Practice of Population-Based Care

Team C Project
NURS 6030 Section 5
The Practice of Population-Based Care
August 16, 2009

Plan for Collaboration Healthcare is a profession in which nurses strive to advocate, guide, and protect those placed in our care. In this spirit, Team C will work together to investigate a healthcare problem to strengthen our collaborative abilities. The team’s systematic approach described below includes team identification, team vision, communication process, determination of roles, conflict resolution, expectations of participation, health problem and target population, and interdisciplinary team identification.
Team C Identification Team C includes four professional nurses. KCE is a Registered Nurse in rural Maryland with 25 years of experience, and is the director of four nursing units (MedSurg-PEDs-Same Day Surgery/PACU-Chemo/Infusion Clinic). LJ is a Registered Nurse with four years of experience in cardiac and home health nursing, and is currently working on a Cardiovascular Intervention Unit in Anchorage, Alaska. JM is a Registered Nurse who has spent the past fifteen years working in clinical support roles, and currently works for a software company as a Clinical Support Analyst for an Operating Room management application. GS is a Registered Nurse with 20 years of experience, and has worked in outpatient surgery for the past five years after fifteen years in the Intensive Care Unit.
Team Vision Team C understands that open communication and collaboration are essential to achieving an excellent outcome on this project, and that compromise may be a part of this process. Team C plans to work together cohesively to meet deadlines and to produce a high quality product for presentation. The team will check in on the discussion board at least three times each week, preferably on Mondays, Wednesdays, and Fridays in order to ensure that all team members are involved in the successful progress of this team project.
Communication Process Communication and sharing of information is crucial to the success of the project by Team C. The expectation is that each team member will participate and submit work within the agreed upon timeframes. Project contributions are to be submitted as attachments and clearly titled as to content and revision number, such as Part 1_1. All team members will collaborate by sharing documents, ideas, and theories through communication under the Team C discussion forum. Collaboration has many attributes including planning, decision-making, problem solving, goal setting, working together, and communicating (Gardner, 2005).
Determination of Roles Determination of roles was voluntary in nature based on individual strengths. Kathy, as organizer, will ensure that the team stays on track by proposing deadlines, posting reminders, and posting project content outline. Lesley will serve as editor of grammar, sentence structure, spelling, and flow of the project. James, as a second editor, will review the project according to APA standards and confer with the Walden Writing Center as needed. Team C’s project presenter is Gulabi who, as presenter, is responsible for the timely submission of the project deliverables. All team members have agreed to contribute to the research process, writing, and review of the paper to ensure quality.
Conflict Resolution Team members will work together as a group of professionals with honesty and respect. Members will discuss any problems that should arise. In this group of equal members, with organizer, presenter, and editor, majority will rule on conflicting ideas. Conflicts can also be seen as positive, and they can bring about good conversation and ideas. When members do not verbalize their thoughts, conflicts cannot easily be resolved. If a conflict should escalate, a mediator can redirect the discussion to the task at hand. Any personal conflicts will be resolved outside of the group discussion. If an issue persists, the group as a whole can work to resolve the issue so that it does not disrupt the group task.
Expectation for Participation Expectations of Team C members will be that we will work well as a group with each member participating equally in discussions, research, writing, and ideas. All assignments will be completed and submitted in a timely manner. It is also expected that should a team member become unable to complete any part of their assignment, for whatever reason, they will immediately notify other members of the team via the discussion board. If any member is perceived as not participating equally, the Team will seek that team member’s participation directly in order to achieve equal input of ideas for this project. If any team member is dominating the project, the Team will politely ask that team member to allow other team members to contribute equally. All Team members’ ideas and opinions equally considered and incorporated as appropriate to produce the best product for submission.
Health Problem and Target Population Team C has chosen smoking cessation and prevention as the health problem that it will study for this project. The target population for this study will be current smokers for the cessation portion, and the non-smoking family members for the prevention portion of the project. We believe that this two-pronged approach will be effective by assisting current smokers in the family cohort with cessation, and by assisting the younger, non-smoking family members with support and education to provide them with tools to use in order that they do not begin smoking cigarettes.
Interdisciplinary Team Member Identification and Roles Team C believes that an interdisciplinary team approach best suits our chosen program. We envision this team to consist of Community Health Nurses (CHN) and other practitioners to both support and augment the work of the CHN. The team will consist of the CHNs assigned to the program. These nurses will perform the actual client interaction and teaching. In addition, there will be a health educator available to assist the CHN with any questions that may arise in the teaching process. An Administrator will be assigned to lead the program. This may be a non-CHN administrator, or one of the CHNs on the team will perform dual roles. Finally, in order to gather meaningful data to present, an office assistant will be available to review the charts created and to perform data entry (Westbrook & Schultz, 2000).
Conclusion
The goal of Team C is to gain a more comprehensive understanding of population based nursing care and the role of the Public Health Nurse in community education and programming. Team C will work together as a cohesive unit assuming best intent in all interactions with team members so that the best work product may be produced and a strong and scholarly project may be submitted.
Investigating Interventions Tobacco use generally and cigarette smoking specifically is a nation-wide health concern. Smoking is linked to lung cancer, coronary heart disease, and chronic obstructive pulmonary disease. It also contributes significantly to high blood pressure, stroke, congestive heart failure, and atherosclerosis (Dowdy). The rate of decrease in cigarette smoking among adults is not sufficient to meet the Healthy People 2010 objective of 12% (Mariolis, Rock, Asman, Merritt, Malarcher, Husten, & Pechacek, 2006). This lack of progress emphasizes a need to establish comprehensive tobacco-control programs that address both the initiation of tobacco use and cessation.
Etiology
Etiology is defined as the study of the causes or origin of a disorder or disease; those factors which predispose toward a certain disease or disorder including the susceptibility of the patient, the nature of the disease agent, and its route of entry into the body (Mosby’s Medical Dictionary, 2009). The etiology of tobacco use is complex. Typically, tobacco use develops in stages progressing from contemplation, initial use, experimentation, regular use, and nicotine dependence or addiction (Dowdy). Many variables affect the probability of tobacco use and nicotine dependence such as tobacco use by one’s family members and age peers, gender, ethnicity, and education. Tobacco dependence is a chronic condition that often requires repeated intervention. Effective treatments do exist that can produce long-term or permanent abstinence (Anderson, Jornenby, Scott, & Fiore, 2002).
Epidemiology
Epidemiology is the discipline that provides the structure for the systematic study of the distribution and determinants of health, disease, and conditions that are related to health status (Maurer & Smith, 2009). In researching the epidemiology of cigarette use and nicotine dependence, a search of the Walden research databases located an article from the American Journal of Public Health with statistics from the National Epidemiological Survey of Alcoholism and Related Conditions. The study by Goodwin, Keyes, and Hasin (2009) indicated while the overall use of cigarettes declined between 1964 and 2002, nicotine dependence has not declined but has increased especially among women. It also found that cigarette use in 2002 was still at 34.4%, which is far from meeting the Healthy People 2010 standard of below 12%. The results were consistent with the possibility that antismoking efforts are successfully reducing the numbers that begin smoking, but those that do begin are more at risk for nicotine dependence (Goodwin et al, 2009). The reason for this trend is unknown. However, it may be those smokers currently smoking are more dedicated smokers and will continue to use tobacco and become nicotine dependent. Another explanation may be that cigarettes have changed over the years to make them more addictive, therefore causing those who are “hard-core” smokers to consume more and more cigarettes. Finally, the study indicated while cigarette smoking prevention efforts appear to have lowered the number of people who start smoking cigarettes, the efforts may not be as effective among those who are already nicotine addicted (Goodwin, Keyes, & Hasin, 2009).
Intervention Programs and Strategies Evidence-based best practice models indicate that self-help programs, while low in cost, are not cost-effective ways in which to achieve smoking cessation. A model which includes “coping and social skills training, contingency management, self-control, and cognitive-behavioural interventions” is midway between a one on one counseling program and a self-help program and provides the greatest level of success while being cost-effective (Robertson-Malt, Roberts, & Kent, 2008). Science-based tobacco control programs have successfully reduced smoking rates among females. In addition, studies have shown that nurse intervention results in a high level of success with cessation programs (Robertson-Malt, et al, 2008). Successful interventions and strategies, according to evidence-based research, include a range of interventions, which are based in nicotine replacement therapy and progress, depending on efficacy, to medication therapy. Patients discharged from a hospital are recommended to receive intense tobacco cessation therapy and intervention for at least a month post-discharge. Alternative therapies, such as hypnotherapy and acupuncture, are not recommended due to high failure rates. Aversion therapy is also not recommended based on evidence, which shows little to no lasting effect on tobacco cessation (Robertson-Malt, Roberts, & Kent, 2008). According to the study done by Lew and Tanjasiri (2003), tobacco use in the Asian American and Pacific Islander population has increased over the last few years because of social norms and targeted marketing by the tobacco companies. This group represents 11.9 million of the total population of the United States and as a result, this study’s policy reflects on methods to prevent tobacco companies in reaching those groups (Lew & Tanjasiri, 2003). Another targeted population is females. According to Preboth (2001), since 1965 smoking-related deaths for women have doubled with the rate of lung cancer increasing to 600 percent since 1950; causing lung cancer to surpass breast cancer as the leading cause of female cancer related death in the United States.
Conclusion
In our investigations, Team C has discovered, as we originally believed, cigarette smoking and nicotine dependence is a national problem of wide scope. A plan is required to facilitate establishment of comprehensive programs to intervene both with non-smokers, to prevent them from beginning the use of cigarettes, and those who are already smokers, to make the attempt to break them of their addiction to nicotine. The goal of this plan would be to reduce the number of smokers to meet the Healthy People, 2010 goal of 12% of Americans actively smoking.
Drawing Conclusions about Intervention Programs Cigarette smoking is a nation-wide health concern and is linked to lung cancer, coronary heart disease, and chronic obstructive pulmonary disease. Successful smoking cessation programs include evidenced-based interventions using complementary therapies. The members of Team C explored local community programs designed to support individuals desiring to quit smoking. Interestingly, despite the geographical distances between team members commonalities were discovered among program interventions as communities strive to meet the goals of Healthy People, 2010.
Health Problem and Target Population For our team project, we chose tobacco prevention and cessation. According to the Centers for Disease Control and Prevention in the United States, cigarette smoking is responsible for about one in five deaths annually or about 443,000 deaths per year. Estimates of 49,000 of these deaths are the result of secondhand smoke exposure, which includes children who live in a house with adults who smoke. Over the years, many researchers have suggested that nicotine is as addictive as heroin, cocaine, or alcohol. Even a brief exposure can be dangerous as non-smokers inhale the same carcinogens and toxins as cigarette smokers do. After focusing on the facts, each of the team members investigated and interviewed nurses in the public health system to find out what is going on in our own communities regarding this problem. The communities that the team researched are Ramsey County in Minnesota, Calgary in Alberta, Canada, Anchorage in Alaska, and Kent County in Maryland.
Intervention Programs In all four communities researched, the tobacco cessation programming was very similar in structure, outreach, and goals. In Anchorage, Alaska, the Tobacco Quitline was the most widely used and successful means of reaching out to the community and achieving successful outcomes for tobacco cessation and prevention. In Kent County, Maryland, the public county nurse has a featured role in creating, implementing, and advancing the goals of the tobacco cessation program. In Calgary, Alberta, the commonly used tobacco cessation program is P.A.R.T.Y., which started out as an alcohol and trauma prevention program. It was so successful in reaching teens and young adults that it later incorporated tobacco cessation and prevention programming as well. In Ramsey County, Minnesota, the primary program for tobacco prevention and cessation appears to be almost identical to the program in Alaska, with heavy use of a quit hotline backed up by counseling and pharmacology in order to achieve long-term success. The programs in all four communities were structured in a multimodal fashion with interventions being available in multiple formats. This allows for a greater outreach and a greater potential for successful outcomes over the long-term. Another common factor in all areas was the use of counter-marketing to neutralize the promotion of tobacco use, in effect trying to overcome the effects of tobacco company promotional marketing, especially to youth.
Synthesis of Programs and Intervention All programs studied have the expressed outcomes of reducing the numbers of new smokers and assisting those that do smoke to quit. These programs consist of online, face-to-face, or group counseling and the use of adjunct medications to assist with the nicotine withdrawal symptoms. These programs are provided at little or no charge to the patient. The programs are funded by Public Health funding sources such as Tobacco Settlement monies in Minnesota and federal/state funds, or directly paid for as a preventative measure by private insurers. There are specific programs targeted at youth smoking prevention. One such program, using an outreach with classroom sessions, targets all risky behaviors, not only smoking. This program uses videos and actual visits by physicians and patients to demonstrate the results of choosing to smoke along with teaching ways of avoiding starting smoking. Each team member brought their local program information to the table and in review, the programs are the similar nationwide. The ultimate goal is to prevent youngsters from beginning the use of tobacco products and to assist current tobacco users with stopping smoking and keeping them tobacco-free.
Best Practices Prevention of tobacco-related morbidity and mortality through smoking cessation is vital for the health and well-being of all community members. Planning and managing effective community specific intervention programs for tobacco use prevention and control by is possible using evidence-based best practices. Multiple studies have demonstrated interventions combining multimodal therapies achieve the most success. The common theme among the research done by Team C for smoking cessation strategies includes counseling (group, individual, telephone help line), social support, cost of programs, and adjunctive pharmacotherapy such as nicotine replacement, buproprion, or Chantix™. In 2000, the U.S. Public Health Service released a clinical practice guideline to promote smoking cessation. Healthcare providers were encouraged to use the following 5-A protocol: Ask about smoking status; Advise all users to quit; Assess willingness to quit smoking; Assist the individual in quitting by referral to cessation program, setting a quit date, and prescribing appropriately pharmacotherapy; and Arrange a follow-up contact (Bastian, 2009). This approach offers many possibilities for modification to suit specific community needs. The 5-A protocol provides the framework for planning community programs and easily incorporated in the daily practice of the public health nurse. Follow-up phone calls are well suited as an evaluation method of smoking cessation programs. Monitoring key processes routinely and tracking trends measures the success of any program. Brunnhuber, Cummings, Feit, Sherman, and Woodcock (2007) suggest calling all program participants at intervals of two weeks, six months, twelve months, and 24 months to assess smoking status and evaluation of interventions. Properly measured, program goals and objectives indicate the level of success or effectiveness and provide a mechanism to adjust interventions.
Conclusion
The Team conducted interviews, researched tobacco cessation, and prevention programming in four communities around the country and in Canada, and found the programs to be essentially the same in structure, content, and goals. While there were some minor variations in the programs, the major finding was that in order to achieve long-term successful outcomes, programs for the prevention and cessation of tobacco use must be multimodal in format, using various means of reaching out to tobacco users and their families, and offering a variety of solutions for quitting. Among these approaches, one of the pivotal interventions in all communities is counter-marketing to minimize and neutralize the effects of tobacco use promotion by tobacco companies. If communities continue to make strides in reducing and eliminating tobacco use, huge monetary savings as well as savings in terms of human life and quality of life will be accomplished.

References
Anderson, J., Jornenby, D., Scott, W., & Fiore, M. (2002). Treating tobacco use and dependence: An evidence-based clinical practice guideline for tobacco cessation. American College of Chest Physicians, 121 (3). Retrieved July 25, 2009, from http://www.medscape.com/viewarticle/431324_2

Bastian, L. (2009). If it is as simple as AAAAA B C, why don’t we do it. Society of General Internal Medicine (24)2. 284-285. Doi:10.1007/s11606-008-0896-2

Brunnhuber, K., Cummings, K.M., Feit, S., Sherman, S., & Woodcock, J. (2007). Putting evidence into practice: smoking cessation. BMJ Publishing Group. Retrieved August 12, 2009, from http://clinicalevidence.bmj.com/downloads/smoking-cessation.pdf

Dowdy, E., (n.d.). Virginia Youth Tobacco Control Project. Retrieved July 24, 2009 from, www.vipbg.vcu.edu/~vipbg/psy691/CC9Dowdy.ppt

Gardner, D. (2005). Ten Lessons in Collaboration. Issues in Nursing, Vol. 10, 1. Retrieved July 13, 2009, from www.medscape.com/viewarticle/499266

Goodwin, R., Keyes, K., & Hasin, D. (2009). Changes in cigarette use and nicotine dependence in the United States: Evidence from the 2001-2002 wave of the national epidemiologic survey of alcoholism and related conditions. American Journal of Public Health , 99 (6) 1471-1477. Retrieved from: http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb

Lew, R., & Tanjasiri, S. (2003). Slowing the epidemic of tobacco use among Asian Americans and Pacific Islanders. American Journal of Public Health, 93 (5) 764-768. doi: 370512401

Mariolis, P., Rock, V., Asman, K., Merritt, R., Malarcher, A., Husten, C., & Pechacek, T. (2006). Tobacco use among adults. Morbidity and Mortality Weekly Report 55 (42) 1145-1148. Retrieved July 26, 2009, from http://www.medscape.com/viewarticle/547878

Maurer, F. A., & Smith, C. M. (2009). Community/Public Health Nursing Practice:Health for Families and Populations. St Louis, MO: Saunders Elsvier.

Mosby’s Medical Dictionary, (2009). Etiology. Retrieved July 26, 2009, from http://medical-dictionary.thefreedictionary.com/etiology

Preboth, M. (2001). Smokeless states issues statement on women and smoking. American Family Physician, 64(8), 1470. doi: 88772727

Robertson-Malt, S., Roberts, M., & Kent, B. (2008). Evidence based information sheets for healthcare providers – smoking cessation interventions and strategies. Best Practice 12(8). Retrieved on July 31, 2009, from http://www.joannabriggs.edu.au/pdf/BP_Book_Vol12_8.pdf

Van Meter, P., & Stevens, R. (2000). The role of theory in the study of peer collaboration. Journal of Experimental Education, 69(1), 113-127.

Westbrook, L. O., & Schultz, P. R. (2000). From theory to practice: community health nursing in a public health neighborhood team. Advances in Nursing Science , 23 (2), 50-61.

References: Gardner, D. (2005). Ten Lessons in Collaboration. Issues in Nursing, Vol. 10, 1. Retrieved July 13, 2009, from www.medscape.com/viewarticle/499266 Mosby’s Medical Dictionary, (2009). Etiology. Retrieved July 26, 2009, from http://medical-dictionary.thefreedictionary.com/etiology Preboth, M Westbrook, L. O., & Schultz, P. R. (2000). From theory to practice: community health nursing in a public health neighborhood team. Advances in Nursing Science , 23 (2), 50-61.