REFLECTIVE JOURNALS 1

Reflective Journals


Submitted by:
Dominique Excelsis J. Degamo


Submitted to:
Professor Isabelita C. Rogado, RN, MAN


Arellano University

June 28, 2014

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Critical Need to Address Accuracy of Nurses Diagnoses
Margaret Lunney, RN, PhD
Studies published from 1966 to 2006 describe how nurses interpretations of clinical data
vary widely, thus significant percentages of nurses diagnoses may be of low accuracy. This is
important because data interpretations, or diagnoses, serve as the basis for selection of
interventions and the subsequent achievement of patient outcomes. Accuracy of nurses
diagnoses is defined as a raters judgment of the match between a diagnostic statement and
patient data. Low accuracy can lead to wasted time and energy, harm to patients, absence of
positive outcomes, and patient and family dissatisfaction. The purpose of this article is to appeal
to nurses in both practice and education to address the accuracy of nurses diagnoses. This appeal
is based on three factors: (a) research evidence indicates the need for greater consistency among
nurses in making nurses diagnoses, (b) accuracy of nurses diagnoses will always be an issue of
concern because diagnosis in nursing is complex, and (c) with implementation of electronic
health records, the degree of accuracy of nurses diagnoses will have broad-based implications.
In this article, the need for nurses to be accountable for addressing diagnostic accuracy is
explained and strategies to improve accuracy related to the diagnostician, the diagnostic task, and
the situational context are recommended. Some of these strategies include a greater focus on
educational methods and content for development of nurses as diagnosticians, adoption of
partnership models of nurse-patient relationships, an increase in opportunities for critical
thinking and clinical decision making, selection of software with appropriate structures and
content libraries, and a change in health care policies.

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Accountability for Accuracy
Because research studies document variance in nurses diagnoses, and variance means that some
diagnoses are not accurate, nurses in both practice and education are encouraged to consider their
accountability for accuracy of diagnoses. Levin, Lunney, and Krainovich-Miller (2005), for
example, applied the five steps of evidenced-based medicine, as described by Sackett, Strauss,
Richardson, Rosenberg, and Haynes (2000), to show how diagnostic accuracy in nursing can be
improved through use of research evidence and patient preferences. A new PCD model
(Population, Cue Cluster, Differential Diagnoses) was proposed for the first step of evidence-
based practice, i.e., asking answerable questions. The five-step, evidence-based process, of (a)
ask answerable questions, (b) find the best evidence to answer the questions, (c) appraise the
validity of the evidence, (d) integrate the evidence with experience and patient preferences, and
(e) evaluate the effectiveness of the first four steps, was explained as it pertains to accuracy of
nurses diagnoses. Accuracy of nurses diagnoses is the foundation for achieving positive
outcomes through use of nursing interventions, either with or without the use of standardized
nursing diagnoses from NANDA-I or other diagnostic languages. When nurses act on their
interpretations of data, they are acting on diagnoses, whether or not the diagnoses are stated.
Reflection
In this article they proposed strategies that can improve accuracy of data interpretations
supported by research evidence, the complexity of diagnosis in nursing, and the impending
implementation of electronic health records.

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Accuracy of nurses data interpretations (diagnoses) should be a serious concern of nurses in
both practice and education because interpretations of patient data serve as the basis for selecting
the nursing interventions that will achieve positive patient outcomes. Nurses should be
responsible in identifying clients strengths and health problems that can be prevented or
resolved by collaborative and independent nursing interventions. And to formulate an accurate
nursing diagnoses the nurse must be familiar with the definitions of terms used, the types, and
the components of nursing diagnoses. The nurse must meet the standardized nursing diagnoses to
have a basis in the selection of nursing interventions that will be rendered to the client. In
generating and completing a nursing care plan, the nurse should be accountable in the outcomes
of his/her interpretations of clinical data. When interpretations vary, some of the interpretations
represent low accuracy. This is serious because low diagnostic accuracy contributes to harm to
patients through: wasted time and energy, implementing ineffective interventions, absence of
positive outcomes, and patient and family dissatisfaction. Data that are based on low accuracy
diagnoses will be misleading, if not useless. Thus, nurses in practice (staff nurses, leaders, and
administrators) and nursing educators need to be more diligent in promoting and measuring the
accuracy of nurses diagnoses. In this way, we can develop and monitor the accuracy of our
nursing diagnoses and will demonstrate accountability in all clinical interpretations that will be
generated. The nurse will also relate the diagnoses to his/her independent functions, that is, the
areas of health care that are unique to nursing and separate and distinct from medical
management.


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Ethics: Ethical Challenges in the Care of Elderly Persons
Ruth Ludwick, PhD, RN, C
Mary Cipriano Silva, PhD, RN, FAAN
Ethical issues are central to any discussion or reflection on aging and health care. The
authors of the OJIN topic, Health Care and the Aging Population: What Are Today's
Challenges?, address a variety of topics including quality of life, long-term care planning,
geriatric education, frail elder care, and successful aging behaviors. Imbedded in these topics are
ethical issues that are relevant to nursing and/or health care. Thus, the focus of this column is to
examine select ethical issues in these five articles on aging.
The article by Bennett and Flaherty-Robb (2003) paints a broad picture of four issues
affecting the health of older persons: lack of resources; scarcity of providers; financial barriers;
and cultural barriers and biases. While there are many ethical problems that can be discussed
within the context of these four issues, cultural biases stand out because nurses can personally
examine these biases and change them in our daily practice. As the two preceding authors note in
their article, stereotyping is common. Nurses are not immune to stereotyping and, thus, must
examine their own beliefs and values about aging. Do nurses and the nursing profession have
their own biases about aging? How do we react when we hear biases expressed by nurses or
other health care workers or by families or by the elderly themselves? How much does age bias
influence our decision to withhold treatment or informed consent?


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In their article, Edlund, Lufkin, and Franklin (2003) address some of the problems related
to long-term care in the US health care system. At first glance one may not consider the
individual ethical implications imbedded in this topic. The article authors, however, point out the
ethical duty nurses have to educate the public and at the same time keep themselves
knowledgeable about long-term care. But are nurses as educated as they should be about long-
term care? Have you heard nurses say, "I do not understand Medicare"? Have you heard acute
care nurses publicly find fault with long-term care nurses or vice versa? Do you listen for and
correct misperceptions such as, "Long-term care is nursing home care," or "Nursing homes are
where people go when nobody wants you"?
Mions (2003) article addresses in depth the limited geriatric education of most nurses,
even though these nurses will have some contact with geriatric populations. Even in pediatrics
and maternity, where one assumes a younger population, we see in developed and in developing
countries a rising number of grandparents who are primary caregivers for children. While the
educational process may have fallen short, are nurses keeping up with the gerontological and
ethical literature as it applies to the areas of nursing in which they work?
Youngs (2003) article outlines the issues related to care of frail elders in acute- and long-
term care, examines subsequent challenges, and then suggests some innovative answers to their
care. As Young discusses the challenge of resource allocation, she also notes ethical dilemmas.
Specifically, she mentions end-of-life care and the decision to treat against the wishes of the
dying person. In our professional or personal lives, have we found family members or other
health care workers who persuaded us to prolong or start a treatment when it was expressly

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against the wishes of the dying person? Or have we been in a situation where we failed to ask in
a timely manner what kind of care that dying persons want?
The last article by Hartman-Stein and Potkanowicz (2003) addresses the behavioral
components of successful aging. Regarding this article, ethical questions can be raised about
individual client responsibility and preference about lifestyle choices, but the ethical questions
for nurses may not seem as apparent. For example, how often do we discuss with the elderly
choices about exercise, religious beliefs, or cognitive activities? Do we routinely screen for
depression, functional change, or cognition changes, or do we wait to do these screens until
symptoms become problematic?
While each of the preceding five articles was addressed separately, in fact, the articles
overlap. Both Bennett and Flaherty-Robb (2003) and Young (2003), for example, discuss
cultural issues, but they do so from slightly different perspectives. Edlund, Lufkin and Franklin
(2003) and Mion (2003) also address education but the issues are presented from varying
standpoints. This overlap, while at first seeming contradictory, only helps to demonstrate the
complexity of the issues. As you, the reader, reflect on the articles both individually and
collectively, we hope you are challenged to think of the ethical issues that connect these articles.
Reflection
In this article, the author discussed different articles that are related to elderly patients
and the ethical challenges that a health care provider will be facing. These presented issues may

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affect the ethical duty of a nurse and how he/she can raise the advocacy for his/her elder patient.
These challenges may affect the nurses own beliefs and values, and subsequent biases while
examining the ethical issues. Furthermore, it will have an impact on care provision, that is, on
what care is provided, as well as when, where, why and how it is provided.
Many of the ethical challenges faced by the nurses are not moral issues at all, but simply
questions of good nursing practice (Kozier and Erb, 2004). The nurse must always be aware of
the social and technological changes and with their conflicting loyalties and obligations. Their
obligation to their clients, to the agency that employs them, to physicians and even to their own
values and beliefs may affect their ethical decisions.
The nurse must create a strategy to overcome possible organizational and social
constraints that may hinder the ethical practice of nursing and may develop moral distress for
nurses. They must first determine the issue and to collaborate with other health professionals.
They also need to acknowledge the older clients ability to think, reason, and make decisions
because aging people need to be recognized for their unique individual characteristics. To plan
an effective care, nurses need to identify their clients health status, values and beliefs as they
influence and relate to a particular health problem and may raise an ethical issue. They should
also include the families of their clients and other health care provider related to the ethical issue.
The nurse must also examine their own values about life, death, health and illness that may affect
their ethical decisions to prevent or resolve the ethical challenges in relation to their elder
patients.


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Open Access: The Movement, The Issues, and The Benefits
Jan M. Nick, PhD, RNC-OB, CNE, ANEF
Todays climate of evidence-based practice requires accessing current literature. Yet
nursing campuses around the world struggle to acquire and maintain sufficient current reference
materials. Given these conditions, the culture of evidence-based practice is difficult to achieve.
In developing countries, reference collections are often decades out of date. In developed
countries, smaller hospitals, private colleges, and other institutions often do not have budgets to
purchase large datasets of journals and may lack access to other current information as well.
Unfortunately, even large universities have seen significant cuts in library budgets due to recent
economic challenges (White & Creaser, 2007). The economic downturn has resulted in
publishers increasing journal prices (Van Orsdel & Born, 2009). Given these conditions,
information access is, and will continue to be, a global problem. The guiding characteristic of
Open Access (OA) material is that it may be accessed via the web without charge. This offers
practitioners and educators worldwide a higher level of information currency and competency.
Open Access Movement
During the last decade the Open Access (OA) movement has taken hold, starting in the
basic sciences followed by the health sciences. Open Access provides people ability to access
information electronically by searching and linking to full-text, peer-reviewed materials without
a fee in order to read or download, copy and distribute, or print the information (Bethesda
Statement, 2003).

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Open Access Issues
As with any new movement, there are advantages and disadvantages to consider. Four major
issues related to OA include: peer review, author-related publication fees, copyright and
licensing, and the related practice of author self-archiving.
Open Access Benefits
There is a growing body of evidence indicating clear benefits of publishing in OA journals. This
is the case both when developing and developed countries use OA resources and when
institutions archive OA materials. Being aware of all research done on a certain topic will impact
networking and increase connectedness at a global scale.
Reflection
Over the last decade, many changes have occurred in electronic publishing. These
changes and associated publishing issues require nurse educators and nurse clinicians to not only
be aware of, but also know how to navigate new publishing models and create policies
supportive of these new models. We, as nurses, must become involved in these changes so we do
not miss out on the associated benefits personally, institutionally, and globally. It is time for the
nursing scientific community to convene and declare its intentions regarding participation in the
Open Access movement. OA offers valuable free, full-text, online resources for all health-related
professionals, regardless of the practice setting. Because much scholarly information may now
be accessed without charge, nurses worldwide can reach a higher level of information
competencya prime requirement for evidence-based practice. In dealing with these online

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references, they must monitor and regulate the issues to protect the rights of the authors and
maintain reliable resources for healthcare professionals. The potential to create a single body of
knowledge accessible to all nurses is both exciting and urgently necessary. Nursing must take
action to participate in and promote the OA movement in order to derive the maximum gain for
our practice.













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Evidence-Based Practices for Safe Patient Handling and Movement
Audrey Nelson, PhD, RN, FAAN
Andrea S. Baptiste, MA, CIE
Nursing personnel are consistently listed as one of the top ten occupations for work-
related musculoskeletal disorders, with incidence rates of 8.8 per 100 in hospital settings and
13.5 per 100 in nursing home settings (Bureau of Labor Statistics, 2002). These are considered to
be low estimates, since underreporting of injuries in nursing is common (U.S. Department of
Health & Human Services, 1999). Aggregated data on prevalence of back injury, compiled from
over 80 studies, revealed an international worldwide point prevalence of approximately 17%, an
annual prevalence of 40-50% and a lifetime prevalence of 35-80% (Hignett, 1996). While there
has been a steady decline in the rates of most occupational injuries starting in 1992, work-related
musculoskeletal disorders in nursing continue to rise (Fragala & Bailey, 2003).
Patient handling and movement tasks are physically demanding, performed under
unfavorable conditions, and are often unpredictable in nature. Patients offer multiple challenges
including variations in size, physical disabilities, cognitive function, level of cooperation, and
fluctuations in condition. As a load to be lifted, they lack the convenience of handles, even
distribution of weight, and have been known to become combative during the lift process.
Shockingly, the cumulative weight lifted by a nurse in one typical 8-hour shift is equivalent to
1.8 tons (Tuohy-Main, 1997). Further, many patient lifts are accomplished in awkward positions
such as bending or reaching over beds or chairs while the nurse's back is flexed (Blue,
1996; Videman et al., 1984).

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Evidence-Based Solutions For High Risk Patient Handling Tasks
Various types of interventions have been implemented in an attempt to reduce high risk
patient handling tasks. An ergonomic approach has been utilized with supporting evidence for
solutions proven to be effective, ineffective, and those that show promise. These solutions can be
considered as controls and are therefore divided into three categories, namely engineering,
administrative, and behavioral controls.
Engineering controls are changes made to the work environment, layout, tools, or
equipment used on the job, or changing the way a job is done to avoid work-related
musculoskeletal hazards (Virginia Polytechnic Institute and State University, 2004). These
controls are the preferred solution because they create permanent changes that eliminate risks at
the identified source. An example is the use of patient handling technology, such as lateral
transfer aids or hospital bed improvements.
Administrative controls are management-dictated work practices and policies that reduce
or prevent exposures to ergonomic risk factors. Administrative control strategies include (a)
modification of job rules and procedures (scheduling more rest breaks), (b) job rotation or
modified duties or length of shift, and (c) training workers to recognize ergonomic risk factors so
they can adopt stress reduction techniques while performing their work tasks (Centers for
Disease Control and Prevention [CDC], 1997). Examples of administrative controls include a no
lift policy (explained later in this article), patient care assessment protocols, and use of clinical
tools such as algorithms.

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Behavioral or work practice controls are those that involve training of staff in body
mechanics, or other joint protection principles (Shepherd, 2001). Such techniques include
manual patient lifting, training in proper use of lifting equipment/devices, and the use of unit-
based peer leaders.

Reflection
This article discussed the efforts to reduce injuries associated with patient handling are
often based on tradition and personal experience rather than scientific evidence. The purpose of
this article is to summarize current evidence for interventions designed to reduce caregiver
injuries, a significant problem for decades. Despite strong evidence, published over three
decades, the most commonly used strategies have strong evidence that demonstrate they are
ineffective. There is a growing body of evidence to support newer interventions that are effective
or show promise in reducing musculoskeletal pain and injuries in care providers.
The authors have organized potential solutions into three established ergonomic solution
types: engineering based, administrative, and behavioral. Given the complexity of this high-risk,
high volume, high-cost problem, multifaceted programs are more likely to be effective than any
single intervention. This new call for action includes systematic change in health care facilities
across the continuum of care as well as a new curriculum for schools of nursing.


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Information Resources: Using E-Journals: Desktop Nuts and Bolts
Barbara F. Schloman, PhD, AHIP
What is an e-journal?
In truth, "e-journals" is not used very precisely as a label. There is lack of clarity about both the
"electronic" and "journal" qualifiers. It makes sense to deal with "journal" first. The following is
the hierarchy for classifying publications used by librarians to differentiate the various types.
Serials: Publications issued in parts indefinitely over time.
Periodicals: Serial publications issued at regular intervals less than a year.
o Magazines: Periodicals containing a collection of articles, stories, pictures, or
other features.
o Journals: Periodicals offering articles on a particular topic for a professional or
scholarly audience.
o Scholarly journals: Journals with research or scholarly content that has been
screened through a peer-review process.
Therefore, not all regularly issued publications are journals, nor are all journals "scholarly." This
is true in both the print and electronic worlds.
With this in mind, then, what constitutes an electronic journal? Obviously, the mode of delivery
must be electronic, but the extent of what is delivered electronically varies. In its purest form, an
e-journal is "an edited package of articles that is distributed to most of its subscribers in

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electronic form" (Kling & Covi, 1995). The group of journals whose primary distribution is
electronic is very small, although growing across all disciplines. Initially, these journals were
developed independently by individuals without benefit of subsidy from institutions or
professional associations and usually offered without cost to the user (Fisher, 1996). This lack of
production support resulted in time in the cessation of some titles.
E-Journal Accessibility
As suggested, some e-journals are freely accessible on the Web. This is most commonly
the case for those titles that have been created independent of a print counterpart. Publishers of
print journals usually limit free, online access to the tables of contents and abstracts of articles.
While this falls short of desktop access to the full-text of articles, it does provide the convenience
of browsing published issues to identify items of interest.
It is possible to locate specific journals that are on the Web with full-text or with table of
contents by using a general search engine (such as InfoSeek or AltaVista) and searching by
specific title. Various Web directories for nursing provide listings of e-journals as well. Again,
caution should be exercised in using these, as the lists often contain an unidentified mix of those
that are and are not peer-reviewed. Examples of Web directories useful for this purpose include:
University of Texas School of Nursing at Galveston Academic Journal Directory
(www.son.utmb.edu/catalog/catalog.htm),CINAHLSources
(www.cinahl.com/csources/csources.htm),HealthWeb-Nursing
(http://www.lib.umich.edu/hw/nursing.html) under "Resources," and a listing of free-to-all e-

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journals in general medicine and health from the Hardin Library
(www.lib.uiowa.edu/hardin/md/ej.html).

Reflection
This article discussed how E-journals differ from other online resources for health care
providers. They also showed the how accessible the E-Journals and how it can help the health
professionals. These available journals are cost-efficient and will save time in reviewing huge
volumes of publications. The increase in availability of full-text journals articles online has made
the electronic literature search process even more productive. In that way, we can easily review
and disseminate health-related information or evidence-based practice.
In relation to innovation and accessibility, we must also monitor and secure the quality of
these resources to maintain their reliability. The software programs like the E-journals must also
be accessible and easily be understood by the user to be able to utilized correctly. The
accreditation of these online materials must be up to date and must be evidence-based to widely
disperse to the practitioners who can use the findings to improve their practices.
Thus, developments to date in electronic publishing have all occurred within the past decade. We
can expect that more significant changes are yet ahead. The economic realities of the existing
publishing marketplace, coupled with a more innovative and fast-paced networked environment,


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are bound to produce new models for scholarly communication that build upon these examples
we now have.














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Reference:
- http://journals.lww.com/ajnonline/pages/results.aspx?txtKeywords=reflection
- http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN
- http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Ta
bleofContents/Vol-17-2012/No1-Jan-2012/Articles-Previous-Topics/Open-Access-Part-
I.html#Table1
- http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Ta
bleofContents/Volume62001/No2May01/ArticlePreviousTopic/OJNI.html
- http://www.nursingworld.org/search.aspx?SearchPhrase=reflective%20journals