The aim of this reflection paper is to give an overall picture of my accomplishments and experiences during my Master of Science in Nursing (MSN) program. It includes an integrated reflection of my achievements, MSN opportunities that have impacted immensely on my professional practice as a nurse leader and my practicum project experience in relation to the QSEN competency of quality. It will conclude with my suggestions for improving the MSN program and nursing student preparation.
Successes and Opportunities in the MSN Program
Working towards this MSN degree has provided me with opportunities to grow both at personal and professional levels. Obtaining the MSN degree has been my ultimate professional goal since completing my BSN. One of my greatest achievements is acquiring skills in research methods to conduct literature searches and synthesize the evidence to support practice improvements. Through the capstone experiences and assignments, I gained confidence in accessing and synthesizing the recent literature to inform evidence-based nursing interventions. This has impacted greatly on my reflective practice and clinical decision-making. Over the past semester, I have strived to apply what I have learnt in research in my area of practice to improve healthcare quality and patient safety.
My other professional accomplishment relates to the presentation and dissemination of research findings. My experience with PowerPoint presentation enabled me to organize my ideas and concepts related to quality improvement projects to interact and communicate effectively with my class audience. I can now incorporate photos and graphs into well-prepared slides to support my main ideas. The MSN program gave me an opportunity to prepare a teaching presentation on CAUTI prevention for staff nurses at my facility (KRMC). Further, through the assignments, I was able to evaluate my facility’s disaster preparedness and analyze the regulatory requirement and guidelines for RN’s role in conscious sedation.
Another achievement related to my MSN program is the use of technology in healthcare. Initially, I envisioned technology as a hindrance rather than a driver of quality health care. I have examined electronic health records and their use by providers. In one of my assignments, I wrote a memo to the medical staff seeking to realign the facility’s systems with the meaningful use requirements through EHR implementation (Harrison & Lyerla, 2012).
I have also used blogs as a communication platform for sharing my practicum project results. I was able to integrate the QSEN competency of safety into my blog post. Through my academic journey at the institution, I have achieved enhanced self-awareness and reflective practice in my work. According to Yanhua and Watson (2013), self-awareness is a continuous process that culminates in a positive therapeutic relationship. I have learnt to be conscious of my actions, the caring environment, and patient’s body language throughout my interactions.
Practicum Project and the Safety Competency
My practicum project was titled, ‘preventing respiratory complications in patients undergoing Interventional Radiology (IR) procedures under conscious sedation at Kendall Regional Medical Center’. The QSEN competency of safety was most relevant to this change project. The project achieved a significant reduction in conscious sedation-related respiratory complications after IR, indicating a positive safety outcome. Out of the 215 patients who underwent radiological procedures in this period (May-September 2016), only 2.7% of them developed respiratory complications. Higher patient safety outcomes were achieved through effective intra-procedure patient monitoring using capnography, nurse education/empowerment, institutionalized technology, and effective clinical communication and collaboration.
The QSEN competency of safety embodies a reduction of the risk of sentinel events in clinical settings. As a nurse, I take safety to mean the provision of care that is devoid of medical errors that lead to increased readmissions and LOS. Patient safety can be achieved through nursing process improvement to achieve quality and avoid communication lapses (Mansour, 2012). My practicum project sought to address systemic risk factors – human and nonhuman barriers – that compromise patient safety at KRMC.
They included lack of knowledge on conscious sedation management by nurses, change resistance, turnover, inefficient nursing communication, and insufficient monitoring technology. The project used a multifaceted approach to reduce adverse post-procedure respiratory prognosis. Adherence to the recommended guidelines in the pre- and post-procedure states and routine monitoring were emphasized in line with the KSAs defined under the QSEN competency of safety (Sherwood & Zomorodi, 2014).
Another area I addressed in this project was increasing patient safety levels through nursing skill improvement. The aim was to increase nurses’ skills in appropriate conscious sedation level, patient monitoring (capnography), and pain assessment and management. To prepare the IR nurses for the change, I developed an educational plan aimed at improving nursing competencies related to depth of conscious sedation. As Tella et al. (2014) state, over-sedation can compromise patient safety in patients undergoing IR procedures due to repressed responsiveness. Skills in airway assessment and management were also considered critical in preventing respiratory complications.
I was able to interact and network with staff nurses drawn from multiple specialties to realize the goals of my practicum project. It was a great opportunity for me to practice my team-building skills. The project brought together IR nurses, IR radiologists, nurse director, ED and ICU nurses, and intermediate care unit nurses. A culture of safety across all these practices was required to improve patient outcomes.
The nursing staff, as the agents of change at the facility, helped establish a culture of safety through patient monitoring and appropriate-level sedation. I was also able to apply theories of change – theory of human caring, transcultural nursing theory, and unitary human being theory – in practice to improve nursing perceptions and practices. Therefore, my project facilitated the achievement of the competency of safety through strategies that improved process and staff efficiencies.
Proposed Changes/Improvements
The MSN program curriculum is well integrated and responsive to the changing healthcare needs and technology changes. Its focus on research, capstone experiences, nursing theory, and practicum project gives students hands-on experiences and critical thinking skills to drive change in their respective clinical practices. In particular, I feel that the practicum experience improves a student’s capacity to develop and implement evidence-based interventions focused on health care quality and safety.
However, I would suggest improvements in the assessment criteria used. While direct assessment through practicum experiences can determine if learning has taken place, it only measures performance (Brown, Feller, & Benedict, 2012). I would suggest the use of indirect assessment methods such as graduate feedback/interviews would give a more holistic picture of the learning outcomes accomplished. Further, besides assessing integrated learning experiences, the program should evaluate acquired skills and abilities from competency-based practicum projects. The program should facilitate further development of the practicum project beyond a single facility. Utilization of the findings to inform practice improvement in other hospitals should be supported through liaison with regulatory agencies.
References
Brown, R., Feller, L., & Benedict, L. (2010). Reframing nursing education: The quality and safety education for nurses initiative. Teaching and Learning in Nursing, 3(5), 115-118. Web.
Harrison, R. & Lyerla, F. (2012). Using nursing clinical decision support systems to achieve meaningful use. Computer Informatics Nursing, 30(7), 380-385. Web.
Mansour, M. (2012). Current assessment of patient safety education. British Journal of Nursing, 21, 536–543. Web.
Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN competencies redefine nurses’ roles in practice. Nephrology Nursing Journal, 41(2), 15–22. Web.
Tella, S., Liukka, M., Jamookeeah, D., Smith, N., Partanen, P., & Turunen, H. (2014). What do nursing students learn about patient safety? An integrative literature review. Journal of Nursing Education, 53, 1–7. Web.
Yanhua, C. & Watson, R. (2011). A review of clinical competence assessment in nursing. Nurse Educator Today, 31(2), 832-836. Web.
Government Policy: Science, Funding And Regulation
Introduction
Innovation plays an important role when it comes to development. Without innovation in the field of science and technology a society stagnates. Imagine a world without cars, airplanes, Internet and mobile phones. Innovations are crucial especially when it comes to agriculture, medicine, and the efficient delivery of goods and services. Innovations enhance the quality of life and help prolong it. It is therefore the responsibility of the government to encourage research that would lead to innovation. In this regard a report from the Productivity Commission of Canberra, Australia will be analysed. The specific target is Chapter 3: Rationales for Public Support.
There are three primary purposes for this chapter. The first one is to determine the impact of public support for science and innovation in Australia. The secondary goal is to determine the impediments to the operation of the innovation system as well as the frameworks that would help assess how public funding has been allocated for the purpose of science and innovation. Finally, the last objective is to determine the importance of having a rationale to support any activity related to science and innovation.
Summary
The discussion begins with the attempt to understand the rationale for government intervention. The underlying reason for doing so is based on the fact that public support takes the form of funds or tax concessions. Therefore the rationale for public support must be linked to net national benefits. The importance of a rationale is to help policymakers decide if public support can be channelled to a particular project or not.
Nevertheless, the identification and assessment of rationales does not contribute anything of significance to the overall goal of the government when it comes to science and innovation. The overall goal is to use public support to create meaningful results, specifically the development of innovations that improve the welfare of the people.
Thus, assessing rationales is tantamount to a well-written report that can prompt action but does not guarantee results. In this report the proponent of the study asserted that one major issue that the study of rationales cannot address is in how to quantify the level of public support needed to affect positive change. For example a rationale cannot determine if public support must be packaged as a $2 billion or $10 billion endeavour.
The proponent of the study therefore suggested that aside from identifying and assessing rationales for public support it is also imperative to improve program design before public support is made available to a particular group or sector. But before going any further it is important to discuss some of the well-known rationales presented to policy makers.
One of the most frequently cited rationale for government intervention is called “spillovers” (Lattimore 56). A “spillover” must be viewed in the context of scientific research. According to those who use this rationale for public support, a “spillover” enables the government to benefit extensively from their investment. In other words, using the “spillover” rationale helps to convince policy makers that there is a foolproof way to use public support to make it appear that the government is doing something for the sake of science and innovation. This is an irresistible offer because if the main project or research endeavour failed to produce tangible results, government officials can point to the justification that a “spillover” effect can be expected and therefore the investment can be recouped in an indirect manner.
The only problem with this view is that a “spillover” does not always occur. There are many factors why the expected outcome is not always realised. One of which is poor management of resources or the inability to access needed resources on time. There are cases wherein a research proposal has shown tremendous promise but the intervention of the government was non-existent. For instance, a project can be underfunded or lacking the necessary complementary inputs such as access to Information Technology and appropriate field work.
Another major reason why a “spillover” is not realised is the absence of efficient diffusion mechanisms. In basic research usually conducted in universities the diffusion mechanisms comes in the form of publication, conferences, and other means of exchanging research ideas. However, there is no guarantee that an efficient diffusion of ideas can be expected each and every time a scientific discovery has been made. From a business standpoint this is an example of a weakness in the system that has to be rectified.
Another major reason why a “spillover” is not a normal occurrence in the scientific community is that for it to happen, the primary requirement is research of good quality. It is therefore important to make sure that before funds are committed to a particular research project, there is a way to determine if the investment can lead to quality results. The proponents of this study discovered that low quality research can be prohibitively costly for the government “the economic loss could be around $1.20 to $1.30 – the original dollar of funding, plus around 20 to 30 cents, associated with the economic costs from raising public finance” (Lattimore 63). Thus, it is imperative to develop a verification process before funds are diverted to a particular research project.
The apparent weakness of basic research prompted many to look into commercially-oriented research as a more reliable means of generating much needed innovation. At first glance it seems like a fool-proof method because the ability to access research funds to enhance their research activities can only be viewed as an advantage. The only problem is that the government does not have one hundred percent assurance that a “spillover” will occur. In other words the government has only one measure for success and it is the “spillover” effect mentioned in the beginning of the report.
Although there are those who can assure the government that firms are unable to contain research information and eventually it will leak-out to the public sector, there are no mechanisms that can measure exactly how and what type of information or innovation can leak out into the public sphere. The competitive nature of firms prevents disclosure of information in order for them to create a competitive advantage. The government must therefore develop mechanisms that encourage firms to diffuse their intellectual property.
According to this report, the “spillover” phenomenon identified by researchers can easily become a drawback to innovation. Interestingly, the government would like research groups from the public and private sector to increase their efficiency when it comes to research that would lead to the leak-out of innovative ideas. However, the promise of scientific breakthroughs may not be enough motivation for firms to invest in R&D. Corporations view such exercise self-defeating because they invested on something that their competitors can use.
This reaction is easy to understand considering the amount of resources invested in a firm’s R&D only to find out that competitors are able to use the same information to enhance their products. Thus, the government has to find ways to encourage private participation in R&D even if the possibility of the intended outflow of trade secrets is inevitable.
The report highlighted the fact that private firms may hesitate to invest in a research project that offers little tangible impact and at the same time a high-probability of unintended leak-out of information to competitors. Nevertheless, this must be considered as a major rationale for the government to intervene. Public support must therefore be focused on businesses that are engaged in novel research and development activities (Lattimore 73). The key to success is identified as: a) spillover is achieved with minimal cost; b) it triggers cycles of innovation by rivals; and c) the creation of generic technologies (Lattimore 73). At this point the report has shown how the rationale for public support takes shape.
By focusing on the problem of diffusion, the proponent of this study were able to discover that aside from funding research initiatives that would lead to innovation, the second most important thing to consider is the mechanism for the diffusion of knowledge that would lead to a chain-reaction of events that hopefully results in more innovation. Therefore, public support must not only focus on providing funds for research but also in enhancing infrastructures that would facilitate the movement of ideas.
In the Digital Age there is no other place to channel public funds other than in investment activities that would result to the diffusion of knowledge. In this regard policymakers must also consider investing in distribution networks such as the Internet, broadcasting, and telecommunication. The end goal of government must be to reduce the cost of information dissemination close to zero. The importance of this type of initiative will be appreciated by those involved in basic research. Investments in knowledge diffusion mechanisms also enhances the effectiveness of basic research because scientists are now able to share, transmit and absorb information much more easily as compared in the past.
It has to be made clear that government intervention when it comes to R&D is a deliberate action with an intended purpose. The reason for doing so is not only to initiate the process that would lead to scientific breakthroughs and innovation; there is another intended goal. The government is looking for specific innovations especially those related to defence technology; alleviation of social and public health problems; efficient and effective social services; higher quality education; better economic policies; foreign defence; and solutions to environmental problems (Lattimore 74). Although the goals are explicit defined, the means of accomplishing them are oftentimes vague.
Analysis
The government should increase public support to R&D but it must be made clear where the funds are going. The first step in the decision-making process should not focus on the rationale to channel funds to R&D because it is easy to justify the importance of R&D. Any person with the right credentials can convince a government appointed agency to release the funds to this particular group because they are on the verge of discovering something important. Instead of assessing the rationale of public support in relation to a particular research project, the government should instead look at the group’s capacity to diffuse knowledge gleaned from their research.
Using this framework the obvious choice would be universities because these are institutions that focus on basic research. This is the type of research that can be used as some form of building blocks for future innovations. However, there is no assurance that universities and other government-funded research laboratories can efficiently translate investment funds into tangible results. In other words a government sponsored project can go on for years without delivering anything useful for the public sector.
One of the problematic issues that have to be addressed is the tendency to channel funds into low-quality research. There is no need to elaborate the negative consequences of low-quality research. Government funds easily goes down the drain without any proof that policymakers acted as good stewards of the money taken from public coffers. Thus, it is imperative to put in place review mechanisms that would ensure that funds are only allocated on high-quality research projects.
Commercially-oriented research is seen as a better alternative because firms already have a mechanism in place to focus their R&D budget on research endeavours that will produce useful data. A profit-oriented organisation has a keen sense on how to efficiently manage their resources. But the only problem is that they hesitate to invest knowing that patents are no longer enough to safeguard their discoveries. In fact, a patent is a weakness that can be exploited by their competitors. This is therefore the time when the government is justified to intervene and use public support for commercially-oriented research.
Nevertheless, the government must not use public funds to support research aimed towards the innovation of a company’s products. The partnership must be clearly defined as a government intervention to support novel research ideas. This move will enable the government to assure various stakeholders that the invested money goes to high-quality research. Secondly, the research findings can benefit not only the target firm but others. Finally, the type of research findings can trigger a chain reaction of events that would lead to more innovation.
The government has identified two fertile areas of investment. The first one would be universities and government funded research facilities that engage in high-quality research. The second one is commercially-oriented research through a partnership with corporations working on novel research ideas. However, the government must improve the design mechanism of public support by focusing on research related to defence technology; alleviation of social and public health problems; efficient and effective social services; higher quality education; better economic policies; foreign defence; and solutions to environmental problems (Lattimore 74). There must be a way to correctly assess research goals to harmonise it with those of the government. The end result should be cost-efficiency.
Conclusion
The government must move beyond identifying the rationale for public support and must focus on the identification of fertile ground for research opportunities. It has been identified that the universities and government funded research facilities must receive support from the government only if there is a way to prove the quality of the research project. The government must also support commercially-oriented research only if these firms are going to use government funds to study novel research ideas.
Bibliography
Lattimore, Ralph. Public Support for Science and Innovation. Canberra: Productivity Commission, 2007.
Nursing Care Advanced Practices And Aspects
Relationship-Based and Patient-Centered Nursing Care
Patient-centered care refers to the approach to care which empowers the patient and engages them the process. This perspective on care is driven by the improved understanding of patients’ agency and respect towards them (Tak, Ruhnke & Shih, 2014). Some of the attributes of this kind of care include the focus on patient education and their physical and emotional comfort, as well as the respect towards the patient’s opinions, values, preferences, and so on.
All these attributes are very pertinent to my workplace, which is a correctional institution. Nurses often have to advocate for the patients’ access to care in these settings, especially given the fact that correctional officers often mistake certain symptoms for aggression, depriving patients of the much-needed interventions. Similarly, in my personal practice, I have always sought to provide customized interventions that take into account the needs and preferences of the patients; I find that the expected outcome of such approach is improved psychological and emotional state of a patient.
As for the efforts to empower patients, it is a crucial component of our attempts to rehabilitate the individuals residing in our institution: an empowered person is more likely to be able to perform self-care and avoid recidivism, and for the nurses of the institution, it is the ultimate goal of our work.
As for relationship-based care, it is a form of patient-centered approach that reviews the relationships of a care provider with patients, coworkers, and oneself (Hunt, 2014). With respect to these attributes, my institution predominantly focuses on teamwork, which is a requirement for effective work and care. However, the nurses also recognize the importance of the relationships with patients and build them in order to support patients and their families and promote healthcare-related activities. As for the relationships with self, they are instrumental in remaining capable of providing high-quality care. Thus, the process of relationship-based care is driven predominantly by the need to ensure high-quality care, and the expected outcome is the improved well-being of the patients.
Intra-/Interprofessional Collaboration and Advanced Nursing Practice
Intra- and interprofessional collaboration is a major aspect of advanced nursing practice, and DNP education programs view this feature as an important competency of healthcare professionals (Dowling, Beauchesne, Farrelly, & Murphy, 2013). Indeed, advanced nursing practice is inevitably connected to teamwork. For example, at my workplace, the interaction between psychiatrists and nurses is a typical form of interprofessional collaboration. Among other things, it involves direct work on patient cases, as well as collaborative educational and quality improvement efforts.
The process is driven predominantly by the acknowledgment of the importance of collaboration for the quality of care and safety of the patients, but apart from that, the organizational culture, which promotes mutual support and fosters effective workplace relationships, is an important factor. The expected outcomes of the collaboration efforts are improved quality of care, patient safety, quality improvement, and some other positive results that depend on the specifics of collaboration.
Another aspect of interprofessional collaboration at my workplace is rather specific because it occurs between healthcare providers and correctional specialists. Unfortunately, the latter often lack essential knowledge on health concerns (Brown et al., 2017), which occasionally can lead to misunderstandings, in which, for example, certain behavioral symptoms of dementia can be mistaken for aggression. Interprofessional collaboration with healthcare providers can help to resolve this issue.
This form of collaboration appears to be driven, among other factors, by the specifics of the environment, the vulnerability of the patients, and our aim of the continuous improvement of care. Thus, by fostering collaboration and communication between the members of these professions, we can hope to achieve the eventual outcome, which is the improved well-being of incarcerated patients.
Emotional Intelligence in Advanced Nursing Practice
There are five elements or attributes of emotional intelligence (EI) that are typically reviewed. They include self-awareness, which refers to one’s ability to recognize one’s emotions, self-regulation, which refers to one’s ability to handle these emotions, and motivation, which refers to one’s ability to motivate oneself with non-monetary rewards. The remaining attributed include empathy, which refers to one’s ability to understand the emotions of others, and social skills, which refers to one’s ability to successfully interact with others and manage social interactions (Banschbach, 2016). It is noteworthy that three of the elements seem to refer to intrapersonal skills, and only two of them focus on the interpersonal ones.
Personally, I have always focused on social skills when developing my leadership qualities, but I recognize the significance of the intrapersonal ones: they can serve as a source of knowledge on human emotions, which implies that they might be predictive of the interpersonal attributes. Apart from that, intrapersonal skills ensure the leader’s ability to be critical and analyze the interactions between oneself and their followers. As a result, the benefits of being aware and in control of one’s emotions are apparent.
Regarding motivation, this attribute is described by Banschbach (2016) as interpersonal. However, it also appears to be predictive of a leader’s ability to understand motivation as a concept and employ this knowledge to motivate others, although it is important to remember that the motivational preferences of individuals can vary. Finally, the benefits of interpersonal attributes are apparent: empathy is instrumental to understanding one’s followers (and patients), and social skills help to manage the relationships that are necessary for practice. Thus, the significance of EI for leaders is well-established (Northouse, 2015, p. 28). In my future DNP practice, I will proceed to develop my abilities in the field of EI to be able to lead my colleagues and care for my patients effectively.
Transformational Leadership in Advanced Nursing Practice
The advantages of transformational leadership as compared to the transactional one are relatively well-established in multiple fields, including nursing (Ross, Fitzpatrick, Click, Krouse, & Clavelle, 2014; Spano-Szekely, Quinn Griffin, Clavelle, & Fitzpatrick, 2016). Transformational leadership can be defined as a form of leadership that focuses on the leader’s ability to empower the followers and inspire them; it is opposed to the transactional leadership that limits the relationships between leaders and followers to the exchange of work and rewards or reprimands (Ross et al., 2014).
Some of the activities that a transformational leader needs to perform include human resource development and support, goal alignment, vision communication, organizational culture adjustment, and so on. It is also noteworthy that a transformational leader is typically expected to possess emotional intelligence; research indicates that it has a significant positive correlation with transformation leadership, resulting in positive outcomes (Spano-Szekely et al., 2016). Ross et al. (2014) state that transformational leadership can reduce rates of burnout and improve job satisfaction while also contributing to the improvement of the quality of care. All these outcomes are very important for nursing practice.
I believe that I have not experienced the transactional leadership approach in its classical form; at my workplace, transformational leadership has always been the norm. Similarly, I have always perceived transformational leadership as the appropriate way of leading employees. In future, as a DNP-prepared nurse, I will be more likely expected to apply my leadership abilities to leading my colleagues, and I intend to employ my knowledge of transformational leadership to enjoy its benefits.
Appropriate Application of Epidemiological Terms in Determining Risk
As established by the assignment, the average lifetime risk of developing breast cancer equals 13.2%, but the women who have relatives that suffer from the condition face noticeably higher risks. In particular, the risk for the women with one first-degree relative with breast cancer doubles (resulting in 26.4% risk), and that for women with two first-degree relatives with the condition is five times higher when compared to the norm (66%). These two cases illustrate the use of certain epidemiological terms that help in determining high-risk populations. From this perspective, low- and high-risk populations are defined by their exposure to risk factors.
In epidemiology, attributable risk can be defined as the “additional” risk which is experienced by a person from a higher-risk population as compared to an average person (Fletcher, Fletcher, & Fletcher, 2013, p. 68). For example, in the two above-mentioned scenarios, the women from the two higher-risk populations have the attributable risks of 13.2% and 52.8% respectively. Relative risk, on the other hand, refers to the relative likelihood of developing a condition, which is expressed as the ratio of the incidence of the condition in low- and high-risk populations (Szklo & Nieto, 2014, p. 80). For example, in the mentioned cases, the ratios are stated in the instructions: in the first case, the risk doubles, which means that its ratio is two, and in the second one, it increases fivefold, which means that its ratio is five.
The two terms (attributable and relative risks) should be used for their respective questions. According to Fletcher et al. (2013), in discussion with a patient, it is typically sufficient to state the absolute risks. However, the relative and attributable ones can be helpful to either highlight the additional risks or to indicate the ratio of the risks for different populations.
The Healthy People 2020 initiative aims to prioritize health concerns and specific areas that require improvement and can be improved based on available evidence (Office of Disease Prevention and Health Promotion, n.d.). Apart from that, the initiative works with the statistical data pertinent to the prioritized areas of public health, developing measurable goals for their improvement. For example, in breast cancer, Healthy People 2020 sets the objectives of reducing breast cancer rates and the rates of late-stage cancer while increasing the use of guideline-based screening (Office of Disease Prevention and Health Promotion, 2017).
In the prioritization of health issues and the development of its objectives and guidelines, the initiative apparently uses the epidemiological approach. For example, Healthy People 2020 recommends breast screening to be used with the women who have risk factors (that is, have relatives with breast cancer) (U.S. Preventive Services Task Force, 2013a). Similarly, the use of preventive chemotherapy is approved for women with high risks of breast cancer (U.S. Preventive Services Task Force, 2013b). Thus, Healthy People 2020 illustrates the use of epidemiological studies for public health.
Applying Epidemiological or Biostatistical Terminology
My evidence-based promotion class project focuses on the risks experienced by incarcerated people with mental issues. Incarcerated populations generally suffer from higher risks of multiple health concerns, including those related to mental health (Kendig, 2016). The latter factor can be attributed to the fact that mental disorders are believed to contribute to the behaviors that result in incarceration (Rich, Allen, & Williams, 2014).
According to Rich et al. (2014), the prevalence of mental issues in prisons amounts to 50%, which is five times greater than the prevalence of the conditions in the non-incarcerated population. However, there exists little information on the incidence of mental issues in incarcerated population, which is why it appears that the prevalence may be the best epidemiological term to describe the magnitude of the problem.
As for the assessment of the population, Rich et al. (2014) suggest focusing on causation and risk factors, especially substance abuse: over 70% of the incarcerated population with mental issues also report addiction issues. Apart from that, the author highlights the fact that incarceration offers an opportunity for therapeutic intervention for both problems, which suggests that screening and secondary and tertiary prevention are of great importance to the population and the nurses working with incarcerated adults.
Frameworks for Assessing High Risk Factors in Populations
The Head Start (2016) Program offers reports that focus on certain statistics, including the health status and access to relevant healthcare services of the participants. Apart from that, there is a continuous effort to assess the outcomes of the application of the program to various populations. For example, Karoly, Martin, Chandra, and Setodji (2016) offer a comprehensive review of the program’s effectiveness in several regions. Some of the outcomes that they cover include those related to the development and learning in children (for instance, literacy, pre-writing, and so on), children’s health and behavior, school readiness, and parenting practices. These outcomes demonstrate the extensive scope of the program and its importance for public health.
When funds are constrained, it is necessary to focus the screening efforts on the populations that are at a higher risk of developing a condition. For example, the U.S. Preventive Services Task Force (2013) suggests that screening for breast cancer is a requirement for the women who have a family history that might indicate heightened risks. Therefore, such prioritization is supported by current evidence and approved by governmental healthcare bodies.
When developing screening programs, it is essential to take into account the cultural specifics of the targeted population. For example, Shirazi, Shirazi, and Bloom (2013) demonstrate that some of the variables that are significant for culturally sensitive approaches include the varied perspectives on health and healthcare, different social roles, and religious beliefs. The authors use these variables to develop a culturally appropriate program for Islamic women: they demonstrate that the role of the men as the gatekeepers who often control the women’s access to healthcare can be employed to instead facilitate it through a faith-based education of both men and women.
Professional Accountability
The professional and ethical accountability during the screening process incorporates multiple features, including those related to the information and services provided to the patient, which should be in line with the current evidence-based guidelines.
In this connection, Battié and Steelman (2014) highlight the significance of the nurses’ responsibility to continually educate themselves, which is why it is important for the nurse to remain aware of the evidence that supports the need for screening and the specific activities related to it. Apart from that, nurses are expected to protect the confidentiality of the information pertinent to screening unless they are legally required to report an issue (as is the case with, for example, child abuse). Nurses’ accountability is an important element of patient safety.
An example of a momentary lapse in professional accountability that I have personally witnessed was a prescription mistake made by the psychiatrist that I work with; I may have been the reason for the error since I had distracted her. Fortunately, after responding to me, she re-read the prescription and immediately corrected the mistake, making a comment on the issue, which is why I remember the case. Distractions are common in the relatively hectic environment of healthcare-related institutions, which is why I am used to double-checking documents, recognizing that I might make a mistake because of it.
Scarce resources are indeed a problem at my workplace, which is a correctional institution, and we predominantly resolve it through collaboration and continued efforts to improve our efficiency. The events in which the resources differ from those required by the policies of my institution must be rare because I have not encountered them. However, I believe that this problem should be addressed by making the administration aware of the problem and, if quick action is required, using one’s understanding of relevant guidelines (including codes of ethics) to find an appropriate solution.
Incarcerated Adults as a High-Risk Population from the Perspective of Developing Mental Health Issues
In epidemiology, a high-risk population is defined as a group of people that exhibit certain characteristics or are exposed to a particular phenomenon, which results in an increased risk for a particular condition or behavior in them (Fletcher, Fletcher, & Fletcher, 2013). An example of a high-risk population is incarcerated people who are proven be more likely to experience a variety of health concerns, including mental issues, when compared to non-incarcerated people (Kendig, 2016).
A Doctor of Nursing Practice (DNP) is expected to have the sufficient competence to be able to identify high-risk populations and provide relevant screenings and interventions based on their needs. The present paper reviews the concerns that a DNP working with incarcerated populations may need to be aware of in order to provide appropriate care to their patients.
Identification of High-Risk Population
In my workplace, which is a correctional institution, I predominantly work with incarcerated adults. These adults, especially the elderly, are a population that can be viewed as a high-risk one from multiple perspectives. It is noteworthy that the idea of “elderly” population is relatively flexible and depends on the settings that are being considered. For example, while people older than 65 years are typically viewed as elderly in the US, incarcerated Americans are regarded as elderly at the age of 50 years (Feczko, 2014, p. 640).
According to Feczko (2014), the primary reason for this distinction consists of the fact that the health of incarcerated people decreases faster, which is partially attributed to the health conditions that they tend to have, including mental ones. This factor demonstrates that incarcerated adults can be viewed as high-risk from the perspective of healthcare.
Mental issues, including, for example, dementia and Behavioral and Psychological Symptoms of Dementia (BPSD) (Feczko, 2014), are a major concern for incarcerated adults (Martin, Colman, Simpson & McKenzie, 2013). At the same time, prisoners with often mental issues remain undertreated (Feczko, 2014), and, in fact, this population and appropriate interventions for it remain understudied (Rich, Allen, & Williams, 2014). It appears that the problem can be viewed as a macro-system one (Caldwell & Mays, 2012). However, in my personal practice, this issue is represented at a microsystem level by the fact that patients with mental conditions often remain undertreated because correctional officers are not sufficiently educated on the matter, which results in the patients receiving reprimands for their behavior rather than care that they require. Thus, there is an apparent interaction between the issue and the environment in which the patients find themselves.
From the perspective of the epidemiological triangle, the situation can be described in the following way. The host (an incarcerated adult) experiences increased susceptibility to the agent (which is mental health issues) within the environment of a correctional institution (Guidotti, 2015; Stanhope & Lancaster, 2014). The environment may be directly conducive to the agent, but apart from that, it hinders the screening and treatment efforts.
In particular, it has been established, for example, that patients with mental issues are rarely referred for treatment services (Martin et al., 2013). In turn, this fact may be related to the evidence which indicates that it is typical for correctional institutions to provide screening services only during the intake, after which the population is hardly screened despite it being a high-risk one (ECRI Institute Evidence-Based Practice Center [EIEBPC], 2013). However, Rich et al. (2014) highlight the fact that incarceration may provide stability, structure, and sobriety required for a successful mental health intervention, which implies that the effects of the environment can be modified, for example, by a DNP professional.
Adverse Health Outcomes
Given the fact that incarcerated adults are exposed to multiple health risks, multiple health outcomes should be mentioned. In general, mental health issues tend to affect the behavior of patients, increasing their vulnerability, especially in the settings of a correctional institution, in which they may attract the unfavorable attention of offices or other inmates. The related outcomes include injury, victimization, and death (Feczko, 2014; Rich et al., 2014).
Moreover, specific mental issues result in their specific outcomes; for instance, the adverse outcomes of dementia and BPSD include an increased rate of falls (and subsequent injury), infections, and, eventually, mortality; also, patients with dementia experience a higher risk of developing cardiovascular problems (Feczko, 2014). Finally, as it has been stated, the adverse health outcomes of the incarcerated population are noticeable in the accelerated aging process, which reflects their poor general health and its rapid deterioration.
In turn, this factor results in multiple negative outcomes, including multimorbidity, disability, various forms of sensory impairment, as well as increased risks of injury and victimization (Rich et al., 2014). In summary, the adverse effects of mental issues are multiple, and the issue requires the attention of care providers, including DNP professionals.
Utilization of Epidemiological Principles and Terminology
In this section, the notions of risk, incidence, prevalence, morbidity, and mortality are going to be applied to the case as major epidemiological terms (Fletcher et al., 2013). The specific estimates of the risks of the incarcerated population in developing mental illnesses vary. A systematic review by Prins (2014) suggests that there have been made attempts at producing such estimates, and some of them can be viewed as high-quality studies, but there are still notable variations in the results, which prevents one from making conclusive statements.
The author suggests that this fact may be explained by different operationalizations of mental illness and other methodology specifics. However, Prins (2014) still reports that the difference between incarcerated and non-incarcerated populations in terms of the prevalence of mental issues are very consistent, which allows making certain conclusions.
According to Rich et al. (2014), the prevalence rates of mental issues in the incarcerated population amounts to 50%. Apart from that, according to the author, it can be suggested that in the US, the relative risks of an incarcerated adult in developing a mental issue are up to five times higher as compared to non-incarcerated adults. As for the development of serious mental issues in offenders, their prevalence has been assessed to be from three to five times greater when compared to non-incarcerated population (EIEBPC, 2013, p. 1). Thus, the variance of the estimates is visible in the presented prevalence rates, but they indicate the differences between incarcerated and non-incarcerated adults, supporting the fact that the former can be viewed as a high-risk population from the perspective of epidemiological analysis.
However, the present study has failed to locate a recent source that would describe the incidence of mental health issues in incarcerated adults. As opposed to prevalence, which describes the portion of the population that is affected by a condition, incidence refers to the new cases of the condition that are discovered in the population (Fletcher et al., 2013). Similar problems can be encountered when searching for the incidence or prevalence rates for specific mental concerns; for example, Feczko (2014) reports that no attempts at defining the prevalence of dementia in the incarcerated adults of the US have been made.
Additionally, despite the fact that deaths can be attributable to mental issues in incarcerated adults (Feczko, 2014; Walker, McGee, & Druss, 2015), no direct information on the mortality rates in the population has been found. As a result, the primary source of information on the condition is related to morbidity, which is limited predominantly to prevalence and is not available for all the individual mental issues.
Regarding the risk factors for the development of mental issues, some of them seem to be relatively prevalent in incarcerated adults. One of the most important risk factors is substance abuse. Rich et al. (2014) point out the fact that addiction is another issue that incarcerated adults are increasingly susceptible to, which emphasizes the significance of this risk for the population. Other notable risks include stress, financial problems, and traumatic experiences during various periods in life (for example, childhood abuse), which are also relatively common in incarcerated adults (EIEBPC, 2013).
Finally, it has been established that genetic factors may be a cause of a mental issue, but no direct evidence on the prevalence of this factor in incarcerated adults has been found. Thus, the analysis of the relevant influences and the causation of mental issues in the population can be used to support the fact that it experiences high risks as compared to the non-incarcerated people.
It should be pointed out that, according to Rich et al. (2014), the incarcerated population receives a temporary opportunity to withdraw from substance abuse and receive medical treatment and other interventions depending on their needs. As a result, the incarcerated population, while vulnerable, can be subjected to positive influences from its environment. Among other factors and actors, these influences depend on the nurses who work in the settings, which highlights the significance of taking into account the above-mentioned risks when caring for the population.
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