REFLECTIVE JOURNALS 1

Reflective Journals

Submitted by:

Dominique Excelsis J. Degamo

Submitted to:

Professor Isabelita C. Rogado, RN, MAN

Arellano University

June 28, 2014

REFLECTIVE JOURNALS 2

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 rater’s 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 client’s 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.

REFLECTIVE JOURNALS 5

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"?

Mion’s (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?

Young’s (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 client’s 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 client’s 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.

REFLECTIVE JOURNALS 9

Open Access: The Movement, The Issues, and The Benefits

Jan M. Nick, PhD, RNC-OB, CNE, ANEF

Today’s 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

competency—a 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.

REFLECTIVE JOURNALS 15

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

REFLECTIVE JOURNALS 16

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-

REFLECTIVE JOURNALS 17

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,

REFLECTIVE JOURNALS 18

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/

TableofContents/Vol-17-2012/No1-Jan-2012/Articles-Previous-Topics/Open-Access-Part-

I.html#Table1

- http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/

TableofContents/Volume62001/No2May01/ArticlePreviousTopic/OJNI.html

- http://www.nursingworld.org/search.aspx?SearchPhrase=reflective%20journals