Global Environment And Public Health summary

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Global Environment And Public Health summaryGlobal Environment And Public Health summaryelect one of the articles you were provided with for this week and write a brief summary of the main ideas presented (200 words).A summary is a concise paraphrase of all the main ideas in an essay or article. See more information on summarizing in these links, the summary of the article you selected formulate an open-ended question that would generate a discussion on the topics covered this week. The questions should lead discussions and not answered in a yes or no format. Your classmates will a short response essay to your question.Here are examples of open ended questions from the Module 1 Readings:As a health provider, physician, nurse how can learning (reading/writing) narratives influence their work in providing health care?Global Environment And Public Health summaryWhat is the significance of narrative medicine?How long should a health provider spend with a patient to listen to their stories. Explain your responseHow does narrative medicine affect the sick, or people with health issues?IHS2215 CSCC Week 3 Global Environment And Public Health summaryIHS 2215_Article Summary Rubric.pdfThe Discussion Board is located under the “Group – Discussion Boards” tab. nihms501412.pdfweek_3_family_narratives_culture_and_patient_centered_medicine_1_.pdfsummary_rubric.pdfGlobal Environment And Public Health summary. NIH Public Access Author Manuscript ANS Adv Nurs Sci. Author manuscript; available in PMC 2013 August 29. NIH-PA Author Manuscript Published in final edited form as: ANS Adv Nurs Sci. 2012 ; 35(1): 64–76. doi:10.1097/ANS.0b013e318244555a. The Influence of the Culture of Care on Informal Caregivers’ Experiences Janice Penrod, PhD, RN, FGSA, FAAN, Brenda Baney, MS, Susan J. Loeb, PhD, RN, Gwen McGhan, MN, RN, and Peggy Z. Shipley, MSN, RN School of Nursing, The Pennsylvania State University, University Park Abstract NIH-PA Author Manuscript The environment of care can have a profound impact on caregiving experiences of families caring for loved ones with a life-limiting illness. Care is often delivered through disease-specific specialty clinics that are shaped by the illness trajectory. In this study, the following 3 distinct cultures of care were identified: interdisciplinary, provider dominant, and cooperative network. Each of these cultures was found to express unique values and beliefs through 5 key characteristics: acknowledgment of the certainty of death, role of the formal caregiver, perception of the patient system, focus of the patient visit across the trajectory, and continuum of care across the trajectory. Keywords culture of care; informal caregiver; life-limiting illness; specialty clinics; supportive care NIH-PA Author Manuscript Modern health care delivery systems have developed in response to the need for short-term health care.1,2 While this care delivery system has advanced exemplary episodic and urgent care, there is a persistent discrepancy in focus between short- and long-term care. Seventy percent of all deaths in the United States are attributed to chronic conditions,3 and 75% of all health care expenditures in the United States are related to their management.4 The current environment of health care delivery often fails to address the complex care demands of living with chronic, life-limiting illnesses, especially during the prolonged non–short-term phases.5 The purpose of this article is to compare and contrast key characteristics of the culture of care in care delivery environments serving patients with life-limiting chronic conditions. Care for patients with complex life-limiting chronic illness is often delivered through disease-specific, specialty outpatient clinics.5–7 Not to be confused with end-of-life specialty clinics, these outpatient clinics serve patients and families for nonacute illnesses. The impact of this system of specialty care delivery has been well documented, including improved quality of care and health status,8 decreased hospital admissions,9 prevention of clinical deterioration, and avoidance of acute health crises.10,11 Clearly, this organization of services is effective in providing clinical expertise targeted at a specific illness12; however, there is a Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & WilkinsIHS2215 CSCC Week 3 Global Environment And Public Health summaryGlobal Environment And Public Health summary. Correspondence: Janice Penrod, PhD, RN, FGSA, FAAN, Center for Nursing Research, Penn State School of Nursing,129E Health and Human Development East, University Park, PA 16802 ( The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Penrod et al. Page 2 range of services designed to support families living through the illness experience that are underutilized. NIH-PA Author Manuscript The service menu of many specialty clinics typifies a dominant biomedical paradigm13 with a focus on monitoring pathology, treatment, and management of symptoms. Far fewer clinics focus on the provision of care that addresses not only physical needs but also the psychosocial concerns of living with a life-limiting chronic condition.14,15 Considering that the chronic illness experience permeates everyday life, accessibility of specialty care is often an issue. While some specialty clinics offer services on a daily basis in a fully staffed clinic, far more offer more limited access on an intermittent weekly or monthly schedule.5 NIH-PA Author Manuscript This degree of variability in the environment of care for life-limiting chronic illnesses can have a profound impact on the experiences of patients and families living each day under the specter of a serious, incurable illness. In the various environments, health care providers are challenged to effectively communicate treatment options, provide patient education, deliver follow-up care, and aid in decision making from diagnosis through end of life.16 For example, a critical consideration in the care of those with chronic conditions would be advanced care planning; however, this is not always the case in the specialty clinic setting. End-of-life discussions can be emotionally difficult for the patient, family, and the health care provider who must constantly determine the best ways to communicate with patients and caregivers about the illness experience.17 As a result, end-of-life discussions often do not occur until the final hours, days, or minutes of life. Specialty clinics provide health care that is largely administered through teams to achieve common goals18 and outcomes19 that are influenced by shared understandings, ideas, and values.20 The beliefs and values that are embraced by a culture such as a specialty clinic provide the underlying rationale for how members of the culture think and behave as well as influence perceptions about the types of useful treatments, probable outcomes of health behaviors associated with the prevention and control of illness, as well as the meaning of the illness experience.21 Thus, these cultural elements comprising health care providers’ beliefs and belief systems about the total delivery of health service for patients as well as their caregivers influence care delivery.22 NIH-PA Author Manuscript Culture is composed of both explicit and implicit shared values and beliefs that are manifest in acquired patterns of behaviors. IHS2215 CSCC Week 3 Global Environment And Public Health summaryORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERSGlobal Environment And Public Health summary. Different types of health care cultures have been linked to performance outcomes such as quality improvement,23 functioning of teams,24 and evidence-based practice.25 Shared values and beliefs are observable at multiple levels including institutional frameworks that influence decision making and patient-provider interactions; distinct work flow procedures; and defined roles for health care providers, support staff, patients, and family caregivers.25 From structural and process components of the delivery system to the more abstract level of ideas,20 cultural influences shape patterns of behavior in care delivery. Thus, implicit or explicit values and beliefs of the organizational unit of the specialty clinic shape the culture of care in that practice environment. In turn, translation of that culture of care into ongoing care interactions has a tremendous impact not only on patients but also on the informal caregivers who share the illness experience. Informal caregivers (defined as persons who provide direct care or supportive care without compensation) are instrumental partners in the care delivery system. In 2009, the economic value associated with informal caregiver services in the United States was conservatively estimated to be $450 billion per year.26 Informal caregiving is difficult work with a well-documented physical, social, financial, and emotional toll.27–30 Especially in the context of life-limiting chronic illness, the duration of informal caregiving often extends ANS Adv Nurs Sci. Author manuscript; available in PMC 2013 August 29. Penrod et al. Page 3 NIH-PA Author Manuscript over years, beginning when the patient is diagnosed, continuing through treatment until the death of the patient. Because of the profound impact of informal care-giving, it is crucial that these partners in care not be viewed merely as coproviders of care to patients but also considered as care recipients with their own unique needs.31 The protracted trajectory of caregiving through the end-of-life has been modeled by Penrod and colleagues.32,33 The unifying theme of the theory is “seeking normal,” a process through which informal caregivers strive to achieve a steady state (or sense of normal) amidst ever-changing demands in their care-giving role. The theory delineates 4 phases of caregiving from diagnosis through bereavement marked by key transitions when the progression of illness challenges an established “steady state” of the caregiver. Transitions prompt a disruption, predisposing the informal caregiver to once again seek a new state of normal by building new patterns integrating care demands into everyday life. NIH-PA Author Manuscript The progression and duration of the care-giving phases are reflective of the course of the illness and the acknowledgment that the end of life is approaching. Using classic models of death trajectories as a foundation,34,35 Penrod and colleagues36 have further described theoretical variations in the caregiving experience in an expected trajectory (eg, the “terminal” diagnosis of amyotrophic lateral sclerosis [ALS]), an unexpected trajectory (eg, the “serious” diagnosis of heart failure [HF]), and a mixed trajectory featuring intensive curative attempts followed by a period of comfort care (eg, lung cancer). As indicated by the trajectory labels, perceptions of the likelihood of death from the life-limiting illness range from an expected, anticipated outcome to a surprising turn of events preceding an unexpected death. However, it is important to note that the life expectancy of persons with these life-limiting illnesses is very similar; death from ALS is likely to ensue within 2 to 5 years of diagnosis,37 less than 10% of individuals with advanced lung cancer survive 5 years,38 and more than half of those with HF die within 5 years.39 NIH-PA Author Manuscript Interactions with health care providers in specialty clinics provide critical evidence through which informal caregivers interpret progression of disease and prognosis. These interactions shape their acknowledgment of the probability of death and perceptions of the future. IHS2215 CSCC Week 3 Global Environment And Public Health summaryGlobal Environment And Public Health summary. The practice environment of the specialty clinic is fraught with implicit and explicit shared values. This value-laden context sets the frame for the nexus of caregiving systems through which informal caregivers build their understanding of the unfolding scene. Understanding the culture within these care environments is critical in development and evaluation of supportive strategies for informal caregivers. In this article, the key characteristics of the culture of care manifest in specialty clinics serving patient systems (patient and family) with life-limiting illnesses exemplifying 3 distinct caregiving trajectories are described, compared, and contrasted. METHODS Informal caregivers interact with health care providers during brief office visits over the course of their charge’s illness. To understand how the experience of the informal caregiver is influenced by these visits, it is necessary to understand the culture of care in outpatient clinical settings. Therefore, ethnographic methods were undertaken to explore and understand the culture that is learned and shared among members of the culture of care in the outpatient specialty clinics. The exploration concentrated on the interaction between health care providers (formal care-givers) and the informal caregiver to identify and interpret patterns of behaviors that reveal implicit and explicit shared values and beliefs.40 ANS Adv Nurs Sci. Author manuscript; available in PMC 2013 August 29. Penrod et al. Page 4 PROCEDURE NIH-PA Author Manuscript Approval was obtained from the medical center–based institutional review board for the protection of human participants. Formal caregivers (n = 32) provided written informed consent under principles of full disclosure prior to engagement in the research. Formal caregivers included physicians (n = 7), nurses (n = 18), social worker (n = 1), counselors (n = 2), occupational and physical therapists (n = 3), and administrative staff (n = 3). The majority of the formal caregivers were female (81%). Verbal consent for observation was obtained from informal caregivers (n = 601) and patients prior to the start of the visit. Similar to the formal caregivers, the majority of the informal caregivers were female (79%). The informal caregiving experience varies in course and duration over various death trajectories.36 To capture the experience of informal caregivers with varied experiences, data were collected in 3 outpatient specialty clinics treating patients and families transversing 3 distinct trajectories: expected (ALS), unexpected (HF), and mixed (lung cancer). These clinics were located in the United States within a quaternary medical center with a large geographic catchment area. NIH-PA Author Manuscript Data collectors (n = 9) for the study were active members of the research team. The team consisted of 2 senior researchers with extensive experience in qualitative research methods and 7 junior researchers who underwent extensive training in observational data collection techniques and completed a university-based graduate-level course in qualitative methods. Although data collectors’ primary assignments were in a specific clinic, they observed interactions in all clinics to increase validity of clinic comparisons and contrasts. Researchers remained nonintrusive and nonparticipatory during 12 months of immersion in the clinics. Naturalistic visual and auditory observations of 601 office visits were made during clinic hours. Observations focused on verbal and nonverbal interactions between formal and informal caregivers. Examples of observed interactions included communication extending from discussion of patient symptom management and availability of caregiver respite services to comforting behaviors offered to informal caregivers by their formal caregiver counterparts. IHS2215 CSCC Week 3 Global Environment And Public Health summaryGlobal Environment And Public Health summary. To enrich the observational data, formal caregivers were interviewed briefly to provide information regarding the meaning behind their actions during these interactions. To fully capture influences upon the observed interactions, data such as general clinic observations, support group observations, and educational/support materials were collected. Observations and formal caregiver responses to brief interviews were recorded digitally as field notes. The recordings were then transcribed verbatim and verified for accuracy. To protect the participants’ confidentiality, all personally identifying information was replaced with generic identifiers (eg, physician). NIH-PA Author Manuscript ANALYSIS Analytic methods described by LeCompte and Schensul40 were used in this study. Analysis began upon researcher immersion in the field with inscription, description, and transcription. Researchers recorded field notes after formal and informal caregiver interactions, brief interviews with the formal caregivers, and informal caregiver support group meetings. Researchers utilized these inscriptions immediately following the observation to digitally record thick description. These recordings were later transcribed verbatim and verified for accuracy by reading the transcribed text, while listening to the audio recording. The verified transcripts as well as the collection of educational/support materials were then organized and stored within the analytic software platform ATLAS.ti (version 5.7.1, Atlasti, GmbH, Berlin, Germany) for data management. Within 3 months of initial data collection, content analysis began within each clinic and then expanded across the clinics. Data were analyzed inductively through a cyclical, iterative process that progressed from ANS Adv Nurs Sci. Author manuscript; available in PMC 2013 August 29. Penrod et al. Page 5 NIH-PA Author Manuscript independent item-level analysis to pattern analysis and category codes. Inductive category coding was done simultaneously with comparison to the ongoing observational data collection permitting testing and refinement of early hypotheses as well as the development of relationships.41 Through this process, a large amount of raw data was compressed into a manageable form permitting exposure of patterns and themes.42 Conceptual insights derived through ongoing analyses were used to focus subsequent data collection.40 Analysis continued for 1 year as data collection continued. Patterns and themes were interpreted by the team through shared insights during weekly team meetings.IHS2215 CSCC Week 3 Global Environment And Public Health summaryGlobal Environment And Public Health summary. Consensus was reached on the emergent interpretation of data. Instances of divergent interpretations were resolved by the team’s close examination of the data or continued data collection to clarify interpretation. All research team analysis meetings were digitally recorded to retain accurate records of the decisional audit trail used in analysis. The rigorous execution of this study is demonstrated with the immersion of the researchers within the clinical setting for 12 months during all hours of clinic operation. Observations were recorded digitally immediately following the interaction to ensure reliability. In addition, all researchers observed in all 3 clinics to verify, confirm, or refute the reliability of inscriptions by other researchers. Finally, findings were presented to key informants in a form of member checking. NIH-PA Author Manuscript FINDINGS A clinical outpatient setting is a sociocultural organization possessing a culture of care composed of shared values and beliefs. The culture of care as viewed from the lens of the informal caregiver differed in each of the 3 clinical settings that were explored in this study. Within these clinics, culture of care is shaped by the context of the illness. Formal caregivers have expectations regarding the trajectory of an illness and this influences their values and beliefs. These values and beliefs are expressed explicitly and implicitly through the care delivery model, shaping the expectations and thus molding the experience of informal caregivers. Values and beliefs within each culture of care are expressed through 5 key characteristics: acknowledgment of the probability of death, role of the formal caregiver, perception of the patient system, focus of the patient visit across the trajectory, and continuum of care across the trajectory (Figure). The key characteristics are co-occurring, interdependent spheres of influence that are shaped by the context of the illness. As the spheres do not exist in isolation of one another, if the values and beliefs expressed in one-sphere shifts, there is a corresponding shift in the remaining spheres. NIH-PA Author Manuscript In this study, exploration of 3 distinct models of delivery (interdisciplinary, provider dominant, and cooperative network) in the clinics revealed distinct values and beliefs or cultures of care. In the Interdisciplinary care delivery model, health care providers had shared power and dynamically care for patients and families based upon expressed needs. In the provider-dominant model, there is a lead provider and the role of the remaining staff is to solely support that provider. In the Cooperative Network model of care delivery, there is a lead provider; however, other interdisciplinary formal caregivers step in to support patients and families (rather than the lead provider). In each of these care delivery models, unique values and beliefs were expressed through the 5 key characteristics. Exemplar 1: The culture of care in an interdisciplinary care delivery model Acknowledgment of the probability of death—The most prominent characteristic within each culture of care is the acknowledgment of probability of death. In this cult … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10 Order NowjQuery(document).ready(function($) { $.post(‘’, {action: ‘wpt_view_count’, id: ‘9483’});});jQuery(document).ready(function($) { $.post(‘’, {action: ‘mts_view_count’, id: ‘9483’});});

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