This essay will focus on hand washing and infection control within the clinical settings and their environment. My inspiration to explore infection prevention and control started during my six weeks placement in a Parkinson’s unit within a National Health Service (NHS) hospital. This unit provides care for patients suffering from Parkinson disease for adults between the ages of 18 to the elderly.

There have been frequent incidents when bays within units have undergone closure due to the out break of infections such as Meticillin Resistant Staphylococcus Aureus (MRSA). I observed that the spread of infections has great implication as an out break causes sickness among healthcare staffs, as well as patients in care. The Health Act (2006) imposed legally binding duties on trust including provision of adequate hand washing facilities and hand rubs and mandated a rolling audit programme on hand hygiene that was embedded in local clinical governance frame works.

I have decided to explore the causes, effects and the difficulties in the management of infection prevention as a means to enhance my personal and professional development. In addition further knowledge of infection prevention and control, gained through this research will be applied in my future practice.

In this research confidentiality is going to be ensured in accordance to NMC( 2008) which emphasizes that nurses have a duty to respect people ‘s rights to confidentiality and data must be processed for limited purposes.

Literature search.

The research articles were selected from academic databases recommended by my lectures which were all found in the university library. I found some of the information from databases such as BNI (British National Index), CINAHL (the Cumulative Index to Nursing and Allied Health Literature), Medline (Medical Literature Analysis Retrieval System Online), and Cochrane. Articles accessed from these databases have been peer reviewed making the evidence more reliable as they have undergone a rigorous process to reduce bias.

Aveyard (2007) suggested that journals accessed from the university library are highly recommended when carrying out research based topics. When searching for articles to use, I typed in key words such as infection control, or infection prevention of qualitative and quantitative research into the search engine and lots of articles came up. I realised that this topic has been written by so many authors, I did not have difficulties searching for the articles. In order to narrow it, the search was further narrowed to display articles between the year 2000 to year 2012 written with England. I downloaded the research that was available via links to Full texts and Full text PDF’s. I then carried out a hand search of the academic journals available at the University . To avoid accessing abstracts on the full text setting was applied. Combinations of search words were used, such as infection prevention and control, hand hygiene, isolation, wound care and cleaning. Several results showed on infection prevention and control. One article outside the United Kingdom was considered due to its relevance’s on the topic.

Discussion

Every year, a lot of people die due to the spread of infection in hospital. Healthcare professionals can take measures to prevent the spread of infectious diseases which is part of infection control.

Good hand washing is the most effective way to prevent the out break of infection with the hospital. It is estimated that it costs the NHS almost £1 billion pounds per year for the treatment of infection related diseases (DH, 2008). Currie and Maynard (1986) conducted a study which estimated the cost of HCAI in the UK to be £ 111 million. It is a fundamental role for hospitals, to be aware and understand as well as identify risks of infection and work towards eliminating or reducing risk of infection. According to Hospital Infection Society (2007) reported that the UK prevalence rate of HCAI of around 9%. The results of the first survey legitimised infection control as an emergency discipline. The introduction of the clinical governance (DH 1999) and control assurance (NHS, 1999) provided a framework for clinical quality improvement. One of the complements in the control assurance was that organisations fulfil their statutory and mandatory responsibilities for infection control (Cole, 2010). The Clean your hands campaign was rolled out in 2004 in England and Wales to healthcare workers in all acute National Health Service (NHS) hospital trusts. The setting of a national target for MRSA bacteraemia was set up in the publication of the Health Act 2006 (department of Health). Wilson (2006) argues that good infection prevention and control reduces morbidity and mortality thereby reducing costs to the health care community. Nurses have a responsibility to make sure that patients receive safe and effective care and that risks to them are minimised NMC(2008),therefore better infection control is a priority for all healthcare professionals in primary care Lawrence and May(2003) Judge and Hill (2004)Jenkinson et al (2006)NMC (2006).In addition NMC (2008a)states that all nurses must work within the limits of their competences meaning having the knowledge and having confidence thereby reducing risks through lack of knowledge.

Infection prevention and control can be defined as the clinical application of microbiology in practice (Royal College of Nursing, RCN 2010). According to Denic (2008, cited in Kirch, 2008) stated that infection control refers to the policies and procedures used to minimize the occurrence of hospital infections such as hand hygiene, cleaning/disinfection, sterilization, vaccination etc.

Furthermore Infection prevention and control can be defined as a series of strategies and practices that aim to reduce the risk of infection to the staff, patients and others where care is delivered (Endacott, 2009).

This research will discuss articles on the practice of infection control by firstly considering the rational, literature search, evidence and analyses of five chosen research articles. In addition a range of research methods used in the articles will be discussed by considering qualitative, quantitative, sampling, ethical consideration and data collection. Furthmore the author a student, working within a Parkinson’s unit will consider recommendations for best practice. Since infection control is a broad topic this research will be focusing on hand washing and Health Care Associated Infections (HCAI). Hand washing is considered as one of the most vital infection prevention measure. Gould and Drey (2008) reported that hand hygiene is the most essential aspect of infection prevention and control for healthcare workers. Furthermore Gould and Grey (2008) stated that hand hygiene is an important procedure for preventing the spread of HCAIs and is considered fundamental to good infection control practice. Failure to comply with hand hygiene in a satisfactory manner could be seen as a breach of the Code of Professional Conduct NMC (2002). This research will also tackle on the importance and ways of reducing healthcare associated infections.

The research was based on semi-structured interviews. Parahoo (2006) support the use of semi-structured interviews because they allow the topic and perspectives to emerge.

In a research conducted by (Erkan, Findik and Tokuc 2011) to evaluate the nurse’s hand washing behaviour and knowledge before and after a training programme. In the study were 350 nurses sampled, however 200 nurses agreed take part. The participants received training on hand washing techniques and they completed pre and post test surveys.

The study received an ethical approval from the Ethics Committee of Trakya University Medical Faculty. Informed consent was obtained verbally from the nurses who participated voluntarily. The participants were given oral information about how the study was going to be carried out.

The nurses were given survey forms before the hand washing training to determine the nurses’ knowledge on hand hygiene. The survey consisted of 44 questions about hand washing. The questions included preferred ways of hand washing, the quality of their hand washing and also the behaviour of nurses on hand washing. The questions that were unclear were clarified during the first session .The training lasted 1 month with two sessions per week. In completion of their training nurses were given booklets on hand washing prepared by the researchers to enhance the effectiveness of their training and badges to raise the awareness of hand washing to the public. The booklet covered topics like the history of hand washing, types of hand washing and their purposes and also hospital infections.

The participants had 8 years experience in nursing 192 of the nurses were females and 8 males. The nurses were all from different departments of health including surgical clinics, intensive care, managing nurses, service nurses and internal clinics.

The results of the study highlighted that training programmes have some positive effects on the quality of hand washing and hand washing behaviour of nurses. Hand-washing training programmes are vital in terms of teaching, renewing the knowledge and also creating understanding. In addition training is the best way to learn and this can transforms knowledge into behaviour thereby allowing trained participants to maintain the information in practice. Finally the study recommended the implementation of hand -washing training programmes in order to improve the behaviour and the knowledge of nurses with respect to hand washing (Erkan, Findik and Tokuc 2011).

A qualitative research was carried out by Randle and Clarke (2011) to understand senior infection and prevention and control nurses experience and perceptions of implementing the day to day aspects of the Code of Hygiene. In the research, Randle and Clarke (2011) elaborate that the code of hygiene is legislative and sets out compliance standards in order to reduce infection rate as well as emphasises how failing healthcare providers can improve upon standards.

A qualitative research is an umbrella term encompassing a wide range of methods such as interviews, case studies, ethnographic research and discourse analysis (Parahoo, 2006). In the research 5 senior infection prevention and control nurses participated in the taped semi-structured interviews and a systematic analysis was applied to analyse the findings.

The study found that managerial intervention in infection control achieves significant control (Randle and Clarke, 2011). This is due to the fact that managers are in the position to champion a course because they understand more about infection control and its implication to healthcare practice and can also acts as role models; hence they can encourage other junior staff to adhere to the good practice of preventing infections.

Parahoo (2006) stated that in a semi-structured interview the researcher is very much in control of the interview process and the prearranged questions provide the structure to the interview. The advantage of using a semi-structured is that they can provide quantitative and qualitative type as the degree of control and structure on the part of the interviewer is minimal to allow the topic and perspectives to emerge (Parahoo, 2006). Furthermore Parahoo (2006) however stated that in semi-structured interviews, the researcher is very much in control of the interview. This exposed the use of semi-structured interview to biased as an element of probes has to be applied to enable valid and reliable data to be collected. Reliability and validity are ways of demonstrating and communicating the rigour of research processes and the trustworthiness of research findings (Lacey, 2006).

Randle and Clarke (2011) requested ethical approval and gained consent from the participants before carrying out semi-structured interviews. The author acknowledges that permission from the local research ethics committee reported that the study fulfilled the criteria of service evaluation. Bell (2010) note that ethical committees play an important part by ensuring that no badly designed or harmful research is permitted. Furthermore Darlington and Scott (2002) refer to ethics committees as having a gate keeping responsibility in all research which involves human subjects as they are extra vigilant when considering research proposals. Randle and Clarke (2011) noted that participants were given an opportunity to withdraw from the study. This process of providing a withdrawal choice follows the ethical procedures required for a research. Credibility to the research was placed by the researcher by covering a different geographical area over England. Credibility has been defined as the extent to which the findings of a study reflect the experience and perceptions of those who provided the data (Parahoo, 2006).

Randle and Clarke (2011) stated the sample size selected prior was seven subjects. The study used a purposive sample approach and five subjects participated in the study. Macnee and McCabe (2008) refer a purposive sampling as consisting of participants who are intentionally or purposefully selected because they have certain characteristics related to the purpose of the research. Parahoo (2006) defined a sample as a subset or proportion of the target population. In carefully selecting a sample which is representative of population, this enables recommendations to be drawn. Polit and Becks (2004) argued that due to the aims and nature of research in which perceptions and experiences are being studied, small sample sizes could be considered appropriate. Macnee and McCabe (2008) argued that the composition and richness of the setting and participants rather than the sample size have greater use in obtaining results of a qualitative study. A systematic approach was used to analyse the data collected. Waltz et al (2010) stated that use of a systematic analysis provides the simplification of recorded language to sets of categories that represent the presence, frequency or intensity of selected characteristics.

The results of the study highlighted interventions and barriers of compliance. The difficulties of implementation of infection and control procedures were clearly evidenced in the recommendations. Gould (2004) stated that infection control policies and procedures are based on key principles which, must be applied correctly to reduce risks for patients, staff and other visitors to the clinical environment these are cleaning, disinfection and sterilisation. The barriers to implementation and compliances infection control and prevention cannot be achieved if they is lack of resources specifically isolation facilities Randle and Clarke (2011). Creedon et al (2008) noted that organisational cultures and staff contribute in affects infection prevention and control practice. It is therefore important and crucial for healthcare workers to be aware inappropriate practice and to be driven into following bad practice.

In another study conducted by (Swanson and Jeanes 2011) aimed at summarising key infection and prevention issues. Swanson and Jeanes (2011) adopted key principles of hand hygiene, asepsis, appropriate use of personal protective equipment, hygiene and cleanliness, decontamination of equipment and sharps as crucial in infection and prevention. Nurses have a duty to ensure that patients receive safe and effective care and that risks to them are minimised (NMC 2008). Therefore better infection control is precedence for all healthcare professionals in primary care (Lawrence and May, 2003. Judge and Hill, 2004. Jenkinson et al, 2006. NMC, 2006).

Hand hygiene is the foundation for infection control conduct and hand washing forms part of hand hygiene practices. Sax et al (2007) suggested 5 moments of hand hygiene which encourages health-care workers to clean their hands firstly, before touching a patient, secondly, before clean/aseptic procedures, thirdly after body fluid exposure/risk, fourthly after touching a patient and fifthly after touching patient surroundings. Hand hygiene is conceded as a reasonably cheap and straightforward procedure than many other infection prevention and control procedures. Healthcare workers however fail to practice it when they as required. According to Beggs et al (2009) hand hygiene is widely regarded as the most effective way of preventing HCAI on the principle that cleansing of hands breaks the chain of infection. The Royal College of Nursing (2005) emphasised that all healthcare staff should undertake infection control training as part of their induction and on an annual basis. Poor hand hygiene plays a role in the transmission of microbes and eventually results in the increased rates of patient to patient and staff to patient infections in clinical and community settings.

In England and Wales, the National Patient Safety Agency (NPSA) has taken the lead for developing hand hygiene guidelines and audit. The CleanYourHands campaign which was launched in 2004 to help reduce the spread of HCAI as an initiative and response to public concerns (National Patient Safety Agency, 2004). The CleanYourHands campaign was started after the government and public concern reported high levels of meticillin resistant Staphylococcus aureus (MRSA) bacteraemia, meticillin sensitive aureus (MSSA) bacteraemia, and Clostridium difficile. The main components of the campaign comprised provision of alcohol hand rub at the bedside, distribution of posters reminding healthcare workers to clean their hands, regular audit and feedback of compliance, and provision of materials empowering patients to remind healthcare workers to clean their hands.

WHO(2006) noted that training, observation and feedback of performance in hand hygiene is important in making sure that staffs are aware of best practice Hand hygiene is often cited as the single most important measure to prevent HCAI; however, compliance is a problem to all health settings WHO (2009). Portsmouth (2007) considered the legal, ethical and professional dimensions to infection prevention and control compliance and posed a question around how health professionals may interpret their obligations and their duty of care. It is significant to not only consider infection control and prevention as a procedure to be followed. The issue of infection and control compliance has legal implication on the safety of patient in care and individual staff member to take responsibility to remain safe from infectious diseases.

Cole (2010) carried out a quantitative research, to chart the rise of infection control in the NHS. The research was based on literature research which focused on the progress and implementation of government legislation on infection prevention and control. Marshall et al (2004) noted that MRSA became increasingly endemic throughout the UK healthcare system, and search and destroy approach was taken. The introduction of clinical governance in 1999 provided for a quality improvement and control assurance standards (Cole, 2010). This policy initiative was driven by the financial cost incurred in the treatment and control of HCAI. Cole (2010) reported that media headlines of superbugs, modern plagues, forgotten massacres and filthy hospitals received considerable support from the government who introduced policy initiatives to address the problem of hospital infections. According to National Audit Office (NAO, 2004) widespread non-compliance with infection control policies and procedure was noted due to lack of evidence based guidelines. Hay (2006) stated that surveillance importance was identified by the NAO report. Surveillance has been defined as routine collection and analysis of infection rates with feedback to staff (Hay, 2006). The introductions of mandatory surveillance in all NHS trust reducing patient acceptance of 1 in 10 chance of acquiring an infection. Cole (2010) failed to provide evidence of reduction of infection in NHS hospitals. The research provided recommendations to measuring progress of infection control or prevention by avoiding organisational self-determination. The introduction of more legislation would accelerate reduction in mortality rates and decrease expenditure (Cole, 2010).

Knoll et al (2010) carried out a quantitative data on factors influencing nursing staff compliance with hand hygiene. A quantitative research has been conceded as explaining phenomena by collecting data that is analysed using mathematically based methods such as particular statistics (Parahoo, 2006). The main purpose of a quantitative research is to measure concepts or variables for example attitudes objectively and to examine by numerical and statistical procedures the relationship between them Parahoo (2006). Knoll et al (2010) monitored 181 nursing staff for sanitary disinfections of the hands and statements were summarized. An analysis of the data collected was done into a numerical form and results were produced in percentages of correct procedures at 51.9% and not carried out or not done properly 48.1%. The study showed results of reduced hand disinfection performed due to shared increased in a stress factor (maximum ward capacity and severity of patients cases) and imbalance of work effort in the context of time available (Knoll et al ,2010). Furthermore relevance of training courses in infection control was found to have implications on compliance with hand hygiene. Gould et al (2007) argued that poor hand hygiene compliance is now widely recognised as a major healthcare issue related to heavy workload and poor staff morals. The introduction of government cuts urge implication of staff level reductions due to cost cutting measures. This further impacts on staff workload and as the Knoll et al (2010) highlights evidence of compliance in hand hygiene measures.

A study carried out by Ali et al (2005) was done on 120 patients without known MRSA from hospital and the community being admitted to a hospice. The focus of the research required ethical approval form a research ethics committee. The researcher clearly highlighted the method used in gaining informed consent from the participants in the study after written information was provided. Ali (2005) study considered investigating MRSA within a sample group of terminally ill patients. A total of 19.5% of potentially eligible participants were involved in the study. This research however noted that constrains of the sample size was mainly to the fact that other potential participants were to ill to provide consent. The findings of the study showed that from the total participants 2.5% only two participants were proven to developed symptomatic infection due to MRSA. The relevance and ethics around this study can be greatly questionable. Chaloners (2007, cited in Keele, 2011) defined ethics as a branch of philosophy concerned with determining right and wrong in relation to peoples decisions and actions. The responsibility of the local ethics committee is to ensure the ethics of a research a assessed and that the nature of research does not impacted or negatively affect participants. It can be argued that Ali et al (2005) research although ethically considered and approved, could have negative impacts on the wellbeing to the participants. It is also arguable that from the results of the research MRSA alone had little influence to the eventual death of the participants involved.

Stone et al (2012) had done a research on 187 acute trusts to evaluate the national Cleanyourhands campaign to reduce staphylococcus aureus bacteraemia and clostridium difficile infection in hospitals in England and Wales. The results were combined from the procurement of soap and alcohol hand rub per patient bed. The sample size used in the research has significant implication on the validity and reliability of the findings. The use of a national as well as vast geographical area enables research finding to provide a true reflection on the population. However Stone et al (2012) research could be criticised for excluding hospital trusts that 18 months of missing data. The research findings demonstrated that the implementation of the cleanyourhands campaign and procurement of alcohol hand rubs. The research illustrated a correlation of alcohol hand rub procurement was associated with a rise in C difficile infection and soap was independently associated with a reduction in C difficile.

In conclusion five research terms which include sample, qualitative, quantitative, ethical consideration and data collection have been discussed from a selection of five research articles. Hand washing and infection prevention and control have been discussed. a variety of recommendation have been drawn from the research studies such education and nursing student encouragement effective hand hygiene and acting as agents of change , good supervision from mentor learn effective correct practice procedures, staff stress and implication on non-compliance on hand hygiene. Correlation studies showed an association with the use of soaps and hand gels in the reduction of infections diseases. The responsibility and expectation for healthcare worker to take infection control procedure and own it has been over emphased. The emphasis on legislative as well as policy on the importance of infection control and prevention has been discussed by the implementation of the Health Act 2006, clinical governance, cleanyourhands campaign and Health and Social Care Act.

Health care organizations face challenges with the initiative to increase racial diversity within the nursing workforce. Despite efforts to diversify, the 2018 Bureau of Labor and Statistics showed that amongst 3.2 million registered nurses in the United States (U.S.), 75.5% are whites, 13.1 % are Black or African- American, 9% Asian and only 7.2% are Hispanic or Latino. In contrary, more than half of all Americans are projected to belong to a minority group by 2044 and foreign-born population depicts an estimated increase from 2.5 million in 2014 to around 3.3 million in 2060 (Colby & Ortman, 2015). The Hispanic population is expected to grow over the next years and the number is projected to exceed the numbers of Whites in the country. The current shift in the nation’s demographic calls for the need to recruit and retain a racially diverse workforce that reflects the country’s population change.

Disparities in healthcare are well documented between majority, and racial minority and underserved populations (HRSA, 2017; Phillips & Malone, 2014; Snyder, Stover, Skillman & Frogner, 2015). Findings from the 2017 Health Equity Report by the U.S. Department of Health and Human Services (DHHS), and Health Resources and Services Administration (HRSA) described that ethnic-minority groups are more likely to live in disadvantaged and low-income neighborhoods than their non-Hispanic white counterparts. As a result, minority groups have increased likelihood to be uninsured.

Racial and ethnic diversity among healthcare professionals has been reported to somewhat improve underserved and minorities population healthcare outcomes, and increase their access to care (HRSA, 2017; Phillips & Malone, 2014; Snyder, Stover, Skillman & Frogner, 2015). There are numerous nursing studies that elucidated on strategies and outcomes of improving health partiality. While healthcare access and outcomes are slowly improving with the inception of the 2010 Institute of Medicine Future of Nursing recommendation to increase diversity in nursing workforce, minority nurses remain underrepresented (Phillips & Malone, 2014). There is a heightened need to diversify nursing workforce at all levels – education, all healthcare practice, and nursing research. Thus far, improving racial healthcare outcome disparity by increasing nursing workforce diversity remains a significant healthcare issue.  The purpose of this paper is to examine nursing workforce diversity and its impact in the nation’s healthcare disparity.

Racial Minority Healthcare Disparity

U.S. federal guidelines defined racial minority as Black not of Hispanic origin, Hispanic, Asian or Pacific Islander, and American Indian or Alaskan Native (Federal Guidelines for Definition as a Minority, 2013). Data suggest that albeit the attempt to improve healthcare outcomes and reduce health care disparities, racial health inequality persist (Mathews, MacDorman, & Thoma, 2015).

One of the widely used indicator of the country’s health is the rate of infant mortality and the priority is to achieve better pregnancy outcomes for women and children’s health. In 2013, the U.S. infant mortality rate (IMR) was 11.11 in infants born to non- Hispanic black mothers which is twice the rate of offspring from non- Hispanic white at 5.06. Similarly, data from HRSA demonstrated that 20.7% of American Indians/Alaska Natives, 19.5% of Hispanics, 11.0% of blacks, 9.9% of Native Hawaiians and other Pacific Islanders, and 7.8% of Asians lacked medical insurance (2017).

Disparities in health care is an endless saga in the nation. Quality of care, population health and health care cost are impacted with the presence of disparities (Artiga, Foutz, Cornachione, & Garfield, 2018). There are various initiatives to address healthcare disparity which includes the passage of Affordable Care Act (ACA). ACA was implemented in 2013, the aim is to include provisions that advance efforts to reduce disparities and in 2014 number of uninsured people was reduced by over 10 million (Artiga et. Al, 2018). Inspite, coverage gains under the ACA, non-elderly Hispanics, Blacks, American Indians and Alaska Natives remain significantly more likely uninsured than Whites. In effect, disease burden associated with the disadvantaged groups and growth of minority to become the majority requires an increase demand of more than 776,400 nurses reported by HRSA (2017). However, Phillips and Malone in 2014 elaborated that decreasing healthcare disparities among racial minorities by increasing nursing workforce diversity was an unspoken assumption (p.48). An exploration is warranted whether a racially diverse nursing workforce will reduce healthcare disparities among minorities.

Impact of Increasing Nursing Workforce Diversity

Nursing Workforce Diversity Ethical Concept

The Future of Nursing Report emphasized the importance to develop strategies in increasing the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution. Influence of a nursing workforce reflects the population demographics will lead to improve treatment and provides a better understanding of a person’s emotional health and well-being (Future of Nursing Campaign for Action, 2016). Increasing nursing workforce diversity is in alignment with the nurse’s code of ethics.

Provision nine of the Nurse’s Code of Ethics pertains to social justice and was defined as reaching out to a world in need of nursing. Nurses must take action to influence non-governmental organizations, international bodies, leaders, legislators and governmental agencies in matters of healthcare by addressing the social determinants of health and reaching the increasing number of minorities and disadvantaged patient population (Fowler, 2015). The need for racially diverse nursing workforce encompasses the ethical principle of Justice which refers to an equal and fair distribution of resources, based on analysis of benefits and decision burden (American Nurses Association, 2016).

Increasing diversity in nursing workforce exemplifies a concept in the ANA Nursing Code of Ethics that a professional nurse should have broad social vision. Socially envisioned nurse will have a sympathetic understanding of different creeds, nationalities and races, and will not permit personal attitude towards various groups to interfere with her function as a nurse. The code accounts for respect for persons and exclusion of unjust discrimination beyond patients to include colleagues, students, and all with whom the nurse comes in contact (Fowler, 2015).

Legislation in Increasing Nursing Workforce Diversity

Affordable Care Act included many provisions that reauthorized the health professions education and training programs under the Title VIII of the Public Health Service Act (PHS). The PHS Act provides the largest source of federal funding grants for nursing education, by offering financial support for organizations to advance their educational programs, promote diversity in the field, and repay loans for nursing students who work in facilities with critical shortages (Congress, 2015). Essentially, the act offers opportunities for individuals who are from disadvantaged backgrounds, students from economically disadvantaged families and racial and ethnic minorities who are underrepresented in the nursing profession (American Nurses Association, 2016).

Funding plays a critical role in recruiting the next generation of nurses and addressing the faculty shortages facing the profession (Fowler, 2015). The PHS act funding will expire by 2020. In response, representative David Joyce introduced House of Representative (H.R.) 728 bill – Nursing workforce Reauthorization Act of 2019. The bill amends title VIII of the PHS act and extend funding towards advanced education nursing grants in support to clinical nurse specialist programs, and for other purposes including section four provision which is to increase nursing workforce diversity (Congress, 2019). H.R. 728 legislation needed collective action of healthcare workers with the nurses in the forefront to lobby and promote advancement of the bill to enact into law.

Implementing diversity action plans and other programs aimed to increase racial and ethnic diversity within the nursing workforce is important (Mason, Gardner, Outlaw, & O’Grady, 2016). Diversifying the nursing workforce entails a quantifiable strategic plan. For instance, increasing programs and resources for minority nurses and students suggested by Phillips & Malone (2018) should incorporate creating and disseminating evaluation metrics and measures that assess the contributions of a diverse workforce towards eliminating health disparities (p.49).

Racial Nursing Workforce Diversity in Nursing Education

The objectives were to increase the number of Hispanic students, recruit the project for the autumn semester Hispanic pre-nursing students, increase the number of Hispanic students to complete the nursing program, and improve cultural competency to increase awareness and understanding of cultural diversity.  A few of the activities involved tasks such as tutoring in all subjects, nursing exam review sessions, summer externships, recruitment sessions at high schools, one-to-one nursing student mentoring and coaching by the project coordinator, financial help, and regular discussions concerning challenges (Georges, 2012).

Prior to the implementation of the project, there were only four Hispanic students admitted to the nursing program. After three years when the project completed, the outcomes resulted with 31 students enrolled and all successfully completed the BSN program. In addition, ten 10 students haved completed an MSN program. The results demonstrated that the activities and tools were effective in achieving the objectives. The ethnicity of the co-coordinator and the project director were crucial to the accomplishments of the project because students could communicate with them in Spanish. However, the lack of funding to sustain the project were depleted. Despite the challenges, the department of nursing remains committed to increasing the number of Hispanic student enrollment (Georges, 2012). Federal funding could help continue the project and increase racial and ethnic diversity in the nursing workforce. A diverse group of nurses or teachers have a competitive advantage with a unique set of skills, experiences, and perspectives.

Racial Nursing Workforce Diversity in all Health Care Practice

The nursing profession exists to serve all patients, regardless of their cultural, racial, or ethnic background which leads to the value of creating a more diverse workforce. Research has suggested that patients prefer care from a member of the same race or ethnicity (Flores & Combs, 2013). The unique, positive interpersonal relationship acquired from a diverse nursing workforce increases both patient and employee satisfaction.

Research studies have demonstrated positive outcomes from having a racial and ethnic diverse nursing workforce. One research study wanted to investigated which types of diversity were associated with which outcomes within the context of nursing. The purpose of the study was to examine the influence of age, gender, education, race/ethnicity, and perceived value diversity on nurse job satisfaction, nurse intent to stay, and patient satisfaction. The sample included 2,900 patients and 6,500 RNs from acute care hospitals. The data were collected from survey questionnaires over a six-month period. The results of the study confirmed a positive relationship between race/ethnicity diversity and nurse job satisfaction as well as age diversity and intent to stay. The findings of the research study supported and suggested that policy initiatives focusing on nursing’s racial diversity should continue (Gates & Mark, 2012). The study is an example illustrating how important racial and ethnic diversity action plans are worth funding. Financial resources could help nurses change their environment, recruit an RN workforce from minority backgrounds and improve quality of care. The nursing workforce must reflect the diversity of the population it serves.

Furthermore, goals to increase minority representation in the APRN and nurse leadership population is important. Nurses seeking funds for a higher level of education should be able to prove how their organizational outcomes resulted in exc

ellence, due to the compassionate and hardworking front line bedside nurses providing care. These nurses should be awarded funding for education for their successes and contribution to improved patient outcomes.

Racial Nursing Workforce Diversity in Nursing Research

Nursing Workforce Diversity Caveat

The initiative to increase racial and ethnic diversity is one aspect for addressing the nursing shortage. Although, the Affordable Care Act emphasized on maintaining health status and preventing acute health crisis, it is too early to determine whether new care delivery models such as nurses taking on new roles in prevention, would even contribute to a new growth in demand for nurses (U.S. Department of Health and Human Services, 2014).

Conclusion

Initiatives to increase racial and ethnic diversity in the nursing workforce is an ongoing challenge. The assessment and evaluation of the initiatives must go beyond monitoring and reporting participation as performance measure; evaluations should focus on the mission and goals of the program in enhancing the diversity of the health workforce at all levels and to reduce health care disparities. It is important to note that programs need to be tailored to specific populations and context (Snyder, Stover, Skillman, & Frogner, (2015).

The goal of eliminating health care disparities, will not be achieved without the engagement of racial minority nurses as reflected in the passage of ACA. It is critically important to secure diversification of nursing workforce, funding should be provided, and policies to attain such goal should be created and supported. What remained valuable is a strategic plan to attract, retain and mentor minority nurses. The entire health care institution from education to all health care practice areas and research should collaboratively work together to achieve a common goal. With a collective voice, nurses could ask representatives to cosponsor the Nursing Workforce Reauthorization Act (H.R. 728) and urge Congress to have fundings remains available for nurses. Greater diversity in the health workforce is critical to improve health care delivery for an increasingly diverse population. Investments in health professions training programs that promote inclusion of students from all racial and ethnic backgrounds are critical for diversifying the workforce, and these investments need to continue. Funding resources is important in recruiting the next generation of nurses, however there are other critical health care investments in other areas that need to be considered.

The U.S. population diversification is apparent, and the nursing workforce is expected to reflect those changes in order to meet the needs of the patient and improve quality care (Mason et al., 2016). Empowering and mentoring minority nurses to assume leadership position could facilitate attracting a more diverse workforce. Initiatives to increase nursing workforce diversity should remain a high priority in an effort to curb healthcare disparities. Overall, nurses could work collectively through political action groups and reshape areas of healthcare policy and legislation.

References

• 
  American Nurses Association. (2016).
  
  Funding for nursing workforce development
  
  . Retrieved from http://nursingworld.org/DocumentVault/GOVA/Federal/Federal-Issues/NursingWorkforceDevelopment.html
  
• Artiga, S., Foutz, J., Cornachione, E., & Garfield, R. (2018, June 14). Key Facts on Health and Health Care by Race and Ethnicity. Retrieved April 30, 2019, from https://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity/

• Association of American Colleges. (2016).
  
  Title VII and title VIII reauthorization
  
  . Retrieved  from https://www.aamc.org/advocacy/budget/healthprof/150298/t7reauthorization.html
• Colby, S. L., & Ortman, J. M. (2015, March).
  
  Projections of the size and composition of the U.S. population: 2014 to 2060.
  
  Retrieved from https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf
• Congress. (2015, June).
  
  Title VII of the public service act.
  
  Retrieved from
  
  
  https://www.congress.gov/114/bills/hr2713/BILLS-114hr2713ih.pdf
  
  
• Bureau of Labor and Statistics (2019).
  
  Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity in 2018
  
  . Retrieved April 29, 2019, from
  
  
  https://www.bls.gov/cps/cpsaat11.htm
  
  
• Federal Guidelines for Definition as a Minority. (2013). Retrieved April 29, 2019, from
  
  
  http://grfx.cstv.com/photos/schools/nacda/sports/moaa/auto_pdf/2013-14/misc_non_event/FederalDefinitionofMinority.pdf
  
  
• Flores, K., & Combs, G. (2013). Minority representation in healthcare: Increasing the number of professionals through focused recruitment.
  
  Hospital Topics
  
  ,
  
  91
  
  (2), 25-36. doi:10.1080/00185868.2013.793556
• Fowler, M. D. (2015).
  
  Guide to the code of ethics for nurses with interpretive statements: Development, interpretation, and application
  
  (2nd ed.). Silver Spring, MD: Nursebooks.org.
• Future of Nursing Campaign for Action. (2016).
  
  Institute of medicine the future of nursing: Leading change, advancing health recommendations related to diversity
  
  . Retrieved from http://campaignforaction.org/wp-content/uploads/2016/04/IOM-Diversity-Recommendations3.pdf
• Gates, M. G., & Mark, B. A. (2012). Demographic diversity, value congruence, and workplace outcomes in acute care.
  
  Research In Nursing & Health
  
  ,
  
  35
  
  (3), 265-276. doi:10.1002/nur.21467
• Georges, C. (2012). Project to expand diversity in the nursing workforce.
  
  Nursing Management – UK
  
  ,
  
  19
  
  (2), 22-26.
• Health Resources and Services Administration. (2017).
  
  The future of the nursing workforce: National and state level projections, 2014-2030.
  
  Retrieved from
  
  
  https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf
  
  
• Health Resources and Services Administration. (2017).
  
  Health Equity Report 2017.
  
  Retrieved from
  
  
  https://www.hrsa.gov/sites/default/files/hrsa/health-equity/2017-HRSA-health-equity-report.pdf
  
  
• Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (2016). Policy & politics in nursing and health care.(7
  
  ^th
  
  edition) St. Louis, MO: Elsevier.
• Mathews, T. J., MacDorman, M. F., & Thoma, M. E. (2015). Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set. Retrieved April 29, 2019, from
  
  
  https://www.cdc.gov/nchs/nvss/linked-birth.htm
  
  
• Morbidity and Mortality Weekly Report (MMWR). (2019, April 29). Retrieved from
  
  https://www.cdc.gov/mmwr/index.html
  
• Phillips, J. M., & Malone, B. (2014). Increasing Racial/Ethnic Diversity in Nursing to Reduce Health Disparities and Achieve Health Equity.
  
  Public Health Reports,129
  
  (1_suppl2), 45-50. doi:10.1177/00333549141291s209
• Snyder, C. R., Stover, B., Skillman, S. M., & Frogner, B. K. (2015, July).
  
  Facilitating Racial and Ethnic Diversity in the Health Workforce
  
  . Retrieved April 29, 2019, from http://depts.washington.edu/uwrhrc/uploads/FINALREPORT_Facilitating Diversity in the Health Workforce_7.8.2015.pdf

Table of Contents

Case Study

Care Plan

Medical Point of view

The Role of the nurse

Building a therapeutic relationship

Respect and Empathy

Communication

Tackling the problem

The Reality Therapy and choice therapy.

Working the therapy with Rachel

Problems met during sessions.

Conclusion

Case Study.

A 21 year old lady presented at Crisis Intervention Team (CIT) stating that she has these thoughts in her mind that she is going to harm her baby. She was experiencing an excessive fear of what she might do to her baby since these thoughts were telling her that she was going to knock the baby’s head against the wall.

She was physically trembling with fear and anxiety. She had reduced her food intake and this had resulted in considerable weight loss. She was not sleeping at night leading to tiredness, lethargy which was hindering Rachel (imaginary name) from performing her daily chores.

The pregnancy was unplanned but her boyfriend Robert (imaginary name) was very supportive during and after the pregnancy. He was very worried about Rachel since she had a complete change in character and from a happy go lucky person she had turned into an introvert always worried and depressed.

Rachel explained that she had always thought that motherhood would be an enjoyable period in life. She had always dreamt of this period but she had never imagined that it would end up to be the worst experience of her life. She was so focused on her baby that she had forgotten how to live. She was all the time concentrating on her childhood, how much she had felt neglected by her mother at that time and her innermost fear was that she will end up behaving like her; that is why she had stopped working, going out and enjoying everyday life. Despite this, she was feeling guilty that she was not giving enough attention to her baby.

CIT offers follow up sessions for 3 to 4 weeks, during which Rachel was asked to identify her problems and prioritise them. By identifying areas where she would like to improve, she would be lessening her suffering and make herself feel better; this was done together with the nurse.

Care Plan

Medical Point of view

Rachel was seen by the CIT psychiatrist who prescribed antidepressants with the aim to try and alleviate Rachel’s mood. Glasser (2003) complained that it is a pity that nowadays psychiatrist and medical doctors prescribe psychiatric drugs prior giving counselling sessions first. The role of the nurse regarding her treatment was to educate the patient regarding the importance of concordance and informing Rachel about any side effects that might occur when starting treatment.

The Role of the nurse

The role of the nurse is to help the patient get better by offering the optimum level of care in order to empower her patient and help him/her improve his/her quality of life. Smith, Wolf and Turkel in 2012, explained that for the patient to be cured, s/he needs to be cared for as no curing can occur without caring (p.137). The nursing care plan should be planned together with the patient in order to identify the patient’s needs, plan and set goals to overcome the obstacles. Kelsey (2013) stated that NHS is emphasising on patient participation in the care plan as this will help the nurse to engage more with the patient while the patient will feel more empowered. This concept is firmly believed at CIT, and it was always stressed that all professionals collaborate for optimum care delivery together with patient. The patient also has the right to choose family members and/or friends whom he wished to be involved in his/her care.

Building a therapeutic relationship

In order to formulate a care plan with the patient, a therapeutic relationship must be built for a successful outcome. Caring is based on a relationship and for relationships to be effective both parties must be involved, (Govier, 1992). The fulcrum of nursing care is building a nurse-patient relationship by engaging with the patient and his carers.

Building a therapeutic relationship helps the nurse to gain indispensible information about her/his patient whilst the patient learns how to trust the nurse (Lehman et al., 2004). Although according to nurses trust is vital for building a therapeutic relationship, this can be very difficult to establish with the patient.

Literature states that trust has been a debatable topic in research; it does not concern only on the health care profession but includes also the institutions and other services providing the care, (Laugharne & Priebe, 2006). In Malta there is still a good amount of stigma regarding Mental Health and Mental Hospital thus people are afraid to talk about their mental health problems. The stigma that surrounds the name of the mental health hospital in Malta still carries fear of the unknown and beliefs about mental illness hinder the patients from seeking help. This often results in severe deterioration leading to an involuntary admission (Farrugia, 2006).

The same thing happened with Rachel at the beginning of our sessions when she was still terrified to discuss her innermost thoughts, believing that she would be judged and labelled as mentally ill thus providing grounds for an admission. Rachel needed to overcome her fears and start to confide in the nurse.

In order to gain her trust, the nurse had to reassure Rachel that no harm will come to her and if she wishes CIT could offer her care in the community reassuring her fears regarding hospitalisation. This could only happen if Rachel agrees to work with the team members and keep to the plan which they had agreed on together. Rachel agreed with the proposal inviting her boyfriend to join the plan, which he accepted. Support and information was provided to both parties and they were satisfied with the plan.

Respect and Empathy

The nurse assured Rachel that both parties should respect each other. Papastavrou et al (2012) explains that to show respect towards a patient one should allow autonomy, show dignity towards the person, care for him/her holistically and ensure privacy and confidentiality. Assuring the patient that since she is seeking help, the team’s aim was to provide that help and not to judge her thoughts and actions.

For the nurse to be able to understand the patient better she has to put him/herself in the patient’s shoes and this skill is called Empathy. Empathy was found helpful to humanize the care delivered to the patient (Barker, 2003). When the nurse shows that his/her intentions are genuine and is trying to understand the situation by offering help and keeping agreements, the patient will start to trust her/him.

Communication

Establishing trust, showing respect and empathy to the patient, needs good communication skills; Taylor, Lillis, Lemone, Lynn, and Smeltzer (1989), claimed that a therapeutic relationship can never be built if there is no good communication skills. It is imperative for the nurse to learn to listen attentively to verbal communication but also to learn to read the non-verbal communication that the patient is sending. Through the non-verbals, the nurse can extract information which the patient wishes to hide such as fear and anxiety through her body language (Stuart, 2009). Glasser (2003), emphasised on the importance to allow time for patient to narrate their problem, in order to be able to assess the patient in depth.

Tackling the problem

• She does not like her life at the moment.
• She misses work and school (she was learning art, her hobby is drawing)
• She hates the thought of becoming like her mother
• She hates the thoughts that are obscuring her mind preventing her from enjoying life.

The nurse went through the list of problems written by the patient and together with Rachel she tried to group them into categories. Keeping in mind that CIT service is provided over a limited amount of time, it is of utmost importance that the team tackle the urgent problems which have prevented the patient from functioning normally and reaching a Crisis. For secondary problems, Rachel will be referred to another team who can offer longer term care.

The first two problems discussed were the fact that she is absent from work and not attending art school at the moment. This fact is making her feel useless and lonely. She is not doing these things because she thinks that if she starts to do things that she used to enjoy, she will neglect her child. This will make her worst fear that she will become like her mother come true. This made it easier for the nurse to narrow the amount of problems because in agreement with Rachel they decided to group all the three problems under one heading: fear of becoming like mum. Rachel admitted that if she could be sure that she would be nothing like her mother she would feel less stressed.

The second problem was her bizarre thoughts which were persecuting her. During the first meeting they discussed at length the issue of harming her child and what chance there was that she would actually harm him. She took so much care of her child since his birth three months ago that it was highly unlikely that she would ever harm him. In reality she was caring fulltime for the child, taking care of him 24 hours a day and never leaving his side. Rachel’s boyfriend assured the nurse that she never left her child unattended. He explained that they were living with her mother who took care of the house chores and gave them moral support whilst Rachel took care of her child.

After discussing all this with Rachel it was concluded that what she was feeling was unhappy, she lost her joy of living. It was important for Rachel to try to control her thoughts and worries and to try learning to sort them out. First she needs to work out if the worries are founded or not and when that answer is found she needs to choose whether to ignore or believe them. The nurse opted to work with Rachel on the steps of Reality/ Reality Theory by Glasser to help her overcome these fears.

The Reality Therapy/Choice therapy.

William Glasser developed Reality therapy way back in the sixties and it was based on identity theory, (Zastrow, 2010). The last two decades Glasser noted that his therapy focused more on human behaviour, how can it be altered and improved leading him to change the name of Reality Therapy to Choice Therapy, (Wubbolding, 2013). The choice theory explains how the life of the individual is determined by the choices he made. Every individual has his perceptions about his/her reality of life and according to Glasser the individual behaviour is in constant attempt to narrow between what we want and what we have (Zastrow, 2010 pg 491). The aim of the therapy is to help and teach individual to satisfy the internal motivation and or basic psychological needs.

The Choice therapy focuses on the basic needs of the individual. Glasser (1996) explained that the therapy emphasised the four basic psychological needs which included belonging, power, freedom and survival (Jong-un, 2007). Belonging refers to family and friends. People; with whom a person can socialise, enjoy him/herself with, as well as feel loved. Power refers to the individual achievements in life such as achieving dreams and feeling worthwhile. Having your own space, acting independently, being autonomous and deciding for yourself covers the need of freedom. Whereas, survival needs are covered by nourishment, intimate relationships and shelter. Sunich (2007) in his article argued that Glasser wrote about five basic needs and the ones mentioned above and adding fun.

Contrary to traditional theories, the Reality Therapy promotes the idea to focus on the ‘here and now’ and reduce concentrating on the past. The therapy is based on the patient’s willingness to change, make choices, take responsibility and sustain commitment. Its aim is to assess and identify the unmet needs of the patient exploring what behaviours they are displaying that either assist or interfere with them meeting their needs (Sunich, 2007 pg.3).

Working the therapy with Rachel

The nurse explained how choice therapy works and Rachel agreed that she would like to give it a try. The nurse explained that reality therapy is best summarized as WDEP which means: wanting, doing, evaluation and planning, (Cameron, 2013)

In Rachel’s situation, it is important to focus on what she really

W

ants; she wished to get rid of her thoughts and fear. It was explained to her that she needs to start to learn to identify unrealistic thoughts and learn to control them. After the problem was ascertained the next step taken was to ask Rachel what she was

D

oing to try and get what she wished for. Rachel tried to explain what she had been doing but

E

valuating the situation together Rachel admitted that the method she had chosen was not working. After that Rachel and the nurse agreed to try and formulate a new Plan which will help Rachel gain her joy in life back,(Cameron, 2013) .

In the first session Rachel described herself as: “blocked in a black tunnel”, she was afraid to talk about her thoughts because the nurse might think that she was “going crazy”. but could feel that with the right support there is hope for her illness. The nurse had to explain to Rachel that she should stop labelling herself as depressed and concentrate on how she was feeling at that moment. Rachel admitted she was feeling unhappy, and this was caused because the patient had stopped doing the things, she liked to do so that she would be able to concentrate on her son 24 hours a day 7 days a week. Although she knew that she was still fearful of the thought that she might harm the baby. The nurse explained that feeling unhappy for a reason is not being “crazy”; the important thing is doing something about it to improve the situation (Glasser, 2003).

The thought that she might harm the baby was explored at length. Rachel admitted that she never did anything to harm her baby, she loved him unconditionally, and she took care of his Adls. She never misses his appointment at the baby clinic where they confirm that the baby is very healthy and this was confirmed by Robert. The nurse documented everything they said on a page divided into two columns, labelled good care and neglect After Rachel finished, the nurse handed her the paper and explained to her what she had done. All the things Rachel had stated were listed under the good care column and the neglect column remained empty. Then the nurse asked Rachel “Seeing this paper how much are the chances that you are neglecting your son?” Rachel stared amazed at the paper as she answered “none”, thus this makes your thought unfounded. The nurse explained to Rachel needs to learn to do this exercise each time she has a thought so that she can identify if the thought is realistic or just an imaginary one.

So they planned Rachel’s homework until her next session which focused mainly on identifying the thought and reasoning it out. After the first session she confessed that she felt better; the fear that she was going crazy subsided, she felt that she was not alone any more in her dark tunnel and hope was instilled.

Sessions went by and Rachel started to learn how to control her thoughts better but choosing to ignore them. She was better but not good enough yet. Rachel had to start to stay away from her son a couple of hours so she has time for herself. It was the biggest step for her and as she described it as the most painful but with the help of Robert and their extended families she started to work a couple of hours a week. This made a drastic change in Rachel’s mood and she started to feel happy again. She started to make friends and felt that she belonged in society again and not isolated anymore.

“Happiness or mental health is enjoying the life you are choosing to live, getting along well with the people near and dear to you, doing something with your life you believe is worthwhile, and not doing anything to deprive anyone else of the same chance for happiness you have”

(Glasser, 2003 pg 7).

Problems met during sessions.

Seeing the story in writing might look as if it had been easy to empower Rachel enough to achieve goal. It included four weeks of intensive counselling with two planned sessions a week and several phone calls from Rachel asking for support and reassurance. This could be done by praising Rachel for her decisions and actions.

There were times that the patient had to be confronted about her decision for example “you are thinking and assuming that your mum will not be capable to look after your baby. Did she show any signs of mistreating him or being unloving towards the baby? Are these just your thoughts tormenting you or there are facts which might lead you to think that she is incapable of looking after him?” There are many authors who criticise this method because of the above: they argue that it is a harshly confronted therapeutic approach towards the patient. Wubbolding and Brickell (2000), did not deny it but emphasised the fact that reality therapy is a gently confronted approach. Glasser (2002), explained clearly the consequences of seven deadly habits, which may arise during reality therapy session. These habits are criticising, blaming, complaining, nagging, threatening punishing and bribing or rewarding to control, but they cannot be allowed in any relationship because they will simply destroy it (Sommers-Flanagan & Sommers-Flanagan, 2012).

There was one episode at the beginning when Rachel entered the office unannounced shaking and sobbing. She was so desperate at that moment that she could not even talk. The nurse waited for Rachel to calm down but each time she did and the nurse asked her to talk Rachel ended up sobbing again. After more than half an hour, in a soft but stern voice the nurse had to tell Rachel that she had to speak up if she wanted help. The statement might have sounded insensible and blunt but it was all about the reality of the situation; Rachel understood that and reached for a paper and with great difficulty wrote what was troubling her. Sommers-Flanagan & Sommers-Flanagan (2012) agreed with other above authors who believe that Reality therapy at times is too directive and might become almost offensive and unethical towards the patient.

Conclusion

Rachel started to look forward to her therapy session; she worked hard on her problems, kept with the plan and gradually she reached her goal. Basic knowledge about the therapy helped the nurse conduct the sessions but also made her aware of the need for more intensive training (Sommers-Flanagan & Sommers-Flanagan, 2012).