abstract - web viewthus patients must be actively involved with their plan of care and need access...

Self-Care Deficit Theory

Running head: SELF-CARE DEFICIT THEORY IN PRACTICE

Self-Care Deficit Theory of Nursing in Practice:

APN Expert Coaching and Guidance in Heart Failure

Emily Duke Koch

University of Virginia School of Nursing

On my honor as a student, I have neither given nor received aid on this assignment.

1


Abstract

Heart failure is a chronic illness characterized by periods of exacerbation and remission,

and coping with heart failure greatly impacts self-care demands. As proposed in the self-

care deficit theory of nursing, heart failure patients enter periods of fluctuating illness and

health states that correspond with varying degrees of self-care deficit and agency. The

APN intervention of expert coaching and guidance creates a dynamic, collaborative

relationship with patients with the goal of restoring their self-care abilities and preventing

heart failure exacerbation and hospitalization. In the process of expert coaching and

guidance, the APN integrates self-reflection and clinical expertise with patients’

understandings, experiences and goals to accomplish therapeutic and educational goals.

The congruence between nursing theory and practice is realized in the relationship

between the self-care deficit theory of nursing and the APN intervention of expert

coaching and guidance. Heart failure patients experience a higher level of self-care

agency as a result of expert coaching and guidance from an APN.

2


Self-Care Deficit Theory of Nursing in Practice:

APN Expert Coaching and Guidance

Introduction

Heart failure is a chronic illness characterized by periods of exacerbation and

remission. Although severely decompensated heart failure may require hospitalization, it

is possible for patients to manage heart failure in the outpatient setting and learn to

identify the symptoms that indicate decompensation before emergency occurs. Coping

with heart failure greatly impacts self-care demands, and as proposed in the self-care

deficit theory of nursing, patients enter periods of fluctuating illness and health states that

correspond with varying degrees of self-care deficit and agency. The Advanced Practice

Nurse (APN) is uniquely prepared to assist patients with heart failure recover and

maintain self-care agency. The APN intervention of expert coaching and guidance creates

a dynamic, collaborative relationship with patients with the goal of restoring their self-

care abilities and preventing heart failure exacerbation and hospitalization.

This paper will discuss the relationship between the self-care deficit theory of

nursing and the APN intervention of expert coaching and guidance. It will begin with a

description of the clinical nursing problem of heart failure patients’ frequent

hospitalization when their self-care deficits outweigh their self-care abilities. Summary

of the self-care deficit theory of nursing and description of the expert coaching and

guidance intervention will follow. Finally, the paper will discuss the relationship between

the theory and the intervention. The congruence between nursing theory and practice is

realized in the relationship between the self-care deficit theory of nursing and the APN

intervention of expert coaching and guidance.

3


Clinical Nursing Problem

Heart failure affects millions of Americans and is the most common reason for

hospital admissions among the elderly, accounting for over one million admissions and

costing $20 billion per year (Mueller, Vuckovic, Knox, & Williams, 2002; Stanley,

1997). Heart failure consumes copious health care resources, is the foremost

complication of heart disease, and is associated with high incidence of early and frequent

rehospitalization (Kegel, 1995). The majority of hospitalizations result from

decompensation of chronic heart failure, and data suggest about half of these

readmissions could be prevented (Artinian, Magnan, Sloan, & Lange, 2002; Mueller,

Vuckovic, Knox, & Williams, 2002).

Managing heart failure requires careful and frequent patient self-assessment for

signs and symptoms of exacerbation and prompt treatment to prevent hospitalization

(Kegel, 1995). Thus patients must be actively involved with their plan of care and need

access to ongoing education, assessment, and counseling (Kegel, 1995). The greatest

barriers to self-care are inadequate knowledge and understanding of disease process and

prescribed treatment, inadequate access to healthcare providers, and inadequate social

support (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Mueller,

Vuckovic, Knox, & Williams, 2002; Stanley, 1997).

Following hospitalization for heart failure exacerbation, key clinical problems

leading to preventable rehospitalizations are inadequate patient and family education,

poor self-assessment skills, inadequate support systems, failure to seek medical attention

promptly when symptom reoccur, and noncompliance with diet and medication regimens

(Artinian, Magnan, Sloan, & Lange, 2002; Stanley, 1997). One way to prevent

4


hospitalizations and to promote positive health outcomes in heart failure patients is to

ensure that the amount and quality of self-care used is appropriate for individual patients’

conditions (Artinian, Magnan, Sloan, & Lange, 2002). Substantial evidence suggests that

frequent hospitalizations for heart failure exacerbation can be prevented by Advanced

Practice Nurse (APN) intervention and coordinated disease management strategies

(Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Kegel, 1995;

McCauley, Bixby, & Naylor, 2006; Stanley, 1997).

APNs are particularly adept at facilitating self-management of heart failure by

collaborating with and coordinating care among care providers, providing education and

planning to prepare hospitalized patients for discharge, following up with discharged

patients, assessing access to resources, maintaining presence in the lives of heart failure

patients, and establishing therapeutic partnerships with patients and families (Davidson,

Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; Kegel 1995; McCauley,

Bixby, & Naylor, 2006). When heart failure patients’ self-care abilities overwhelm their

self-care deficits, it is possible to prevent hospitalization and manage heart failure in

outpatient setting.

Summary of the Theory

Purpose

This paper will use Chinn & Kramer’s (2008) guide to describe the self-care

deficit theory of nursing (Orem, 2001). Orem’s work on the self-care deficit theory of

nursing began in the 1950s when nursing curricula were based on conceptual models

from medicine, psychology, and sociology (Fawcett, 2001). She was motivated by the

desire to foster agreement about the proper focus of nursing and the need to clarify the

5


domain and boundaries of nursing practice (Orem, 2001). Orem felt that nursing lacked

an organizing framework for its knowledge and hoped that formal articulation of the

foundations and essential elements of the self-care deficit theory of nursing would serve

to upgrade nursing education curriculums and enhance nursing’s disciplinary evolution

(Fawcett, 2001).

The self-care deficit theory of nursing asserts that human limitations in self-care

associated with states of illness give rise to the requirement for nursing care (Fawcett,

2001). Orem refined and formally described what nursing is and should be in the self-

care deficit theory of nursing, which has three constituent articulating theories: (a) the

theory of self-care, which describes why and how people care for themselves; (b) the

theory of self-care deficit, which explains why people require nursing; and (c) the theory

of nursing systems, which describes relationships that must be fostered and maintained

for effective nursing care (Fawcett, 2001; Orem, 2001). The self-care deficit theory of

nursing is a general theory, applicable across all nursing practice areas and situations in

which people require nursing care (Orem, 2001).

According to the self-care deficit theory of nursing, the special focus on human

beings is what distinguishes nursing from other human services (Orem, 2001). It follows

that the role of nursing in society is to assist individuals’ development and exercise of

their self-care abilities to the extent that they can adequately and completely provide for

their care requirements (Isenberg, 2001). According to the theory, individuals who cannot

adequately provide for their self-care requirements are experiencing a self-care deficit,

and it is this deficit that identifies individuals in need of nursing care. The theory’s

6


purpose in formulating the self-care deficit theory of nursing is to describe when and why

nursing is needed (Isenberg, 2001).

Concepts

The self-care deficit theory of nursing implies two categories of human beings:

the agent of action and the object of action (Denyes, Orem, & SozWiss, 2001). The three

interrelated theories of the general self-care deficit theory of nursing identify and define

four concepts about individuals who require nursing care: self-care, self-care agency,

therapeutic self-care demand, and self-care deficit. The theory identifies and defines two

concepts about those who provide nursing service: nursing agency and nursing systems.

Orem proposes that human beings throughout the lifespan have self-care agency, which

she defines as the power to develop and exercise capabilities to know and meet self-care

requirements (Orem, 2001). According to the theory, self-care agency varies qualitatively

and quantitatively throughout the lifespan, and a self-care deficit exists when, for health

and health-care associated reasons, individuals’ self-care agency proves incapable of

meeting therapeutic self-care demands (Orem, 2001). The imbalance between a person’s

self-care agency and therapeutic self-care demand creates the need for nursing care.

Nursing agency is defined as the power of nurses to design and produce nursing care for

others. It follows that nursing agency extends to assist individuals with health-associated

self-care deficits to know and meet with assistance their self-care demands and to

exercise their powers of self-care agency (Orem, 2001).

In the latest edition of the self-care deficit theory of nursing, nursing is recognized

as a tripartite nursing system comprised of a professional-technical system dependent on

an interpersonal system and a societal system that provide the context for the nurse-

7


patient relationship (Orem, 2001). The nursing system concept describes the evolution of

nursing to include details of the structure and process of providing nursing care to

individuals, families, and communities (Orem, 2001). Nurses make decisions about what

type of nursing system is appropriate to attend to a self-care deficit by asking who can

and should perform the self-care operations (Isenberg, 2001). The nurse then designs and

applies the appropriate system with the goal of empowering the person to meet their self-

care requirements. The continuum of nursing systems range from wholly compensatory if

the nurse provides for the self-care demand to supportive-educative if the nurse assists

the individual to develop agency, with a partly compensatory system falling in between

the two extremes when nurses both provide for and assist the patient to provide for self-

care demands (Isenberg, 2001).

Relationships, Structure, and Assumptions

The self-care deficit theory of nursing describes and explains the relationship

between self-care agency and therapeutic self-care demand, identifying a self-care deficit

when capabilities to engage in self-care are less than the demand for self-care (Isenberg,

2001). The theory states that nurses provide a therapeutic system when individuals are

identified with an existing or potential self-care deficit. The theory’s conceptual

framework treats the concept of the whole person as greater than the sum of the parts. For

Orem, the individual is an integrated whole person with varying degrees of self-care

capabilities informed by the individual’s internal physical, psychological, and social

nature (Chinn & Kramer, 2008). The theory assumes that restoration of self-care agency

is the desired goal and purpose of nursing. Additionally, the theory assumes individuals

are motivated by self-preservation to participate in the restoration of self-care agency.

8


Application of the Theory: Nursing Care of Patients with Heart Failure

The theory implies that nursing actions are required to restore self-care ability and

provides comprehensive development of the self-care concepts, rendering the theory

applicable and useful as a guide to nursing practice areas involving individuals across the

lifespan experiencing health or illness, as well as to nursing interventions designed for

health promotion, health restoration, and health maintenance (Isenberg, 2001). The

theory’s application to nursing practice is well documented in the literature across a wide

range of age groups, practice settings, and nursing systems of care (Isenberg, 2001). This

paper will consider the theory’s relevance to the heart failure patient population, which is

also well documented in the literature.

Description of the APN Intervention: Expert Coaching & Guidance

Coping with heart failure greatly impacts self-care demands, and as proposed in

the self-care deficit theory of nursing, patients enter periods of fluctuating illness and

health states that correspond with varying degrees of self-care deficit and agency. The

Advanced Practice Nurse (APN) is uniquely prepared to assist patients with heart failure

recover and maintain self-care agency. Expert coaching and guidance is an APN core

competency and describes a complex, invisible process wherein the APN provides

education, surveillance, and reassurance to equip patients with the tools to manage their

health and illness transitions (Spross, 2009). Spross defines APN coaching as “a

complex, dynamic, collaborative and holistic interpersonal process that is mediated by

the APN-patient relationship and the APN’s self-reflective skills” (Spross, 2009, p. 167).

In the process of expert coaching and guidance, the APN integrates self-reflection and

clinical expertise with patients’ understandings, experiences and goals to accomplish

9

Kane, 05/04/10,

Write a step by step guide and put it in a figure at the end of the paper for the reader…


therapeutic and educational goals (Spross, 2009). The interaction of self-reflection with

technical, clinical, and interpersonal competence (Figure 1) drives the expansion and

refinement of the APN’s expertise in this process (Spross, 2009).

The intervention is termed coaching and guidance because these terms imply the

existence of a relationship that is fundamental to effective patient education and teaching

(Spross, 2009). A coach facilitates safe passage through transition, and the work of

coaching is complex and requires interpersonal confidence and competence. In the model

of APN expert coaching and guidance, the APN integrates physical examination,

interviewing, and intuition to acquire the patient’s perspective and reflect or translate this

understanding back to the patient (Spross, 2009). The APN involves the patient’s

significant other as appropriate. As coach, the APN helps patients uncover opportunities

for personal growth and assists them to clarify goals, decide what matters most to them,

acknowledge trade-offs and losses, and develop coping strategies (Spross, 2009). The

term coaching applied to the nurse-patient relationship permits both parties to experience

intense emotion and it simultaneously connotes the one-sided aspect and mutuality in the

relationship (Spross, 2009). Coaching is multidimensional involving cognitive, spiritual,

behavioral, physical, and social aspects of the human experience, and competence in its

administration requires a tailored approach to meet each individual patient’s needs

(Spross, 2009).

In the setting of heart failure, the APN can provide expert coaching and guidance

to address patient self-assessment, adherence to medication and diet regimen, knowledge

of disease maintenance, social support, and resource utilization (Kegel, 1995; McCauley,

Bixby, & Naylor, 2006). The APN is uniquely equipped with advanced communication

10


skills to build therapeutic relationships with patients. The APN can elicit the patient’s

thoughts, perspectives, expectations, values, and goals; provide patients with self-care

information to enable participation in health decisions; and develop disease management

plans collaboratively with patients (Spross, 2009).

The APN can conduct individualized patient assessment to identify signs and

symptoms of heart failure exacerbation and teach the patient how to problem solve and

identify emergency (McCauley, 2006). The education plan in the expert coaching and

guidance model considers the patient’s knowledge base, learning style, and capabilities. It

is important for patients to understand the importance of adhering to disease maintenance

regimen even when symptoms subside (McCauley, 2006). APNs use multiple strategies

to improve patients’ self-management including education about the chronic nature of

heart failure, practical solutions such as pill organizers and patient-specific prompts to

remember to take them, detailed nutrition counseling sessions (McCauley, 2006). The

APN uses patient-centered communication to learn the patient’s beliefs about their illness

and treatment, perceptions of severity of the condition because studies have shown that

the patient’s subjective interpretation of the severity of disease is often more influential

than objective reality (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown,

2003; Spross, 2009).

The effectiveness of telemanagement as a component of the expert coaching and

guidance intervention is well-documented in the literature (Kegel, 1995; Mueller,

Vuckovic, Knox, & Williams, 2002; Ryder, 2005). This is a particularly effective

strategy for reinforcing and clarifying how to take and follow medication regimen and

disease management strategies that a patient may have received at time of discharge from

11


the hospital or during a physician visit. Patients experiencing heart failure

decompensation are under duress and typically forget two thirds of diagnosis and

treatment explanations and half of instructional statements immediately after physician

visit (Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003).

Discussion of the Theory as Supportive of the Intervention

Since heart failure is a chronic disease characterized by exacerbations and disease

maintenance, self-care is important to optimize outcomes. Self-care behaviors include

adherence to medication and diet regimen, seeking assistance when symptoms indicate

exacerbation, and performing daily weights (Kegel, 1995; McCauley, 2006). The self-

care deficit theory of nursing identifies three sets of limitations for self-care: limitations

of knowing, limitations of judgment, and limitations on result-achieving courses of action

(Orem, 1995). All three sets of limitations are present to varying degrees in heart failure

patients. The nursing system that seems to be most applicable for addressing these

limitations for maintenance of heart failure is the supportive-educative system. The self-

care deficit theory of nursing describes general methods of nursing action in the

supportive-educative system, including support, guidance, provision of developmental

environment, and teaching (Orem, 1995). Several articles documented Orem’s general

theory as a framework for studying, describing, and developing supportive-educative

nursing interventions to prevent potential self-care deficits and enhance self-care agency

for heart failure patients in the outpatient setting (Artinian, Magnan, Sloan, & Lange,

2002; Jaarsma, Abu-Saad, Dracup, & Halfens, 2000; Jaarsma, Halfens, Senten, Saad, &

Dracup, 1998).

12


Coping with heart failure greatly impacts self-care demands (Davidson,

Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003). Phases of adjusting to heart

failure include acceptance, adjustment to crisis and diagnosis, and decision to resume

living with new knowledge of the condition (Davidson, Macdonald, Paull, Rees, Howes,

Cockburn, & Brown, 2003). APNs can promote self-care by providing information within

a supportive-educative framework that is consistent with the individual’s phase of

adjustment. In particular, an Orem-inspired supportive-educative nursing system has

facilitated several programs designed to enhance patients’ abilities to perform self-care

operations to maintain a prescribed medication regimen and to monitor and manage

symptoms (Artinian, Magnan, Sloan, & Lange, 2002; Fujita & Dungan, 1994; Schneider,

Hornberger, Booker, Davis, Kralicek, 1993). One example is the utilization of a diuretic

treatment algorithm, in which APNs and patients agree on a set of signs and symptoms of

decompensation for the patient to use to determine when to take an extra dose of diuretic

and when to see a physician (Meuller, Vuckovic, Knox, & Williams, 2002).

During periods of exacerbation and in the instance of end stage heart failure

patients who are under consideration for heart transplant, the wholly compensatory and

partly compensatory nursing systems become more applicable, but these scenarios are

less documented in the literature. Casida, Peters, & Magnan (2009) eloquently propose

the use of self-care deficit theory of nursing as a framework to identify and organize

nursing care for hospitalized heart failure patients on left-ventricular assist devices and to

assess readiness for discharge.

In the expert coaching and guidance intervention, the APN individualizes

strategies for changing health behaviors, fosters initiative, encompasses an unambiguous

13


treatment plan, and incorporates patients’ significant others (Davidson, Macdonald, Paull,

Rees, Howes, Cockburn, & Brown, 2003). Evidence suggests that APN expert coaching

and guidance, in conjunction with coordinated care and collaboration among providers

can decrease hospital readmission in heart failure patients by as much as 50% (Mueller,

Vuckovic, Knox, & Williams, 2002). Through expert coaching and guidance, the APN

uses multiple strategies to simultaneously address heart failure patients’ limitations of

knowing, limitations of judgment, and limitations of result-achieving courses of action

(McCauley, 2006). Significant increases in self-care agency occur when education and

support are provided and when patients perceive themselves to be a partner in the

development of their treatment plans (Artinian, Magnan, Sloan, & Lange, 2002).

Concluding Summary of the Relationship Between the Theory and the Intervention

The congruence between nursing theory and practice is realized in the relationship

between the self-care deficit theory of nursing and the APN intervention of expert

coaching and guidance. The expert coaching and guidance APN intervention is a perfect

practical application of the self-care deficit theory of nursing. The goal of the expert

coaching and guidance intervention is to restore patients’ ability to provide for their self-

care needs. As coach, the APN helps patients discover opportunities for personal growth

and assists them to clarify goals, decide what matters most to them, acknowledge trade-

offs and losses, and develop coping strategies (Spross, 2009). The APN coach can equip

heart failure patients with the knowledge and tools to recognize their self-care agency and

self-care deficits.

Heart failure is characterized by exacerbations and remissions (Stanley 1997).

Coping with heart failure greatly impacts self-care demands, and as proposed in the self-

14


care deficit theory of nursing, patients enter periods of fluctuating illness and health states

that correspond with varying degrees of self-care deficit and agency. The Advanced

Practice Nurse (APN) is uniquely prepared to assist patients with heart failure recover

and maintain self-care agency. By maintaining the commitment to the coaching and

guidance process, the APN establishes a supportive and therapeutic partnership with heart

failure patients that allows for fluctuations in the patient’s ability to self-manage a labile

chronic disease in the outpatient setting (Ryder, 2005). The APN coach can expertly

individualize strategies in accordance with patients’ varying degrees of confidence, fear,

knowledge, abilities, and resources within a supportive-educative nursing framework

(Orem, 1995; Spross, 2009).

Increases in self-care behaviors as a result of expert coaching and guidance from

an APN are well-documented in the literature (Artinian, Magnan, Sloan, & Lange, 2002;

Davidson, Macdonald, Paull, Rees, Howes, Cockburn, & Brown, 2003; McCauley, 2006;

Ryder, 2005). Specifically, after APNs addressed self-care limitations, heart failure

patients demonstrated improved and effective self-care decision making in response to

signs and symptoms of heart failure exacerbation, promptly and appropriately seeking

medical care (Artinian, Magnan, Sloan, & Lange, 2002; Davidson, Macdonald, Paull,

Rees, Howes, Cockburn, & Brown, 2003). Additionally, heart failure patients

demonstrated improved understanding of their disease process and better self-

management relative to medication compliance and weight monitoring in response to

APN expert coaching and guidance interventions (Artinian, Magnan, Sloan, & Lange,

2002).

15


The relationship between knowledge and self-care behavior is significant and

documented throughout the literature without exception, revealing the practical

application of the self-care deficit theory of nursing. The theory proposes that knowledge

is a power that enables self-care and that strategies to address knowledge limitations must

be specific and organized around known self-care requisites (Artinian, Magnan, Sloan, &

Lange, 2002). The APN intervention of expert coaching and guidance is uniquely suited

to apply the self-care deficit theory in practice. Through the intervention of expert

coaching and guidance, the APN considers the patient’s knowledge base, learning style,

and capabilities to develop disease management plans collaboratively with patients

(McCauley, 2006; Spross, 2009). Heart failure patients experience a higher level of self-

care agency as a result of expert coaching and guidance from an APN.

16


References

Anderson J. H. (2007). The impact of using nursing presence in a community heart

failure program. The Journal of Cardiovascular Nursing, 22 (2), 89-94.

Artinian, N. T., Magnan, M., Sloan, M. & Lange, M. P. (2002). Self-care behaviors

among patients with heart failure. Heart & Lung, 31 (3), 161-172.

Casida, J. M., Peters, R. M., & Magnan, M. A. (2009). Self-care demands of persons

living with an implantable left-ventricular assist device. Research & Theory for

Nursing Practice, 23 (4), 279-293.

Chinn, P. L. & Kramer, M. K. (2008). Integrated Theory and Knowledge Development in

Nursing (7th ed.). St. Louis: CV Mosby.

Davidson, P., Macdonald, P., Paull, G., Rees, D., Howes, L., Cockburn, J., & Brown, M.

(2003). Diuretic therapy in chronic heart failure: Implications for heart failure

nurse specialists. Australian Critical Care, 16 (2), 59-69.

Denyes, M. J., Orem, D. E., & SozWiss, G. (2001). Self-care: A foundational science.

Nursing Science Quarterly, 14 (1), 48-54.

Fawcett, J. (2001). Scholarly dialogue: The nurse theorists: 21st century updates –

Dorothea E. Orem. Nursing Science Quarterly, 14 (1), 34-38.

Fujita, L. Y. & Dungan, J. (1994). High risk for ineffective management of therapeutic

regimen: a protocol study. Rehabilitation Nursing, 19 (2), 75-79, 126.

Isenberg, M. A. (2001). Part two: Applications of Dorothea Orem’s self-care deficit

nursing theory. In Parker, M. (Ed.), Nursing theories and nursing practice (2nd

ed., pp. 149-159). Philadelphia: F. A. Davis.

17


Jaarsma, T., Abu-Saad, H. H., Dracup, K., & Halfens, R. (2000). Self-care behavior of

patients with heart failure. Scandinavian Journal of Caring Sciences, 14 (2), 112-

119.

Jaarsma, T., Halfens, R., Senten, M., Saad, H. H. A., & Dracup, K. (1998). Developing a

supportive-educative program for patients with advanced heart failure within

Orem’s general theory of nursing. Nursing Science Quarterly, 11 (2), 79-85.

Kegel, L. M. (1995). Advanced practice nurses can refine the management of heart

failure. Clinical Nurse Specialist, 9 (2), 76-81.

McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006). Advanced practice strategies

to improve outcomes and reduce costs in elders with heart failure. Disease

Management, 9 (5), 302-310.

Mueller, T. M., Vuckovic, K. M., Knox, D. A., & Williams, R. E. (2002).

Telemanagement of heart failure: A diuretic treatment algorithm for advanced

practice nurses. Heart & Lung, 31 (5), 340-347.

Orem, D. E. (2001). Part one: Dorothea E. Orem’s self-care deficit nursing theory. In

Parker, M. (Ed.), Nursing Theories and Nursing Practice (2nd ed., pp. 141-149).

Philadelphia: F. A. Davis.

Orem, D. E. (1995). Nursing: Concepts of Practice. St. Louis, MO: Mosby.

Ryder, M. (2005). Is heart failure nursing practice at the level of a clinical nurse specialist

or advanced nurse practitioner?: The Irish experience. European Journal of

Cardiovascular Nursing, 4 (2), 101-105.

Schneider, J. K., Hornberger S., Booker, J., Davis, A., & Kralicek, R. (1993). A

medication discharge planning program: Measuring the effect on readmissions.

18


Clinical Nursing Research, 2 (1), 41-53.

Spross, J. A. (2009) Expert Coaching and Guidance. In Hamric, A. B., Spross, J. A., &

Hanson, C. M. (Eds.), Advanced Practice Nursing: An Integrative Approach 4th

Edition (pp. 575-604). Philadelphia: Elsevier Saunders.

Stanley, M. (1997). Current trends in the clinical management of an old enemy:

Congestive heart failure in the elderly. AACN Clinical Issues 8 (4), 616-626.

19


Figure 1. Model of the APN intervention of expert coaching and guidance.

20

abstract - web viewthus patients must be actively involved with their plan of care and need access...

Documents