In recent years, the rural hospital closure crisis has escalated with 2015 closure rates six times higher than in 2010. The National Rural Health Association (2020) reported that currently one in three rural hospitals may be at risk of closure. Much of the blame for closures has long been attributed to factors external to rural communities, such as reduced Medicare reimbursement, a declining rural economy, provider shortages, and being located in states that did not expand Medicaid under the Affordable Care Act. Improving equity in access to care has been an ongoing concern throughout most of the past half century, and rural access to care has been a particularly persistent problem. Improving equity in access to care has been an ongoing concern throughout most of the past half century, and rural access to care has been a particularly persistent problem. This chapter focuses on the Acceptability Scale.

Evidence-based practice (EBP) is a seven-step problem-solving approach to the delivery of healthcare that integrates the best evidence from well-designed studies with a clinician’s expertise and the values/preferences of the patient/family. This chapter discusses the importance of EBP in achieving the quadruple aim in healthcare, describes the current state of EBP in healthcare, including EBP competencies, identifies the barriers and facilitators of EBP, and discusses the key leadership strategies to ignite and sustain EBP in healthcare. It briefly describes EBP competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings. Leaders must first understand that EBP is the direct pathway to achieve the quadruple aim in healthcare and be willing to invest in it knowing that healthcare quality and safety will be enhanced, population health outcomes will improve, healthcare costs will diminish, and clinician job satisfaction will increase as EBP diffuses throughout the organization.

This chapter explores the use of virtual simulation from an administrative perspective. Nursing education is moving from PowerPoint lectures and technical skills laboratories on static body parts to engaged learning with high-fidelity simulation, learner-centered experiential teaching, and simulated and standardized patients, all of which help students learn to think, act, and reflect like nurses. Virtual simulation is one way of teaching and learning professional skills, assisting with the integration of acquired scientific knowledge, theory, and practice to promote clinical reasoning and critical thinking. The chapter explores ways in which administrators can support faculty and students while enhancing the educational experience at their institutions. It is important that administrators manage faculty and student expectations and needs while assessing university support for a variety of options; they must address the challenges and opportunities, and explore ideas for leveraging support by developing partnerships.

Administrators must make a decisive, purposeful, realistic, and practical allocation of resources to lead and support the effort to adopt new, cost-effective, and learning enhancing instructional technologies. Nursing education administrators facilitate faculty development and active engagement in the area of virtual simulation and the use of technology in the teaching–learning process. The nurse administrator’s role is to ensure that technological systems are transformed effectively and that financial, ethical, and legal implications are considered. This chapter focuses on the positive aspects of the administrator’s roles as they relate to the integration of virtual simulation. The roles described provide a brief overview of the influence administrators can have on their institution’s technology plan, faculty’s willingness to engage in technology integration, and student learning. Visionary administrators are able to inspire, motivate, and support their faculty and students while paving the path to a smooth transition into virtual simulation integration.

One important goal of Healthy People 2020 is to improve the healthy development, health, safety, and well-being of both adolescents and young adults. Patterns of behavior during adolescence and young adulthood determine adult health status and health risks. While youth are generally healthy, it is important to assess and screen for issues that begin or peak during this developmental phase. These issues include mental health concerns, substance and tobacco/nicotine use, nutrition and weight concerns, sexually transmitted infections (STIs) and HIV, unintended pregnancy, homelessness, academic issues, homicide and suicide, and accidents such as motor vehicle collisions.

Nurses play a key role in the field of epidemiology and in population health. Population-focused nursing demands application of nursing theory and practice while integrating the tenets of public health to contribute to the improvement of community and population health. While advanced practice nurses may not all specialize in public health, it is essential that advanced practice nurses have a foundational knowledge of concepts on the health and illness continuum from a population perspective. This chapter articulates the meaning of advanced practice nursing. It describes the role of the advanced practice nurse in epidemiology and population health. Consistent themes emerge across all functional roles of advanced practice nursing. Advanced assessment and analytic skills to include use of epidemiologic data and concepts to better understand disease occurrence and distribution are crucial to optimal health outcomes.

This chapter addresses the influence of the student role, especially in relation to students studying nursing informatics (NI). The NI student’s influence moves beyond the beginner roles and should be in the expert role. As students learn about NI, they also explore emerging technologies that provide opportunities for student-to-student collaboration. With the advent of virtual learning environments (VLEs) and virtual simulation, there is a greater need for faculty to develop informatics skills and competencies. The chapter provides a description of an educational process used to develop and deploy a program of simulation previously lacking in the graduate program and now used to improve NI skills and knowledge for both student and faculty. The foundations and framework for this project are based on needs and mandates identified by industry, healthcare, and professional organizations such as the American Nurses Association, Quality and Safety Education for Nurses Initiative, and National League for Nursing.

Aiming for impact means that one not only thinks that one can transform clinical service, but wants to develop and provide patients and their families with the kind of positive moments that are remembered 20 years later. Leadership presupposes aiming for impact; that is, a determination to address the challenges inherent in the current healthcare system. Impact means always giving some thought to how something good can be parlayed into something better. If one is aiming for impact, developmental learning will inevitably move from focusing on mastery of what today is considered to be best practice to imagining and developing a new and improved version of future practice. Nurses have historically been socialized in the direction of convergent thinking, but leadership requires divergent thinking, experiences that promote creativity and innovation.

In the United States (U.S.) there are 574 federally recognized tribes across 35 states. According to the 2010 U.S. census, about 5.2 million (1.6%) reported their race as American Indian/Alaska Native (AI/AN) and 2.9 million (0.9%) reported AI/AN as their only race. Fifty-four percent of AIs/ANs live in rural regions, with 68% residing in or close to their tribal reservation. Provision of healthcare services is a “federal promise” granted to federally recognized AI/AN tribes through treaties with the federal government. The Indian Health Service (IHS) is the federally designated healthcare provider for AIs/ANs from federally recognized tribes. This chapter briefly reviews healthcare services for AI/AN people. It defines hospice and palliative care, and describes their individual approaches to understanding end-of-life (EOL) and palliative care in two AI tribal communities. The chapter concludes with lessons learned and implications for rural nursing practice, research, and education.

This chapter helps the reader to understand the history of the Americans with Disabilities Act (ADA), specific components of the ADA and how the ADA provides resources to older adults and people with disabilities. The ADA, while groundbreaking, was not initially intended for people with disabilities rather than for older adults. As time progressed, however, the benefits of the ADA were much more far-reaching than originally intended, especially for aging adults with disabilities. The individual titles of the ADA have had some dramatically positive and specific impact for older adults wishing to remain in their homes or in their communities as long as possible. Although the ADA is still in its young adulthood, the benefits of the ADA have only grown as new and further linkages, such as the ADRCs, have developed in all regions of the United States.

Anxiety, depression, and delirium are common symptoms experienced by patients with serious illness. In palliative care, anxiety and depression commonly arise from fear of death, loss of independence, fear of being a burden to others, hopelessness, and loneliness, in addition to concern about symptom burden and disease progression. Anxiety manifests itself in four ways: physical symptoms, affective symptoms, behavioral responses, and cognitive responses. The patient and the family should be reassured that symptoms of depression and anxiety are effectively treated most of the time with pharmacological and nonpharmacological interventions. Effective treatment of anxiety, depression, and delirium necessitates a collaborative effort between the patient, family, and the health team. This chapter addresses the comprehensive patient-centered and family-focused care necessary for effective diagnosis, assessment, and treatment of anxiety, depression, and delirium in the palliative care patient.

Later life anxiety is often found in conjunction with major depressive disorders, and can have foundations in dietary issues as well as drug associations. There has been a correlation between long-term presence of anxiety in older adults associated with female gender, lower level of educational achievement, being unmarried as well as having three or more co-morbid chronic conditions. The most common diagnosed anxiety disorder in the geriatric population is generalized anxiety disorder. Other anxiety disorders frequently encountered in practice include social phobia, agoraphobia, panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder. This chapter briefly outlines and discusses each disorder. It helps the practitioners to: define anxiety; distinguish between anxiety disorders; discuss example tools that can be used to establish an anxiety disorder diagnosis; assess a geriatric patient for post-traumatic stress disorder using an appropriate clinical rating scale; and recommend general pharmacological (class) and non-pharmacological treatment options for anxiety disorders.

The process of technology integration is continually shifting. Successful integration of technology into the nursing curriculum is contingent on a myriad of contributing factors, not the least of which is that technology and curriculum continue to develop. The Faculty Administrators Students Technology Strategic Integration Model (FAST SIM) provides a framework for guiding the process of technology integration with the nursing curriculum. As stakeholders, faculty, administrators, or students may find relevance in applying the model from their individual perspective and particular needs. Paying particular attention to the influence and contribution from faculty, administrators, and students plays a significant role in the success of a technology integration plan or strategy. This chapter provides an overview of the key contributors to the technology integration process. It also offers suggestions as to how faculty, administrators, and students influence the process and identify opportunities to apply the FAST SIM.

As a health-care provider, one must be able to accurately and efficiently correlate subjective information with objective findings. This is especially important in electrocardiogram (EKG) interpretation. This chapter presents patient’s basic history and a corresponding EKG for clinical practice. Space is provided to document the pertinent findings. The exercises include heart rate calculation, rhythm evaluation, axis evaluation and heart block assessment including sinus block; first-, second-, or third-degree atrioventricular (AV) block; bundle branch block; and QT prolongation. It also includes evaluation for signs of ischemia and infarction and strain patterns such as those seen in ventricular hypertrophy and consider atrial enlargement. The chapter aims to improve EKG interpretation skills.

There is no aspect of leadership as gratifying as helping others reach their potential. It is rewarding in a way that other things aren’t because any investment in people pays dividends forevermore. Appreciating others includes giving feedback that is customized to the person. There is growing evidence that indiscriminate praise doesn’t change behavior positively, particularly if the commendation is for something relatively immutable like being smart. Appreciating others includes a broad range of behaviors—valuing the contributions of different kinds of people; respecting what each generation contributes to the mix; developing a community of learning so all continue to grow and develop throughout their careers; understanding that investments in people have a ripple effect because those who have been helped tend to “pay it forward” and providing timely and effective feedback that encourages improvement or advancement. Appreciating others also means valuing what others have done to help your advancement.

The learning landscape continues to evolve as new technological tools enable teachers to deliver robust learning experiences. It is important to help teachers, administrators, and students know where to begin so that the transition to virtual learning is smooth, without educational loss. This chapter consists of two sections: current trends and issues in technology integration and technological pedagogical content knowledge. The first section briefly reviews the trends in instructional or educational technologies that are causing administrators, teachers, and students to reflect on and modify their thinking about learning and educational content delivery. The second section explores constructivism, the scientific underpinnings of nursing informatics, and ethics. Nurse educators must also address the ethical challenges brought about by this evolving learning landscape. After reading this chapter, one can understand current trends and issues, as well as the influence of nursing informatics and ways to approach new ethical dilemmas.

This chapter describes the cardiac axis. Axis refers to the general direction of electrical conduction through the heart. The QRS complex represents ventricular depolarization. Each lead represents a different angle or vector of depolarization through the ventricular myocardium. All of these added together represent one average QRS vector, referred to as the axis. The four axis categories are: normal, left, right, or indeterminate. This is determined based on the four quadrants that are created by the intersection of leads I and aVF. These two leads are the most important in determining axis. They intersect at the center of the heart and form four right angles. The normal vector points down and to the patient’s left side. Axis is described in degrees.

This chapter highlights some of the current health programs and policies in place and changes in demographic trends for older adults living within American society. In addition, substantial changes within the social, political, and cultural expectations of communities over the past century pose challenges for policies and programs serving older adults. The chapter presents several issues emerge as realities within the context of policy development and program planning for older adults. These issues include changes in living arrangements, education levels, economic well-being, and rural population settings; trends in morbidity and mortality; and changes within the social, political, and cultural expectations of communities. Despite the availability of programs and services resulting from health policies, many programs have focused upon “medically necessary” services and have lacked a health promotion, health education, or community-based focus.

Definitions of aging continue to evolve. This chapter considers aging a part of normal life processes which consists of the acquisition of knowledge and skills over time, the honing and maximizing of these traits and eventually the time period in which all body systems decline from maximal functioning capacity. It reviews normal aging processes in addition to factors which can affect life longevity such as genetic and environmental factors and the human response to environmental stressors. The chapter also presents a brief review of healthy aging and holistic measures. After reviewing the chapter, practitioners will be able to: define aging, longevity and life expectancy; recognize factors that may impact longevity; summarize major normal age-related physiological and psychosocial changes in humans; explain domains that may promote healthy aging; and discuss the importance of the Annual Wellness Visit in supporting healthy aging.

It has been said that working in interdisciplinary teams is a core competency all health professionals will need in the 21st century; they need to be able to collaborate, coordinate, and, most of all, communicate with one another in order to optimize care and maximize operational excellence. Nurses need to be active in interdisciplinary organizations from the start of their careers, and present/publish their work in interprofessional forums. Nurses have many advantages in interdisciplinary collaboration—sound basic education in humanities, social sciences, and basic sciences; many community connections; and experience in facilitating care across different providers. Interdisciplinary opportunities provide more prospects for effecting large-scale change than discipline-specific opportunities do. Moving beyond the discipline specific doesn’t mean that nurses leave nursing; it means they assume positions in which they can now advance the perspective of nursing in ways that others can appreciate, while attracting additional public support.

This chapter reports the findings of a literature review designed to examine the level of support for the Symptom–Action–Timeline process and O’Lynn’s Symptom Action Process (SAP) model. It addresses the recommendations proposed by O’Lynn to: (a) expand the definition of symptom to include psychological symptoms; (b) expand the definition of symptom to be more reflective of a health need so that self-care measures to prevent illness or promote health are included; (c) recognize that intentional disregard of a health need is a type of self-care action, especially when mental health needs are involved; (d) embed the model within an environmental context external to the decision tree to account for demographic variables, access to resources, and so on; and (e) design the model to be more circular in nature, allowing for sequential or concurrent health-related actions.

Statistics is all about recognizing and addressing sources of variability, either through study design or statistical analysis. Variability is both essential for understanding associations and a nuisance that encumbers our efforts at measuring them. This chapter provides a description of the properties of variables. Variables are measurable characteristics or traits that vary from object to object. It is useful to classify variables by their scale of measurement. Two goals of research are to characterize attributes or features of a population and assess associations of interest. These activities necessitate the need for observing characteristics of members of a population. Sensitivity can be expressed as the conditional probability that a diagnostic test produces a positive test result given an individual has the disease. Specificity is the conditional probability that a diagnostic test produces a negative test result given an individual is disease free.

Bipolar disorders affect 2.5 million adults in the Unites States annually and approximately 6 million Americans have a bipolar spectrum disorder and 1 million are age 60 or older. Bipolar mood disorders are the sixth leading cause of disability worldwide. This chapter introduces practitioners to bipolar spectrum mood disorders, etiology, prevalence and comorbidities. In addition, it discusses the differences in bipolar 1, bipolar 2, cyclothymic disorders, and bipolar mixed episodes. The chapter presents a case study with differential diagnoses and risk factors for comorbidities. It discusses mood disorder assessment tools including evidence based treatment options. After reviewing this chapter, practitioners will be able to: identify diagnostic criterion for bipolar spectrum disorders; analyze unique differences in bipolar spectrum disorders; apply assessment tools and differential diagnosis to support bipolar diagnosis; evaluate risks and comorbidities of geropsychiatric populations with bipolar disorders; and understand treatment options for geropsychiatric populations with bipolar disorder.

This chapter discusses breast conditions such as breast cancer screening guidelines, abnormal breast discharge, breast mass, and mastalgia/breast pain. Evidence-based guidelines for breast cancer screening continue to evolve with research findings. National organizations publish their own guidelines that can vary slightly. Practicing clinicians must decide which organizational recommendation they will adhere to and stay updated on any published changes and the rationale for the change. The chapter discusses etiology, history, physical examination, laboratory/radiologic testing, differential diagnosis, treatment, complications, consultation/referral, and follow-up for abnormal breast discharge, breast mass, and mastalgia/breast pain.

Primary care providers have become the main providers of mental health services for their patients. Building on long standing relationships with children and their families along with an emphasis on development, early intervention and prevention, pediatric practices are the ideal setting for the integration of mental health into primary care. One model for working with families that is being used successfully in many health care settings is SBIRT, which stands for screening, brief intervention, referral and treatment. This chapter presents brief interventions that are evidence-based interventions and can be provided by primary care providers in the context of brief office visits or several standard office visits. Brief interventions can be used as a stand-alone treatment for those at-risk as well as a vehicle for engaging those in need of more intensive specialized care.

The importance of mentoring to nurses gathered steam in the 1980s with the growth of graduate education and specialty practice, the development of nursing research, and awareness of the paucity of role models as more nurses took on leadership positions. Building a mentoring network is the means by which one keeps up-to-date, surmounts limitations, discovers opportunities, and continue to evolve as a leader. The feminist critique of mentoring pointed out that not only had gender been ignored in who got mentored, but race and social class were also disregarded. The best way to grow our mentoring network is through professional organizations. Understanding the reciprocal nature of collegiality can be especially useful to top performers because their triumphs can engender envy and retaliatory behaviors; to counteract such competition, they should make sure that anyone who works with them profits from the relationship.

Regardless of the setting and the structure of our pitch, we first to understand how to develop a pitch that compels our target audience to help provide us with the resources we need. This chapter explores eight essential components that will help us find success when pitching our idea/product/service. The eight essential components include: evoking emotion through story; knowing your audience; grabbing attention; painting your unique value proposition; providing enticing solutions; showing results (or evidence); keeping it conversational; and asking for what you need. These components should serve as the foundation for all pitches. Also covered are the three main structures of commonly used pitches: the elevator pitch, the sales pitch, and the venture pitch.

Cancer is a devastating diagnosis that many individuals still associate with death. Upon initial diagnosis, individuals embark on a treatment journey that is overwhelming with medical jargon, new healthcare providers, unknown outcomes, and fluctuations of hope amid the distressing effects of the disease and its treatment. The most frequently diagnosed adult cancer types are female breast, prostate, lung, and colorectal cancer. These four most commonly occurring cancers will be the focus of this chapter. The overall incidence and prevalence of cancer has increased with individuals living with cancer as a chronic illness. Treatment options have improved survival rates, decreased toxicity, and provided palliation. Symptoms associated with the disease and the toxicities of treatment require a commitment to an interprofessional model of care across healthcare settings. Palliative care focuses on the physical, psychosocial, and spiritual needs of the cancer patient and family as well as bereavement needs of families.

It is estimated that approximately 5" to 10" of cancers are inherited as a result of germline mutations. Inherited cancer syndromes result in an increased risk of a specific type of cancer as well as other cancers or conditions. This chapter focuses on hereditary cancer syndromes associated with breast and colon cancers. Like that of other genetic conditions, the importance of risk assessment is key to early recognition of the syndromes so that appropriate management of risk can be implemented, which includes enhanced surveillance, chemoprevention, or risk-reduction surgery, if applicable. It discusses the RISK assessment process when evaluating individuals for inherited breast cancer syndromes, discusses the RISK assessment process when evaluating individuals for inherited colon cancer syndromes and Identifies resources for risk communication and risk management when suspecting individuals for inherited cancer syndromes. The chapter provides additional educational resources for the advanced practice registered nurses (APRNs) pertaining to cancer genetics.

This chapter briefly discusses the history of the Caregiver Support Act and its specific components and explains how the Caregiver Support Act provides resources to older adults and people with disabilities. It provides an overview of the current status of family members serving as caregivers, with special attention to grandparents raising grandchildren. It then discusses a current profile of relative caregivers raising children in the United States; reasons for the increase in relative caregiving; and issues facing grandparents raising grandchildren. It also provides some background into the literature and promotes an awareness of issues that grandparents face as primary caregivers. A literature review examines some of the current issues and services needed. The chapter discusses resources and services designed to meet the needs of grandparents raising grandchildren, and reviews programmatic responses through the national resources. Finally, the chapter outlines some best practice interventions for review in the text.

One important goal of Healthy People 2020 is to improve the health, safety, and well-being of persons who are sexual or gender minorities. This chapter reviews basic concepts for clinicians to support delivery of culturally competent and affirming health care to foster health for all individuals, no matter how they identify their sexual orientation or gender identity. It also reviews language, development of affirming environments, and clinical care considerations. Receipt of culturally competent affirming care is directly associated with increased mental and physical well-being, reductions in disease transmission and progression, reduction of health care costs, and increased longevity. Understanding and using correct and clearly defined language and terminology helps clinicians: understand the unique needs and experiences of varied subgroups of minority individuals, measure health disparities in the practice, locally, and nationally, and provides a foundation to foster understanding, build trusting relationships, and provide affirming and culturally competent care.

During a pandemic such as COVID-19 that creates much uncertainty and rapid changes, supporting elderly patients as well as their families is more integral than ever before. Most individuals that are exposed to a crisis such as a pandemic can experience various challenges that can remain in effect even after the pandemic is over. Deaths associated with pandemics have been repeatedly reported to affect vulnerable populations at different rates including the elderly and women who are pregnant. This chapter helps the practitioners to: describe how elderly patients can connect to care during a pandemic such as COVID-19; explain potential barriers to care for elderly patients during a pandemic; list examples of approaches that can be used to alleviate exacerbations of psychiatric illness during a pandemic and identify any health disparities; and recommend resources and treatment supports that are available during and after a pandemic.

Nursing as a practice discipline positions nurses to encounter unique events and situations that can serve as the foundation for future research exploration. Case control studies serve as a catalyst to differentiate the occurrence of disease among cases and controls to generate hypotheses. Nurses should remain astute and vigilant for unique situations encountered that could be the tipping point for exploration of unique cases. A case control study design groups the research subjects into cases or controls. This chapter helps the reader calculate an odds ratio from a case control study design, differentiates prospective and retrospective research designs, and describes other research designs such as historical, exploratory, methodological, and correlational. It also differentiates the types of triangulation. Epidemiologic research study appraisal is the systematic evaluation of a research study’s quality based on scientific merit and methodological rigor. The epidemiologic research study appraisal is dependent upon the research study design.

This chapter presents brief case studies that correspond to chapters 10–24: These studies refer to contraception, preconception care, breast conditions, HPV and cervical abnormalities, genitourinary tract conditions, infertility, pelvic floor dysfunction, medical abortion, menstrual disorders, gynecologic conditions, peri-and postmenopause, polycystic ovary syndrome, sexual dysfunction and sexually transmitted infections as well as vaginitis and vaginosis.

Healthcare is in a state of rapid change. Although practice environments have become more complex, educational delivery methods have remained stagnant. Innovative technologies provide opportunities to enhance nursing student learning and help nursing programs become more responsive to changes in the practice environment; however, obstacles may hinder successful implementation. With the increasing complexity of today’s health care environment, innovations in nursing curricula are necessary. This chapter explores some of the general challenges associated with the integration of innovative educational technologies, as well as some challenges unique to virtual simulation. It helps the reader to analyze the challenges of integrating educational technologies into nursing education associated with faculty, administrators, and students. It also helps the reader to examine practical and philosophical barriers related to technology integration and explores challenges unique to the adoption of virtual simulation.

Rural Veterans are an important subset of both the Veteran and the rural population with differing healthcare needs that are sometimes misunderstood. The majority of rural Veterans have multiple, complex, physical and mental health needs that require ongoing care throughout their lives. Concurrent palliative care, when delivered as a critical component of comprehensive primary care in rural areas, may offer the best opportunity for rural Veterans to remain productive amid the increasing incidence of multiple chronic conditions (MCCs). Rural Veterans suffering from diabetes, heart disease, Parkinson’s, Alzheimer’s or other dementias, multiple sclerosis, cancer, kidney disease, and rheumatoid arthritis may be candidates for concurrent palliative care. This chapter describes the rural Veteran culture. It outlines the current research on the barriers to palliative care in the rural setting, and provides direction in the opportunities that exist addressing the concerns of the rural Veteran population.

This chapter address a number of areas that will affect the lives of people as they age or people who are older adults. Philosophical paradigms, statistics, evidence-based approaches, dealing with the media, making people aware of new technologies, and preparing for communities to best deal with issues of aging are all major issues of concern. It provides a range of issues; however, the chapter provides an overview of the most significant ones to be addressed or to require intervention. It cites 10 major challenges that the future will bring, in reality, policy advocates will have to be prepared to address and deal with these challenges by using innovative strategies for policy development and policy change. The chapter addresses policy development and program design to meet the needs of an aging and ability-challenged society are unique challenges.

“Doing good” is the prime directive of health profession education, but everyone doing her or his personal best is no guarantee that excellence will prevail. Building clusters of excellence, one can get more productivity as resources are shared and people play off of each other’s ideas, positioning all concerned more effectively to seize new opportunities. Excellence is a “stretch” goal, but if everyone stretches a little, the shape and quality of the organization can be transformed. Even if one achieves only a small portion of what one wanted to accomplish in the name of excellence, this improvement can be just the upstream redirection needed to achieve something even more substantive downstream. Excellence is a journey full of next steps that can only be seen as you move forward and are able to catch a glimpse of what is now on the changing horizon.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and the leading cause of death due to a respiratory cause. Development of this disease occurs as the result of cigarette smoking and exposure to environmental pollution. In addition, the normal physiologic changes due to the aging process place individuals at an increased risk for the development of complications, such as cor pulmonale and pneumonia. In order to reduce the risk of developing the complications of COPD, smoking cessation is recommended. Pharmacologic modalities focus on improving ventilation, reducing inflammation, and preventing complications. Nonpharmacologic interventions including exercise, rest, and improved nutrition can be valuable complementary therapies in the care of patients with COPD. To provide palliative care for patients at every stage of COPD, from diagnosis to the end of life, the nurse needs to acquire the knowledge and skills for expert nursing care.

Clinical epidemiology is considered a basic science of medical practice that informs diagnostic, prognostic and therapeutic clinical decisions related to individual healthcare. Healthcare epidemiology broadens the scope of clinical epidemiology to include various types of healthcare settings not limited to the acute care setting. It is a more comprehensive term to use to designate epidemiology of clinical care in both acute and primary care settings. This chapter provides an overview of healthcare epidemiology, inclusive of clinical infectious hospital-acquired infections, and the basis of health care epidemiologic data in evidence-based healthcare. Healthcare epidemiologists are expert clinicians who provide information and education in areas such as but not limited to infectious diseases, infection control and prevention principles, antibiotic stewardship, occupational health and safety, and prevention of hospital- or healthcare-acquired infections or health conditions, along with regulatory compliance guidance.

The 12-lead electrocardiogram (EKG) can be a valuable resource to utilize in the diagnosis and management of clinical conditions. Many medical conditions can cause a change in the structure and/or electrical excitation of the cardiac anatomy. This chapter focuses on some of the more common diagnoses encountered in everyday practice that affect the EKG. There is a variance in sensitivity and specificity for each finding; however, any association that can be identified may prove invaluable to the clinician. The chapter describes the impact of the following conditions on the EKG: left ventricular hypertrophy, right ventricular hypertrophy, right atrial enlargement, left atrial enlargement, biatrial enlargement, pericarditis, pericardial effusion, pulmonary embolism, hypothermia, acute neurologic injury.

Predictions that the current nursing shortage will continue and most likely intensify as the demand for nurses grows have resulted in a variety of recommendations for strategies to reduce the shortage and meet the demands for additional nurses. Despite the growing numbers of nursing school applicants, the number of graduates from nursing programs has not sufficiently increased to meet the demand for registered nurses. In many cases, nursing school applicants are turned away due to a shortage of faculty and inadequate numbers of clinical sites or financial constraints. Rural hospitals can provide nursing students with experiences surrounding the interprofessional collaboration of acute care settings with community networks through community/public health agencies. This chapter describes opportunities for clinical in rural hospitals, implementation of one new program, and benefits and challenges of placing students in rural facilities for their clinical rotations.

This chapter helps the reader to be familiar with the role coalitions play in advocacy and policy development and to understand the various types of coalitions that affect the policy landscape. It also helps the reader to be familiar with the various roles that exist within groups and coalitions that contribute to the success or non-success of the group process. A number of strategies can be used to develop initiatives to impact one’s advocacy efforts. These strategies can be used to promote the development of new programs and services and can include the use of and/or development of coalitions, the media and media advocacy, and consumer advocates. The chapter addresses each of these strategies in greater depth. It outlines a variety of issues related to coalitions, group development, and coalition building for aging policies and programs.

The basic philosophy of cognitive behavioral therapy (CBT) is that psychological issues and psychiatric disorders are the result of distortions of automatic thoughts and core beliefs; and, these distortions are learned and reinforced through life experiences. Once the core belief system is known, the therapist targets automatic thoughts and conclusions that may no longer be useful to the client. CBT is the treatment of choice for clients with dysfunction automatic thoughts and core beliefs. CBT aids in developing skills and tools that will enhance internal resources and coping skills. This chapter initially describes the author's experience with Adlerian psychology and CBT while working as a psychiatric nurse. It then elaborates the key concepts, goals, assessment and interventions of CBT. Finally, the chapter presents a case study of a client who was treated with CBT for shock and grief after the sudden death of her only sister.

Cohort study designs are a population-based observational epidemiologic study. Cohort studies evolve over time as diagnostic and medical science advances; for example, improved diagnostic screening and testing methods will be integrated into a cohort study design as they are developed or improved. This chapter describes an epidemiologic cohort study design, differentiates a prospective and retrospective cohort study design, and shows how to calculate a risk ratio and rate ratio. Cohort study designs can be developed with an integration of other study designs. A case-control study design can be nested into a cohort study design. In addition, there can be a nested case-control study design within a cohort study design with matching of cases and controls to account for confounding variables. Other study designs can be combined with or integrated into a cohort study design as a strategy to increase internal and external validity of the research study design.

When nurses communicate with their dying patients and the patients’ families, they have a clearer understanding of their patients’ needs and goals at the end of life. This chapter explores ways to encourage both nursing students and graduate nurses to facilitate communication with dying patients, their families, and their healthcare providers. It also explores ways in which nursing faculty members might assist undergraduate nursing students to enrich themselves by working with dying patients. The chapter is organized according to the phases of the therapeutic relationship because in many ways the phases of the therapeutic relationship—introductory, working, and termination—parallel the dying trajectory. When appropriate in the phases, distinctions are made between the roles and educational needs of the undergraduate nursing student, the nurse with an undergraduate degree, and the nurse with an advanced practice degree.

Increasingly, women are using complementary and alternative medicine (CAM) therapies for preventive and palliative care as alternative or adjunct therapies to their traditional medical care. This chapter discusses the most commonly used therapies for a variety of conditions that affect women. Women may not perceive vitamins, minerals, herbs, and supplements as medications. Because drug interactions exist with both prescription and over the counter products, it is important for the clinician to ask each woman about the use of CAM therapies at every visit. Women who are pregnant and/or breastfeeding should not use any CAM therapies without consulting their health care provider. Alternative therapies refer to treatment approaches that, though used for many years, have not been evaluated and tested by conventional methods and rigorous research. The chapter provides the general categories of CAM, reasons for selection/use of CAM, concerns regarding CAM, considerations, and frequently used/recommended CAM therapies.

This chapter provides a summary of the analyzed concepts contained in Conceptual Basis of Rural Nursing, other conducted relevant research, and the concept analysis work on lack of anonymity. It provides a quick reference of the analyzed concepts and allows for easy identification of areas needing further work. The concepts are organized according to the framework provided in the rural nursing theory base. Following each theoretical statement are concept summaries pertinent to that statement. Each concept summary is presented using the analysis framework selected by the chapter authors from Conceptual Basis of Rural Nursing. Further development of the concepts is needed. Paramount is the need for validation of concepts with rural dwellers from multiple settings and varying races and ethnicities.

Today’s healthcare environment increasingly requires nursing practitioners to collaborate with professionals from other disciplines. One way to prepare nursing students for this eventuality is to incorporate immersive virtual simulations containing skill-based or collaborative-based interdisciplinary elements. Development of such simulations requires identifying potential assignments for the simulation, determining whether interprofessional involvement should be internal or external to the simulation, and finding an interdisciplinary professional with the appropriate background willing to volunteer for the effort. It is not a question of whether incorporating interprofessional skills and collaborations into immersive virtual simulations enhance the effectiveness and depth of student learning. It is more a question of how to identify viable proposals for interprofessional virtual simulations. This chapter helps the reader to assess the difference between skill-based and collaboration-based interdisciplinary assignments, explore the two types of interprofessional involvement in simulation development and describe ways to encourage interdisciplinary professionals to volunteer in simulation development.

Culture and spirituality structure human experience, values, and behaviors. Spirituality plays a vital role in times of crisis and illness, as it provides a sense of connection to self, others, nature, and God, and is a means to cope with loss, grief, and death. Spiritual and cultural competences are central tenets of palliative care. Palliative care (PC) addresses the cultural and spiritual needs of patients and families. This chapter discusses the health beliefs of the African American, Chinese, Asian Indian, Latino and Hispanic, and Native American on the basis of recent studies or cultural inquiries. It provides a framework for offering culturally competent hospice and PC to members of these cultural groups. The chapter describes nurses’ cultural self-awareness and development of cultural competency. It also discusses nurses’ need for self-reflection and self-healing in palliative care.

This chapter describes the various intervals seen on the electrocardiogram (EKG). It describes the P wave, the PR interval, the QRS complex, the ST segment, the T wave and the QT interval. The classic 12-lead EKG represents about 10 seconds of time. On the EKG paper, one large box is equal to 200 ms or 0.2 seconds. Each large box is composed of five smaller boxes, each equal to 40 ms or 0.04 seconds. This is helpful to remember when estimating intervals. The P wave represents atrial depolarization. The PR interval represents the period of time in between atrial and ventricular depolarization. The QRS complex represents ventricular depolarization. The ST segment represents the period of time in between ventricular depolarization and repolarization. The T wave represents the rapid phase of ventricular repolarization. The QT interval represents the entirety of ventricular systole.

Geriatric depression or late-life depression is a complex mood disorder that can comprise of various etiological pathways and often occurs in the context of medical illness or cognitive decline. Major depressive disorder (MDD) is one of the most commonly diagnosed mental illnesses in older adults and is often underrecognized and undertreated. Depressive symptoms are frequently associated with the normal aging process because depression in older adults may be disregarded as frailty, irritability, agitation, or helplessness; therefore, the need to seek medical attention is often overlooked. After reviewing this chapter, practitioners will be able to: describe the prevalence, risk factors, and protective factors for older adults with depression; differentiate between MDD and other mood disorders; discuss example screening tools to help screen older adults for depression and suicide risk; describe evidence-based general pharmacological and nonpharmacological treatment options for depression in older adults; and identify barriers and facilitators to promote treatment compliance.

This chapter helps the reader to identify the process for designing and creating virtual gaming simulations (VGS) in nursing education, assess key decision points associated with game designs, and compare and contrast different forms of virtual environments and tools that inform game design. It provides an overview of virtual learning environments and tools, followed by a discussion of two VGS exemplars related to a mental health assessment and prescription of the controlled substances. The former is focused on baccalaureate students, whereas the latter is focused on advanced practice nurses. These exemplars examine challenges encountered, resolutions considered, and lessons learned in VGS design. The chapter applies the Faculty Administrators Students Technology Strategic Integration Model^© model as a method to reflect on and critique the groups’ processes for making design decisions and to frame a discussion of the lessons learned in the process.

Design thinking is a process that cannot function under the same constraints that have been built around more linear and quantitative approaches in healthcare. It requires a different ecosystem, one that allows for and embeds empathetic engagement, radical collaboration, and rapid prototyping. Design thinking is an action-oriented problem-solving framework. This chapter helps the reader to: define design thinking and describe its role in healthcare leadership, innovation, and practice; develop an understanding of how design thinking relates to, and complements, other effective management and practice approaches; develop comfort in, and a way to navigate, ambiguity and unknowns; and describe strategies for successful implementation of design principles and practices within their own practice/organization. Design thinking yields increased systematic understanding of a problem and its possible solutions because it starts, and is driven by, key stakeholder’s lived experience(s), which cut across sectoral, social, geographical, and political boundaries.

Addressing critical health issues requires utilization of tools, such as epidemiology, to assist in determining why people get sick, disabled, or die. Answering why this happens requires one to understand the determinants of health. The World Health Organization identifies the determinants of health as the social and economic environment, the physical environment, and the person’s individual characteristics and behaviors. This chapter describes the determinants of health. It articulates how risk factors affect health and how the social determinants of health affect health inequities. Epidemiology is a discipline that deals with the determinants of health. There is increased realization that focusing on the determinants of health and health disparities is an important aspect of improving the health of populations and improving healthcare outcomes. Inequities in education, housing, job security, and environmental health must be eradicated if health disparities are to be addressed effectively.

Rural nursing varies greatly based upon geography and cultural values; however, the attitudes and attributes of rural nurses remain constant. Many registered nurses (RNs) have grown up in the area with family ties that result in their decision to stay and work in rural settings. However, there is a shortage of RNs in these healthcare settings. Reasons for shortages in rural settings include lack of educational opportunities and resources; lack of diversity, social support and cultural congruence; feelings of isolation, and policies that are inconsistent to support rural healthcare. Collaborative initiatives in education and institutional support can enhance the professional characteristics of rural nurses. This chapter utilizes case studies to illustrate strategies to build capacity while offering ideas for collaborative education models that address recruitment, retention, and workforce development of rural nursing.

Addressing gaps in student knowledge regarding rural nursing concepts can be difficult without a valid and reliable measurement tool. By identifying and addressing gaps in knowledge, nursing faculty members may be able to impact student interest and confidence in rural nursing practice, potentially increasing their desire to practice in rural healthcare settings upon graduation. This chapter describes the process for developing an instrument to assess nursing student knowledge of rural nursing practice and conducting psychometric evaluation of the newly developed Rural Knowledge Scale. The final 27-item version of the Rural Knowledge Scale demonstrated acceptable psychometric properties and can be utilized to identify gaps in student knowledge related to rural nursing practice and rural healthcare issues. By identifying and addressing gaps, students’ interest and confidence in rural nursing practice may be impacted and result in more nurses who are interested in practicing in rural settings.

The reliable diagnosis of mental health disorders is essential for guiding appropriate evidence-based treatment along with identifying prevalence rates for the planning of mental health services and accurately documenting important public health information, such as morbidity and mortality rates. Mental health disorders are diagnosed according to criteria in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) by the American Psychiatric Association. Diagnostic criteria include symptoms, behaviors, cognitive functions, personality traits, physical signs, syndrome combinations, and durations requiring clinical expertise to differentiate from normal life variation and treatment responses to stress. Before a diagnosis is made, it is necessary to gain collateral information from multiple sources and to conduct a comprehensive interview with the child and family. This chapter describes general approach to the evidence-based management and prevention of mental health disorders in children and adolescents.

Testing consists of screening and diagnostic testing. Both screening and diagnostic testing are secondary prevention measures. The actual test used for screening and diagnostic testing is often the same. However, the differentiation is the context and purpose for which the test is conducted. Screening and diagnostic testing are essential components of surveillance systems. Screening is the presumptive identification of an unrecognized disease or health condition in a population by the application of a test, examination, or other procedure. This chapter differentiates between screening and diagnostic testing. It helps the reader calculate sensitivity and specificity rate. The chapter calculates positive predictive value and negative predictive value measures; and differentiates the types of reliability measures.

In dialectical behavior therapy (DBT), dialectics reflect the relative nature of truth, which is subject to change according to the frame of reference. Reality is considered within a systems perspective in which a part of an experience cannot be held separately from the whole of that experience as each invariably shifts in relation to the other. In the biosocial theory of DBT, client's struggles are thought to originate from a combination of biological vulnerability and an invalidating early environment leading to difficulty with emotional vulnerability and emotion regulation. This chapter initially outlines the author's experience in treating clients presenting with trauma exposure. It then describes the key concepts, goals, assessment and intervention of DBT. The chapter finally presents a case study of a client who underwent trauma-focused psychotherapy for significant emotion dysregulation including symptoms of depressed mood, generalized anxiety, insomnia, recurrent flashbacks and nightmares, and repeated self-injurious behaviour.

Epidemiologic tools consist of counts, rates, ratios, and proportions. The tools of epidemiology present data about health conditions with consideration to person, place, and time. Measures of disease occurrence provide essential data to understand the dynamics of morbidity and mortality in a population in order to develop population-based measures of control and prevention. This chapter helps the reader to calculate morbidity and mortality statistic and describes how to utilize morbidity and mortality data to describe the distribution and determinants of disease within specific populations. The chapter differentiates the population surveillance system methods used to generate epidemiologic data and presents essential elements of a population surveillance system to prevent and control outbreaks, epidemics, and pandemics. The quality of life measures the extent to which a disease or health condition causes alterations in an individual’s daily life and ability to participate in and contribute to society.

Rural nursing practice, be it hospital practice, private practice, or community health practice, is distinctive in its nature and scope from the practice of nursing in urban settings. It is distinctive in its boundaries, intersections, dimensions, and even in its core. Being rural means being a long way from anywhere and pretty close to nowhere. Being rural means being independent or perhaps just being alone. Being a rural nurse means being able to deal with what she or he has got, where she or he is, and being able to live with the consequences. The information for this chapter comes from the author’s ethnographic study of rural hospital nurses in the Inland Northwest, completed in 1987, from dialogue with key informants before and after the study, and from the author’s personal experiences within rural healthcare systems spanning more than 20 years.

This chapter discusses the effect of drugs and electrolyte on the electrocardiogram (EKG). The specific effect a medication will have on EKG intervals is directly related to the physiologic effect it will have on the electrical conduction system. Therefore, it is easier to understand what occurs if the medicines are thought of in groups based on their mechanism of action. Antiarrhythmic medications need to be closely monitored with regular EKGs because their effect on the conduction system can be potentially harmful. The cardiac myocyte has a negative resting charge. The myocytes become electrically excitable when there is an influx or efflux of ions from the cell through distinct ion channels. Antiarrhythmic medications suppress arrhythmias by altering the action potential via one or more of these ion channels. Blocking these channels results in an interruption of reentrant mechanisms and makes it more difficult for an arrhythmia to manifest.

Dyspnea is a multidimensional, self-reported symptom that is often underreported or undertreated, resulting in symptom invisibility. Dyspnea assessment is based on the patient’s report. Efforts should be made to encourage and promote reporting dyspnea using an appropriate assessment tool, considering age (children and elders may underreport) and the ability to self-report. Treatment of the underlying cause(s) does not necessarily mean dyspnea resolution. Interventions should be directed at more than one dimension of dyspnea, that is, physical (impact or burden), sensory (perception), affective (distress), and social domains. This chapter presents cognitive-behavioral approaches and complementary therapies for dyspnea. Caregivers of patients with dyspnea need to be included in the treatment plan. Despite progress made in the treatment and management of dyspnea, too many individuals continue to suffer breathlessness at the end of life. Dyspnea in advanced disease is often prognostic of impending death.

According to the National Institute on Aging (2019), hundreds of thousands of adults over the age of 60 are abused each year. Elder abuse is often under the umbrella of elder mistreatment, which includes abuse, neglect, and exploitation among individuals aged 65 or older. This chapter describes risk factors, types of elder abuse, and approaches for prevention and treatment. Advanced practice nurses must be prepared to report as mandated by law, be advocates for prevention and treatment while meeting the needs of elderly patients to ensure quality care. Elder abuse is defined as an act or lack of an appropriate action that results in harm or distress to an older person. The chapter helps the practitioners to: recognize signs and symptoms of elder abuse; summarize laws pertinent to elder abuse; describe factors that contribute to elder abuse; and identify how to respond to needs related to elder abuse.

This chapter helps the reader to understand the history of the Elder Justice Act (EJA). It provides specific components of the EJA and how programs and services flow for older adults and people with disabilities. The chapter discusses the limitations in programs and services within the EJA. The EJA requires the oversight and the appropriation of federal funding to protect people growing older and people with disabilities from abuse. It addresses legal issues with a special emphasis on the concept of a power of attorney. The chapter explores several legal issues that face older adults. It also address elder abuse, power of attorney, and a differentiation made between the types of power of attorney and the healthcare power of attorney. In addition, the chapter explores legal services provided to older adults as a result of the Older Americans Act, and outlines the challenges within the realm of legal issues.

Lack of access to timely and appropriate emergency medical services (EMS) was listed as the top priority by participants who responded to both the 2010 and 2020 Rural Healthy People survey. Several factors contribute to the lack of timely and appropriate rural emergency response: distance, which equals time, availability of EMS providers, and level of training of responders and/or medical directors. This chapter addresses nursing’s role regarding frontier EMS, technological advancements in EMS, and models that have been proposed to mitigate some of the problems related to provision of emergency services on the frontier. Due to the dearth of information regarding frontier healthcare, specifically EMS, the author also includes their personal experiences from 17 years of nurse practitioner practice in a frontier community.

The emerging trends in innovation that will occur over the next several years will be staggering, including everything from the rapid adoption of artificial intelligence in healthcare, to virtual or augmented reality and wearables for both patients and clinicians. This chapter discovers the most common innovation categories in healthcare, the impact of innovation and technologies on healthcare and patient outcomes, and strategies to promote successful adoption of emerging technologies. It examines three categories of innovation in healthcare, describes the impact that emerging innovations have on nursing practice and patient care outcomes, and discusses strategies by organizational leaders to support the successful adoption and implementation of emerging technologies. There are three broad categories of innovations that impact healthcare: innovations associated with purchasing and using healthcare, innovations in health technology, and innovations in our healthcare-related business models.

Heart failure (HF) is a terminal disease. Predicting the illness trajectory is much harder in HF than in cancer. Nursing has a key role in the management and outcomes of patients with HF. Patients often turn to nurses for information on their disease especially in the end stages of the disease. A coordinated effort by nursing has been developed as to how to help patients with not only the physical symptoms of HF but also the psychosocial aspects. In caring for the patient with advanced HF, there are clinical, evidence-based therapies that should drive clinical decision making. This chapter helps the reader to understand the disease of HF: how important disease management is, how nurse-based HF interventions can lead to positive outcomes, and, most importantly, how to communicate with patients and families regarding their treatment options and what is important to them in the final phase of their life.

Chronic liver disease and cirrhosis are the 12th leading causes of death in the United States. There are many chronic liver diseases that lead to cirrhosis, such as viral hepatitis, autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, nonalcoholic steatohepatitis, alcohol, some toxins, and inborn errors of metabolism. Liver cancer is one of the fastest growing cancers in the world. Patients with end-stage liver disease (ESLD) present with malnutrition, muscle wasting, hyperlipidemia, fatigue, jaundice, and renal disease. Nurses need to be aware of the pathophysiology and etiologies of liver disease. Nurses need to explore and acknowledge their assumptions and biases about patients with liver disease and their families. Nurses play a pivotal role in advocating for advance care planning and early palliative care for patients with ESLD and their families. Patients with liver disease benefit from physical, psychosocial, and spiritual interventions offered through palliative care.

The diagnosis of end-stage renal disease (ESRD) can be difficult for patients and families to hear because this means they will need some form of kidney replacement therapy to survive (hemodialysis, peritoneal dialysis, transplantation). ESRD means a patient has severe end-organ kidney damage and failure. When confronted with the extensive list of medical and psychological problems often associated with patients with ESRD, healthcare professionals often focus on treating the medical issues by implementing strategies to address abnormal laboratory values and treating comorbid conditions. The goal for patients with ESRD cannot be simply to preserve life but also to promote quality of life. This chapter discusses palliative care in relation to three groups of patients with ESRD: undergoing dialysis, choosing conservative management, and withdrawing from dialysis. It also provides a brief review of the major comorbidities and complications associated with ESRD and available palliative treatment options.

Clinical simulation has changed significantly over the last three decades. The introduction of virtual simulation programs enables safe repetition of practice in standardized scenarios that, if rigorously developed, can support validity and reliability. This chapter focuses on enhancing rigor across the five stages of development of virtual simulation programs, drawing on our experience of developing a patient deterioration management program known as Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends. The program includes background educational materials, precourse and postcourse knowledge tests, and three interactive management scenarios (acute myocardial infarction [AMI], hypovolemic shock, and chronic obstructive pulmonary disease). The chapter helps the reader to assess approaches to enhancing rigor in the development, implementation, and evaluation of virtual simulation and appreciate the importance of and steps necessary to trialling a virtual simulation prior to full integration with an established curriculum.

There are many principles of entrepreneurship that can be applied to the bedside or to managing a team of healthcare providers. This chapter examines 15 core concepts of entrepreneurship and directly applies them to the clinician’s experience. It explains the need for entrepreneurial leadership in healthcare, examines the foundations of entrepreneurship through the evidenced-based entrepreneurial learning concepts, applies entrepreneurial concepts to healthcare settings, and inspires the reader to change behaviors and adopt entrepreneurial principles into his/her healthcare role.

Epidemiologic investigations and research studies attempt to explore the occurrence of a health event or disease within a population. This chapter provides an understanding of the different types of research bias and describes the strategies to impact research bias. It also provides an understanding of confounding and interaction. Bias can be introduced at multiple points in an epidemiologic investigation or research study and can have a direct impact on both the internal and external validity of the epidemiologic findings. The ability to determine the extent of association and causal inference is impacted by research bias, confounding variables, and interaction of variables. Bias reduction or elimination is the responsibility of the nurse researcher, nurse epidemiologist, or public health epidemiologist. Nurses themselves should also explore the extent to which their behavior or method of data collection introduces bias into the epidemiologic research study.

The dissemination of epidemiologic knowledge must be of the utmost ethical manner. Epidemiologists have to promote the development of their scientific reputation to advance their professional careers, but most do this in an ethical manner. Meanwhile the public has the right to know their health risks and expect that epidemiologic research is conducted in a manner of scientific rigor while protecting human subjects. Ethical guidelines and principles guide the ethical practice of epidemiology. This chapter helps the reader to integrate ethical principles into the ethical decision-making process. It demonstrates the utilization of personal and professional core values that influence ethical decision-making.

Epidemiologic data can be used as the evidence base to substantiate the development of public health policy. In addition, epidemiologic measures can be used to generate the data necessary to substantiate public health program effectiveness. Essentially, epidemiologic measures serve as evaluative metrics to determine programmatic improvements in population health. Quality improvement metrics can be epidemiologically based for continual quality analysis. Nurses engage in public health policy development, implementation, evaluation, and analysis. Additionally, nurses are involved in policy advocacy for individuals and communities. This chapter defines health policy and differentiates the types of policy. It describes the policy development process and discusses the Centers for Disease Control and Prevention (CDC) policy process model, a nationally accepted policy model that can be applied to population-based community problems. The chapter also distinguishes among efficacy, effectiveness, and efficiency, and presents the PDSA model.

Advances in population health science and population health management are grounded in the utilization of epidemiologic a information. Epidemiologic studies provide another set of tools to assist the epidemiologist to understand the distribution and determinants of health in a population. Thinking epidemiologically integrates scientific method, epidemiologic reasoning, and the epidemiologic triad into a coherent thought pattern. Epidemiologic thinking uses an integrative investigative approach to understanding the distribution of health conditions and determinants of health conditions within a population to develop preventive and therapeutic population-based strategies. This chapter provides an understanding of the definition and scope of epidemiology. It describes a comparison of descriptive and analytic epidemiology and demonstrates an understanding of the epidemiologic process. The chapter compares the similarities and differences in the epidemiologic approach and scientific methods and analyzes a health or disease-related condition using the epidemiologic triad. It describes the differences in the epidemiologic tools.

This chapter focuses on ethical issues in nursing care for patients approaching death. It presents a case study of a 78-year-old woman who has end-stage dementia. Ethics and morals are frequently used interchangeably in nursing ethics to refer to conduct, character, and motivations involved in moral acts, although distinctions are sometimes made between these terms. The chapter includes resources to assist the nurse in managing ethical concerns or dilemmas effectively. Moral theories are methods of determining what counts when a decision must be made, and to offer a method for weighing or ranking considerations identified as morally relevant to that decision. There are two major approaches to theoretical considerations—deontological and teleological systems of ethics. The chapter explores issues of patient autonomy and decisions about end-of-life interventions that range from instances of allowing or permitting death to hastening or intentionally causing death, and how these decisions are understood by nurses.

A disease has a typical course of progression in a human. This natural course of disease progression that occurs over a period of time provided is known as the natural history of disease. The natural history of disease consists of five stages of disease: susceptibility, incubation, prodromal, acute, and convalescence. This chapter describes an interrelated natural disease history model to include the natural stages of the disease with integrated incubation time periods, subclinical, clinical, prepathogenic, pathogenic, and targeted disease specific interventions. It provides population-based prevention strategies that integrate several types of immunity and prevention levels. The chapter presents prevention strategies to break the chain of infection for specific diseases. Infectious disease incubation periods are dependent upon the rate or organism growth in the host, exposure dosage to the infectious agent, portal of entry, and host immune response.

Anxiety disorders are the most common mental health problems in children and teens. Worries and fears are a normal part of a child’s development, but should not be excessive, interfere with functioning, or persist beyond developmentally appropriate periods. Youth with anxiety disorders experience severe and persistent distress that interferes with their daily functioning in school and in social interactions, affecting the child’s cognition, emotional regulation and behavior. Anxiety disorders are often comorbid with depression, bipolar, obsessive-compulsive, learning/language, eating, attention-deficit/hyperactivity disorder (ADHD), and substance related disorders. Children and teens with obsessive-compulsive disorder (OCD) have obsessions, compulsions or both, which are time-consuming and cause clinically significant distress or impairment in social, occupational or other areas of functioning. Routine mental health screening is recommended at all well-child visits and for presentation of symptoms or concerns. This chapter reviews evidence-based assessment and management of anxiety disorders and obsessive-compulsive disorder.

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common chronic behavior disorder in children. ADHD is present in 4% to 12% of school-age children. Worldwide, it is estimated to affect 5% of children. ADHD is more common in males than in females (3-6:1). It typically presents during early childhood, before 7 years of age, although changes in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5^TM) have noted that most lifetime cases are captured with an onset of age 12-14. The disorder involves a persistent pattern of inattention, hyperactivity, and impulsiveness, or all three. Children with ADHD often have co-morbid disorders (e.g., anxiety disorders, depressive disorders, learning disorders, oppositional defiant disorder). This chapter presents the assessment, screening tools and management of ADHD.

The diagnostic category of Autism Spectrum Disorder (ASD) refers to a group of symptoms characterized by delays in the development of socialization and communication skills in addition to the presence of restrictive and repetitive behaviors. One of the early indicators of a possible ASD is a child’s lack of responsiveness to their name or other social communication. It is important to rule out any hearing deficits. Individuals with a diagnosis of ASD should also have an accompanying level of severity rating ranging from 1 (lower level of support needed) to 3 (high level of support needed). Children with ASD vary widely in abilities, intelligence, and behaviors. The earlier an accurate diagnosis can be made, the earlier treatment can begin, which may have significant educational and developmental benefits to the child. This chapter describes the assessment and management of ASD.

Child maltreatment is defined as the causation of a nonaccidental injury. It may be physical or sexual abuse. Inflicts or allows to be inflicted: a physical or sexual offense against a child. Child neglect is defined as the omission in care of a child’s basic needs that may result in harm or potential harm. It is a significant cause of morbidity and mortality in children. Domestic violence is significantly correlated with child maltreatment. Girls who are abused as children may be more likely to become victims of violence as adults. Boys abused as children may be more likely to commit acts of violence as adults. Child maltreatment tends to be repetitive and frequently will escalate over time. It is essential that every child, regardless of race, religion or socioeconomic background be screened for child maltreatment in their primary care office.

Depressive disorders include major depressive disorder, persistent depressive disorder (dysthymia), disruptive mood dysregulation disorder, premenstrual dysphoric disorder, substance/medication-induced depressive disorder, and depressive disorder due to another medical condition. The common feature of depressive disorders is the presence of sad, empty, or irritable mood, which is associated with somatic and cognitive changes that interfere with functioning at home, in school and/or with peers. The risk in children/teens is increased if one or more parents are depressed. Depression is a risk factor for other high-risk behaviors and often precedes substance abuse by about four years. Depression is often misdiagnosed as ADHD in young children as they may present with inattention, impulsivity, and hyperactivity. This chapter provides a brief overview of depression and discusses the assessment and evidence-based management of depressive disorders in children and teens.

All children are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy parents, teachers and other adults in authority. Openly uncooperative and angry/hostile behavior becomes a concern when it is so frequent and consistent that it stands out when compared to other children of the same age and developmental level and when it affects the child’s home, school, and social life. The child with disruptive behaviors may have ADHD or the “externalizing behaviors” (i.e., acting out behaviors) may be the symptoms of anxiety or depression. There is significant overlap between attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), the two conditions are often co-morbid. Current evidence-based guidelines for treating ODD recommend treating the ADHD symptoms first as the best initial approach. This chapter discusses the assessment and management of disruptive behaviors.

Eating disorders associated with body image disturbance tend to emerge during adolescence, between 11 to 19 years of age, related to normal developmental tasks related to transformative changes of puberty, identity formation, establishing autonomy and maturation of brain pathways. Although predominantly affecting teenage females, eating disorders associated with body image disturbance are distributed widely across populations. Eating disorders in children and adolescents are increasingly recognized as potentially serious threats to normal growth and development in the first two decades of life, requiring a biopsychosocial approach, rather than one focused exclusively on associated mental health issues, such as anxiety or depression. Increasingly being considered “brain disorders”, optimal mental health outcomes for pediatric age patients may require initial emphasis on restoration of nutrition and physiologic stability to support family-based cognitive-behavioral treatment. Early recognition and treatment improve outcomes.

Although obesity is a chronic medical condition, not a psychological disorder, many researchers and clinicians agree that the psychological and social impact of living with obesity is a risk factor in the development and persistence of mental health problems. In adults with mental health disorders, the prevalence of obesity is nearly twice as high as compared to adults without mental health disorders. The research evidence supports the predictive relationship of child emotional and behavioral problems (e.g., high levels of internalizing and externalizing behaviors) and the later life development of obesity or overweight. About 80% of adolescents with obesity will continue to be obese as adults. Psychological and social comorbidities associated with excess body weight in childhood and adolescence includes anxiety, depression, poor body image and self-esteem, and decreased social competence and academic achievement. This chapter discusses the assessment and management of obesity.

Somatoform disorders often first present in general medical or non-psychiatric settings. Diagnostic criteria apply across the lifespan, so it is important to consider the child or adolescent’s developmental level during assessment and diagnosis. These disorders may or may not overlap or be comorbid with other medical disorders, such as irritable bowel syndrome, abdominal pain, fibromyalgia, headaches, or chronic pain. These disorders may or may not overlap or be comorbid with other psychiatric disorders that may have physiological symptoms, such as anxiety and depressive disorders. Somatization is a key concept. It refers to the subjective experience of physical symptoms for which clear pathology or injury is lacking or not diagnosable by standard-of-care methods, or when level or distress or disability exceeds what is typically associated with clinical findings. This chapter presents the four somatoform disorders that are particularly relevant to children and adolescents.

While many children and adolescents have normal and healthy developmental processes, approximately 6.1 million children and adolescents between the ages of 12-17 years needed treatment for substance-related or addictive disorders between the years of 2015-2019, yet only 5 million of these children and adolescents received treatment. Their use of addictive substances intensify the development of comorbid mental health disorders, developmental delays and problems with everyday functioning all of which affects their ability to contribute to society as the emerge into adulthood. Appropriate screening and early identification are critical in order to institute evidence-based practice (EBP) approaches for children and adolescents who use addictive substances. This approach includes early detection and treatment of behavioral issues that may affect children and adolescents. This chapter describes the assessment and management of substance abuse and addiction.

Stress and adversity are not always a negative situation for the child or adolescent. Some stress and adversity can promote strength of character and resiliency, especially, if handled in the correct way. Repetitive and prolonged exposures to adverse childhood experiences (ACEs), especially four or more, tend to lead to the development of toxic stress. When that toxic stress persists is when the changes are seen both physiologically and behaviorally. ACE exposure can limit the development of important healthy coping skills in the child and adult who experiences them. Screening in primary care settings can contribute significantly to earlier identification of children at risk. The importance of a positive adult relationship as a safeguard is vital in preventing toxic stress responses to the child. Early home visiting is one of the nationally recognized, evidence-based programs that improves outcomes and leads to better health down the line.

Neonatal abstinence syndrome (NAS) is an emergent issue due to the increase in prenatal maternal opioid use. The term NAS is used to describe a neonate experiencing withdrawal symptoms, ranging from feeding difficulties to seizures, as a result of exposure to maternal opioid use. This chapter describes a Doctor of Nursing Practice professional project completed in 2019 at a critical access hospital (CAH) in Montana. The purpose of the project was to assess the change in team member confidence when providing care for neonates suspected of substance withdrawal at a CAH in Montana by: (a) developing and implementing a policy on care and treatment of a drug dependent newborn; (b) educating the team providing care to these neonates on the use of NAS scoring tools; and (c) evaluating the education and improved confidence levels of the health care team.

This chapter focuses on sources of evidence for evidence-based policy development. It explores some of the dilemmas with developing an evidence base and provides a range of empirical sources within the aging and disabilities arenas that can be used in building an evidence-based approach to policy development. The journey, however, will not be without struggle—since philosophical paradigms, and social and economic factors will interface and play a role in the development of evidence-based policy. The chapter helps the reader to be aware of healthy people 2020 benchmarks that are used to guide program planning and policy development. Benchmarks currently have been established in order to identify where health goals for the nation and individual states should be, and the program is evaluated routinely by local and state health departments. Healthy people 2020 is also used to gauge the impact of health policy.