Nursing Practice 6: Consolidation of Contemporary Nursing Practice in Diverse Settings 

Table of contents

Background Information

Health Inequalities

Health Inequities

Health Outcomes

Nursing care considerations

Patient with severe asthma

Registered nurse standards for practice

Standard 1: Thinks critically and analyses nursing practice

Standard 2: Engages in therapeutic and professional relationships

Standard 3: Maintains the capability for practice

Review

References

The following academic report is about developing a nursing practice plan in managing asthma in elderly population in the aboriginal community.

Background Information

The aboriginal population of Australia are classified under the category of Indigenous Australians and are at a huge loss of the disparity between them and other population groups in relation to “education, employment, health and safe housing” (Australian Institute of Health and Welfare, 2018). The population difference is alarming as well, the elderly Indigenous population consisting of just 31,000 in the category of 65 years and above in comparison to non-Indigenous population of 3.4 million (AIHW, 2018).

The aboriginal population face disproportion in majority of the social determinants of health and in all of their age groups (AIHW, 2018). The Indigenous population’s demographic mostly in the young age department results in them occupying 6.7% school enrolment of the government schools (Department of the Prime Minister and Cabinet, 2016). The gap between them and non-Indigenous population of 15 years old stands at a high of 20% (DPMC, 2016). Closing the Gap initiative aims of improving transparency around school attendance, literacy and numeracy (DPMC, 2016). The low employment rate among the Indigenous population is linked with low educational status 47.5% compared with Australia’s overall employment rate of 72.1% (DPMC, 2016). The Community Development Employment Projects (CDEP) aims at helping the Aboriginal population for work and reducing the gap (DPMC, 2016). The reduce the gap in life expectancy, better health care access and smoking reductions have helped and more is planned with the “Medicare Benefits Schedule and Pharmaceutical Benefits Scheme” focusing on chronic disease (DPMC, 2016). The government’s initiative of “Indigenous Advancement Strategy: Safety and Wellbeing Programme“ aims at decrease in family related assault, less substance misuse, more rehabilitation for the prison population, counselling services to aid in emotional and social wellbeing and night patrols for community (DPMC, 2016).

Health Inequalities

The health inequalities faced by the Indigenous population are closely linked with the social determinants of health which included their status, location, gender, age and due to unequal distribution of resources the gap has further increased between them and the non-Indigenous population (Cameron et al., 2014). Addressing the health inequalities faced will go a long way on improving the health status and life expectancy (AIHW, 2019).

The life expectancy gap between the Indigenous population and non-Indigenous population is still significant from the data of 2010-2012, with the male population showing a difference of 10.6% and the female population showing a difference of 9.4% (DPMC, 2016).

The data from the image above shows that although the decline in mortality rate has been evident for the Indigenous population in particular for age 15 or older, the smoking rates have seen 7% decline (DPMC, 2016).

75% of the mortality rate gap are accounted by the chronic diseases (DPMC, 2016).

Health Condition

Gap situation

Circulatory disease

41%

Respiratory disease

27%

Kidney disease

38%

Cancer

10% (Indigenous), (6%) Non-Indigenous

From the data collected, the mortality gaps have overall decreased in the Indigenous population with the exception of cancer (DPMC, 2016). Addressing the gap in life expectancy, the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 focuses on strong collaboration between the local, regional and the Indigenous health leaders (DPMC, 2016). The Indigenous suicide rate is twice as high as the non-Indigenous population and to address this gap, intervention in the early youth stage of life is advised along with community initiated prevention solutions (DPMC, 2016). A concerning gap is that assault (family violence) related hospitalisation is high among the Indigenous population and much more in remote areas; as are the Indigenous children have a higher chance of being a victim of abuse and neglect (DPMC, 2016).

Health inequities

From the image above, the gap of Indigenous child mortality rate has reduced but it can be made better by providing more access to pregnant mothers for their antenatal care (DPMC, 2016). Babes born with low birth weight to the Indigenous mother population accounted to 12%, as compared to the nonindigenous with 6% (DPMC, 2016). To address this gap, programs like “The Baby One Program “ funded by the Australian Government focuses on the pregnant women getting sufficient ante-natal care, other programs focus on early childhood education, support for the parents, and child protection services (DPMC, 2016). To address the unequal distribution has attributed to the following schemes have been implemented (DPMC, 2016).

Schemes

Benefit

Community Stores Licensing Scheme

Reducing price mark-ups on healthy food.

National Affordable Housing Agreement

Access to affordable, safe and sustainable housing including improving amenities and reducing overcrowding in remote areas.

National Rental Affordability Scheme (NRAS)

Low income households by 20% below market rate.

National Partnership Agreement on Homelessness

Key focus on Aboriginal homeless population.

Reconnect

Focus on homeless people age 12-18 years for Aboriginals

(DPMC, 2016).

Low educational standing of the aboriginal population tends to lead them to getting low employment or none at all (DPMC, 2016). This creates a financial burden on the state, territorial government to provide funding for the (DPMC, 2016). A negative aspect faced in the younger population is that when they are shifted to welfare homes, the duration is longer in comparison to Non-Indigenous youth (DPMC, 2016). “jobactive” started by the government to focus on the 80% Aboriginal population living in the cities, and other major areas focus on them getting jobs through developing technical skills and thus relieving the financial burden (DPMC, 2016). The Government’s Indigenous Procurement Policy aims to reduce the gap by investing more than the current 0.02$ ($6.2 million) of the entire $39 billion procurement budget (DPMC, 2016).

Health Outcomes

Asthma is a respiratory chronic condition caused by viral agents, allergens, smoke, polluted workplace with the individuals showing signs and symptoms such as “wheezing, shortness of breath, coughing, chest tightness and fatigue” (AIHW, 2020).

In the Indigenous people population, 16% (128,000) suffer from asthma, with more commonly found in female than in male, their prevalence was 1.6 time higher than non-Indigenous population (Australian Bureau of Statistics,2019; AIHW, 2020). While the gap in all the age groups from Image4 is obvious, the most marked difference is among the elderly age group of 55 years and above. Asthma rates increase and are higher in outer regional areas and those living in low socio-economic conditions (AIHW, 2020). Asthma generally occurs with other comorbidities and with an increase in age, the risk of mortality increases (Australian Health Ministers’ Advisory Council, 2017). Asthma was responsible for 41% of the disease burden in the Indigenous Australian population, as well as Asthma was the most common self-reported breathing problem by the Indigenous population (AHMAC, 2017).

Hospitalisation rates in the age group of 65 years and above were highest due to respiratory conditions (AHMAC, 2017). The biggest gap in age-standardised hospitalisation rates for respiratory disease by Indigenous status and remoteness between Indigenous and non-Indigenous was observed in remote areas and smallest was in major cities (AHMAC, 2017). In age-specific hospitalisation rates for respiratory disease, by Indigenous status the gaps were highest in 0-4 years, 35-44 years, 55-64 years and biggest gap in 65 years and above between Indigenous and non-Indigenous (AHMAC, 2017).

Nursing Care Considerations

Patient with Severe Asthma

Primary care for asthma patient with moderate symptoms is treated with inhaled corticosteroids and bronchodilators while dealing with severe asthmatic symptoms is below average and challenges the healthcare work force (Chung, Johnson & Summers, 2018). A structured approach is necessary for treating an asthmatic patient with varying severity of symptoms which cannot be done in a normal respiratory clinic (Chung, Johnson & Summers, 2018). Treating severe asthma needs a team of “respiratory physicians, nurses and allied health professionals” and multiple medications (Chung, Johnson & Summers, 2018). Assessment of the patient’s asthma can be done by either The Asthma Control Questionnaires or Asthma Control Test, to be followed by the action plan to be taken; all these are necessary to educate the patient about treatment strategy and if exacerbation occurs (Chung, Johnson & Summers, 2018). While considering the treatment plan, environmental factor should also be taken into account as they increase mortality from cardiopulmonary regions, affecting lung growth and higher risk of asthma exacerbations (Sly, & Holt, 2018). The tobacco smoke present in the environment also leads to worsening of the asthma condition (Sly, & Holt, 2018). Along with environment, genetics also affects and has a major say in the treatment options as research has shown there are multiple phenotypes associated with asthma (Raedler & Schaub, 2014). Tuleta et al., (2017) states that blood vessel changes occurred in asthmatic patients with higher prevalence of atherosclerosis in comparison to non-asthma individuals. Tuleta et al., (2017) also states that atherosclerosis incidence is sped up in allergic asthma and is directly related to increase in arterial inflammation.

Registered Nurse Standards for Practice

Standard 1: Thinks Critically and Analyses Nursing Practice

A patient with severe asthma faces a decrease quality of life, less to no physical activity, exclusion from social circles and high risk of morbidity (Majellano et al., 2019). Asthma management is complex and sometimes requires treating asthma and obstructive sleep apnea leading the nurse for a deeper analysis while handling those (Majellano et al., 2019). The nurse has to follow the proper protocol and framework in the case (Majellano et al., 2019; Tuleta et al., 2017). The nurse has to judge the severity of asthma following the signs and symptoms while also keeping in mind the environmental factor (Majellano et al., 2019; Sly, & Holt, 2018). This important step allows and strengthens the treatment plans regulation, duration, amount and therapy type’s calculation for the severity control of asthma (Majellano et al., 2019). Some researchers have shown that despite the age, few nurses show genuine interest in elderly caring and the level of interest and respect shown towards patients from different backgrounds differs in each nurse (Xiao, Shen & Paterson, 2013). The elderly population of the aboriginal are sensitive in regards to care approach and the nurse handling them should be aware of any such cultural differences (Majellano et al., 2019). The nurse’s handling of information gathering and paper work is of high importance as it requires a proper flow of documentation with proper follow up (Keenan et al., 2008). The documentation done ny nurses is a time pressure part of their job, and errors can happen, which might lead to legal actions being taken (Keenan et al., 2008).

Standard 2: Engages in Therapeutic and Professional Relationships

The nurse developing an effective “nurse-patient relationship” goes a long way in the patient’s treatment plan (Kornhaber, Walsh, Duff & Walker, 2016). The nurse also focus on the safety of the patient due to health care settings in extreme asthma situations, taking into multiple human error factor (Kornhaber, Walsh, Duff & Walker, 2016). The nurse should make the patient feel safe, build a trusting relationship and it can be done by more information-sharing with the patient all the time being displaying patience and attentiveness to the patient’s requisites whether it be “cultural, physical, psychological or emotional” (Kornhaber, Walsh, Duff & Walker, 2016). The nurse needs to develop an instinct to anticipate the patients’ needs as the condition in asthma can go into exacerbation very quickly (Kornhaber, Walsh, Duff & Walker, 2016). This is done by the nurse forming a team with the family members or significant ones and discussing about the environmental factors, explain to the patient why they are getting the specific acre is in accordance with situation they presented with (Kornhaber, Walsh, Duff & Walker, 2016). Any threat physical or mental faced by the patient will damage the fostering nurse-patient relationship and issue of trust will come up; thus promoting the safety factor leads to quicker recovery and healing of the patient (Kornhaber, Walsh, Duff & Walker, 2016). As the patient is from a different cultural background of the aborignials, culral consideratiosn should be taken along with emotional by understanding their cultural, spiritual identify and respecting it (Kornhaber, Walsh, Duff & Walker, 2016).

Standard 3: Maintains the Capability for Practice

For the nurse to continuing be effective, they have to develop within themselves a sense of competence and regularly maintaining practice at the optimum level (Nilsson et al., 2014). Their educational level lets them be confidence when dealing with different patients and difficult clinical scenarios such as extreme asthma being presented (Nilsson et al., 2014). A nurse with the proper educational background and clinical practice will be able to handle it aptly all the while considering the patients and their family members different needs because she has trained herself for it and keep a consistency to keep it at that level (Nilsson et al., 2014). In addition to knowledge, skills the nurse also develops a holistic attitude of treatment towards the patient, critical thinking and research skills (Nilsson et al., 2014). The organisation or place where the nurse works also has a duty of ensuring that they hire competent nurses as they forma ac crucial part of care and safety for the patient and it should be in compliance with the national and state regulations (Nilsson et al., 2014).

Review:

The nurse-patient relationship is fragile at times and requires constant work ethic from the nurses side (Nilsson et al., 2014). This often means that nurse has to focus on improving the patients’ health, meeting the patient’s needs, counselling them and their family members. Respecting their cultural, and /or different religious identity (Nilsson et al., 2014). They also have the obligation to continue their professionapl development to ensure that the patient receives the latest care including medicines, and providing educational knowdleged to them so the treatment process makes sense for the patient thereby establishing trust between them (Nilsson et al., 2014).

References for Nursing Practice Plan

Australian Bureau of Statistics. (2019). National Aboriginal and Torres Strait Islander Health Survey. Retrieved from: https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/national-aboriginal-and-torres-strait-islander-health-survey/latest-release#asthma-and-chronic-obstructive-pulmonary-disease

Australian Health Ministers’ Advisory Council. (2017). Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report. AHMAC. Canberra.

Australian Institute of Health and Welfare. (2018). Older Australia at a glance. Retrieved from https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance

Australian Institute of Health and Welfare. (2019). Health and welfare links. Retrieved from https://www.aihw.gov.au/reports/australias-welfare/health-and-welfare-links

Australian Institute of Health and Welfare. (2020). Asthma. Retrieved from https://www.aihw.gov.au/reports/chronic-respiratory-conditions/asthma

Cameron, B. L., Plazas, M. D. P. C., Salas, A. S., Bearskin, R. L. B., & Hungler, K. (2014).

Chung, L. P., Johnson, P., & Summers, Q. (2018). Models of care for severe asthma: the role of primary care. The Medical journal of Australia209(S2), S34–S40. https://doi.org/10.5694/mja18.00119

Department of the Prime Minister and Cabinet (PMC). 2016. Closing the gap—Prime Minister’s report 2016. Canberra: PMC. Retrieved from https://www.pmc.gov.au/sites/default/files/reports/closing-the-gap-2016/assets/pdfs/closing_the_gap_report_2016.pdf

Keenan GM, Yakel E, Tschannen D, et al. (2008). Documentation and the Nurse Care Planning Process. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2674/

Kornhaber, R., Walsh, K., Duff, J., & Walker, K. (2016). Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. Journal of multidisciplinary healthcare9, 537–546. https://doi.org/10.2147/JMDH.S116957

Majellano, E. C., Clark, V. L., Winter, N. A., Gibson, P. G., & McDonald, V. M. (2019). Approaches to the assessment of severe asthma: barriers and strategies. Journal of asthma and allergy, 12, 235–251. https://doi.org/10.2147/JAA.S178927

Nilsson, J., Johansson, E., Egmar, A. C., Florin, J., Leksell, J., Lepp, M., ... & Carlsson, M. (2014). Development and validation of a new tool measuring nurses self-reported professional competence—the nurse professional competence (NPC) scale. Nurse Education Today34(4), 574-580. https://doi.org/10.1016/j.nedt.2013.07.016

Raedler, D., & Schaub, B. (2014). Immune mechanisms and development of childhood asthma. The Lancet. Respiratory medicine, 2(8), 647–656. https://doi.org/10.1016/S2213-2600(14)70129-8

Sly, P. D., & Holt, P. G. (2018). Pollution, climate change, and childhood asthma in Australia. The Medical journal of Australia208(7), 297–298. https://doi.org/10.5694/mja17.01145

Tuleta, I., Skowasch, D., Aurich, F., Eckstein, N., Schueler, R., Pizarro, C., Schahab, N., Nickenig, G., Schaefer, C., & Pingel, S. (2017). Asthma is associated with atherosclerotic artery changes. PloS one, 12(10), e0186820. https://doi.org/10.1371/journal.pone.0186820

Understanding inequalities in access to health care services for aboriginal people: a call for nursing action. Advances in Nursing Science, 37(3), E1-E16. doi: 10.1097/ANS.0000000000000039

Xiao, L. D., Shen, J., & Paterson, J. (2013). Cross-cultural comparison of attitudes and preferences for care of the elderly among Australian and Chinese nursing students. Journal of Transcultural Nursing, 24(4), 408-416. https://doi.org/10.1177/1043659613493329

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