Background

Medication compliance is an issue that revolves around many disciplines and specialties in healthcare. A great public concern in the community is the consequences of medication noncompliance in psychiatric patients where accompanying symptoms and behaviors of psychosis pose unique risks and challenges. While limited infrastructure and community resources remains a large issue with policymakers, medication noncompliance is an underlying and overlooked issue that must be addressed. The first step in management is to investigate, through quantitative research, factors affecting adherence particularly in patients diagnosed with psychiatric disorders.

Definitions and Measurement

Quantitative research is utilized to determine and analyze the relationship between an independent variable and an outcome variable within a population. This method emphasizes objective measurement and the statistical, mathematical, or numerical analysis of data (Babbie, 2010). There are many advantages to utilizing quantitative research methods as it allows statistical analysis for greater objectivity. The obtained numerical data can be displayed as graphs, charts, tables, and other formats to enhance interpretation (“Research Guides: Organizing Your Social Sciences Research Paper: Quantitative Methods”, 2012). Additionally, numerical quantitative data may be viewed with greater credibility.

Application of Quantitative Method

The methodology is applied to this study in the form of the survey questionnaire in Appendix A, which patients fill out. From this raw data, patient opinion is translated into numbers via a Compliance Rating Scale by focusing of contributing factors for patient non-compliance including: remembering medication administration, reasons for forgetting administration times, reasons for not taking medications, the ability to list personalized regimens, and having general understanding of medications they currently take. This rating system is seen in Table 1.

Trouble Remembering	Never +3	Rarely +2	Sometimes +1	Always +0
Number of Reasons for not Remembering	None +3	1 +2	2 +1	>3 +0
Reasons for Not Taking Medications	0 +3	1 +2	2 +1	>3 +0
Ability to List Medications	All +3	Most +2	Some +1	None +0
Medication Understanding	Yes +3	Kind of +2	MD not explaining +1	None +0

Table 1. Compliance Rating Scale. Scores are based on a point system with 15 out of 15 representing the best possible chance for compliance towards medications.

This paper will analyze the quantitative findings of the study through statistical analysis, interpret and describe the comparison and relationships among variables, and discuss implications and summary of findings.

Research Topics

The topic of this survey was centered around the issue of medication compliance in such a vulnerable patient population. For this study, the population surveyed were patients who were admitted into an acute inpatient psychiatric hospital and those who were being prescribed psychotropic medication. The patient population survey included male and female patients of varying ages who were admitted with a variety of primary psychiatric diagnosis including bipolar disorder and schizophrenia. However, all the patients surveyed were currently prescribed and taking antipsychotics. In psychiatric patients, it is important to mention that although consent is required for administration of psychotropics, patients still have the right to refuse medications. The only exception would be unique situations that include permanent conservatorship, Riese status (legal incapacity to consent), or emergency situations all of which were excluded in this survey.

The questionnaire included in Appendix A provided basic patient demographics while also preserving their privacy. Additionally, it surveyed a basic comprehension of the patient’s current medication regimen. The patients were also questioned regarding their compliance or lack thereof and reasoning.  The goal of the survey was to compare and determine if offering an injectable medication in lieu of oral antipsychotics would increase medication compliance in this specific

patient population.

Hypothesis Based on Analysis

Null Hypothesis:

There is no significant difference in compliance rates between different formulations of medications.

Alternative Hypothesis:

There are significant differences in compliance rates between different formulations of medications.

Goals of Research

Beyond the evaluation of this research study, another invaluable aspect worth learning would be patient perspective. The population surveyed were patients diagnosed and affected by psychiatric disorders in which thought or mood dysregulation was more likely present. The question then would be how the current cognitive or behavioral state could affect the comprehension and interpretation of the results. The patient’s perspective would be worth investigating in the hopes that it would reveal more than compliance issues. Other intriguing goals of this study include determining other variables that might affect compliance such as logistical, geographical, or insurance issues. Regardless of the patient’s comprehension of medications and willingness to take an injectable medication, other variables might adversely affect the likelihood

of compliance as the unintended result.

Interpretation of Results

After applying a linear regression analysis, it is obvious that the research does not support the alternative hypothesis of there being a significant difference in compliance rates between different formulations of medications. This is proven via P value testing as calculated in Appendix B. Here, the P value is calculated to be 0.3466 for an unpaired T-test using a 0.05 or 5% significance interval. As the P value is greater than the significance interval, it proves the results are statistically insignificant and we can reject the alternative hypothesis.  Thus, the null hypothesis of no meaningful connection between medication formulation and compliance outcomes is a possibility.

As shown in Figure 1, we see the comparison with standard deviation of the two populations, and although at first glance it would appear that oral medications are more favorable in terms of compliance, with such a large standard deviation, the compliance rating of both medication administration methods is approximately 8 out of 15.

As the maximum score is 15 out of 15, with an average compliance across both medication formulations being 8 out of 15 this is consistent with current data that patients traditionally are non-compliant with antipsychotic medication.

Figure 1. Graphical Representation of Injectable and Oral Medication Compliance Rates with Standard Deviation.

Relevant Studies

Few studies have thoroughly compared long-acting injectable antipsychotics to its oral counterparts. Long-acting formulations were manufactured to combat the issue of medication noncompliance in psychiatric patients deemed at risk. Although long-acting injectable medications are a powerful tool to assure compliance or signal noncompliance, recent results from randomized controlled trials failed to show superiority compared to oral antipsychotics (Kane, J. M., Kishimoto, T., & Correll, C. U., 2013). This further suggests that there is not a non-adherent personality observed among this patient population that is valid nor reliable in predicting medication compliance. It is also significant to note that medication noncompliance, especially in psychiatric patients, can be influenced by the level of knowledge or insight and attitude towards their psychiatric disorder and the resulting treatment regimen. The patient’s perceived risks and benefits of medication and treatment of their disorder greatly influences the likelihood of compliance.

Application to Healthcare

The issue of medication compliance is an issue in healthcare that would be invaluable to research. A concept learned in this course that was relevant in this process of this survey and analysis is utilizing tools for data organization, analysis, and presentation.  Data analytics is a critical aspect in the healthcare field. This course emphasized establishing standards to enhance data quality. it is important as it provides guidelines and a general direction in the process of collecting data. Also, establishing a numbering or tracking system as it is demonstrated in Appendix B. A unique numbering system helps to develop and identify all organizational forms so that as research is continued, the process of data collection, measurement, and results could be

repeated (Sayles, N.B., 2016).

Limitations of Research

The findings of the survey yield a quantitative result that suggests the preparation or formulation in which antipsychotic medication is administered did not improve or increase the likelihood of adherence to prescribed medication. A limitation to this study is the size of subjects completing the questionnaire as only ten patients were surveyed. Also, the specific population that was surveyed is unique in which there may be symptomology present related to their psychiatric illness which could be considered a limitation to the questioning in this study.  The risk being the inability or lack of insight to comprehend the study and the subjective bias this may entail. This also influences the results as any potential thought dysregulation may dictate if medication compliance is possible. Another limitation to consider is this patient population may exhibit symptoms such as paranoia secondary to their primary diagnosis in which administration of injectable medication may further exacerbate their acute condition. These alone did not inhibit effective interpretation of the results as the compliance rate system used for statistical analysis scored patients appropriately based on numerous factors that would predict the likelihood of compliance.

Summary of Findings, Recommendations and Future Research

Prior to the study, one could occupy the assumption that offering an alternative to oral medication such as a long-acting injectable medication would increase medication compliance. The findings of this research study invalidate the concept that there is no significant difference in compliance rates between different formulations of medications offered to psychiatric patients.  The results may help illustrate one of the issues relating to the public community. Noncompliance can have negative consequences and an increase in medication adherence would decrease the incidence of decompensations that result in institutionalization or incarceration. It would be imperative to intervene in the early phase and manage patient compliance to help prompt providers, healthcare administrators, and policymakers realize the gravity of the issue. There is a need for continued research and insight relating to the factors that influence medication noncompliance and further investigation is warranted to bridge the gap between medications and

patient compliance.

References

• Babbie, Earl R.
  
  The Practice of Social Research
  
  . 12th ed. Belmont, CA: Wadsworth Cengage, 2010; Muijs, Daniel.
  
  Doing Quantitative Research in Education with SPSS
  
  . 2nd edition. London: SAGE Publications, 2010.
• Fenton, S.H., Biedermann, S. (2017).
  
  Introduction to Healthcare Informatics
  
  (2
  
  ^nd
  
  ed
  
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  . Chicago, IL: AHIMA.

  Kane, J. M., Kishimoto, T., & Correll, C. U. (2013). Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies.
  
  World psychiatry : official journal of the World Psychiatric Association (WPA)
  
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  (3), 216-26.

• Research Guides: Organizing Your Social Sciences Research Paper: Quantitative Methods. (n.d.). Retrieved from http://libguides.usc.edu/writingguide/quantitative
• Sayles, N. B. (2016).
  
  Health Information Management Technology: An Applied Approach
  
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Appendix A

The following survey/questions do not require you to disclose your name/identification.

Please answer the following questions to the best of your ability and to what you feel you are comfortable in answering. Please stop and ask for clarification when necessary.

▢ Male ▢ Female     Age: _______

Primary Diagnosis (if possible): __________________________________________

1. What route/forms/preparations of medications are you familiar with?

▢Pills (tablets/capsules) ▢oral suspension/liquid(syrup) ▢Injection ▢Intravenous (IV)

2. What route/forms/preparations of medications do you



currently take



?

▢Pills (tablets/capsules) ▢oral suspension/liquid(syrup) ▢Injection ▢Intravenous (IV)

3. Do you have trouble remembering to take the medication prescribed by your psychiatrist daily?

▢ Never ▢Sometimes ▢ Rarely ▢ I never forget

4. What are the reasons you forget or have trouble taking medication(s)? *Please explain (i.e, work schedule, travel, appointments, access)

_________________________________________________________________________________________________________

5. Please list some of the reasons why you



do not like



to take the medication(s) prescribed by your psychiatrist:

▢ Side effects ▢ Taste ▢ Lab/blood work for therapeutic levels ▢ Amount of medication ▢ difficulty keeping follow-up appointments ▢ Cost/Copays ▢ Transportation issues ▢ Effectiveness ▢ This doesn’t apply to me ▢ Other:____________________

6. Please list the medications (If you can) that you are being prescribed by your



psychiatrist



:

_________________________________________________________________________________________________________

7. Do you have a general understanding of these medications? (What they are for? What do you need to look out for or monitor?

)▢ Yes ▢No ▢ I kind of understand ▢ My physician hasn’t explained them to me * If yes, please explain:

_________________________________________________________________________________________________________

8. Would you be willing to take a long-acting injectable medication in place of the oral medication taken every day prescribed by the psychiatrist? The injection would/could be ONCE every 1 or 3 months

.

▢ Yes ▢ No * If NO, please explain why: ______________________________________________________________________

9. Would offering you a long-acting injection once a month help you to be compliant with your medication?

▢ Yes ▢ No * If NO, please explain why: ______________________________________________________________________

10. Please list any other questions or comments regarding taking a long-acting injectable medication?

__________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for participating in this survey/questionnaire. Your feedback is greatly appreciated!

Appendix B

Injectable
Patient 3 37 Bipolar affective disorder	5
Patient 4 64 Bipolar affective disorder	3
Patient 5 29 Schizophrenia	4
Patient 8 57 SAD	8
Patient 9 24 Bipolar disorder	7
Oral
Patient 1 25 schizophrenia	5
Patient 2 57 SAD	6
Patient 6 23 Bipolar affective disorder	7
Patient 7 27 Schizophrenia	5
Patient 10 55 Bipolar Affective disorder	12

Oral Population Total: 5

Injectable Population Total: 5

Stdev (oral): 2.915475947

Stdev (long acting): 2.073644135

Confidence Interval 0.05

Unpaired T-test results: P value = 0.3466

As the P value > 0.05 the results are not statistically significant for any difference in any of the variables. We cannot reject the null hypothesis at this time; there may be no significant impact on medication compliance with change of medication formulation.

Tables

Table 1

Compliance Rate System

Trouble Remembering	Never +3	Rarely +2	Sometimes +1	Always +0
Number of Reasons for not Remembering	None +3	1 +2	2 +1	>3 +0
Reasons for Not Taking Medications	0 +3	1 +2	2 +1	>3 +0
Ability to List Medications	All +3	Most +2	Some +1	None +0
Medication Understanding	Yes +3	Kind of +2	MD not explaining +1	None +0

Note:  Compliance Rating Scale. Scores are based on a point system with 15 out of 15 representing the best possible chance for compliance towards medications.

Figures

Figure 1

Comparison of Injectable Vs Oral Medication Compliance Rating

Figure 1. Graphical Representation of Injectable and Oral Medication Compliance Rates with Standard Deviation.

“Up to 65 per cent of Australians are likely to experience or witness an event which threatens their life or safety” (19). Quite often trauma victims can recover by their own. However, with others it may have a negative reaction to a traumatic event which can then lead to an illness called Acute Stress Disorder (ASD) (16). This disorder is associated with mental and physical conditions combined thus causing reductions in a person’s quality of life and as a consequence includes economic burdens (12). (3) Due to the result of all the accumulating evidence, Diagnostic and Statistical Manual – fifth edition (DSM-5) has marked and modified goals and criteria for ASD. Under new criteria, ASD diagnosis will no longer predict chronic Post-traumatic Stress Disorder (PTSD). It will help to identify more severely affected survivors of trauma prior a diagnosis of PTSD can be made. Furthermore, the acuity people will perhaps get benefit from earlier interventions and short-term rehabilitation programs that are the great help in the recovery process. Early rehabilitation interventions, including self-care strategy, thought control strategy, and cognitive behavior therapy (CBT) would speed up recovery and prevent chronic longer term problems. Besides that, family members, clinicians, and social support networks play an important role in support mechanism for recovery process. Inaddition, some potential barriers are also discussed in predicting of new problems and relapse which may occur in order to manage them.

Potential recovery

According to (2) DSM-5 in 2013, ASD was relocated in Trauma- and Stressor-Related Disorders. ASD is a psychological and physical shock which usually appears in response to a traumatic event in a person’s life. The acutely traumatized person can be directly exposed to or be the witness of a traumatic events such as serious accident (21%), physical assault (19%), rape or witnessing a mass shooting (50%) or natural disaster (10%)(19). (9) Symptoms of ASD occur immediately right after the trauma, and it lasts for more than 2 days and less than 1 month (4). The victim usually suffers from anxiety, distress, intense fear, helplessness, avoidance behaviours or re-experience the event (16). (15) It has been recorded that 15% to 45% of children and adolescents directly experience to at least one traumatic event. There is no statistics of how many distressed people can fully recover due to these traumas; however in many studies it has been confirmed that ASD patients can have a full recovery under appropriate treatments. This study strongly emphasis on ASD rehabilitation rather than attempting to predict subsequent PTSD. Due to ASD timeframe is short, many victims are usually been ignored. Particularly, children and adolescent are in high risk of developing PTSD which leads to long-term psychological sequel in their life and causes a burden on health care systems. Therefore, (15) highlighted that recognizing ASD symptoms is an important step in toward enhancing intervention in the right time and speed up the recovery process. Additionally, with a formal diagnosis, it will allow highly distressed people to claim compensations from the health care service and payment for recovery treatment (4). In order to get appropriate diagnosis and early intervention, physicians play a critical role for assessments and monitoring all physical and psychological symptoms.

Recovery process

Whenever a referral from a physician has been made, the traumatized patients will go through a rehabilitation process. This process needs self-care strategy, thought control strategy, and CBT to support patients’ recovery and to decrease the future incidence of PTSD. (7) With self-care strategies, it focuses on personal strengths and their own judgment. Whether any kind of psychotherapies are provided to traumatic people, they should rely on their own recovery ability first. Without their own effort, all the supports will become ineffective. Traumatic patients, then, will receive reassurance and support, such as simple information and advices on self-care to overcome the normal recovery process. However, if the person cannot scope with these extremely severe events, and express a prolonged distress, or interfere with daily activities, they will need to be referral to another level of psychotherapy.

Currently, it has been found that thought control strategy is an acceptable strategy for managing trauma related distress in the short term rehabilitation. Use of thought control strategy will aim to reduce the

emotional distress

by sharing the traumatic stories in the unforgettable period of time (14). There are four components (worry, distraction, social element and re-appraisal) which are the most commonly used to focus on helping the patient to normalize reactions to trauma (22). The first being Worry/Stress, it is best trying to get the patient to not concentrate on the stressful thought itself. Encouraging the patient to try and replace worry or stress with other day to day concerns that may hold a more minor bearing. The second is distraction. Finding a healthy distraction could be simple as think about things that provide a positive feeling or immerse the patient in an activity that is pleasurable. This will stop the patient concentrating on the traumatic event and allow them to go about a daily routine. The third would be social elements that could help. This could be asking or speaking with friends about their thoughts and how they have dealt with such events in their lives. Asking about what worked for them or what may have helped them avoid concentrating on the stressful event. This would be discussed fully so that the patient could reflect and understand how this could apply to their situation. The fourth is re-appraisal, trying and interpreting their feelings and understanding why these things are affecting them emotionally and rationalize their reactions to these feelings. From here they should challenge the validity of their emotions and feelings in order to control positive or negative feelings.

If these self-care strategy and thought control strategy still have not worked well for recovery, CBT would be the next step of treatment in rehabilitation. (12) CBT will be given in five therapy sessions this comprising prolonged exposure (PE) and cognitive restructuring (CR). (12) found that these sessions provide brief forms of treatment in reducing acute symptoms of ASD in the initial month after trauma exposure. (8) PE focuses in emotional processing of thoughts. It helps interrupt and reserve recovery process by blocking cognitive and behavioral avoidance. This is accomplished through in vivo and imaginal expose. Vivo exposure involves repeatedly activities and situations that are avoided because of trauma. Overtime, the patient can reduce distressing emotion and fear. Then, they can cope effectively through these distresses. Imaginal exposure is related to repeatedly describe the event aloud in details, then recording. After that, they listen to their record in order to help them to realize their coping skill.

Following initial assessment, patients were informed that they would



be reassessed after 6 weeks

Support mechanism

Besides psychotherapy in rehabilitation process and early supportive care structure being delivered is an important step which supports the recovery process. Its result last long in reductions of ASD symptoms. Supportive care deliverers are family members, physician or social support network will help the traumatic patient go though the acute phase. (17on) In most cases, family members usually ask for advices on how to help their love in stressful situation. This will let the family to be able to utilize a communal experience in order to enhance the therapeutic growths. The use of positive family members has also been shown effectively assisted their traumatic member to manage their stressful conditions. They provide support, love and reinforce coping strategy with the trauma. The individual does not feel isolated, but also they feel warm and being caring. The individual, therefore, can describe what happened and how they response though this hard time.

However in some cases family sometimes is not enough to support traumatic patients. If the trauma patients and their family feel unable to cope with this traumatic event, they can seek professional help from a physician such as an Australian Psychological Society (APS) psychologist. An APS psychologist will help the severe distress people to understand and manage the symptoms associated with the trauma. An APS psychologist would develop effective coping strategies for affected individual as well as their family to support the recovery process (18). If not, traumatic people also seek help from social support network such as Beyondblue, Sane or Mental Health organizations. Beyondblue is a support service designed to support, give advice and create actions. Whatever the situation is, Beyondblue always listens to their distress stories and share their misfortune. Beyondblue members can really help patients come to terms with their illness and help them to move forward (23). Similarly, The Australian Centre for Posttraumatic Mental Health is a not-for-profit organization which its aim to reduce the impact of trauma causing to the victims. They connect the capability of individual’s family with their organizations within the community. Therefore, they can understand about the traumatic victims, then, help them to prevent and recover from the adverse mental health effects of trauma.

Barrier : wrong diagnosis, overwhelm with treatment, comorbid psychiatric disorders

Due to a shorten timeframe of ASD, there appear some barriers which prevent the recovery process such as late diagnosis, overwhelmed treatments. Besides that some will subsequently develop comorbid psychiatric disorders. In case of traumatic events happen, the victims are late identified. Then, they will receive some simple advices how to overcome that situations. They are supposed to recover on their own. However, there are still significant people who cannot go through this recovery process by themselves. They need help from physicians to be assessed in order to receive a formal diagnosis. This process somehow is taken time which lead to a late diagnosis. If this is too late for appropriate treatment of stress disorder, it will develop further into PTSD. Furthermore, without this proper diagnosis, traumatic patients will not get the benefit from standard rehabilitation treatments (4). This problem can be predicted by the role of physicians who can manage clinical judgments in order to give their patient an early diagnosis.

For those patients who have received treatments within hours or days after an acute trauma incident, they sometime do not response well to treatment plan due to overwhelm of different interventions. They will present a psychosocial and environment difficulties related to problems such as agitation, emotional pain, and dissociation. Quickly treatment but also slowly explanation and monitoring the response from patients will enhance effective support to recovery process. With patients that respond positively and appear to be recovered from ASD, they sometimes sudden relapse when new event happen to their life. They suffer from fear about safety for themselves as well as their family. The relapse can be recognized by close family members who help the patients to report it to physician in order to get continual treatment (17).

Treatment of ASD is usually focused on its specific symptoms. However, some subsequently develop with ASD might be appear such as depression, withdrawal, shame or drug and alcohol abuse, and even suicidal behavior (17). The comorbid psychiatric disorders occur due to the inability scoping with that such traumatic events. These occurssing will significantly affect the recovery process; therefore, it is a requirement for careful attention in both pharmacologically and psychotherapeutically. The patient at high risk of suicide or drug and alcohol abuse should be highlighted during initial assessment. It is necessary to evaluate this potential harm which gets into the treatment pathway and the recovery process.

Conclusions

In conclusion, (4) the criteria set for ASD in DSM-V will allow identifying the people who had negative reaction to a traumatic event. Because of the short duration, it is necessary to assess severe traumatic people as quickly as possible. Then, they can receive an appropriate diagnosis in order to get benefit from rehabilitation treatments. Having an early treatment will move towards healing and recovery process. Moreover, as a result of suffering both physical and psychological conditions, these fragile people require a high level of support from family member, physicians as well as social support network to be back to normal life.

Virginia Henderson’s Need Based Theory and Practice Implications

According to Nicely and DeLario (2010) Virginia Henderson’s theory, Need Based, which is derived from the Principles and Practice of Nursing is a grand theory that focuses on nursing care and

activities of daily living

. This theory is appropriate to my future practice setting as a Family Nurse Practitioner within the Emergency Department or Fast Track/Urgent Care setting. This theory is applicable within this setting since “meeting patient needs in the areas of respiration, nutrition, elimination, body mechanics, rest and sleep, keeping clean and well groomed, controlling the environment, communication, human relations, work, play, and worship (Masters, 2015, p. 384), as these will be advanced nursing care areas that I will need to promote for my patients basic needs.

Henderson’s Background and Theory Development

Virginia Henderson, born in 1897, was a world renowned Nurse educator, researcher and author of many nursing textbooks whose career spanned 60 years; considered by many as the modern day Florence Nightingale (Masters, 2015). A profound change occurred in her life which was around the time of WW one, during this time her nursing experience evolved while in school which resulted in obtaining a bachelors and a masters in nurse education (Masters, 2015). This experience was able to help her see a vision for basic nursing care with patient focus on patient independence with activities of daily living (ADLs), being the basis of her framework and practice. Henderson became a professor at Yale University where she wrote many nursing textbooks that emphasized nursing care, studies, principles and practice (Masters, 2015). She was able to define her personal nursing theory and create the theory that focused on basic nursing care and patients ADL’s. Encouraged by her nursing research she was able to speak around the world and focused on an international approach for better patient care (Masters, 2015). According to Masters (2015) Virginia Henderson received several honorary degrees during her respectable nursing career which included the Christiane Reimann Prize from the International Council of Nursing.

Possible Reference for Theory

Due to Virginia Henderson being an author she received a position collecting, reviewing and chronicling every nursing research that has been published allowing her to write volumes on nursing research and studies (Vera, 2014a). This may have allowed her to come up with analytical applications on what nursing was and could have drawn her strengths and assumptions from her review of researched material. Some may say that Maslow’s Hierarchy of Needs was the reference to her theory as the needs are somewhat similar of what actions or roles one may be or need assistance with in order for independence and wellbeing.

Phenomenon of Nursing and Common Problems

The common problems of Virginia Henderson’s need based theory, this theory outlines the 14 components of fundamental nursing care and interventions that patients have or use as part of their independence and ADLs (Masters, 2015). As a future APRN the common problems that are resolved are 14 components that maintain the patient’s physical functions, safety and maintaining a sense of wellbeing and finding oneself in relation to where they see themselves in life (Masters, 2015).

Deductive Reasoning for Theory

Virginia Henderson utilized scientific method which is considered deductive reasoning to come up with the needs based theory. Deductive reasoning allows for an inquiry decision to arrive at a solution to an issue, an action – reaction system where there is a cause to a component there will be an effect on the component, with independence on its own essence with or without external circumstances (Masters, 2015). According to Masters (2015), Virginia Henderson’s utilized the physical, emotional and mental (psychological components) to deductively arrive to this theory even though she did not intend to imply a new nursing theory; the theory is in relation to Maslow’s theory though Henderson was not aware but the 14 sub-concepts relate and coincide with Maslow’s.

Explanation, Definition and Interpretation of Concepts and the Four Metaparadigms

Henderson made an assumption of her work that it was not a nursing theory so she did not fully identify her concepts but researchers were able to come up with concepts from her work that actually follow the common metaparadigm’s of nursing which she included within her definition of nursing. According to Masters (2015), Virginia “did not intend to develop a theory of nursing, she did not develop the interrelated theoretical statements or operational definitions necessary to provide theory testability (p. 390)”. Concepts include person, environment, health and nursing. Person is defined “as the patient who is composed of biological, psychological, sociological, and spiritual components (Masters, 2015, p. 387)”. These compositional segments are not separate entities but help to assist the nurses towards interventions for the 14 components of care, the person and family are not separate either but are considered a whole item (Masters, 2015). Virginia Henderson was able to keep all concepts of theory and definition consistent throughout since they overlapped and interrelated with each other to include a whole person aspect.

Environment is important to a person’s perception of health and wellbeing but can also affect a person’s physical as well as mental wellbeing. Henderson identified a person’s environment as external elements that help to mold and shape an organisms life and physical change; three areas of environment that are important are biological, physical and behavioral (Masters, 2015). Biological includes anything that is living and breathing organism, such as flora and vertebrate, physical components like basic elements for life such as the sun, elemental chemicals and compounds. Both physical and biological elements work harmoniously together in symbiosis, when something changes it affects the whole ecological system and puts a strain on the symbiotic relationship of the physical and biological environment (Masters, 2015). Behavioral health influences the person and is the last component of environment; influencers include socioeconomic elements, political, cultural, and spiritual aspects.

Health was not a component of Henderson concept that was clearly defined but Henderson did imply that health was in relation to one’s independence (Masters, 2015). Basically, the 14 components of basic needs relate to the persons health as health relates to independence with activities of daily living.

Nursing is very clearly defined by Virginia Henderson and she has one of the best known definitions of nursing. According to Virginia Burggraf (2012) Virginia Henderson defined nursing as:

the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

As for advanced practice nursing fields Virginia Henderson was a proponent for nurses to be independent practitioners she may have not wanted full practice independence as she was not for nurses taking on what she perceived as physician duties such as diagnosis, treatment, and making judgment calls (Masters, 2015).

Proposition of Concepts

Masters (2015) suggest that nurses are viewed as a helper, assistant and companion to a patient’s health role and wellbeing. The relationship aspect is that when a patient is sick the nurse helps the patient to get better and recover, while the patient is in rehabilitation role the nurse assists the patients in achieving independence. Lastly the nurse is a companion during planning of care, goal setting, and preventive maintenance initiatives.

Assumptions of Needs Theory

According to Masters (2015) there are seventeen assumptions of the Needs theory that were implicated from Henderson’s theory they include: Nurses must assist people with illnesses; nurses must collaborate within an interdisciplinary team and become independent professionally from the physician; 14 concepts of nursing describe patient needs and complete nursing functions; goals are achieved with a symbiotic relationship between patient and nurse with health promotion as the nurses main goal; patient and family are one with mind and body being one within the person; assist patient with independence while the patient controls their physiological and psychological harmony; people function in health at all times and must maintain independence and relationships; people maintain health status with knowledge and awareness; illness effects environment conditions and nurses should maintain a safe environment; nurses must be culturally competent and must maintain best practice methods while relying on evidence-based research methods.

As explained above the four major concepts were defined by Virginia Henderson that also describes the four metaparadigm’s as Henderson theory is the foundation of nursing practice. Henderson theory does include sub-concepts which will be explained. These 14 sub-concepts are: normal respiration, proper nutrition and hydration, waste elimination and management, mobility for posture maintenance, sleep and relaxation, proper appearance and grooming, thermoregulation through external factors, safe environment and preventive injury, communicate emotional concerns and distress, spiritual worship, career leading to achievement, recreational activities, and utilization of health resources and using healthcare facilities (Vera, 2014b). These are all relevant elements to an APRN as these can be used within assessment towards finding the patient’s independence level and to assess patient’s assistance in obtaining or maintaining activities of daily living for basic needs (Masters, 2015).

Theoretical Clarity and Applicability

Virginia Henderson theory is very easily understandable and covers a broad range of nursing especially the APRN as independence was a goal for Henderson’s nursing goal besides patient’s health promotion. The definition of nursing is clear and very lucid and applicable to her assumptions and components of theory. Since it was not her motive to come up with a nursing theory consistency within the theory is adequate though death is not clarified as she maintains that nurses should be there for patient death and comfort but no suggestion as what one must do or grief assistance with the family and patient.

Theory Sub-concepts in Practice and Guidance of Nursing Actions

Utilizing Virginia Henderson’s basic needs theory and its 14 concepts will be beneficial in my practice as a new Family Nurse Practitioner. As I would like to work within the emergency department, putting into action clinical provider interventions would lead to examples such as: concept of breathing normally would lead me to administer my patient oxygen with an Albuterol treatment and treat with intravenous Solu-Medrol.

Eating and drinking appropriately, proper nutrition is vital for diabetes management, weight management, heart health, wound healing, autoimmune disease, and patients overall health.

Body waste removal, imbalanced removal of body waste can indicate if there is an organism illness such as C. difficile, being aware of normal elimination methods and treating with antifungals and antibiotics with probiotic treatment for maintenance for good gut health.

Movement and mobility, it is important to maintain my patients independence so splinting fractures from sports injuries, or advising low impact exercise and flexibility exercises to arthritic and osteoporosis patients are crucial to my practice development.

Sleep and relaxation is important sub-concept of Henderson theory, maintaining my patients sleep rhythm and patterns by decreasing external stimuli while my patient is in the ED at night, and providing privacy and comfort during the day and more importantly at night will allow a calmer and more enhanced patient experience.

Dressing appropriately is important to the patient’s perception of physical self and wellbeing. Being able to dress independently is an important ADL, within the ER this can be seen when patient is able to wear a gown and apply it on themselves without assistance, providing them time to dress themselves without being an inconvenience to acuity.

Body temperature regulation is important to the patient’s physical health, if a patient can not regulate their temperature heat blankets or mechanical regulated blankets like a Bair hugger can be applied to maintain proper thermoregulation.

Clean body and protection of the skin, importance of promoting proper body hygiene and infection prevention practices and isolation procedures for my fellow employees and nurses and educate them to teach patients as well as family upon entering the ED and seeing the patient.

Avoiding a dangerous environment, it is important to teach staff to transport patients within the ED and to other areas of the hospital is important for their physical health. Properly utilizing body mechanics, identifying fall risk patients intervening by locking bed and wheelchair wheels when necessary and maintaining a clean uncluttered patient room and hallway environment for patient safety.

Communication with others about feelings, it is important to use interpersonal and therapeutic communication and as a future APRN it is vital for me to actively listen to my patients and fellow team. Being able to empathize with a patient can open up to psychiatric, emotional and social traumas one may have occurred during an assessment history intake and being able to empathetically listen while making a proper medical judgement call is important for patients wellbeing.

Spiritual worship is important to the person’s mental and emotional wellbeing. As an APRN allowing others cultural and spiritual options influence their medical decision needs to be respected and nurtured as vital for the patients and families. Assimilation into the healthcare system that may or may not nurture their spiritual/cultural decision. This will increase my spiritual/cultural competence.

Work that increases oneself worth, important for patients mental health, leads to feelings of independence. Allowing one to continue their work and hobby benefits them to feel independent and able to fulfill their ADL’s. So maintaining ones finger after a work related accident by suturing and referral or assistance with a plastic surgeon is important knowledge to maintain in allowing ones independence.

Recreation activities benefits the patients physical health, some patients come to the ED after a sports injury so maintaining a sprain ankle by wrapping it and teaching the patient to utilize crutches and slowly introduce low impact, low weight bearing exercise while teaching proper NSAID administration is important in preserving my patients future recreational activities.

Normal health development and its resources, when I become a new APRN learning the different patients and diagnosis I see and utilizing a cohesive interdisciplinary team who is more knowledgeable as a resource is important for best practices towards the patient for their optimum health.

Conclusion

Virginia Henderson’s needs theory is applicable to many disciplines of nursing with various practice scopes. Utilizing this theory and putting it into action within practice is very adaptable and allows one to reflect on their nursing competency when it involves maintaining a person’s health promotion and independence level. As stated by Masters (2015) with Henderson’s philosophy of applying best practice methods which involve evidence-based research, advanced practice application of theory can be a foundation for their nursing process.

References

Burggraf, V. (2012). Overview and summary: The new millennium: Evolving and emerging nursing roles.

OJIN: The Online Journal of Issues in Nursing

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17

(2). doi:10.3912/OJIN.Vol17No02ManOS

Masters, K. (2015). Models and theories focused on nursing goals and functions. In J. B. Butts, & K. L. Rich (Eds.),

Philosophies and theories for advanced nursing practice

(2nd ed., pp. 377-407). Burlington, MA: Jones & Bartlett Learning.

Nicely, B., & DeLario, G. T. (2011). Virginia henderson’s principles and practice of nursing applied to organ donation after brain death.

Progress in transplantation, 21

(1), 72-77.

Vera, M. (2014).

Virginia henderson – The first lady of nursing

. Retrieved from

http://nurseslabs.com/virginia-henderson/

Vera, M. (2014).

Virginia henderson’s nursing need theory

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Factors Affecting the Compliance of Hand Washing Among Healthcare Workers in a Long-term Care Facility in Los Angeles, California

• 
  Noela Gadingan
  
• 
  Samantha Tweeten, PhD
  

Healthcare workers deal with different types of patients every day. Every patient has their own microorganisms that contributed to the development of their diagnosis. Hand hygiene plays a critical role especially among healthcare workers as they deal with not only one but several patients. Hand washing is vital in the prevention of the different hospital acquired infections or also known as the nosocomial infections. The increasing incidence of nosocomial infection is very alarming knowing that there are many organizations such as the Joint Commission and Centers for Disease Control and Prevention who exert effort to implement the guidelines of hand hygiene among healthcare workers.

A research article on a survey on hand washing practices and opinions of healthcare workers shows that healthcare workers knew the importance and benefits of hand washing, but still, they tend to overestimate their own compliance. It also shows that healthcare workers were more concerned on the different interventions that would make hand washing easier (Harris et al., 2000).

Another research article on hand hygiene compliance rate in the United States of America presented a 12-month multicenter collaboration where researchers measured the product usage and provided feedback about hand washing compliance to assess the hand washing compliance rates in the United States of America. The result shows that the rate of hand washing among healthcare workers is still at or below 50%; the researchers suggest that with the combination of monitoring and providing feedback, compliance rate would increase (

http://ajm.sagepub.com.ezproxy.nu.edu/content/24/3/205)

.

The researcher of this study chose this topic because there are many programs and organizations that exerted efforts, time, and money to implement hand washing, yet there are still incidences of non-compliance. The topic on hand washing seems is common and seems to be easy yet ignored by some individuals. As a result, there are a lot of unanswered questions on the aspects of hand washing compliance. The increasing incidence rate of nosocomial infections among the patients provides a significant reason to conduct this research study. Healthcare providers are expected to care, cure, and help patients achieve a quality of life; thus, hand washing should not be a want but rather a need.

However, there are some knowledge gaps that still need answers and limitations that may not have given a complete solution to address this issue. The purpose of the study is to know the different factors that affect the compliance among healthcare workers in a long-term care facility in Los Angeles California and to assess the knowledge and attitude of the healthcare workers concerning the practice of hand washing.

The hypothesis is that there are several factors affecting the compliance of hand washing among healthcare workers, such as lack of awareness, lack of education on the importance of hand washing, personal attitude of healthcare workers, and insufficient supply of hand washing materials. The researcher believes that through knowing the different factors that affect the compliance of hand washing among healthcare workers, it would give benefits not only among individuals but also to the community and society as a whole. Individuals, both patient and healthcare providers, protect themselves from different infectious diseases knowing that proper hand washing is the universal precaution. It would also help build a healthy community if there will be an absence or decrease incidence of infectious diseases. To the society as a whole, it would help in developing appropriate planning to identify the different solutions that would address the different factors identified. It would contribute to the different healthcare organizations and health policy makers to implement suitable actions and would hopefully achieve 100% compliance among healthcare workers and decreasing incidence rate of nosocomial infections among patients.

Review of Literature

A research study by assessed the knowledge, attitude, and practice of hand washing among healthcare workers in Ain-Shams University Hospital and had an inspection of 10 wards on that hospital for facilities needed for hand washing (Elaziz, 2009). A cross-sectional study was being conducted from the period of June until November 2006. For the data collection of this study, 10 infection control nurses were trained on how to carefully observe hand washing opportunities and to fill out forms needed for the study. There were three research instruments used: observation form on hand washing, form on ward inspection, and, to assess the knowledge and attitudes of healthcare workers regarding hand washing, a self-administered questionnaire was used. The results showed that doctors had a 37.5% compliance, which is significantly higher compared with the other groups of healthcare workers, but only 11.6% executed the proper hand washing correctly. Routine hand washing, which is 64.2%, was the most common type of hand washing that is being practiced among healthcare workers, compared with the antiseptic hand washing, which is only 3.9%. In addition, inadequate supply of paper towels was identified as another factor. Nurses were identified to have more knowledge on hand washing compared with doctors. They believed that to increase the compliance on hand washing, administrative orders and a continuous observation as well must be implemented. The researchers of this study suggested that to give solution to theses factors that affect the compliance of hand washing, there should be an implementation on multifaceted interventional behavioral hand hygiene program that would monitor and provide performance feedback, an increase in hand washing supplies, and an institutional support.

McGuckin, Waterman, and Govednik (2009) studied on hand hygiene compliance rates in the United States of America. Their study is a 1-year multicenter collaboration with the use of a product/volume usage measurement. All healthcare facilities were offered the measurement program. The only criteria for enrollment that was used in the study was the site’s willingness to submit the monthly summaries of the volume of the product usage and patient bed days to a more secure protected database that is important in generating, measuring, and benchmarking reports. The sites that were enrolled were encouraged to make use of the reports in giving feedback to the healthcare workers. They received as well an implementation manual, and they would also receive a support from the researchers of the study in implementing the program at their site. The researchers made use of three reported methods of measuring the hand washing compliance. These are as follows: direct observation, healthcare workers self-reporting, and an indirect calculation based on the product usage of hand washing. The results showed that hand washing compliance in an intensive care unit were 26% and 36% for non-ICUs. Meanwhile, after 12months of measuring the usage of product and giving feedback, the compliance rate increased to 37% for ICUs and 51 for non-ICUs. However, the compliance rate on hand washing among healthcare workers is at or below 50%. The researchers suggested that to give solution to this, there must be a combination of monitoring and feedback to increase the compliance rate.

Aziz (2013) studied on how availability of materials improved the hand hygiene compliance. The annual National Health Survey provides healthcare workers the opportunity to share their opinions on the availability on the materials used in hand washing. There were three community buildings and 31 wards that were reviewed to assess the availability of materials needed in hand washing, as well as alcohol hand rub located on wards and at entrances. The results showed based on the audit that in 30 out of 34 areas, the availability of hand washing materials was good. Both staffs in ward and in community emphasized what other materials were required for hand washing. After knowing the inadequacies, steps were made to provide these. The audit carried out made the practice of hand washing to be benchmarked across the trust and enhanced the awareness of the staff on the importance of hand washing. Therefore, as a result of this, compliance of hand washing among healthcare workers increased from 80% to 95%.

A survey on hand washing practices and opinions of healthcare worker was conducted (Harris et al., 2000). The research instrument that was used in this study is a 74-question survey that was given to healthcare workers in two tertiary care hospitals. The result of the study shows that healthcare workers knew the importance and benefits of hand washing, but still, they tend to overestimate their own compliance. It also shows that healthcare workers were more concerned on the different interventions that would make hand washing easier.

The different literature review from the four researches provide an explanation to conduct further studies to enhance the compliance rate of hand washing practices among healthcare workers. Alhough there are many studies conducted previously from different researchers, there is still a need to know more on the different factors why we cannot achieve a 100% compliance among the healthcare workers who were known to care and cure the sick.

Methods

The participants of the study are the healthcare workers, which includes the following: doctors, nurses, nursing assistants, and therapists. It will include both male and female, all types of ethnicity, and age. They must be a current employee in a long-term care facility.

This research study will make use of a cross-sectional study design that will be conducted in a long-term care facility in Los Angeles in a period of 2years. The researcher will conduct a study observation where different areas in the healthcare facility will be checked. The observation will be carried out where healthcare workers usually do invasive procedures, have personal contact with the patients, and perform non-invasive procedures such as taking the vital signs of the patients and obtaining specimen for the laboratory, during waste disposal.

For the data collection, it will make use of the same process that was carried out on the research study by Elaziz (2009). In collecting data, there will be two infection control nurses who will be trained on doing the hand washing observation and in filling out the observational and ward inspection form. In a covert manner, the nurses that were trained will fill out the observational form, which records whether hand washing was carried out or not and if it is carried out appropriately or not. He or she will also record the type of hand washing that was carried out by the person observed and note what type of errors that was committed when it was done incorrectly. In checking the availability of the hand washing materials, which include soaps, sinks, towels, drying materials, and hand washing posters and guidelines, a ward inspection form will be filled up.

There will be three research instruments that will be used in gathering the data for this research study. The same research instruments that were used by Elaziz (2009) in her study will be used. The three research instruments are observation form of hand washing, form for ward inspection, and, to know whether there is lack of awareness and education and whether a problem on healthcare workers attitude is a factor, a self-administered questionnaire will be used as part of the research instrument. The self-administered questionnaire would assess whether lack of awareness and education, and personal attitude among healthcare are factors affecting the compliance on hand washing. The questionnaire to assess for lack of awareness and education will include different questions covering different aspects of hand washing practices, including the use of time, proper execution, and materials needed for hand washing. A Likert scale will be used in assessing the attitude of healthcare workers. The program that will be used for data entry, checking, and analysis will be the Statistical Package for Social Science.

For the ethical consideration, the approval of the design and the different steps of the study were conducted with the different members of the infection control unit in a long-term care facility in Los Angeles, California. This study will prepare informed consent forms that will provide prospective study participants information regarding the research. The observation of hand washing practices among healthcare workers is already considered as a routine checking of infection control activities by the infection control nurses.

The bias that may include in this study is information bias because participants may not provide honest answers to appear in compliance to the guideline on proper hand washing. Another bias that might happen is the measurement bias when a research cannot control for the effects of the data collection and measurement, knowing that self-administered questionnaire is one of the types of the research instrument used in this study

The limitation of the study will include the possible biases that might be present especially in the data collection process, which will affect the credibility and reliability of the result of the research study, and the time and resources in conducting this research study.

References

Aziz, A. (2013). How better availability of materials improved hand-hygiene compliance.

British Journal of Nursing

,

22

(8), 458–463.

Elaziz, K. (2009). Assessment of knowledge, attitude and practice of hand washing among health care workers in Ain Shams University hospitals in Cairo.

Journal of Preventive Medicine and Hygiene

, 50(1), 19–25.

Harris, A. D., Samore, M. H., Nafziger, R., Rosario, K. D., Roghmann, M. C., & Carmeli, Y. (2000). A survey on hand washing practices and opinions of healthcare workers.

Journal of Hospital Infection

. doi: 10.1053/jhin.2000.0781

McGuckin, S., Waterman, R., & Govednik, J. (2009). Hand hygiene compliance rates in the United States—A one-year multicenter collaboration using product/volume usage measurement and feedback.

American Journal of Medical Quality

. doi: 10.1177/1062860609332369