Tailoring nursing care to the individual client: empirical challenge of a theoretical concept

The driving and restraining forces that promote and impede the implementation of individualised nursing care: a literature review

BACKGROUND

Despite substantial attention devoted to the development of individualised care in recent years, there is a lack of coherent information and empirical research assessing the driving and restraining forces that promote and impede its implementation.

OBJECTIVES

The aim of this integrative literature review is to describe the driving and restraining forces for the implementation of individualised nursing care from the nurse's point of view. This information is useful for the development of clinical nursing care and in identifying areas for future research.

DESIGN

An integrative literature review.

DATA SOURCES

An integrative analysis of empirical studies and reviews derived from the MEDLINE, CINAHL databases and EMB Reviews - The Cochrane Database of Systematic Reviews (individual* care & nurse, from earliest through April 2008) was conducted focusing on studies which used nurses as informants. The final sample of 43 articles published in English focusing on the individualised care of adult patients from the nurse's point of view was retrieved after a two-stage process.

REVIEW METHODS

The integrative analysis of the studies included three steps. Firstly, the full texts of the final eligible studies were read. Secondly, the driving and restraining forces, that respectively promote or impede the delivery of individualised care were identified and listed in a working sheet. A total of nine categories were identified. Thirdly, a working sheet was completed summarising the information found in the studies reviewed and listing the authors.

RESULTS

Nine categories describing both driving and restraining forces for individualised nursing care were identified: (1) nurse's personal characteristics, (2) skills enhancement, (3) ethical issues, (4) nursing care delivery and interventions, (5) patient characteristics, (6) organisation of work, (7) staffing, (8) team work and group dynamics, and (9) leadership and management.

CONCLUSIONS

A body of knowledge was identified for future research. The results inform both clinical practice and education and promote better use of the nursing work force in order to provide individualised care for patients and maximise good patient outcomes.

A review of outcomes of individualised nursing interventions on adult patients

AIMS AND OBJECTIVES

This review describes the outcomes of individualised nursing interventions on adult patients. Background. Although the delivery of individualised nursing interventions is important there is limited evidence about how these interventions enhance patient outcomes.

METHODS

A computerised search was undertaken using the Cochrane Library, MEDLINE, CINAHL and PsycINFO. The selection criteria chosen were: reports of individualised nursing interventions focusing on adult patients in a variety of health care settings and using experimental designs. These involved randomised controlled trials, clinical controlled trials and pre- and posttest controlled studies. After a four-stage inclusion strategy 31 documents were accepted for the review.

RESULTS

The studies were mostly focused in preventative arenas such as health promotion and counselling. Others were care of older people in the community and in hospital and patients with chronic diseases. Over half of the nursing interventions (58%) involved educational or counselling activities which seem to be more effective than ordinary, standardised or routine education and counselling. Overall, 81% of the studies reported a positive impact of individualised interventions on patient outcomes showing that there is evidence, though limited, that individualised interventions can produce positive patient outcomes.

CONCLUSIONS

There is sufficient evidence, especially in specific areas such as patient education and counselling, to acknowledge that individualised interventions are superior to non-individualised interventions. Evidence for this effect within clinical nursing interventions on patient outcomes was limited by the scarcity of research in this area. There is a need for additional intervention studies to determine the effect of individualised interventions in a wide variety of contexts. Relevance to clinical practice. Experience of health is individual. Therefore, nursing interventions should also be individualised to each patient. These findings show some promise that individualised interventions may be useful in delivering positive patient outcomes.

Tailoring peripartum nursing care for women of advanced maternal age

Births to women of advanced maternal age have increased dramatically over the last decade in both the United States. The majority of women who deliver their first baby after age 35 are healthy and experience positive birth outcomes. According to current research, primigravidas over 35 tend to be educated consumers. Their physical and psychosocial needs differ from those of the mother in her 20s, due to advanced age and factors related to difficulty conceiving and life circumstances. This paper presents (a) an overview of the possible risks to outcomes of childbearing for women over the age of 35; (b) a discussion of how women of advanced maternal age may differ from younger women related to developmental stage, stress or anxiety or both, decision making, and support systems; and (c) an exploration of tailoring nursing care strategies during the peripartum period specifically for this age cohort.

Testing the individualized care model

BACKGROUND

Although there has been some research to identify the dimensions on which individualized care should be measured, the indicators that constitute individualized care remain unclear.

OBJECTIVES

To describe briefly the maintenance of individualized care and to test a hypothetical model of individualized care in a sample of surgical patients.

DESIGN AND METHODS

A correlational survey design was used. Data were collected with questionnaires from adult patients (n = 454) discharged from surgical wards in one Finnish hospital district (response rate 91%). Structural equation modelling LISREL SIMPLIS using maximum likelihood estimation was used to estimate and test the parameters of the hypothesized model derived deductively from the previous literature.

RESULTS

The goodness-of-fit statistics supported the basic solution of the Individualized Care Model, although two additional paths indicating error covariances between the sub-concepts were identified in the revised model. In this model individualized care is defined in terms of patients' views of nursing activities aimed at supporting individuality in care and in terms of perceptions of individuality in their own care.

CONCLUSIONS

The model has been found to capture attributes that characterize individualized care. It can be used as a basis for evaluation in clinical nursing practice from patients' point of view. The study highlights the importance of patients' clinical situation, personal life situation and decisional control as predictors of individualized care. The results also confirm the construct validity of the previously developed Individualized Care Scale.

Online exclusive: a model of health behavior to guide studies of childhood cancer survivors

PURPOSE/OBJECTIVES

To describe the Interaction Model of Client Health Behavior (IMCHB) and its application to health promotion in childhood cancer survivors.

DATA SOURCES

Periodical literature about cancer survivors, health behavior models, and the IMCHB.

DATA SYNTHESIS

Childhood cancer survivors are at risk for various late complications of treatment. The primary goal of intervention is the modification of health-related behavior. Conceptual models that extend beyond health beliefs are needed to guide explanatory and intervention studies in this group.

CONCLUSIONS

The IMCHB identifies background, cognitive, affective, motivational, and contextual variables that explain health-related behaviors. The model defines the interactive and collective contributions of a survivor, family, and provider to adherence to protocols, reduction of risk behavior, and promotion of health-protective behavior.

IMPLICATIONS FOR NURSING

This model may identify new determinants of health-related behavior that can be targeted by specific inter- or intrapersonal interventions to protect the health of childhood cancer survivors and reduce their risk of late sequelae.

Do nurses exercise power in basic care situations?

Power is a matter of authority and control. It can be wielded either consciously or unconsciously, and it can be either overt or latent. Using a structured questionnaire, this study set out to describe nurses' opinions about the exercise of power in basic care situations in both acute and long-term care. The questionnaire was organized into four categories in which items concerned: power in obligatory daily activities; power in activities necessitated by obligatory activities; power in voluntary activities; and power in activities that take into account the patient's characteristics. The samples consisted of 228 nurses from five medical and surgical wards of district hospitals, and 233 nurses from five geriatric units of a community health centre and from one nursing home in Finland. The final response rate was 65% (acute care 76%; long-term care 55%). Data analysis was based on statistical methods. The results showed that, in the nurses' own opinion, negative power is exercised only in certain situations and in the patient's best interest, when for instance there are concerns that something may happen to the patient.

The interpersonal contexts of negotiating care in home care nurse-patient interactions

In this article, the author describes six interpersonal contexts within which care is negotiated between home care nurses and their patients, based on qualitative analysis of 31 videotaped visits. The interpersonal contexts were negotiation of (a) territoriality, (b) shared perceptions of the situation, (c) an amicable working relationship, (d) role synchronization, (e) knowledge, and (f) taboo topics. Analysis of moment-by-moment communication explored how social identity related to care activities is constructed, challenged, or threatened in the flow of events in the encounter. This approach does not problematize negotiation by assuming negative connotations of inequality of power; rather, it examines the therapeutic consequences of specific communication acts. It demonstrates how both nurse and patient are, paradoxically, both empowered and made vulnerable through everyday conversation.

"Individualised care" from patients', nurses' and relatives' perspective--a review of the literature

This paper provides an overview of the empirical research literature on individualised care. It offers a description of the methods that have been used in studies of individualised care over the years, and then discusses the meaning and realisation of individualised care from patients', nurses' and relatives' points of view in order to highlight needs for further research. The review focuses on empirical articles retrieved from the MEDLINE database published between 1973 and June 1999. It draws attention to the complexity of individualised care, which at first sight may look like a relatively straightforward nursing activity. It is shown that a wide range of methods have been used to study individualised care in the current literature. There is a lack of research where patients' experiences of the individuality of care in hospital settings are concerned.

Managing the complexity of best practice health care

Best Practice Health Care is a designed product. Various types of evidence must be accessed, interpreted, and integrated into care design. This integration requires thoughtful organizational planning. The Best Practice Health Care Map provides a model for managing the characteristics of quality clinical care within the framework of multi-disciplinary professional practice. The model incorporates the contributions of various forms of evidence into pre-specification design and point-of-care design.

Developing and testing an instrument for the measurement of individual care

This paper describes a preliminary study in which an instrument was developed for the measurement of individual care in adult patients and in which the reliability and validity of the instrument were evaluated. Individual care was defined in terms of how patient individuality was taken into account and how patient participation in decision-making was facilitated. The purpose here is to describe the process by which the individual care instrument (IC) was developed, the preliminary testing of the instrument and psychometric evaluation of the instrument in a sample of adult patients discharged from a Finnish general Hospital (n=203). Item analyses showed an acceptable level of internal consistency reliability and homogeneity in each scale of the IC, and Cronbach alpha values were high in every measurement. Exploratory factor analysis supported a three-factor solution. The psychometric evaluations suggested that the instrument is worthy of further development.

Individualized care in a Finnish healthcare organization

This paper reports the findings of a study exploring the provision of individualized care in a regional hospital in Finland. Individualized care was defined in terms of how patient individuality was taken into account and how patient participation in decision-making was facilitated. The data were collected from hospitalized patients (n = 203) using a questionnaire specially developed for this study. The response rate was 89%. A strong support to facilitate patient participation in decision-making was reported. Most shortcomings concerning the provision of individualized care related to consideration of the patient's cultural background and the involvement of the patient's family in the planning of care. Patients' age and the type of ward were associated with the provision of individualized care: patients aged 65 or over were more satisfied than younger age groups with the way in which their personal life situation had been taken into account. Patients from the gynaecological ward thought, more than patients from the surgical ward, that their situation had been taken into account during hospitalization.

Using a nursing framework to establish a nurse-managed Senior Health Clinic

This article describes the organizing framework and evaluation component of a newly initiated nurse-managed Senior Health Clinic that is being collaboratively run by a school of nursing and a senior service agency in Central Florida. Background is provided on choosing a partner agency; negotiations; developing a mission statement, goals, and operation plans; determining the target audience; and marketing strategies. The clinic targets residents who are 55 years old and older and who do not currently have a primary care provider. Cox's (1982) Interactional model for Client Health Behavior provides the framework for care delivery and all process and outcome evaluation activities. As such, the model provides an innovative nursing focus to the delivery of primary care services. Client characteristics are used to form the components of the client data collection tool, which was developed to provide baseline information on seniors who are using the clinic. Three elements of client professional interaction are included in the Health Care Form, which documents the nurse practitioner services that were provided: health information, affective support, and professional technical competencies. The Client Satisfaction Tool measures the client's satisfaction with each of the elements of client-professional interaction that are theorized to influence health outcomes. Information management is facilitated by a computer program that enables staff to enter the information directly into the computer. Data collection is ongoing and will quantify the type and extensiveness of services provided and the quality of care at the Senior Health Clinic.

Condom use and fertility among divorced and separated women

Sexually active divorced and separated women constitute a significant population at risk for sexually transmitted diseases. With components of the Interaction Model of Client Health Behavior (IMCHB) used as the conceptual framework, a convenience sample (N=254) of women--mostly educated, White, and in their 30s (20 to 49 years)--was examined relative to condom use and individual and social context characteristics. To explore the effect of fertility on condom use, the sample was divided into fertile and infertile subsamples. The IMCHB explained 49% of the variance in infrequent condom use by the fertile women (n=93) and 21% of the variance in less frequent condom use by the infertile women (n=161).

Evaluation of the Interaction Model of Client Health Behavior through the first decade of research

The Interaction Model of Client Health Behavior was proposed in 1982 as a prescriptive nursing framework. The model is grounded in multidisciplinary perspectives, and early research suggests that the model may be useful for research and practice. The elements of client singularity and health outcomes have been the primary focus of research during the past decade. Statistical analyses have been exploratory. This article concludes that the model is ready for hypothesis testing with more rigorous statistical procedures, more diversity in samples, and more comprehensive use of the model, including the elements of client-professional interaction.

Interactional aspects of self-efficacy and control in older people with leg ulcers

1. Interventions that increase the sense of self-efficacy or competence of the client may have positive health outcomes. 2. Health professional (powerful other) interaction is proposed to have beneficial effects upon health beliefs and health outcomes in the elderly with chronic disease. 3. Beliefs about the ability to perform the required behavior (self-efficacy) are associated with beliefs about a positive health outcome being contingent upon behavior performance (response efficacy).

Creating a future for nursing through interactive planning at the bedside

Interactive planning is introduced as an approach to planning amidst change that may be useful in clinical practice. The underlying principles and unique characteristics of interactive planning are presented. In addition, clinical studies suggesting its inherent presence in nursing practice are identified. Effective care planning as a developmental process provides nurses with a favorable opportunity to both contribute to individualized patient care and create our own professional future.

Communication strategies used by an expert nurse

Individualization of care, or tailoring of care, involves taking into account the client's individuality, and allowing that individuality to determine interpersonal approaches and health-illness management actions (Cox, 1982). Cox's definition of tailoring was empirically supported in a study of three naturally occurring clinical encounters (Brown, 1992). The present analysis was conducted using the research methods of discourse analysis to further understand how the expert nurse in Brown's study used speech actions to enact tailoring. The nurse provided clients with explicit opportunities to introduce their issues, elicited descriptions of their daily lives, expressed personal regard for them, yet also assessed their clinical states. This discourse profile is unlike others reported in the literature and may be considered exemplary.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge

1. The concepts of local and cosmopolitan knowledge may be used by gerontological nurses in creating partnerships with family caregivers to frail older people. 2. Local knowledge is the understanding and skills that the family brings to the caregiving situation; cosmopolitan knowledge is the understanding and skills that the gerontological nurse brings to the situation. 3. Four nursing interventions are guided by the conceptualization of local and cosmopolitan knowledge: acknowledging and affirming local knowledge when it is adequate; developing or enhancing local knowledge when it is inadequate; assisting family caregivers to apply local knowledge to problem solving; and blending local and cosmopolitan knowledge.