University of Applied Sciences , Utrecht, The Netherlands
Nursing professionals provide comprehensive care, based on evidence, using health and patient education as an intrinsic part of it. The following are described with regard to the nursing process: the (needs) assessment; the diagnosis; the planning of nursing and medical; stating objectives; implementation; evaluation (Sect. 6.1). Nursing diagnoses aimed at promoting patient self-management, the PES structure, are the health perception–health management pattern, cognitive–perceptual pattern, self-perception–self-concept pattern, coping–stress tolerance pattern, and value–belief pattern (Sect. 6.2). Health patterns aimed at promoting health can be specified for patient self-management (Sect. 6.3). Nursing interventions aimed at promoting patient self-management are in the health behavior domain, etiological factors and symptoms, potential problems, and wellness-related interventions (Sect. 6.4). Nursing classification systems and health and patient education are the Nursing Intervention Classification (NIC) and the Home Health Care Classification developed by Saba et al. (1991) (Sect. 6.5). Nursing interventions aimed at promoting patient self-management should use intervention mapping. With the intervention mapping protocol, you develop professional self-management interventions for health promotion and disease prevention (Sect. 6.6). Implementing nursing interventions aimed at promoting patient self-management, is about the role that the nursing professional plays in promoting patients’ self-management. How well do nursing professionals support the patients’ self-management? Is the effectiveness of patient self-management dependent on how well the nursing professional is able to promote self-management? The nursing professional is described as a health coach. The professional plays an important role as a health coach to support the patient in his self-management. To improve your skills as a health coach, you take a closer look at: you motivation to inform and motivate a patient; your personal advantages and disadvantages; the support you receive or do not receive from colleagues; your personal perceived self-efficacy and skills; your action planning for your personal intention; coping planning to handle barriers to behavioral change; sustaining your professional behavior, all to change or improve patient self-management or lifestyle behavior (Sect. 6.7). Finally, there is a separate professional training program for the nursing professional to become a health coach, in which you become a better health coach in seven steps, able to improve and support the self-management and lifestyle behavior of the patient (Sect. 6.8).
Changing the health and self-management behavior of patients is a much more complex process, than previously thought. Nursing professionals often overestimate the extent to which patients have changed their health and improved their self-management behavior. Although nursing professionals are one of the main occupational groups for facilitating health education, they are not always well equipped with proper, evidence-based knowledge and skills to facilitate the patient’s self-management properly (Coster and Norman 2009). Nursing professionals wrongly assume that patients change their health and self-management-behavior, because improved self-management would have many benefits, including health benefits, and would increase well-being. A more scientific understanding has taken place within the nursing profession, that has led to a clearer positioning of nursing, both inside and outside the direct workforce and has resulted in diagnosis- and intervention-based nursing. The success of self-management interventions depends largely on the involvement and consent of health care providers (Jordan and Osbourne in: Coster and Norman 2009).
Promoting the self-management of patients is important, so that the patient can carry on his life with his (chronic) health problem. For more control over his life and optimal self-management (within given limits), the patient can give the disease a place in his life, increase the quality of life (as much as possible), and prevent restrictions or other health problems. Changing the health and self-management behavior of patients for health professionals themselves requires a positive attitude of the nursing professional and a personal understanding of the advantages and disadvantages of motivating patients. Changing the health and self-management behavior of the patient requires social support and the possible resistance of nursing professionals against the more negative influences of colleagues and team members. Changing the health and self-management behavior of the patient always requires specific psychosocial and communication skills of the nursing professionals, because although motivating seems easy, this is often not the case in the complex situation of patient needs, informed consent, guidelines, evidence-based practice, health care facilities, and government policy. Nursing professionals would have to fulfill a facilitating and coaching role focused on patient outcomes and patient satisfaction, concordance, and optimal self-management. This requires appropriate skills, together with? Nursing professionals often have working in a multidisciplinairy team of health care providers to motivate the patient.
6.1 Nursing Process, and Health Promotion and Disease Prevention
To improve patient self-management, comprehensive, integrated care is important for nursing professionals. In integrated care, care should be patient-oriented, the patient with his wishes and needs is central, and the patient is self-directing. In integrated care, nursing professionals work proactively from different sectors and organizations together, so that there is a coherent care supply for the patient.
Nursing professionals say that disease prevention and health promotion are important tasks on which they spend a lot of time during each consultation (Sassen 2011). It is important that nursing professionals give each patient health and patient education that fits the needs and the interests of the patient and his specific health problem, and that they do so in a careful and structured way. Education should be an intrinsic part of every meeting and of any consultation with a patient. Education should not be given only incidentally or informing the patient only in specific cases. A relationship of cooperation can emerge, as the nursing professional in any consultation uses the opportunities for patient-specific education, makes an inventory of the patient’s self-management needs, invites patients to participate, and discusses questions in a patient-specific way. The effectiveness of nursing care increases, as the nursing professional in each consultation works together with the patient, describes the desired goals, teaches the required self-management skills, tackles barriers together, and gives feedback on progress.
What is the link between the nursing process and health promotion and disease-prevention? The nursing process is a way of thinking and acting that allows nursing professionals to smooth the care process. In health promotion and health education this is identical; the nursing professional works professionaly and methodically. The nursing process is aimed at expanding and promoting health, at preventing health problems and health limitations, and recovering from health problems or dealing with restrictions. The nursing process intends to ensure quality of care. The same applies for health promotion and disease prevention. The purpose of health promotion and disease prevention extends from maintaining health, over the continuum of health, to optimize health within given constraints related to present (chronic) health problems. For health promotion, health interventions are aimed at motivating the people to other, healthier behavior. For disease prevention, self-management interventions are aimed at motivating the patient to implement the desired self-management. Of course, nursing professionals have more strings to their bow than merely education-targeted interventions, but health and patient education has an importance place within all nursing roles and tasks. For good quality care, each professional should work based on evidence-based care and cure, that is, on scientific evidence-based care and treatment.
The nursing professional aims to deal with the whole person, sick or healthy. The nursing professional supports the patient who is ill or is likely to be, and helps him to solve problems or to handle the (consequences of) health problems. The nursing professional helps the patient to adapt to changed circumstances and problems, and to accept problems that require a permanent adjustment by the patient. Promoting health and preventing disease always play important roles.
In healthy people, your aim as a nursing professional is to prevent health problems and to promote health and well-being. For example, by teaching a healthy lifestyle and self-care strategies, or by supporting decisions that promote healthy behavior. In people who have a health problem, your aim as a nursing professional is to maintain health and to expand health. This includes a large group of people who favor a particular condition, but for whom it comes down to promoting and expanding (aspects of) health that may or may not be directly related to the patient’s health problem. For example, a patient after stroke with restrictions may very well benefit from changing unhealthy eating habits. There is then not just a question of education aimed at promoting self-management, but it is also about promoting a healthy lifestyle, expanding health, and avoiding health risks. For good-quality nursing professional care education, this is an important, if not the most important, intervention. This way of improving quality of care improves the quality of life and well-being of the patients.
World health report 2013, research for universal health coverage, reports that a good health care system gives priority to health, and human-centered integrated care should be offered. People-oriented integrated care consists of informing and encouraging people to stay healthy and prevent disease. It is also about the early detection of health problems. Motivated health workers would have to provide health care services that meet the needs of patients and that are offered based on the best available evidence, evidence-based practice.
The results of the nursing care are central. As the results of nursing professional care are the departure point, the nursing process should be effectively monitored, possibly adjusted, and judged on outcomes. Care-related results should be focused on improving the quality of life, but also recording time and care intensity, so that care not only meets high-quality standards in results-directed care, but also fits the national health policy.
6.1.1 Nursing Assessment, and Health Promotion and Disease Prevention
The first phase of the nursing process is the assessment. The nursing professional makes an inventory of the needs and expectations of the patient and gathers information to identify the patient’s problems (and his family, relatives), ultimately to make a care plan. The nursing professional makes an inventory of the current health situation and potential health problems and limitations from the point of view of the patient as a holistic unit. In the assessment, the following questions are to be covered: how does the patient perceive his well-being? What need is there to identify current or potential health problems? What information and education needs are latent? Is there a need to improve lifestyle? Is there a need to improve self-management? What are the health- and self-management behaviors, and do risk factors play a role? What experience does the patient have in (changing) his health and self-management behaviors? The assessment is performed by asking open-ended questions. For example: “it would help me if you can tell me what you already know about your health problem. Or “it would help me if you can tell me whether you have previously tried to get more exercise, or take your medication twice daily.”
The assessment phase in the nursing process is about exploring the health education and self-management needs and the wishes of the patient (and possibly the social environment). You work out that you as a nursing professional understands: the patient’s current level of knowledge of the patient; his individual needs; his individual skills; the advantages and disadvantages that the patient connects with self-management; social factors and the impact that they may have on the willingness of the patient to implement health and self-management advice; environmental factors that facilitate or hinder the patient in implementing health and self-management advice; and the complexity of the care–treatment process. The purpose of this is to enable the patient to make decisions about his health, treatment, and care. But you also want to allow the patient to learn to handle his specific health problem and his lifestyle and behavior so that this has a positive effect on his health. If nursing professionals after the assessment state accurate education and self-management-focused nursing diagnoses, and implement nursing interventions based on health education and patient education, this will improve the care process.
6.1.2 Nursing Diagnosis, and Health Promotion and Disease Prevention
The second phase of the nursing process describes the nursing diagnoses. As a nursing professional, you analyze the collected data about the patient after the assessment and identify the current and potential health problems. Then you define the problem, you describe the situation and etiology of the problem, and set priorities. The nursing diagnosis is your professional conclusion based on the first step of data collection. Nursing diagnoses or nursing problems are the concrete descriptions of the care needs of the patient. The nursing professional usually changes the nursing diagnoses during the care process, based on changes in the patient situation and additional data collection. For example, if certain risk factors are going to play a role, such as an increased risk of social isolation. Nursing diagnoses give direction to the further course of the nursing process.
Nursing diagnoses will be related to health and patient education, and be based on the patient’s education and self-management needs. A part of nursing diagnosis goes hand in hand with education and self-management. For example, the diagnosis that the patient has pain because of a gallbladder surgery can be reconciled with the diagnosis that the patient has insufficient knowledge and skills to adequately cope with pain. Another example, the diagnosis of the patient with psychiatric limitations is afraid of recording medication use and being in a hospital, can be reconciled with the education-oriented diagnosis that the patient is afraid to lose control over his medication. Nursing diagnoses specifically describe what education and self-management needs the patient has, which self-management skills need to be learned, what behavior obstructs an extension of self-management and stands in the way of health.
6.1.3 Nursing Planning Phase, and Health Promotion and Disease Prevention
Nursing professional planning stands for the what and how of nursing interventions in the nursing process. In the planning phase, in consultation with the patient, goals are formulated and aimed at preventing, reducing or dealing with the health problem. For every actual or potential nursing diagnosis, a goal is formulated in terms of self-management and health behavior and expected results. The whole thing takes shape in a plan. Each goal calls for nursing professional intervention(s), which lead to solving, reducing or dealing with the health problem. For example, for the diagnosis of pain, the goals may be that the patient says that pain is a characteristic of a rheumatic condition, identifies changes in the intensity of the pain, and uses a pain management method in an appropriate manner. The formulated nursing diagnosis gives clear direction to the planning process and to the choice of nursing interventions. This means that the nursing professional formulates one or more outcomes or effects for each diagnosis. A outcome gives direction to the solution and is focused on the condition with a high risk of a nursing diagnosis, or an improvement in the level of well-being for a healthy person.
Also, education- and self-management-oriented targets are formulated with the necessary education-targeted interventions to eliminate the diagnosis. For health and patient education, it is important that there is agreement between the nursing professional and the patient on the goals and that the patients specifies the priority goals. Goals should be related to patients’ desired changes in self-management and lifestyle. The planning phase ends when a nursing care treatment plan is developed that can be used in the implementation phase.
6.1.4 Nursing Implementation Phase, and Health Promotion and Disease Prevention
In the phase of the implementation of the care, the nursing interventions are carried out in accordance with the previously established nursing care–treatment plan. This care–treatment plan, with self-management of lifestyle-oriented goals prioritized by the patient, the nursing professional starts to battle the planned actions with the patient. Meanwhile, the nursing professional collects information about the condition of the patient, his needs and feelings, increased knowledge, learned skills, etc., to the nursing process as required to update and complete features. This is certainly true for (patient) education because education will always assume a more concrete form in the course of the care process.
The goal is to reach an optimal level of health and well-being for the patient. The care–treatment plan shows when which nursing interventions get a place in the patient’s care–treatment. The nursing interventions are combined with the care and treatment. The goal is to motivate the patient to perform other, healthier (self-management of lifestyle behavior) in collaboration with the patient’s conduct, through a systematic and planned change process that the self-management and well-being of the patient to be promoted.
6.1.5 Nursing Evaluation Phase and Health Promotion and Disease Prevention
The nursing process is concluded with the evaluation of nursing care results. Central questions are: Were the goals achieved? Was the nursing care–treatment plan for a specific diagnosis effective? What changes have taken place in the patient in relation to the purpose and behavior outcomes? How do the individual nursing diagnoses relate to the entire care–treatment plan? The evaluation phase completes the nursing process and gives an indication of the extent to which the nursing diagnosis and interventions have been correctly carried out. Data are being collected to determine whether improvement has occurred in the stipulated patient outcomes, and whether the self-management and the well-being of the patient have improved.
For health and patient education this means concretely that you check to what extent the education targeted in data collection, diagnosis, and implementation of the education-targeted interventions has been successful. For example, has the patient’s knowledge about issues associated with his health problem and self-management increased? Have the self-management skills of the patient increased and are these effective to perform the self-management at the desired level? Is the patient able to continue self-management independently at home? Is self-management now an integral part of the daily life of the patient and integrated into his daily activities? Have the patient’s health and well-being been assessed as well? During the evaluation phase you can clarify by using open questions: “can you tell me how you took your medication yesterday? Can you tell me what you ate for breakfast and lunch yesterday …?” Such questions give a much more concrete picture of the lifestyle and health advice carried out in whole or in part than questions such as: “do you take your medication as prescribed? Do you follow your diet?”
6.2 Nursing Diagnoses Aimed at Promoting Patients’ Self-Management
Nursing diagnoses that are linked to health education and self-management, PES structure:
Health perception–health management pattern, pattern of health experience and-conservation
Altered health maintenance
Altered protection, and
Health seeking behavior
Coping–stress tolerance pattern
The nursing professional plays an important role in identifying behaviors of patients who have a relationship with self-management and health (Ryan 2009). The nursing diagnosis is to approach it from different angles. The conceptual angle indicates who is responsible for what, and offers a view of the responsibilities of nursing professionals. The contextual perspective describes the concept of diagnosis in a nursing context, within which the actions of the nursing professional take place: the diagnosis from the anamnesis data; do the goals distract from the diagnosis and the interventions? The structural perspective of a nursing diagnosis harks back to the PES structure (Gordon 2013; McFarland and McFarlane 1993).
Which diagnoses are related to health education and improving self-management? The PES structure is about a health problem, with the attached etiological factors. The recognition of the health problem is reflected in the signs and symptoms. In the PES structure the P indicates the patient’s health problem. Health problems can be divided into a number of categories of nursing diagnoses. For example, a high risk for damage, fear, and knowledge deficits. In the PES structure, the E stands for the etiological factors, or determinants that are connected to the health problem. These related factors may have a causal link to the health problem. Etiological, related factors are internal or external factors that have an effect on the patient, his family or the community. They contribute to the creation or maintenance of a health problem. These etiological factors can be all kinds of causes of the problem. The nursing professional’s intervention can be derived directly from these etiological factors. For example, if the patient’s problem includes not taking his medication conventionally, and the cause of this is not understanding the medicine’s instructions, then the nursing professional intervention is a different one than when the cause is that the patient is experiencing strong nausea as a side effect. In the PES structure the S stands for signs and symptoms. The sign and symptoms give both the subjective and objective characteristics of the health problem. These characteristics provide an input for the nursing diagnosis. For each nursing diagnosis, there are symptoms that together define the characteristics. Based on these characteristics, nursing professionals assess whether the patient is having certain problems. All of these characteristics determine the specific nursing diagnosis. The structural definition thus gives a view of the problem, the characteristics, and the causes.
The PES structure offers nursing professionals a way to assess whether patients have certain health problems. The PES structure fits in well with health promotion and disease prevention, because it is also based on health problems, etiological factors, and signs and symptoms are distinguished.
6.3 Health Patterns Aimed at Promoting Patients’ Self-Management
There may be a format to 11 functional health patterns, according to Gordon, which collectively form the nursing domain. These health patterns make it clear what is relevant in health education and patients’ self-management, and offer starting points for education-oriented diagnoses.
Which health patterns are relevant for health education and patients’ self-management? This is about giving full information and the use of information, understanding the health situation, dealing with social influences, the acquisition of skills, and supporting and maintaining the behavioral change (McFarland and McFarlane 1993).
The health perception–health management pattern involves the perception and experience of the patient of his own health. It is down to the patient’s perception and experience of his own health status, health goals, and health beliefs that make him behave in a certain way. The purpose of this pattern is to gain an insight into “health search behavior”: to lifestyle and health advice, to resources that are available to stay healthy and to recommendations for medical treatments.
The cognitive–perceptual pattern is the patient’s ability to receive information, to understand, to remember, and, on this basis, to take decisions. The goal of the cognition and observation pattern is to assess if patients are cognitively and emotionally able to handle this.
The self-perception–self-concept pattern is about the attitude of the patient and skills. The goal of this pattern is to assess the attitude of the patient with regard to his capabilities. Emotions and feelings for example as fear and mourning may be important.
In the coping–stress tolerance pattern, the attention is focused on whether or not the patient is able to perform certain skills. The goal of the coping and stress tolerance pattern, is to assess the capabilities of the patient regarding his coping skills for dealing with stress.
The value–belief pattern, is about factors that influence the choices of the patient, in addition to his lifestyle and (health) behavior. Attitudes (considerations and ratings of these considerations) play a role. The goal of the values pattern is to gain insight into the choices of the patient focused on his self-management and health behavior.
Other patterns that play a role for the patient and health education, and for promoting and maintaining health are: the nutritional and metabolic pattern, the elimination pattern or excretory pattern, the pattern of activity–exercise role, the role-relationship pattern or relationship pattern, and the sexuality–reproductive pattern.
Why is the health perception–health management pattern important for health education and self-management? The health pattern health perception–health management pattern makes an important subdivision in altered health maintenance, noncompliance, altered protection, and health-seeking behavior. The health pattern altered health maintenance is clearly related to the nursing profession. Nursing professionals are involved in supporting individuals and their social environment in achieving optimal health. The task of nursing professionals is that the patient adopts skills and such to achieve maximum independence of the patient. After determining this altered health maintenance diagnosis, the nursing professional should intervene through nursing interventions. In the phase of data collection, the perception and experience of the patient with regard to his health status is assessed. Defining features for the altered health maintenance pattern is: poor eating habits; incomplete immunization; need for alcohol, drugs or tobacco; incomplete education; inadequate accident prevention; inability to deal with stress. The related factors to the health pattern may be: the inability to take decisions; inadequate information search behavior; the inability to carry out age-related prevention activities or poor learning skills. The related nursing diagnoses may be: “altered health maintenance related to a lack of knowledge with regard to (for example) drug use.”
The health pattern noncompliance is about the patient making informed decisions to keep to a therapeutic recommendation, according to the North American Nursing Diagnosis Association (NANDA). The noncompliance may refer to the prescription of medication, due to a lack of knowledge and a complex medication regimen. Noncompliance can also cover a prescribed diet, related to confusion in communication about the expected results. The nursing diagnosis noncompliance should give a clear description of the current and potential health problems. A nursing professional’s diagnosis could be: “the inability to adapt to the treatment regime” or “a potential deficit in the participation in the treatment and/or care process.”
For the health pattern altered protection, the nursing diagnosis could be: “altered protection related to excessive alcohol consumption” or “altered protection related to or a decrease in the use of food nutrients”.
The health pattern health seeking behavior, the goal is to optimize health. A person with a stable, positive state of health, is exploring ways to improve certain health behaviors. For health-seeking behavior, the goal is to further optimize the health status. A nursing diagnosis can be: “health seeking behavior related to the reduction of body fat and the risk of heart disease”.
Why is the health pattern cognitive–perceptual pattern important for health education and self-management? Another health pattern is the cognitive–perceptual pattern. Knowledge deficit falls under this health pattern. Knowledge deficit can refer to an individual lack of education, that the patient is unable to show that he is informed or to demonstrate the required skills. A nursing diagnosis is “knowledge deficit by a lack of exposure to appropriate education sources or by fear.” This diagnosis can lead to the lifting of the knowledge deficit by acquiring education, application, and troubleshooting.