in a representative sample of the U.S. population and to examine the association between the selected genetic variants and disease outcomes available in NHANES III data. Week 7 Global & Environmental Health Pandemics and epidemics are inevitable. There is good historical information to support significant outbreaks of disease, in global proportions, for all of history. For example, the 1918-1919 influenza outbreak killed 21 million people, the majority over a 16-week period from September to December in 1918 (Barry, 2004). At that point in time, the world's population was a little more than a quarter of what it is today. Likewise, global travel was not as rapid or readily accessible. Containing the spread of such a disease would be difficult if not impossible today. How would the numbers change in such an outbreak? The World Health Organization defines a pandemic as a global epidemic that spreads to more than one continent (WHO, 2009). One of the more recent pandemics that you might be familiar with is the H1N1 influenza outbreak of 2009. The H1N1 outbreak began in Mexico and was considered a swine flue, because the virus was similar to strains found in pig populations. That outbreak brought over 13,000 deaths globally (WHO, 2014). Consider the definitions below and then review the global news for any disease that might fight the definitions. Definitions Pandemic—a global epidemic of disease that spreads to more than one continent (WHO, 2009) Outbreak—the occurrence of disease within persons in excess of what would normally be expected in a clearly defined community, location, or time of year. An outbreak may only last for a matter of days or weeks, but may last for years (WHO, 2014). Quarantine—the separation and restriction of the movement of people who were or are exposed to a contagious disease for a set period of time, to see whether they become ill (CDC, 2014). Isolation-—the separation of sick people with a contagious disease from those who are not ill (CDC, 2014) Disaster epidemiology—“Disaster epidemiology is defined as the use of epidemiology to assess the short- and long-term adverse health effects of disasters and to predict consequences of future disasters. It brings together various topic areas of epidemiology including acute and communicable disease, environmental health, occupational health, chronic disease, injury, mental health, and behavioral health” (CDC, 2012). What Causes New Strains and Outbreaks? Childhood risk conditions before birth and early in childhood influence health in adult life. Risk accumulation Ageing is an important marker of the accumulation of modifiable risks for chronic disease Underlying determinants a reflection of the major forces driving social, economic, and cultural change. I.e. globalization, urbanization, population ageing, and general policy environment Poverty interconnected with chronic disease in a vicious circle increasing exposure to risks and decreased access to health services Primary prevention aims to prevent disease. I.e. banning hazardous products, educating on healthy/safe habits, immunizations Secondary prevention reduce impact of disease or injury that has already occurred. I.e. screening tests, low-dose ASA, suitably modified work Tertiary prevention aims to soften impact of ongoing illness. I.e. cardiac or stroke rehab, support groups, vocational rehab Cross Cultural Health Care Program (CCHCP) materials to improve cultural competency among health providers to provide healthcare interventions and other cultural variants Marginalization Major cause of vulnerability referring to exposure to a range of possible harms Variables at risk for marginalization high risk health literacy, cultural barriers, low english proficiency Cultural competence a dynamic, fluid, continuous process whereby an individual, system or health care agency find meaningful and useful care delivery strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behavior of those whom they render care Norms & values soecific practices that guide the actions and decisions of each person in a group based on their culture. Can be learned or shared. Kleinman Explanatory Model A set of questions that the APN can use in order to assess the culture of a patient. Socioeconomic status A measure that takes into account three interrelated dimensions: a person's income level, education level, and typ of occupation. Disparities a higher burden of illness, injury, disability, or mortality experiences by one grup relative to another Minorities a group of people who because of their physical or cultural characteristics, are singled out from the other in society Food desert neighborhoods and communities that have limited access to affordable and nutritious foods Social determinants of health poverty, education level, raciam, income, and poor housisng that effect access to healthcare Social justice theory the goal that all people will have equal opportunity to healthcare access and quality of healthcare will be the same Data sources utilized to access determinants of health Healthy People 2020, US Census, US Department of Health and Human Services, Office of Minority Health and Health Disparities Accommodation To create an environment that accomodates health practice and ritual from other cultures within a plan of care Acculturation degree to which an individual from one culture has given up the traits of that culture and adopted the traits of the dominant culture in which they now reside Assimilation the social, economic, and political integration of a cultural group into mainstream society to which it may have emigrated Genetics Acculturation Degree To which an individual from one culture has given up the traits of that culture and adopted the traits of the dominant culture in which they now reside Assimilation This social, economic, and political integration of a cultural group into main stream society to which it may have emigrated Genetic risk assessment When a patient is determined to get to have a gene that faces them at a higher risk of having a disease such as cancer, diabetes, or cardiovascular disease Genomics The study of all genes in the human genome as well as their interaction with other genes, the individuals environment, and the influence of cultural and psychosocial factors. Pharmacogenomics Medication efficacy, toxicity, and drug interaction based on genetic variations Genetic epidemiology The link between epidemiology and genetic Genetics Non-Discrimination Act Was passed to offer some protection against the potential misuse of genetic information Epidemic Outbreak at a population level Disaster epidemiology The use of epidemiology to assess the short and long term adverse health effects of disasters and to predict consequences of future disasters. It brings together various topic areas of epidemiology including a cute and communicable disease, environmental health, occupational health, chronic disease, injury, mental health, and behavioral health WHO (World Health Organization) specialized agency of the United Nations that is concerned with international public health. The world health organization recognized that international collaboration could control infectious disease better than any single country. Sustainable Development Goals (SDGs) Goals resulting from a UN-led effort to end extreme poverty by focusing on 17 key indicators, the top five of which are no poverty, zero hunger, good health, quality education, and gender equality, with key benchmarks for 2030. Universal declaration of human rights All people have the right to a standard of living that guarantees health Call to Action Call for nurses and midwives to assume a leadership role in addressing planetary health because nurses and midwives are the most numerous and most patient centered component of the health workforce. This leader ship begins with educating ourselves, students, staff, patient, and communities about planetary health by engaging in political and policy processes Community health needs assessment Assessing whether or not the region has the community resources that it needs. situation analysis To analyze and identify the relationships among patterns of morbidity, mortality, and disability within the demographic and other factors shaping thecircumstances of the population of a specified community, country, or region. Culture Practices, beliefs, values, norms (can be learned or shared) which guides the actions and decisions of each person in the group. Cultural Organizing Factors Communication, personal space, social organization, time perception, environmental control, and biological variations Macro-scale influences Broad understandings of illness, suffering and healing. Social roles and bureaucratic and economic context of health care services Micro-scale influences Face-to-face interaction at front-lines. Successful and failed communication efforts. cultural awareness An in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people Cultural Humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient- clinician dynamic and to developing mutually beneficial and advocacy partnerships with communities on behalf of individuals and defined populations Cultural Knowledge obtaining a sound educational foundation concerning the various worldviews of different cultures. Obtaining knowledge regarding biological variations, disease, and health conditions and variations in drug metabolism. Cultural Skill Ability to collect culturally relevant data regarding the client's health history and presenting problem and conduct a culturally sensitive assessment. Cultural Desire Motivation of the provider to want to engage in the process of cultural competence, characteristics of compassion, authenticity, humility, openness, availability, and flexibility, commitment, and passion to caring regardless of conflict. 4 principles of cultural competence Things such as she, gender, race, immune status, genetics Environment diverse elements such as water, food, neighborhood, pollution Sustainable Development Goals agreement between countries to create an environment at the national and global levels alike conductive to development and the elimination of poverty Climate change due to human activity, trigger global migration, and local relocation due to sea level rise. Population health the health outcomes of a group of individuals, including the distribution of such outcomes within the group. I.e. seatbelt laws, no smoking areas, allergy free schools. Risk reduction the health protection when individuals participate in behaviors that enable then to react to actual or potential threats Assessment the gathering of information abut a patient's physiological, psychological, sociological, and spiritual status. Outcomes an end result that follows some kind of healthcare profession, treatment, or intervention and may describe a patient's condition or health status Public health policy collected laws, regulations, and approaches taken to make a decision including a wide range of topics including health care reform, insurance reform with an eye to individuals who are not covered by an employer or a group, and the prevention and control of communicable diseases. Ethics practices with compassion and respect committed to patient, family, community, and population promoting, advocating, and protecting the rights, health, and safety of the patient. Fairness the state, condition, or quality of being fair or free of bias or injustice Internal Validity Whether the study measures what it was supposed to measure External Validity The generalizability of the results to other populations Reliability The ability of test results being replicated if the test is repeated Probability Study of the laws of chance Sensitivity The tests' ability to yield a positive result when the person actually has the condition, disease, or disorder Specificity The tests' ability to yield a negative result when the person does not have the condition Gold Standard Tests with 100% sensitivity and specificity Positive predictive value Probability the person actually having the disease when the screening test or diagnostic test is positive Negative Predictive Value (NPV) The probability of the person being free of disease when the screening test or diagnostic test is negative Clinically significant Referring to results that have clinical significance Natural history of disease Nature of the disease and how it progresses primary prevention Interventions aimed at preventing the condition, disorder or disease secondary prevention Interventions aimed at detecting a disease early in its course Tertiary prevention Limiting the effects of the disease once it is established True Positive (TP) Occurs when the test correctly reports disease presence when disease is in fact present False positive Occurs when the test incorrectly reports disease presence when disease is, in fact absent interprofessional collaboration Coordination and communication between all providers involved in patient care Healthy People 2020 A national document with national objectives that guides advanced practice nurses to focus on an identified levels of population health care for persons across the lifespan Determinants of health The range of behavioral, biological, social economic and environmental factors that influence the health status of individuals or populations Risk analysis The review of the risk associated with a particular event or action Epidemiology The science of public health. Concerned with studying the factors determining in influencing the frequency and distribution of disease Population Health Focuses on risk, data, demographics and outcomes Elements that are part of collaborative practice Responsibility, accountability, coordination, communication, cooperation, assertiveness, autonomy, mutual respect Campaign for Action Organization that improves access to care, fosters interprofessional operation, promote nursing leader ship, transform's nursing education, increase is diversity in nursing, collect workforce data Descriptive epidemiology Describes the distribution of disease and other health related states in terms of personal characteristics, geographical distribution and time. Helps to understand the process of disease by looking at raves, incidents, prevalence, mortality, survival and prognosis. Case reports succinct written accounts of generally rare unusual cases in which treatment of management of the disease is worth reporting Case series Report of a series of patients with similar diseases or conditions that describe their management or treatment in order to identify new strategies that will be helpful to treat patients with similar conditions Correlation studies Used to conduct studies of aggregate or population characteristics. Rates calculated for characteristics that describe populations and are used to compare frequencies between different groups at the same time or the same group at different times. Useful for identifying long-term trends & seasonal patterns, Cannot be linked to exposure in individuals. Cross-sectional studies a study in which people of different ages are compared with one another. Exposures and outcomes are collected at the same time. Excludes people who have died or choose not to participate to reduce by us. Usually surveys that sample a population and characteristics Analytic epidemiology Looks at origins and casual factors of disease and other health related events. Often carried out to test hypotheses formulated from descriptive studies. Cohort studies, case control study, randomized controlled trials Executed with a goal to identify factors that increase or decrease risk Screening tools Can utilize to detect disease in groups of asymptomatic individuals with the goal of reducing and/or preventing morbidity and mortality Screening tests applied to groups of individuals or to high-risk populations. For example pap smears, TB test, mammograms. should be inexpensive, easy to administer, and have minimal side effects Causation for population research an increase in the causal factor or exposure causes an increase in the outcome of interest preclinical disease start of disease, no symptoms, not always detectable clinical disease disease present with recognizable symptoms "treatment stage" nonclinical disease consists of 4 stages: preclinical, subclinical, chronic/persistent, latent preclinical no symptoms but destined to progress subclinical disease is present, not destined to progress clinically chronic/persistent disease persists over time latent disease disease with no active multiplication of biological agent determines if exposure is associated with an outcome, retrospective, inexpensive and quick Cohort studies prospective/retrospective, can be time-consuming, expensive, higher risk of withdrawal bias if participants drop out over time prospective studies begins with a defined population and then follows a group of people who were exposed or not exposed to compare incidence of outcome retrospective studies exposure is ascertained from past records and outcomes are ascertained as the study begins bias/systematic error broken down into two categories: selection and information selection bias occurs when selected subjects in a sample are not representative of the population of interest or comparison group withdrawal bias can occur when people of certain characteristics drop out of a group at a different rate than they do in another group or are lost to follow-up at a different rate volunteer bias people who volunteer to participate in a study may have characteristics that are different from people who do not volunteer impacting outcome of results information bias bias in how information and data are collected exclusion information bias can occur when one applies different eligibility criteria to the cases and control groups measurement bias occurs during data collection possible caused by an error in collecting info for an exposure or outcome. misclassification differential bias occurs when a case is misclassified into exposure groups more often than controls misclassification bias a control may be recorded as a case or a case is classified as having an exposure incorrectly contamination bias occurs when members of a control group are exposed to an intervention reporting bias occurs when a subject may not report a certain exposure as he or she may be embarrassed or not want to disclose personal information recall bias happens when subjects are asked to remember or recall events from the past publication bias refers to the tendency of peer-reviewed journals to publish a higher percentage of studies with significant results rather than those studies with nonsignificant or negative statistical results randomized control trial assigns patients randomly to either receive new treatment/intervention or not to. Inclusion criteria must be precise and spelled out strengths: lower chance or confounding variables, minimize bias in treatment assignments, able to control intervention/treatment weakness: labor intensive, costly, sometimes unethical cohort study prospective or retrospective. No random selection of subjects strengths: able to identify and address confounding variables, able to control exposure, able to calculate relative risk and incidence rate, also able to study multiple outcomes weakness: labor intensive, costly, lengthy randomized controlled trial useful for evaluating treatments and for assessing new ways of organizing and delivering health services, example: education programs, policy intervention cohort study used when nurse has good evidence that links an exposure to an outcome. example: exercise as a method to prevent heart disease relative risk the incidence rate in the exposed group divided by the incidence rate in the nonexposed group. measures strength of association between an exposure and an outcome/disease attributable risk amount of risk that can be attributed to an exposure scientific misconduct fraud. includes gift authorship, data fabrication, plagiarism, conflict of interest random error Measurements are either too high or too low in equal amounts because of random factor. Less serious than bias because they generally don't distort findings confounding error occurs when it appears that a true association exists between an exposure and an outcome but in reality, the association is from another variable or exposure. a situation in which an exposure and an outcome is distorted by the presence of another variable. Cystic fibrosis (CF) is an incurable autosomal recessive, multisystem disease that is characterized by exocrine gland dysfunction. It is a hereditary disorder that primarily affects the lungs, gastrointestinal tract, and reproductive tract, (Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M., 2015). Cystic fibrosis is a chronic health disease that affects many Americans, and it can be life threatening while also shortening one’s life span. In Nevada alone, there are at least 200 cases of people living with cystic fibrosis. The Cystic Fibrosis Foundation Patient Registry handles the mandated reporting processes in the United States which is the first vital step in planning prevention or treatment programs. By understanding the epidemiological analysis healthcare providers are able to dive further into the significance of cystic fibrosis. As a nurse practitioner, there are numerous evidence-based practice interventions one can use to address patients with cystic fibrosis. When providers educate themselves on chronic health diseases such as CF, they are more capable to diagnose and treat patients with better outcomes.