Van Dette, Crystal D.
Phenomenon of Interest
As an electrophysiology nurse practitioner managing patients with arrhythmias is the definition of my practice. In the outpatient setting, I have noticed a correlation between years of under-treatment of hypertension leading to new-onset atrial fibrillation given VA providers have access to years of medical data. It is well known hypertension is a risk factor for the development of atrial fibrillation, but the correlation between chronic under-treatment of hypertension and risk for acute illness with the prevalence of emergency room visits has not been associated (Kikuko et al., 2023). It is only fitting that a study to formally correlate the two variables is relevant to my everyday practice. By evaluating the prevalence of patients admitted to an emergency department with new-onset atrial fibrillation and a history of poorly controlled hypertension from the outpatient clinic settings, a true appreciation of chronic disease management can be seen with a reduction in acute care of illnesses.
Philosophical Influences
Analytic philosophy offers an approach related to finite numbers where data is collected to equate a final significance or not. As the goal of the project is to compare admissions to chronic disease management, it is easy to obtain objective data from the calculations of numbers that analytic philosophy offers. Although this takes a rather literal approach to the differences between analytical and continental philosophies, it indeed remains valid in the outcome. Rozen et al. (2018) attributed an increase in emergency room visits from 2007 to 2014 by 30.5% as well as an overall decrease in the number of inpatient admissions from 70% to 62% in that same time. However, another study noted that patients often admitted into the acute care setting underwent routine diagnostic testing that was not indicated therefore inflating the cost of healthcare (Mullins, 2020). By targeting blood pressure control in the outpatient, primary care setting and avoiding the acute care phase of illness, costs of healthcare utilization could be curtailed making the overall system more affordable which validates the necessary cost attainments to sustain healthcare in the U.S.
Ethical Framework
The ANA Code of Ethics (2017) outlines the basic components of a nurse-patient relationship with the ethical principles of human dignity, autonomy, and overall respect for the nature of health regardless of the patient’s circumstance. Through moral and ethical obligations, patients have delivery of care or lack thereof. The patients have the individual autonomy to make their own decisions regarding self-administration of prescribed regimes. By merging the two intervals, the beneficence of the mutual patient-provider relationship is established to create an approach between the caretakers and patients to manage blood pressure to an acceptable range which in turn would theoretically reduce the acute phase of illness. Nurses must provide essential discussion regarding adherence and altering their outcome for disease management while prescribing guideline-directed medication regimes whether in individual or community-based approaches (Heinert et al., 2020). Through an understanding of chronic disease, psychological barriers to anti-hypertensive regimes and the opposition to medications are reduced supporting individual autonomy of the patient’s right to choose (Cummings et al., 2023; Kang & Jeong, 2020).
Theoretical Influences
The King Conceptual System is the process of obtaining knowledge through open systems interacting with the environment (Butts & Rich, 2022; King, 1992, 1997); which transcends into the individual interactions of the nurse-patient relationship for the goal of attainment. Both concepts are interwoven to create the conceptual framework. Mutual goal setting through transactions allows for the evolution of the patient-nurse relationship from the outpatient setting to the inpatient acute-care setting and addresses the barriers of each (Butts & Rich, 2022; Fawcett, 2005; King 1992, 1997). Patients’ priorities shift depending on the location of goal attainment as the emphasis on the severity of the disease is identified in the acute phase and the overall necessity of change to health patterns (King, 1997; Perera et al., 2019; Xu et al, 2022). Through the admission process in the emergency department, it is often found that patients are aware of the diagnosis but often are not taking medications whether it is due to cost or lack of understanding of the potential severity of the illness (Kim et al., 2022; Ware et al., 2022). Yet, it has been found that patients with a new diagnosis of hypertension seen in the emergency department who have a visit within a week in a primary setting had a 136% increase in the likelihood of medication compliance (Atzema et al., 2018; Chiu et al., 2022). Goal attainment with these transactions increases the likelihood of compliance and simply improves the individual’s overall health status through beneficence.
Similar to the transaction process with goal attainment, complexity science creates a complex adaptive system of a living organism within its environment which applies to individual variables on a micro level to macro systems of the overall health care utilization as seen with King’s Conceptual System (King, 1992, 1997). Individuals seeking care in an emergency room are more costly to the individual and the system, but overall mortality implications related to the comorbidities are significantly influenced by the acute-care setting (Ware et al., 2022; Kim et al., 2022). The patient as an independent variable would benefit from early discussion and chronic disease management to avoid emergency room care for uncontrolled disease (Ware et al., 2022). One small change earlier on in the disease process significantly reduces the impact on the individual risk for comorbid conditions and the organization’s cost impact. The individual care of the nurse-patient relationship creates an additional sub-system where beliefs are expressed and care is exchanged. The care is the subtlety of the embededness that exists within the complex adaptive system between the individual, care provider, and organization; ultimately with the patient as the individual decision maker in chronic disease management and prevention of re-hospitalization (Kim et al., 2022).
Concept Map of Praxis Framework
Concept Analysis Article:
Kolan, K.D., Lee, H. & Choi, E.K. (2021). Hypertension literacy: Concept analysis. Nursing Open 10: 6078-6090. DOI: 10.1002/nop2.1829.
References
Azema, C. L., Yu, B., Schull, M. J., Jackevicius, C. A., Ivers, N. M., Lee, D. S., Rochon, P., & Austin, P. C. (2018). Physician follow-up and long-term use of evidence based medication for patients with hypertension who were discharged from an emergency department: a prospective cohort study. Canadian Medical Association Journal 6 (2): 151-161. DOI: 10.9778/cmajo.20170119.
Butts, J. B. & Rich, K. L. (2022). Philosophies and theories for advanced nursing practice (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Chiu, D. T., Stenson, B. A., Nathanson, L. A., & Sanchez, L. D. (2022). Module to improve outpatient follow up for emergency department patients with elevated blood pressure. High Blood Pressure & Cardiovascular Prevention 29(5): 481-485. Doi: 10.1007/s40292-022-00533-6
Code of ethics for Nurses. ANA. (2017, October 26). https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
Cummings, D. M., Adams, A., Patil, S., Cherrington, A., Halladay, J. R., Oparil, S., Soroka, O., Ringel, J. B., & Safford, M. M. (2023). Treatment intensity, prescribing pattersn, and blood pressure control in rural black patients with uncontrolled hypertension. Journal of Racial & Ethnic Health Disparities 10(5): 2505-2512. doi: 10.1007/s40615-022-01431-2
Heinert, S., Escobar-Schulz, S., Jackson, M., Del Rios, M., Kim, S., Kahkejian, J., & Prendergast, H. (2020). Control following participation in a church-based hypertension intervention study. American Journal of Health Promotion 34(1): 52-58. Doi: 10.1177/0890117119868384
Kang, J. & Jeong, Y. J. (2020). Psychological resistance to drug therapy in patients with hypertension: a qualitative thematic analysis. Korean Journal of Adult Nursing 32(2): 124-133. Doi: 10.7475/kjan.2020.32.2.124
KiKuko, I. H., Julario, R., Puspitasari, A. N., Intan, R. E., Azmi, Y., Fatimah, F. N., Savitri, C. G., Firmanda, D. R., Suhandoko, L. P. & Dini, A. S. F. (2023). ECG abnormality and predictor of new-onset atrial fibrillation in hypertension and diabetes population: an observational analytic study from cardiovascular outpatient clinic at a national cardiovascular center in Indonesia. Journal of Arrhythmia 39(6): 860-867. DOI: https://doi-org.libproxy.usouthal.edu/10.1002/joa3.12938.
Kim, H. J., Kim, B. S., & Shin, J. H. (2022). Clinical characteristics and prognosis of patients with very severe acute hypertension visiting the emergency department. Clinical Hypertension 28(23). https://doi.org/10.1186/s40885-022-00208-3.
King, Imogene. (1992). King’s theory of goal attainment. Nursing Science Quarterly 5:1. Retrieved from: https://libguides.southalabama.edu/c.php?g=314770&p=2565779 on February 25, 2024.
King, Imogene. (1997). King’s theory of goal attainment in practice. Nursing Science Quarterly 10:4. Retrieved from https://libguides.southalabama.edu/c.php?g=314770&p=2565779 on February 25, 2024.
Kolan, K.D., Lee, H. & Choi, E.K. (2021). Hypertension literacy: Concept analysis. Nursing Open 10: 6078-6090. DOI: 10.1002/nop2.1829.
Mullins, P. M., Levy, P. D., Mazer-Amirshahi, M., & Pines, J. M. (2020). National trends in U.S. emergency department visits for chief complaint of hypertension (2006-2015). American Journal of Emergency Medicine 38(8): 1652-1657. https://doi.org/10.1016/j.ajem.2019.10.004.
Perera, M., Kanatiwela de Silva, C., Tavajoh, S., Kasturiratne, A., Luke, N. V., Ediriweera, D. S., Ranasinha, C. D., Legido0Quigley, H., De Silva, H. A., & Jafar, T. H. (2019). Patient perspectives on hypertension management in health system of Sri Lanka: a qualitative study. British Medical Journal 9(10):e031773. https://doi-org.libproxy.usouthal.edu/10.1136/bmjopen-2019-031773.
Rozen, G., Hosseini, S. M., Kaadan, M. I., Biton, Y., Heist, E. K., Vangel, M., Mansiur, M.C., & Ruskin, J. N. (2018). Admission rates and economic burden from 2007 to 2014. Journal of the American Heart Association 7. https://doi.org/10.1161/JAHA.118.009024.
Ware, K. S., Chidume, T., & Chou, C. (2022) Social determinants of health and preventable emergency department patient encounters among adults with hypertension. Public Health Nursing 40(1): 171-174. https://doi-org.libproxy.usouthal.edu/10.1111/phn.13152.
Xu, W., Yang, Y., Zhu, J., Wu, S., Wang, J., Zhangm H., & Shao, X. (2022). Impact of renin-angiotensin-aldoseterone-system inhibitor drugs on mortality in patients with atrial fibrillation and hypertension. BMC Cardiovascular Disorders 22(1): 1-10. https://doi.org/10.1186/s12872-022-02580-2
