Nursing Process in Prevention Evaluation

1
Nursing Process in Prevention - Evaluation

• Week 8
• Thanks to the collaborative team for this
  presentation

2
Factors Influencing Health Outcomes

• Comprehensive complex
• 4 main factors
• Client
• Provider of care
• System characteristics
• Process of delivering health promotion
  interventions.

3
Measuring the Effects of Nursing Practice on
Client Outcome

• To determine the most appropriate, effective
  intervention
• And the most cost effective interventions in
  current competitive health care market.

4
Improving Quality of Care

• Evaluate the contribution of health care and
  health related interventions for individuals,
  families and community on outcomes.
• Measure
• Monitor
• Manage outcomes.

5
Defining Health Outcomes?

• Consequences of a treatment or intervention
  (goal) which is intended or unintended
• Effects of interventions manifested by changes in
  any dimension of health or resolution of problem
  targeted by the intervention
• Health promotion outcomes differ according to the
  structure of intervention as well as the process
  of implementing intervention.

6
Measuring Quality

• Evaluate
• Structure
• Process
• Health outcomes.

7
Measuring Quality (cont.)

• Tools used to measure these called performance
  measures or indicators
• Clients choice important when defining outcomes
  of health promotion interventions
• Traditionally health outcomes included 5 Ds
  death, disease, disability, discomfort
  dissatisfaction - client subjective opinion use
  to be considered too vague unreliable, now very
  important.

8
Monitoring Managing

• Outcomes monitoring Repeated observation,
  description quantification of outcome measures
• Outcomes management data collected from
  measuring monitoring outcomes used to
  continuously improve nursing practice.
• E.g. costs quality are continuously
  retrospectively measured examined to improve
  quality of care health status of clients.

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Challenge

• Nurses practice in a multidisciplinary
  environment how do we identify what health
  outcomes are nursing-sensitive, or those that are
  influenced by nursing activities?
• How do we carve out, measure document nursings
  contribution to health promotion outcomes?
• Need to differentiate dependent, independent
  interdependent nursing interventions to determine
  outcomes that nurses are accountable for.

10
ANA Identified Nurse-Sensitive Outcomes

• Physiological
• Psychosocial
• Functional
• Behavioural
• Cognitive
• Home functioning

• Safety
• Symptom control
• Goal attainment
• Satisfaction
• Costs.

Table 10-1 Pender
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Instruments

• After identifying appropriate health promotion
  outcomes, accurate reliable instruments will
  have to be developed to measure these outcomes
•  Although measures are available, many do not
  fully capture the effects of nursing practice.

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Significance of Nursing-Sensitive Outcomes

• Demonstrate nursing contributions to patient
  outcomes
• Employers, consumers, health policy makers are
  asking nursing to identify which interventions
  are most effective (achieves goal) efficient
  (with least amount of time resources)
• Enhances our visibility.

13
Deciding Which Health Outcomes to Measure

• Depends on
• Goals to be attained
• The purpose type of intervention
• The ability to access information needed to
  measure results of care
• Challenge is to select health outcomes that are
  comprehensive, comparable, meaningful accurate
  in reflecting the effects of the health promotion
  intervention.

14
Outcomes Classification in Health care

• Client focused
• Diagnostic specific/Holistic
• Provider focused
• Health care provider/Family
• Community focused.

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Short-Term, Intermediate, Long-Term Outcomes

• Timing of measurement of outcomes is critical to
  result obtained
• Information collected too soon change in
  lifestyle may not be made
• Information collected too late other factor may
  have intervened to influence expected results.

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Short-term, Intermediate Long-term Outcomes
(cont.)

• Short-term outcomes are measured immediately
  following the intervention
• Intermediate outcomes are measured soon enough
  following the intervention so that its effects
  can be accurately isolated from other possible
  reasons
• Long-term outcomes are the ultimate outcomes
  final or end results.

17
Economic Outcomes Types

• Cost effectiveness What is the most inexpensive
  way to achieve a given outcome?
• Cost utility What is the cost per
  quality-adjusted life years?
• Cost benefit What is the net benefit of a given
  alternative?.

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Developing a Plan to measure Health Outcomes

• 4. ID potential factors that may influence
  outcomes clt characteristics, demographics,
  family characteristics
• 5. Select outcomes to measure effects of
  intervention short term, intermediate,
  long-term.

• 1. Select health protection/ promotion area of
  interest
• 2. Identify most effective intervention for
  defined area.
• 3. Tailor intervention to client

Table 10-3 Pender
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Challenges in Measuring Health Outcomes

• Separating the contribution of nursing from other
  health care providers
• Sensitivity of measures of outcomes
• Holistic-focused outcomes
• Measurement of community or organizational
  focused outcomes.

20
Directions for Nursing Research in Outcome
Measurement

• More explanatory studies to identify holistic
  outcomes that reflect nursings contribution to
  learn patient preferences
• Experimental research needed to test health
  promotion interventions evaluate client
  outcomes at multiple points in time
• Need sensitive measures of health promotion
  outcomes that reflect nursings influence  
• Need measures of community-level outcomes
• Need to learn how to measure economic outcomes.

21
Directions for Nursing Practice in Achieving
Health Outcomes

• Nurses must focus on the value of their practice,
  delineate its contribution to health outcomes
• Plans of care must be continually assessed to
  identify the most effective approaches for
  quality care
• Nurses must keep up to date with the literature.

22
Evaluating Individual Community Interventions
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Research

• A scientific knowledge base to guide health
  promotion interventions is established by
  evaluating the accumulating results of research
  (Pender, p 276)
• Our knowledge of the effectiveness of health
  promotion interventions is based on quality
  research that has been conducted and published
  (Pender, p 276).

24
Scientific Knowledge Base

• The effectiveness of a particular intervention
  can only be assessed through careful examination
  of accumulated research evaluation evidence
  about the specific type of intervention
• Knowledge base both guides health promotion
  interventions is established by evaluating the
  accumulated results of research on those HP
  interventions.

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How to Evaluate Health Promotion Interventions?

• Need to understand several components of
  evaluation first
• Efficacy evaluation effectiveness evaluation of
  interventions
• Process or Outcome Evaluation.

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Efficacy or Effectiveness of Intervention

• Efficacy - capacity or power to produce a desired
  effect in an ideal environment
• Refers to improvements in health outcomes due to
  intervention achieved in research setting, under
  ideal circumstances by expert researchers
• Demonstrate outcomes are due to intervention not
  to chance or other factors
• Best demonstrated by randomized clinical trials.

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Efficacy or Effectiveness of Intervention (cont.)

• Effectiveness is the effect it achieves in the
  real world, with limited resources, in entire
  populations
• Addresses the clinical usefulness in a typical
  setting
• Have been called large sample trials or public
  health trials, as they are implemented on large
  populations are thought to have immediate
  effect on clinical practice.

28
Class exercise
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Efficacy or Effectiveness of Intervention (cont.)

• Both useful in developing testing interventions
• Efficacy studies considered less generalizable,
  often used as first phase of study
• Effectiveness studies follow - findings are
  applied to real-life settings for feasibility,
  cost utility, effectiveness acceptance of
  intervention by differing groups of clients
• Nurses participating in research must implement
  protocols as faithfully as possible keep good
  records.

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Process or Outcome Evaluation

• Process Evaluation how the program was
  implemented, variations of delivery at different
  sites, quality of delivery, who received the
  intervention whether it was implemented as
  planned.
• Provides information about intended or unintended
  outcome, target audience, client satisfaction
  (feedback loop important)
• Outcome evaluation focus on the results intended
  unintended.

31
Class Exercise
32
Collecting Evidence for Practice

• In current health care environment, cant rely
  solely on clinical experiences, tradition
  opinion-based processes to guide HP interventions
• Must use current best practice evidence
• Start by looking at research literature, must
  then critically evaluate synthesize evidence
  evidence based practice.

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Evidenced Based Practice

• Integration of clinical expertise with best
  available clinical research findings
• From many sources synthesis of relevant
  research, international/national/local standards
  of practice, cost effective analysis, clinical
  expertise, client preferences
• Aim is to ? wide variations in practice,
  eliminating worst practices, improving quality
  ? costs
• Builds/expands research base.

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STEPS IN EVIDENCE BASED PRACTICE (table 11-1) pg
266

• Identify what evidence is needed
• 1. Assess need for change in practice
• Retrieve evaluate the evidence
• 2. Conduct literature search
• 3. Critically evaluate/appraise literature
• Decide design what to implement
• 4. Identify results applicable to practice
• 5. Develop practice change to implement results
• Implement
• 6. Apply change to practice
• Evaluate both process outcome evaln
• 7. Evaluate outcomes of new change.

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EBP - What it is what it is not.

• Evidence based practice does not replace clinical
  expertise.
• It is not a cookbook approach.
• The use of EBP helps to plan systematically
  evaluate health promotion practices.

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Evaluation of Interventions with Individuals
Communities

• Levels and Types of Interventions

Upstream Public policy Environment Tax
incentives or deterrents, policy changes,
local ordinances, laws, media campaigns
Midstream Communities Work site programs School
programs Community based programs
Downstream Individuals Education/
Counseling Support
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Challenge for health care professionals
reseachers

• is to develop, test, evaluate, implement
  models of health promotion that incorporate the
  influences of community factors (work sites,
  schools, etc.), environmental factors,
  sociocultural factors with individual behaviors
  to promote wellness.

38
Evaluating Effective Evidence-Based Individual
Strategies

• Effective strategies aimed at improving health of
  individuals that warrant continued use based on
  the evaluation results include
• contests/ competitions to recruit/maintain
  participants
• self help minimal but repeated contact programs
• screening for health education case finding.

39
Evaluating Effective Evidence-Based Community
Strategies

• Build on existing community structures
• Target system where ind. lives works
• Collaboration of ind. organizations, requires
  time money
• E.g. Workplaces, churches, schools
• Activation of community difficult - need to
  coordinate agencies - may not have same
  mandate/conflicting goals
• Community ownership important
• Media campaigns found useful.

40
For success in health promotion we need a balance
between individual community strategies.
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Lessons learned from evaluation of HP
Interventions

• Program components that facilitate success
  include
• The design of the interventions
• The selection of outcomes to measure
• The time frame for implementing the intervention
  evaluating the results
• Maintaining behaviour change also reviewed.

42
Designing the intervention

• Assess appropriateness for target populations
• Should be evidence to show intervention works on
  this targeted setting population before
  beginning
• Has to be affordable to individuals, agencies, or
  communities
• Must be manageable compatible with existing
  programs - less complex the more likely it will
  succeed.

43
Selecting Outcomes

• Realistic outcomes must be chosen
• Community-level outcomes complex often
  expensive to measure
• Short term/intermediate/long range outcomes need
  to be realistic, affordable meaningful
• Choice of measurement method important.

44
Selecting Outcomes (cont.)

• Community-level outcomes not as well developed
• Ind. community measurements must be precise
  sensitive to change
• Look at program participation rates
• Look at process to help refine intervention
• Measure delivery dose - aspects of program
  delivered received dose - number of
  participants.

45
Deciding Time Frame

• In order to properly conduct program evaluate
  results - need realistic time frame.
• For individual focused interventions need at
  least 6 months to evaluate short-term results
• For more complex community-based programs - need
  5 years
• Time frame for community-based programs is
  related to acceptance action by community may
  backfire if rushed.

46
Maintaining Behaviour Change

• Most progress been on promoting beh. change, less
  on promoting maintenance
• Maintenance seen as process rather than end
• Psychological processes believed to underlie
  decision to change thought to also affect
  maintenance of change
• 2 exceptions Banduras cognitive theory TTM
• Neither theory offers guidance about process of
  maintenance how it differs from initiation
  adoption of beh.

47
Collaboration key to success in community-based
interventions

• Models developed to link nursing schools to
  communities to provide culturally competent, EBP
  HP interventions
• Holistic collaborative approach found to be
  effective
• Requires funding ability to balance multiple
  agendas/missions
• Community collaboration long term maintenance
  strategies also promotes sustainability.

48
Directions for Research in Evaluating Health
Promotion

• Expand/test current theories
• Develop models of beh. maintenance
• Develop test social ecological models
• Accurate measures of beh. change needed
• Reliable/valid/sensitive self-report measures
  new objective measures needed
• Standardize outcome measures  
• Research to describe, predict intervene to
  promote long-term maintenance needed
• Assess cost effectiveness of HP.

49
Directions for Practice in Evaluating Health
Promotion

• Evaluation of HP is evidence on which to base
  practice
• Need to develop research skills
• Nurses need current knowledge of effective HP
  programs interventions so they can deliver
  interventions or provide info to clients
• Consider cost effectiveness
• Maintenance is a major problem in health
  behaviour change - Nurses need to follow-up
  carefully identify early relapse.