Research Korner: Nursing Literature Review

Literature Review: Case Management Application to Care for Patients with High-risk Complex Needs Inside and Outside the Hospitals

Literature Review: Case Management Application to Care for Patients with High-risk Complex Needs Inside and Outside the Hospitals    Introduction In the medical arena, it is important that individuals that are involved must have specialization in order to have unparalleled opportunity and capability to address the critical issues that the world’s current health care system face. The role of the nurse as a vital member of the healthcare team through collaborative professional practice must always give priority through caring its patient. The primary goal of being a nurse is to assist individuals in the achievement of an optimal level of wellness. The focus of nursing is on individuals' specific needs based on their healthcare choices related to physiological, psychological, socio-cultural, developmental and spiritual dimensions of individual lifestyles. Nurses are working to promote health, prevent disease, and help patients cope with illness. However, there are cases when the capabilities and responsibilities of the nurses are needed and called for by the patients because they are the one who can provide it for them. Such happens if patients are classified as individuals with complex and high-risk needs inside and outside the hospital and other health institutions. There are hospitals and health organizations that avail of the services of case managers in order to answer the special needs of clients and patients with critical conditions. This follows the belief that the function of case managers to  this particular type of patients will improve the overall condition and well-being of the patient. The succeeding literature review will focus on the application of case management concept and the success of such type of medical intervention in the nursing field.      Discussion Case management is a systematic, cyclical approach used to assess and organize the provision of health and social care for people with complex needs as the term was first used in the provision of care to community mental health clients in North America in  1950s ( 1998). A lot of studies and experts have acknowledged the use of case management and its objectives. Accordingly, case management aims to provide balance in terms of nursing and patients’ care both in terms of quality and cost. Its objectives include (1) improved quality  of patients’ care through health restoration, maintenance and continuous care, (2) minimize the cost of health care expenses by providing the patients’ families and the patients themselves the ability to self-care, and (3) offer better patient, nurse and physician professional relationship through multi-disciplinary application of coordinated care services (1989; 1991; 1994; 1994;  1994).       A lot of medical researches and other academic studies  aimed to assess and evaluate the application of the concept of case management in health care and medical services across different countries including the United States, Canada, Australia and Great Britain.   (1988),  (1992) and (1996) claimed and testified the improved and efficient outcomes of utilizing the case management method for chronic mentally ill patients. According to (1981), clients were observed to have display better mental state, psychosocial functioning as well as improved quality of life as a result of the care processes initiated by the case management approach. (1981) and  (1983) likewise supported these positive claims as their studies projected that clients perceived increased environmental support and satisfaction with the service provider. A meta-analysis review was conducted synthesizing 24 published studies which dealt and focused mainly on the effectiveness case management among the mentally ill concluding that 75% of the patients who participated under the case management care were fared better compared to the average client who did not (1998).  (2000) demonstrated that the case management model can be effective in caring for clients with long-term mental health problems as they compared the outcome of case management service with that of the conventional practice of community psychiatric nursing service (CPNS) among patients with chronic schizophrenic mental illness as they measured the impact of case management service to the clients’ clinical status, functional level and satisfaction. They found out that those patients under the case management service showed better medical response in terms of their mental status and functional level than those under the traditional and current CPNS being generally more satisfied with the service. The study likewise noted that case managers performed more in areas such as assessment, liaison, case discussion and life skills training as compared to the conventional responsibilities and duties of medical personnel under the original CPNS. (2005) likewise described the effects of the case management approach in treating diabetic patients. They proved that a case management team of four nurses with different degrees of clinical experience have been effective in improving the adherence with diabetes services characterized with a favourable effect on short-term glucose control trends.  Meanwhile, (2001) recorded a decrease in the length of days of stay of the patients with chronic obstructive pulmonary disease and recurrent admissions in health institutions, thereby, improving their quality of life.  Proper health conditions and individual well-being of old people in the community at present is a growing concern for a lot of countries worldwide.  (2004) claimed that preventive actions targeting community-dwelling frail older people will be increasingly important with the growing number of very old and thereby also frail older people. Their research study found out that nurses who are trained in gerontological practice, have a key role in case/care management for frail older people which calls for developing the content of case/care management so as to incorporate a more salutogenic, rehabilitative and family-oriented approach. To this end, it may be useful for nurses to strengthen their psychosocial skills or develop close collaboration with social workers. (2005) recognized the cyclical nature of the case management approach evident in the processes of assessment, planning, implementation, monitoring, and evaluation to be able to provide pro-active care services to people with complex health and social care needs. They found out that in the application of the said approach to care for old people, practice nurses assess, plan and implement care. However, reviewing and evaluating medication are uncommon practices. Practice nurses with post registration education in district nursing are likely to refer patients to social care services. They also observed that case management approach is more likely to be used in on-going management activities than in one-off treatment room care and that the lack of time and central role of the general practitioner are significant reasons for not incorporating case management into practice. The authors concluded that the extent of utilizing elements of case management approach is greatly dictated by the individual professional expertise of practice nurses, nature of the consultation and the practice nurse’s position in general. Leadership roles among case mangers needs to be developed and supported in the organizational level of general practice as well as in a wider primary health care team and care trust. They claimed that unless a proactive approach to care for old people is more comprehensively practiced in general, their chance to maintain their health and independence will not be recognized. The important aspects of effective and comprehensive treatment of HIV among the youth have been correlated to its treatment. Medical care alone cannot meet the needs of effective care without the support of flexible and multi-disciplinary approaches in the form of case management as case managers help attend to the immediate needs of the clients and patients ensuring that they can avail the benefits of personal support system. All these facilitate and reinforce treatments through case management multi-faceted form being more than a medical component. Continuous treatment outside the premises of the hospitals, attending to walk-in clients, and availability whenever possible to assist medical needs are all offered by the case management approach (2003).  (1998) provided some reviews regarding the conceptual definitions and the practice of case management among different context that were available. They acknowledged the innovative and cost-effective benefits of the said approach in its utilization to different nursing practices and health services. However, they critiqued the absence of a concrete definition and understanding of the concept of case management which, according to them, have resulted to the slow progress of the approach in terms of practice and research. They reviewed the application and utilization of the case management as well as the issues that are relevant to its practice. The researchers found out that there is a need to define the concept of case management in different contextual applications. They recognized the studies which recognized the impact of case management but called for researches that will focus on the structures and processes of case management in order to advance its programs and thereby compare studies to improve future applications. However,  (1999) concluded that the effect of case managers on a general medical service was limited to shortening length of stay only among a stratum of high risk patients.     Synthesis               The cyclic process of the case management approach has been praised for its nature to provide cost effective and quality health care service. Health institutions that are concerned with clients and patients with mental illnesses; care for old people as well as youth rehabilitation centers and other care service agencies and institutions around the world have long recognized the advantages of utilizing the case management framework. Such benefits include the continuous, less expensive and developmental contributions of the approach to the patients’ families and to the well-being and health conditions of the patients themselves. The review of literature presented resulted to a lot of information pertaining to the application, perceptions toward and impact of the case management approach. However, as was claimed by one of the cited researchers, lack of studies which deals with standard definition of the concept of case management, its structure and its processes in order to provide valid and reliable evaluation case management application summons future medical and health care research enthusiasts.                    Critical Essay on the Practice of the Case Management Approach   It cannot be denied that one of the world’s major problems is to ensure the health of millions of people.  Although there are may professionals who are certain about their works and whom can be considered as an exemplary member of the healthcare professionals, there are still issues that can be attached on them professionally.  The individual healthcare professional’s ability to do what is proposed with proper competence, ability and skill is, of course, very crucial in ensuring safe clinical care.  But professional competence is only part of the picture since nobody is perfect.  Good people with good skills and good intentions, sometimes commit mistakes.  As part of this professional issue, to be a nurse is to observe a dynamic based of caring based on a theoretical body of knowledge. Caring may be fundamental to the continuance of civilization. In the past, numerous definitions of caring in nursing have been presented. The most commonly accepted of it is that of . He said that the moral idea of nursing consists of transpersonal and human-to-human attempts to protect, enhance and preserve humanity (1998). Nursing is a discipline focused on assisting individuals, families and communities in attaining, re-attaining and maintaining optimal health and functioning. Modern definitions of nursing define it as a science and an art that focuses on quality of life as defined by persons and families. Nursing is not only concerned about health and functioning but with quality of living and dying, lived experience, and universal lived experiences of health. Like other maturing disciplines, nursing has developed different theories that are aligned with diverging philosophical beliefs and paradigms or worldviews. Nursing is a knowledge-based discipline committed to the betterment of humankind (1979).   The Changing Theories, Practices and Researches in the Nursing Discipline The existence of this field in the healthcare system is believed that in the world of nursing, nursing science is developed predominantly through a combination of theory, research and practice. Each component enjoys periods of popularity, which is often dictated by the prevailing ethos of the time. Which elements have the most influence on how health care is delivered is determined in part by the way it complements the other realms of health care system. The current health care arena requires nurses with diverse levels of preparation to provide comprehensive, high quality and cost effective care delivery. Authorities have imposed many changes in order to bring quality service to different individuals who are seeking care regarding their health. These rapid changes in society and the health care system over the past decade have sparked dialogue about how best to conceptualize and label the advanced practice domains of nurses. Initially, debate focused on similarities and differences between these roles of advanced practiced nurses that include nurse practitioner and clinical nurse specialists. In light of recent changes to the health care delivery system, advanced practice registered nurses have been placed in the interesting position of witnessing both victory and loss within the progression of their field over the past few years. As managed care places an increased emphasis on the value of primary and preventive care, advanced practice nurses see more and more doors open to welcome them into an environment hungry for quality health care skills at a cost lower than that of physicians. At the same time, varying reimbursement laws and lobbying on the part of physician organizations leave many struggling to operate at a level of autonomy for which they've been prepared.    Nursing as a Task-Oriented Profession According to an interview with a hospital lead nurse (assigned in older people’s acute care) people published in the Evening Chronicle (2004, November 8) good nursing practice is defined as: “Good nursing practice is all about providing holistic, personalized care that is respectful of the individual and nurses are at their best when caring for older people”. Commitment, dedication, hard work and patience, these are the qualities entwined to the holistic profession of nursing. Nursing as it is being portrayed is primarily a task-oriented profession (1999). Nurses existed and come hand in hand with in the portals of the medical world and health care service. With this kind of profession nursing has been accountable for its distinct kind of professionalization through the form of education and wide dynamism of research. This view has a big recognition on the moral standards and diverse ethics of nursing.  Registered nurses engage themselves to bring into practice the knowledge they have gained. These attributes and unique skills are essential for the management of diverse health care problems and challenges experienced in the society. The nurse functions in an interpretative and anticipatory nature, where in it involves the patient in making decisions about his/her physical or physiological condition, the personal monitoring of patients that undergoes a life threatening situation and giving service to patients where in their life supporting treatment mechanisms are malfunctioning or underlying a critical process (1995). These practices form a well define perspective is holistic in manner, may the nurse be in a deferent environment, from community to a hospital setting. Clearly the main thrust of nursing is to help clients attain and regain optimal health wellness; and in this sense the nurse would be reputable by their accountability. In speaking of accountability, we are talking of a nurse that possesses a trust in which from time to time is being checked by his/her self and the relationship he/she profess to the patients. Accountability of nurses appears as a mode of moral conduct that are foremost in the understanding of those willing to be informed by means of nursing health care and service (1997). When nurses do a health service task, the nurse carries a responsibility performing it.  A registered nurse in practice of the profession is accountable to what was done. Accountability is not just a mere sense of licensed to be achieved but accountability must be an integral and essential element of a responsible practice. Obligations of the nurse to be knowledgeable about the rights of their patients, be it moral and legal, the nurse is also accountable in protecting the patient that is in cause. In assessing the patient’s information, the nurse also is handed out to explain and present the implications of the decisions. Such situations like this, the nurse would act as a surrogate relative to the patient on addressing and understanding the problem. Accountability’s main role in professionalism is to recognize the situation of the patient in a self-determined manner. Being a nurse, privacy, dignity and confidentiality should be maintained. You tend to know the very private information of the patients but you should never break the tradition of having a good impression to nurses. Nursing is such a noble profession. Being in this field, one should be ready to serve, have enough patience and give your wholehearted care to the patients especially in situations where the patients have complicated diseases.    The Case Management Approach Nurse practitioners are increasingly being identified as legitimate providers of health services throughout the world. The emergence of the role of nurse practitioners has tended to occur where a clear need arises. This may be because there are no other providers of timely health services or because health consumers are seeking alternatives to their customary health service providers. In this regard, nurses must be able to have enough and sufficient knowledge about their responsibilities especially in managing and caring for patients. According to  (2000), case management is a way of organizing social provisions that emphasizes the coordination of services so that they appear to the clients to be delivered as an integrated whole. The more personal and well-rounded approach of the case management model of care service made it possible for nurses to improve their skills not just in the field of medicine but also in the interpersonal communication as well as in the psychological approaches bestowed to their patients. This conglomeration of duties and responsibilities among case managers enable them to provide and answer to the needs and demands of their patients more effectively and efficiently. The multitude of expertise exhibited by a case manager so as to take full care among patients with long-term and complex high-risk needs contributed to the improvements in the care service discipline which offered quality life among special medical patients. The reviewed journal articles revealed the benefits and contributions of the case management approach in improving the quality of life among patients with high-risk complex needs not just within the confinement of health institutions but also outside these medical centres. Developing a more effective personal support system through increased communication and interaction among with the patients as well as to their families greatly improved the health conditions and overall well-being of the patients. It was elaborated further the lowered number of days of being in the hospital as well as the self-help contributions of the case management approach resulted to less expensive medical costs.     Issues on the Application of the Case Management Approach Healthcare professional works as a team. Each and every healthcare professional that works in relation to a patient’s care and treatment coordinates with one another. Each and every one of them respects each other’s abilities, skills and opinions regarding the patient’s medical condition. Harmonious relationships lessen if not totally avoid misunderstandings, conflicts and tensions within the healthcare institution. Thus, a harmonious relationship in the medical team produces better results in the patient’s medication. Aside from that, a harmonious relationship amongst the healthcare professionals improves their performance, which leads to better service and/or care to the patient. (2005) who conducted a study on the workload of case managers among indigenous diabetic patient population found out that the subjects of observations, being considered as a minority, were somehow empowered through the medical intervention approach of case management. The study further elaborated the increased number of opportunities for consultation among the said patients which likewise resulted to more attention provided to them contributing to a better and more quality life experience. All these improvements and developments in the care services offered by utilizing the case management called for increased workload and numbers of hours dedicated to patients by case managers compared to the conventional duties and responsibilities shouldered in the medical field.   A specific example of a good nursing practice witnessed is having an open and effective communication between the patient and the patient’s family with the healthcare professional. The healthcare professional consults the patient about what are his preferences regarding his care and/or treatment. This is of significance in the patient – healthcare professional relationship because it will prevent any misunderstanding that might arise when a decision regarding the patient’s care and treatment must be made.  (2000) argued the political nature of the case management approach being a cyclic process that is dependent on the people functioning within it who have their own personal stakes and interests. The phenomenological, qualitative and subject perspective that the approach partakes in its different applications depicts the complex interactions of the people involved in it as well as the power struggles fuelled by its political context. Understanding these aspects will provide the complete picture of the case management approach as a service innovation which will serve as a comprehensive, valid and reliable standard and guideline to initiate further research, application and development. Furthermore, he claimed that the direction that will define the approach through its future evolution as an applied approach is greatly dependent on the interests of the stakeholders who possess the power to influence and eventually, somehow dictate such changes.       Critical Reflections   Nurse practice in a wide range of settings from hospital to visiting people in their homes. Nursing is the most diverse of all healthcare professions. It is a universal phenomenon appearing in some form in every culture (1979). Concurrently, the nursing profession faces several issues, which include the increased emphasis on primary health care, new models of collaborative practice, the shift from institutional to community care, new developments in technology, and the supply and demand for various health providers with particular skills. These new trends in the delivery of health care emphasises the need for nurse to expand and broaden their skills. In short, to better meet the changing needs of health care of patients in our modern times, the practice of nursing must continue to develop.    Nurses are advocates and health educators for patients, families, and communities. When providing direct patient care, they observe, assess, and record symptoms, reactions, and progress in patients; assist physicians during surgeries, treatments, and examinations; administer medications; and assist in convalescence and rehabilitation. Nurses also develop and manage nursing care plans, instruct patients and their families in proper care, and help individuals and groups take steps to improve or maintain their health. While state laws govern the tasks that the nurse may perform, it is usually the work setting that determines their daily job duties.    The bulk of studies that assessed and evaluated the impact, effectiveness and cost-efficient contributions of the case management approach were criticized have long been available as future research references. However, a call for studies and researchers that will assess the case management approach as a medical intervention method characterized with structure, processes and well-defined concepts was addressed in order to fill the gaps in the study of such approach. Studies dealing with the interplay among individuals and medical practitioners following the principles of case management seemed to have been somehow neglected with all the other issues that can be investigated in the study of the approach.

Literature Review: Case Management Application to Care for Patients with High-risk Complex Needs Inside and Outside the Hospitals

Literature Review: Case Management Application to Care for Patients with High-risk Complex Needs Inside and Outside the Hospitals I...

Can negative pressure wound therapy improve wound condition? A critical literature review

Can Negative Pressure Wound Therapy Improve Wound Condition? Literature Review The wound care clinicians are expertly facilitating have a wide array of available treatment options to manage and help heal acute and chronic complex wounds that require a systematized and comprehensive approach to address the complexity of wound care and to optimize patient outcomes. The treatment of wounds represents a major cost to society. Therefore, most of the clinical researchers and medical practitioners have an increasing focus on quality of care, patient outcomes, and lowering costs. Wound care clinicians are not immune to these pressures. Wound care clinicians must ensure that their assessments, treatment pathways, and product selections are both clinically and economically sound. Negative pressure wound therapy (NPWT) has been demonstrated to be an efficacious option to promote healing in a variety of acute and chronic complex wounds. Previous guidelines on the use of NPWT have focused on application but have not provided recommendations on when it is most appropriate to use NPWT. Actually, there are few criteria for the wound management such as (1) when to initiate NPWT based on various wound types, (2) pre-application management to optimize treatment outcomes, (3) identification of appropriate candidates for NPWT, (4) benchmark indicators for treatment response, and (5) recommendations for the future issues in NPWT for such events like the transition between NPWT and moist wound healing (MWH) or another treatment modality. In general, there are guidelines that focus on the multiple disciplines convened to develop a document to guide clinicians in making decisions about the appropriate use of NPWT within the spectrum of wound healing. Where empirical research was lacking, clinical experiences and patient factors were considered to ensure the clinical utility of the document. The goal of these guidelines is to encourage responsible wound management across the healthcare continuum and spectrum of wound pathologies to achieve positive, cost-effective patient outcomes (Bollero, et al., 2010). In addition, there are available equipments that can be used to assist the nurses in their practice (Genadyne Biotechnologies Inc, 2008). In the process, the Negative Pressure Wound Therapy (NPWT) applies subatmospheric pressure, or suction, to the wound bed via a computerized therapy unit attached to an open-cell foam sponge that is placed in the wound and secured with an adhesive drape. The adhesive drape helps to provide a semiocclusive environment that supports moist wound healing, which has been the standard for wound care since the mid-1980s.5 The drape is vapor permeable to facilitate gas exchange, an important consideration when treating wounds infected with anaerobic organisms that would thrive in an occlusive, oxygen-depleted environment. The foam and drape also protect the wound base from environmental contaminants and reduce the risk of friction or shear, enhancing the body's ability to heal. Risk Management Issues with NPWT The system used for negative pressure wound therapy (NPWT) is meant to be just that a system whose components are designed to work together. The NPWT system has been approved by the Food and Drug Administration (FDA) to treat a variety of chronic, acute, traumatic, sub-acute, and dehisced wounds. In general, the system is relatively easy to use and tolerated by patients. Some institutions, however, are using alternative means of supplying negative pressure. These variations on the FDA-approved system have the potential to injure patients, thus putting the institution and individual clinicians at risk for liability. The following discussion focuses on the variations that have been reported anecdotally and why these variations could jeopardize patient safety. Control of pressure levels Instead of the computerized therapy unit that is part of the NPWT system (and which must be rented), wall suction and portable suction devices are being used to provide negative pressure. Wall suction in which negative pressure is delivered through a stationary unit mounted to a wall is appropriate in many clinical situations; however, it lacks the control mechanisms needed to provide safe negative pressure for wound care. Many wall suction devices have control panels that are notched to dial in low, medium, or high levels of suction. Others have a control panel with numeric values that indicate pressure averages. In general, neither style can be adequately regulated to deliver a precise amount of sub atmospheric pressure, which is important in providing the maximum benefits of NPWT and maintaining vascular decompression. Standard wall suction devices are unable to provide the controlled intermittent suction that stimulates replication of cells via mechanical stretch. Intermittent negative pressure is also an essential component for accelerated cell proliferation (Mendez-Eastman, 2001). References: Bollero, D., Driver, V., Glat, P., Gupta, S., Lázaro-Martínez, J.L., Lyder, C., Ottonello, M., Pelham, F., Vig, S., & Woo, K., (2010) The Role of Negative Pressure Wound Therapy in the Spectrum of Wound Healing: A Guidelines Document, Ostomy Wound Management, 56 (5) [Online] Available at: http://www.woundsresearch.com/files/00_ConvaTecCVR2A_lr-3.pdf [Accessed 06 Jan 2011] Genadyne Biotechnologies Inc., (2008) Genadyne A4 Negative Pressure Wound Therapy (User Manual / Technical Manual) [Online] Available at: http://genadyne.com/Manuals/A4_Manual_071609_V1.pdf [Accessed 06 Jan 2011]. Mendez-Eastman, S., (2001) Guidelines for Using Negative Pressure Wound Therapy, Advances in Skin & Wound Care: The Journal for Prevention and Healing, 14 (6) [Online] Available at: http://endoflifecare.tripod.com/imbeddedlinks/id2.html [Accessed 06 Jan 2011].

Can negative pressure wound therapy improve wound condition? A critical literature review

Can Negative Pressure Wound Therapy Improve Wound Condition? Literature Review The wound care clinicians are expertly facilitating h...