RESOURCES FOR PRACTICE
Articulating new outcomes of nurse practitioner practice Esther Sangster-Gormley, RN/NP, PhD (Assistant Professor), Noreen Frisch, RN, PhD (Professor and Director), & Rita Schreiber, RN, DNS (Professor and NP Program Coordinator) School of Nursing, University of Victoria, Victoria, British Columbia, Canada
Keywords Health care; mid-range theory; nurse practitioners; outcomes; primary care. Correspondence Esther Sangster-Gormley, RN/NP, PhD, School of Nursing, University of Victoria, 3800 Finnerty Road, Victoria, British Columbia, Canada V8P 5C2. Tel: 250-721-7962; Fax: 250-721-6231; E-mail: [email protected] Received: September 2011; accepted: January 2012 doi: 10.1002/2327-6924.12040
Abstract Purpose: The purpose of this article is to describe how two mid-range theories, Kolkaba’s Comfort Theory and Antonovsky’s Sense of Coherence can be used to illuminate the holistic nature of nurse practitioner (NP) practice. Data Sources: Original research and theoretical papers related to both theories described. Conclusions: The NP role has been in existence for more than 40 years and can be found in healthcare systems in more than 60 countries around the world. Increasingly, NPs are assuming responsibility for providing primary health care to people with complex care needs. Although researchers have consistently demonstrated the NPs provide safe, effective care, and patients are satisfied with that care, theories demonstrating the holistic nature of NP practice are less evident. Implications for Practice: Comfort Theory and Sense of Coherence can be used to demonstrate how the holistic nature of NP care results in patientcentered outcomes.
Although the nurse practitioner (NP) role is the most researched role of all of the health professions (DiCenso, 2008) and, according to Lewis (2008), likely the best studied occupational group in human history, the nursing aspects of NP practice are just coming into focus as outcomes for evaluation. Historically, NP outcomes have been focused on quantifying the impact of practice by demonstrating patient satisfaction (DiCenso, 2008), effectiveness, and efficiency (Horrocks, Anderson, & Salisbury, 2002). Although these outcomes are important, they are provider driven. In the current healthcare climate, it is essential to move toward patient-centered outcomes to demonstrate the less easily quantified “value-added” benefit that NPs’ nursing background adds to care (World Health Organization [WHO], 2008). As nurses, NPs are thought to bring a holistic perspective to their care, often referring to their care as patient centered. In 2008, the WHO drew global attention to the need to have healthcare systems delivering care for people in such a way that care providers have understandings of individuals, their life contexts, and personal meanings. It would seem that NPs make every attempt to do just this. Thus, we embarked on a review of the history of the NP role and theoretical frameworks that help us not only
understand how patient-centered care is enacted by NPs, but also to provide guidance on ways that such care could be operationalized and measured. The purpose of this article is twofold. First, to contribute to the discussions of the use of theory related to the nature of NP practice (Carron & Cumbie, 2011; Nicoteri & Andrews, 2003; Shuler & Davis, 1993; Shuler & Huebscher, 1998) and second, to propose that mid-level theories can guide selection of evaluative tools to operationalize and measure the outcomes of patient-centered NP care. We present two mid-level theories that could lead to measures of NP sensitive outcomes, or patient-centered outcomes that result directly from care provided by NPs. We begin by acknowledging the historical foundations of NP care and the current state of evaluation of NP practice. Finally, we suggest concepts taken from two mid-range theories congruent with NP practice that can be used to measure outcomes of NP care. Such theoryderived outcome measures would augment our current cadre of NP outcome measures and illuminate a nursing perspective of health that includes caring for people as whole beings within the contexts and meanings of their lives. We present two theories, Kolcaba’s (1992, 1994, 2003) Comfort Theory and Antonovsky’s (1985, 1993) Stress-Health-Coping Theory as examples of
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mid-range theories containing concepts and outcomes that could be useful in exploring care provided by NPs.
Historical background Nightingale advised, above all, that nurses collaborate to promote health, value health for all, and influence health through nurturing the “vital force,” the living impulse for health (Beck, 2010). In her writings, she also emphasized the importance of looking beyond the individual as the focus of care to include population health. Other early nurse leaders, such as Lillian Wald and Lavinia Dock, also recognized the importance of nurses caring for individuals as well as families and communities (Keeling & Bigbee, 2005). We believe that the establishment of the Frontier Nursing Service in Kentucky and nurse anesthetists during the American Civil War (Faut-Callahan & Kremer, 2000; Schreiber & MacDonald, 2003), and the creation of outpost nursing in the Canadian North (Kaasalainen et al., 2010) set the stage for the evolution of the NP role. As the NP role has evolved, accountability for healthcare funding has come to the fore, and researchers have sought ways to demonstrate the value-added benefit of NP practice. Although researchers have documented outcomes of NP care, only some have begun to examine NP practice through the lenses of nursing and other theories.
Evaluation of NP practice NPs provide holistic care to patients, their families, and communities in more than 60 countries around the world (Delamaire & Lafortune, 2010; Schober & Affara, 2006) and they focus on health promotion and maintain the underlying value of health for all people. At the outset of implementing the NP role, expected outcomes were cost reduction, assurance of high-quality care, and increased access to healthcare services (Sangster-Gormley, 2010). Although there has been a call for NPs and researchers to develop an evaluative agenda to document the contributions NPs make to patient care (Edmunds, 2007; Kleinpell, 2009; Spross & Lawson, 2009), much of the research to date has focused on provider-driven quantifiable outcomes. Researchers have consistently found, over the past 35 years, that NPs provide safe, cost-effective care (Horrocks et al., 2002; Laurant et al., 2009) that is comparable to the care provided by physicians, and that patients are satisfied with the care provided by NPs (DiCenso et al., 2003). Not only are patients satisfied, they trust NPs (Benkert, Hollie, Nordstrom, Wickson, & Bins-Emerick, 2009), feel that NPs take their problems seriously and discuss their concerns (Thrasher & Purc-Stephenson, 2008), and be654
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lieve that NPs are approachable and have expert communication skills (Beal & Quinn, 2002). NPs also have longer consultation times with patients, ensuring that patients receive more information (Kinnersley et al., 2000) and counseling (Sidani et al., 2006). NPs are reported to emphasize health promotion, and involve patients in self-care management of their chronic and acute conditions (Charlton, Dearing, Berry, & Johnson, 2008; Russell et al., 2009). Furthermore, NPs accurately order and interpret diagnostic tests, prescribe medications appropriately, and use clinical practice guidelines (SangsterGormley, 2010). These researchers have demonstrated the nature of NP practice that is grounded in nursing tenets dating back to Nightingale (Keeling & Bigbee, 2005). What is less apparent is how evaluation of this approach to care can be translated in a way that healthcare decision makers can understand and appreciate. In the healthcare arena, the value-added benefit of NPs care too often remains obscure.
NP practice outcomes Few authors have begun to explore patient-centered nursing and NP outcomes of care. For example, Clark (2003) conducted a Delphi study of nursing experts regarding expected outcomes of nursing care across the continuum of care. She identified five patient outcomes of nursing care: (a) appropriate self-care behaviors, (b) symptom management, (c) health promotion behaviors, (d) perceptions of being well cared for, and (e) healthrelated quality of life. Doran (2011) reviewed the state of the science of nursing outcomes that can be related to nursing interventions, and for which nursing is accountable. These include: (a) clinical, including symptom control and management; (b) functional, including physical, psychosocial, and self-care management; (c) safety, including adverse events or complications, for example, pressure ulcers, infections; and (d) perceptual, including satisfaction with nursing care. Looking specifically at NPs, Sidani and colleagues (2007) compared levels of physical and social functioning of patients cared for by acute care NPs to that other providers. Sidani and her team (2007) reported that those who received care from NPs had higher levels of functioning than did their counterparts who received care from other providers. Through their work, Sidani et al. (2006) moved NP evaluation to a level that looks beyond provider-centered outcomes to examining patientcentered outcomes resulting directly from care provided by NPs. They were able to demonstrate how patients cared for by NPs benefited in their ability to function and engage in their lives in meaningful ways.
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Collectively, these researchers are shifting our approach to evaluation of NPs’ value-added benefit for patients. This work, however, remains preliminary and the theoretical underpinnings are not evident. Taking a more holistic theoretical perspective could promote understanding of patient-centered outcomes resulting from an emphasis on health promotion and self-care management. It could also help in documenting the result of the time spent with patients in activities such as active listening, counseling, education, and presence. To begin a more holistic examination of NP practice, we explore the use of two theories and relate them to NPs practice.
Theories related to NP practice The use of theory to guide NP practice is not new. Researchers have advocated for a unique theory of nurse practitionering to identify how NPs provide care (Nicoteri & Andrews, 2003). Shuler and Davis’ (1993) Nurse Practitioner Practice Model, based on General Systems Theory, identified the process of care provided by NPs (Shuler & Huebscher, 1998). Other researchers have included concepts useful for conceptualizing, and ultimately evaluating NPs practice (Bernick, 2004; Guthrie, Billings, Martyn, Oakley, & Walker, 2001; McFarland & Eipperle, 2008; Thrasher, 2002). For example, Thrasher (2002) advocated for NPs to use Orem’s self-care model to guide their practice. Bernick (2004) suggested that Watson’s Caring-Healing Model was beneficial for use by NPs caring for older adults. McFarland and Eipperle (2008) suggested culture care theory to assist NPs in primary care settings. Other theories such as cognitive theory (Guthrie et al., 2001) and common sense model of illness (Fowler, Kirschner, Van Kuiken, & Baas, 2007) have also been suggested. Each of these theories provides a way of organizing care and could also be used to suggest approaches to evaluating patient-centered outcomes of NP care. Building on this work, we present two mid-range theories used in nursing that we theorize can also be applied to NP care: Kolcaba’s (2003) Comfort Theory and Antonovsky’s (1985) Stress-Health-Coping Theory. We discuss each below, highlighting their applicability to NP practice.
Comfort Theory Kolcaba (1992) proposed comfort as a holistic state encompassing the simultaneous, interrelated aspects of positive human experience. According to Kolcaba, comfort is not simply the absence of pain or distress; it is a positive subjective feeling reflecting a sense of holistic well-being (Kolcaba, 2003). Kolcaba created a taxonomic matrix of comfort that includes four contexts in which comfort oc-
curs: physical, psychospiritual, sociocultural, and environmental. The matrix also includes three types of comfort: relief, ease, and transcendence. Relief is gained when specific needs, such as pain management, are addressed. Ease, a sense of calm, could be addressed when a patient gains a sense of understanding of his/her pain and its management. Transcendence, rising above the problem, enables the patient to feel in control and able to manage the problem (pain). To understand patient comfort, Kolcaba states that holistic measures are required (Kolcaba, 1992). To that end, she developed a questionnaire to survey the three types of patient comfort in the identified contexts, as well as a family/patient comfort care plan (Kolcaba, 2003). Others have refined Kolcaba’s questionnaire for use in perioperative care, hospice, and radiation therapy (Kolcaba, 2003). Using instruments such as these, the provider is able to see the person as a whole and determine where she or he is on the comfort scale. The premise is that enhancing comfort promotes health-seeking behaviors, and patients feel strengthened and are motivated to engage more fully in their therapeutic regimes (Kolcaba, 2003). Patients expect and hope to have their complex comfort needs addressed (Kolcaba & Steiner, 2000) by those providing their care. Because patients who experience comfort engage in health-seeking behaviors, they are satisfied with their care, and have improved outcomes (Kolcaba, 2003). NPs provide care for people of all ages, many of whom have multiple, complex health needs that are not just physical, but are also psychospiritual, sociocultural, and environmental (Carron & Cumbie, 2011). People do not bring unidimensional problems to their encounters with NPs because they are embedded in a world of interrelationships that affects their well-being, and influence their ability to manage their health needs on their own. They need and want support and comfort beyond having their physical needs met (Carron & Cumbie, 2011). Because of this, measuring comfort could provide a window on a patient-centered outcome of NP care.
Sense of coherence From a different, yet complementary perspective, writers using the work of theorist Antonovsky (1985), and building on Stress-Health-Coping Theory, take up his notion of “sense of coherence” to provide understanding of how people act in response to the challenges of living with chronic disease (Evangelista, Kagawa-Singer, & Dracup, 2001; Kattainen, Merilanen, & Sintonen, 2006; Motzer & Stewart, 1996; Nahlen and Saboonchi, 2010). Antonovsky (1985) defines sense of coherence as a pervasive and enduring feeling that people have when they 655
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understand events taking place in their worlds as comprehensible, predictable, and manageable. The components of sense of coherence include understanding of one’s situation; feeling that it is manageable; and finding meaning in life’s experiences, including living with chronic illness. A sense of coherence is likely to have an important impact on care needs of patients with complex health challenges. Researchers have demonstrated that patients’ ability to manage their health conditions is strongly correlated to how they understand and perceive the conditions (Evangelista et al., 2001). Nahlen and Saboonchi (2010) used sense of coherence to understand how patients live with chronic disease, and found that a high sense of coherence was associated with acceptance of the condition, and that a low sense of coherence was associated with denial, venting, and self-blame. Gallagher, Donoghue, Chenoweth, and Stein-Parbury (2008) documented that patients with a low sense of coherence are at risk of poor self-care management of their illnesses, which is further associated with perceived quality of life (Kattainen et al., 2006; Motzer & Stewart, 1996). Buetow, GoodyearSmith, and Coster (2001) showed that personal qualities, such as coping ability and the presence or absence of social support contributes to people’s perceptions of their health and wellness. According to sense of coherence theory, those with high sense of coherence have both resources to draw upon and a belief that they can cope with the situations in which they find themselves, for example, managing chronic pain (Antonovsky, 1993). As a result, sense of coherence can enhance NPs’ holistic lens when caring for patients with complex health needs. By assessing and promoting a sense of coherence, NPs create the conditions for patients to assume an active role in their own care. As patients become more active in successfully managing their health conditions (e.g., controlling their pain), their sense of coherence increases, which may translate into further health-seeking behaviors (e.g., beginning an exercise program). Assessment of sense of coherence can be an outcome measure to help us understand the NPs role related to patients’ engagement with self-care behaviors, their understanding of their health conditions, and their sense of being able to manage life’s challenges. Taken together, these two theories can create a comprehensive assessment of NPs practice that illuminates the value added when care is provided from a nursing standpoint. Each is appropriate for different uses. Although there may always be a need to demonstrate the safety and cost effectiveness, the value of the holistic NPs approach to care of patients within the contexts of their complex lives is a significant indicator of NP practice. 656
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Assessment measures In assessing NP practice, instruments for measuring holistic care are necessary. Such instruments have been developed and validated for both comfort and sense of coherence. To assess comfort, Kolcaba (1992) developed the General Comfort Questionnaire, a 48-item Likert scale on which a higher score indicates a higher level of comfort. In its first use with 206 hospital and community-dwelling adults, Chronbach’s alpha was calculated at .88, indicating good reliability. Face validity was established through its representation of the attributes of comfort as described in the theory (Kolcaba, 1992, 1994, 2001). Other researchers developed a shorten version of the instrument because the original length was a barrier for some individuals (Kolcaba, Schirm, & Steiner, 2006). The resultant 28-item scale was used in a sample of 60 participants and had reported Chronbach’s alpha scores of .86, .83, and .82 at three different points in data collection (Kolcaba et al., 2006). Several other measures of comfort derived from Kolcaba’s theory have been developed, and these include a visual analog scale for both adults and children (Kolcaba, 2003). To assess sense of coherence, the Sense of Coherence Scale has been used for over two decades in at least 32 countries and in over 33 languages (Eriksson & Lindstrom, 2005). Originally developed by Antonovsky and reported in 1985, the first Sense of Coherence Scale had 29 items presented in a Likert scale. Later, Antonovsky shortened the original Sense of Coherence Scale to 13 items. In 1993, Antonovsky presented a report of the use over a 5-year period of both scales confirming their reliability and validity. At that time (1993), the 29-item scale had been completed by over 10,000 individuals and the 13-item scale has been completed by over 4000 persons. Antonvsky (1993) reported an average Chronbach’s alpha score of .91 and .82 for the longer and shorter versions, respectively. He cautioned that the instrument was developed to measure sense of coherence as an indivisible outcome rather than a discrete measure of components, thus it is difficult to assess content validity accurately. Ericson and Lindstrom (2005) noted that the instrument has been used extensively since 1993. Others report that the Sense of Coherence-13 is equal to the longer version (Kattainen et al., 2006), thus making it appropriate for use among people with complex health needs. We are unaware of any assessment of NP practice that has made use comfort or sense of coherence theories. In spite of this, we argue that using theories, such as these, to explicate patient-centered outcomes, we can better understand the “value added” holistic quality of NP practice, thereby adding to the growing list of NPs sensitive outcomes. Therefore, we plan to use these two mid-level theories in a study evaluating the integration of
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NPs into the province of British Columbia. Our intent is to measure patients’ sense of coherence using the Sense of Coherence-13 scale and the General Comfort Questionnaire to determine if patients cared for by NPs have a greater sense of coherence and comfort.
Conclusions and implications for nursing The theories we have discussed, sense of coherence and comfort, have several implications for evaluation of NP practice. In this article, we have situated NP practice in the realm of theory-informed nursing care. All too often, theories are not overtly reflected in discussions of NP practice and outcomes. Yet theories of and for NP practice are gaining recognition for their importance in evaluation. NP practice is, and should be, a holistic endeavor in the same way as any practice of professional nursing. Use of mid-level theories can provide patient-centered outcomes that are sensitive to NP practice, potentially altering the dominance of provider-centered discourses around evaluation. Such patient-centered outcomes allow for consideration of the complex lives of patients, shift the focus away from providers, begin to demonstrate the value-added benefit of patient care provided by NPs within a holistic nursing framework, and highlight the nursing in NP practice.
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Articulating new outcomes of nurse practitioner practice Esther Sangster-Gormley, RN/NP, PhD (Assistant Professor), Noreen Frisch, RN, PhD (Professor and Director), & Rita Schreiber, RN, DNS (Professor and NP Program Coordinator) School of Nursing, University of Victoria, Victoria, British Columbia, Canada
Keywords Health care; mid-range theory; nurse practitioners; outcomes; primary care. Correspondence Esther Sangster-Gormley, RN/NP, PhD, School of Nursing, University of Victoria, 3800 Finnerty Road, Victoria, British Columbia, Canada V8P 5C2. Tel: 250-721-7962; Fax: 250-721-6231; E-mail: [email protected] Received: September 2011; accepted: January 2012 doi: 10.1002/2327-6924.12040
Abstract Purpose: The purpose of this article is to describe how two mid-range theories, Kolkaba’s Comfort Theory and Antonovsky’s Sense of Coherence can be used to illuminate the holistic nature of nurse practitioner (NP) practice. Data Sources: Original research and theoretical papers related to both theories described. Conclusions: The NP role has been in existence for more than 40 years and can be found in healthcare systems in more than 60 countries around the world. Increasingly, NPs are assuming responsibility for providing primary health care to people with complex care needs. Although researchers have consistently demonstrated the NPs provide safe, effective care, and patients are satisfied with that care, theories demonstrating the holistic nature of NP practice are less evident. Implications for Practice: Comfort Theory and Sense of Coherence can be used to demonstrate how the holistic nature of NP care results in patientcentered outcomes.
Although the nurse practitioner (NP) role is the most researched role of all of the health professions (DiCenso, 2008) and, according to Lewis (2008), likely the best studied occupational group in human history, the nursing aspects of NP practice are just coming into focus as outcomes for evaluation. Historically, NP outcomes have been focused on quantifying the impact of practice by demonstrating patient satisfaction (DiCenso, 2008), effectiveness, and efficiency (Horrocks, Anderson, & Salisbury, 2002). Although these outcomes are important, they are provider driven. In the current healthcare climate, it is essential to move toward patient-centered outcomes to demonstrate the less easily quantified “value-added” benefit that NPs’ nursing background adds to care (World Health Organization [WHO], 2008). As nurses, NPs are thought to bring a holistic perspective to their care, often referring to their care as patient centered. In 2008, the WHO drew global attention to the need to have healthcare systems delivering care for people in such a way that care providers have understandings of individuals, their life contexts, and personal meanings. It would seem that NPs make every attempt to do just this. Thus, we embarked on a review of the history of the NP role and theoretical frameworks that help us not only
understand how patient-centered care is enacted by NPs, but also to provide guidance on ways that such care could be operationalized and measured. The purpose of this article is twofold. First, to contribute to the discussions of the use of theory related to the nature of NP practice (Carron & Cumbie, 2011; Nicoteri & Andrews, 2003; Shuler & Davis, 1993; Shuler & Huebscher, 1998) and second, to propose that mid-level theories can guide selection of evaluative tools to operationalize and measure the outcomes of patient-centered NP care. We present two mid-level theories that could lead to measures of NP sensitive outcomes, or patient-centered outcomes that result directly from care provided by NPs. We begin by acknowledging the historical foundations of NP care and the current state of evaluation of NP practice. Finally, we suggest concepts taken from two mid-range theories congruent with NP practice that can be used to measure outcomes of NP care. Such theoryderived outcome measures would augment our current cadre of NP outcome measures and illuminate a nursing perspective of health that includes caring for people as whole beings within the contexts and meanings of their lives. We present two theories, Kolcaba’s (1992, 1994, 2003) Comfort Theory and Antonovsky’s (1985, 1993) Stress-Health-Coping Theory as examples of
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mid-range theories containing concepts and outcomes that could be useful in exploring care provided by NPs.
Historical background Nightingale advised, above all, that nurses collaborate to promote health, value health for all, and influence health through nurturing the “vital force,” the living impulse for health (Beck, 2010). In her writings, she also emphasized the importance of looking beyond the individual as the focus of care to include population health. Other early nurse leaders, such as Lillian Wald and Lavinia Dock, also recognized the importance of nurses caring for individuals as well as families and communities (Keeling & Bigbee, 2005). We believe that the establishment of the Frontier Nursing Service in Kentucky and nurse anesthetists during the American Civil War (Faut-Callahan & Kremer, 2000; Schreiber & MacDonald, 2003), and the creation of outpost nursing in the Canadian North (Kaasalainen et al., 2010) set the stage for the evolution of the NP role. As the NP role has evolved, accountability for healthcare funding has come to the fore, and researchers have sought ways to demonstrate the value-added benefit of NP practice. Although researchers have documented outcomes of NP care, only some have begun to examine NP practice through the lenses of nursing and other theories.
Evaluation of NP practice NPs provide holistic care to patients, their families, and communities in more than 60 countries around the world (Delamaire & Lafortune, 2010; Schober & Affara, 2006) and they focus on health promotion and maintain the underlying value of health for all people. At the outset of implementing the NP role, expected outcomes were cost reduction, assurance of high-quality care, and increased access to healthcare services (Sangster-Gormley, 2010). Although there has been a call for NPs and researchers to develop an evaluative agenda to document the contributions NPs make to patient care (Edmunds, 2007; Kleinpell, 2009; Spross & Lawson, 2009), much of the research to date has focused on provider-driven quantifiable outcomes. Researchers have consistently found, over the past 35 years, that NPs provide safe, cost-effective care (Horrocks et al., 2002; Laurant et al., 2009) that is comparable to the care provided by physicians, and that patients are satisfied with the care provided by NPs (DiCenso et al., 2003). Not only are patients satisfied, they trust NPs (Benkert, Hollie, Nordstrom, Wickson, & Bins-Emerick, 2009), feel that NPs take their problems seriously and discuss their concerns (Thrasher & Purc-Stephenson, 2008), and be654
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lieve that NPs are approachable and have expert communication skills (Beal & Quinn, 2002). NPs also have longer consultation times with patients, ensuring that patients receive more information (Kinnersley et al., 2000) and counseling (Sidani et al., 2006). NPs are reported to emphasize health promotion, and involve patients in self-care management of their chronic and acute conditions (Charlton, Dearing, Berry, & Johnson, 2008; Russell et al., 2009). Furthermore, NPs accurately order and interpret diagnostic tests, prescribe medications appropriately, and use clinical practice guidelines (SangsterGormley, 2010). These researchers have demonstrated the nature of NP practice that is grounded in nursing tenets dating back to Nightingale (Keeling & Bigbee, 2005). What is less apparent is how evaluation of this approach to care can be translated in a way that healthcare decision makers can understand and appreciate. In the healthcare arena, the value-added benefit of NPs care too often remains obscure.
NP practice outcomes Few authors have begun to explore patient-centered nursing and NP outcomes of care. For example, Clark (2003) conducted a Delphi study of nursing experts regarding expected outcomes of nursing care across the continuum of care. She identified five patient outcomes of nursing care: (a) appropriate self-care behaviors, (b) symptom management, (c) health promotion behaviors, (d) perceptions of being well cared for, and (e) healthrelated quality of life. Doran (2011) reviewed the state of the science of nursing outcomes that can be related to nursing interventions, and for which nursing is accountable. These include: (a) clinical, including symptom control and management; (b) functional, including physical, psychosocial, and self-care management; (c) safety, including adverse events or complications, for example, pressure ulcers, infections; and (d) perceptual, including satisfaction with nursing care. Looking specifically at NPs, Sidani and colleagues (2007) compared levels of physical and social functioning of patients cared for by acute care NPs to that other providers. Sidani and her team (2007) reported that those who received care from NPs had higher levels of functioning than did their counterparts who received care from other providers. Through their work, Sidani et al. (2006) moved NP evaluation to a level that looks beyond provider-centered outcomes to examining patientcentered outcomes resulting directly from care provided by NPs. They were able to demonstrate how patients cared for by NPs benefited in their ability to function and engage in their lives in meaningful ways.
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Collectively, these researchers are shifting our approach to evaluation of NPs’ value-added benefit for patients. This work, however, remains preliminary and the theoretical underpinnings are not evident. Taking a more holistic theoretical perspective could promote understanding of patient-centered outcomes resulting from an emphasis on health promotion and self-care management. It could also help in documenting the result of the time spent with patients in activities such as active listening, counseling, education, and presence. To begin a more holistic examination of NP practice, we explore the use of two theories and relate them to NPs practice.
Theories related to NP practice The use of theory to guide NP practice is not new. Researchers have advocated for a unique theory of nurse practitionering to identify how NPs provide care (Nicoteri & Andrews, 2003). Shuler and Davis’ (1993) Nurse Practitioner Practice Model, based on General Systems Theory, identified the process of care provided by NPs (Shuler & Huebscher, 1998). Other researchers have included concepts useful for conceptualizing, and ultimately evaluating NPs practice (Bernick, 2004; Guthrie, Billings, Martyn, Oakley, & Walker, 2001; McFarland & Eipperle, 2008; Thrasher, 2002). For example, Thrasher (2002) advocated for NPs to use Orem’s self-care model to guide their practice. Bernick (2004) suggested that Watson’s Caring-Healing Model was beneficial for use by NPs caring for older adults. McFarland and Eipperle (2008) suggested culture care theory to assist NPs in primary care settings. Other theories such as cognitive theory (Guthrie et al., 2001) and common sense model of illness (Fowler, Kirschner, Van Kuiken, & Baas, 2007) have also been suggested. Each of these theories provides a way of organizing care and could also be used to suggest approaches to evaluating patient-centered outcomes of NP care. Building on this work, we present two mid-range theories used in nursing that we theorize can also be applied to NP care: Kolcaba’s (2003) Comfort Theory and Antonovsky’s (1985) Stress-Health-Coping Theory. We discuss each below, highlighting their applicability to NP practice.
Comfort Theory Kolcaba (1992) proposed comfort as a holistic state encompassing the simultaneous, interrelated aspects of positive human experience. According to Kolcaba, comfort is not simply the absence of pain or distress; it is a positive subjective feeling reflecting a sense of holistic well-being (Kolcaba, 2003). Kolcaba created a taxonomic matrix of comfort that includes four contexts in which comfort oc-
curs: physical, psychospiritual, sociocultural, and environmental. The matrix also includes three types of comfort: relief, ease, and transcendence. Relief is gained when specific needs, such as pain management, are addressed. Ease, a sense of calm, could be addressed when a patient gains a sense of understanding of his/her pain and its management. Transcendence, rising above the problem, enables the patient to feel in control and able to manage the problem (pain). To understand patient comfort, Kolcaba states that holistic measures are required (Kolcaba, 1992). To that end, she developed a questionnaire to survey the three types of patient comfort in the identified contexts, as well as a family/patient comfort care plan (Kolcaba, 2003). Others have refined Kolcaba’s questionnaire for use in perioperative care, hospice, and radiation therapy (Kolcaba, 2003). Using instruments such as these, the provider is able to see the person as a whole and determine where she or he is on the comfort scale. The premise is that enhancing comfort promotes health-seeking behaviors, and patients feel strengthened and are motivated to engage more fully in their therapeutic regimes (Kolcaba, 2003). Patients expect and hope to have their complex comfort needs addressed (Kolcaba & Steiner, 2000) by those providing their care. Because patients who experience comfort engage in health-seeking behaviors, they are satisfied with their care, and have improved outcomes (Kolcaba, 2003). NPs provide care for people of all ages, many of whom have multiple, complex health needs that are not just physical, but are also psychospiritual, sociocultural, and environmental (Carron & Cumbie, 2011). People do not bring unidimensional problems to their encounters with NPs because they are embedded in a world of interrelationships that affects their well-being, and influence their ability to manage their health needs on their own. They need and want support and comfort beyond having their physical needs met (Carron & Cumbie, 2011). Because of this, measuring comfort could provide a window on a patient-centered outcome of NP care.
Sense of coherence From a different, yet complementary perspective, writers using the work of theorist Antonovsky (1985), and building on Stress-Health-Coping Theory, take up his notion of “sense of coherence” to provide understanding of how people act in response to the challenges of living with chronic disease (Evangelista, Kagawa-Singer, & Dracup, 2001; Kattainen, Merilanen, & Sintonen, 2006; Motzer & Stewart, 1996; Nahlen and Saboonchi, 2010). Antonovsky (1985) defines sense of coherence as a pervasive and enduring feeling that people have when they 655
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understand events taking place in their worlds as comprehensible, predictable, and manageable. The components of sense of coherence include understanding of one’s situation; feeling that it is manageable; and finding meaning in life’s experiences, including living with chronic illness. A sense of coherence is likely to have an important impact on care needs of patients with complex health challenges. Researchers have demonstrated that patients’ ability to manage their health conditions is strongly correlated to how they understand and perceive the conditions (Evangelista et al., 2001). Nahlen and Saboonchi (2010) used sense of coherence to understand how patients live with chronic disease, and found that a high sense of coherence was associated with acceptance of the condition, and that a low sense of coherence was associated with denial, venting, and self-blame. Gallagher, Donoghue, Chenoweth, and Stein-Parbury (2008) documented that patients with a low sense of coherence are at risk of poor self-care management of their illnesses, which is further associated with perceived quality of life (Kattainen et al., 2006; Motzer & Stewart, 1996). Buetow, GoodyearSmith, and Coster (2001) showed that personal qualities, such as coping ability and the presence or absence of social support contributes to people’s perceptions of their health and wellness. According to sense of coherence theory, those with high sense of coherence have both resources to draw upon and a belief that they can cope with the situations in which they find themselves, for example, managing chronic pain (Antonovsky, 1993). As a result, sense of coherence can enhance NPs’ holistic lens when caring for patients with complex health needs. By assessing and promoting a sense of coherence, NPs create the conditions for patients to assume an active role in their own care. As patients become more active in successfully managing their health conditions (e.g., controlling their pain), their sense of coherence increases, which may translate into further health-seeking behaviors (e.g., beginning an exercise program). Assessment of sense of coherence can be an outcome measure to help us understand the NPs role related to patients’ engagement with self-care behaviors, their understanding of their health conditions, and their sense of being able to manage life’s challenges. Taken together, these two theories can create a comprehensive assessment of NPs practice that illuminates the value added when care is provided from a nursing standpoint. Each is appropriate for different uses. Although there may always be a need to demonstrate the safety and cost effectiveness, the value of the holistic NPs approach to care of patients within the contexts of their complex lives is a significant indicator of NP practice. 656
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Assessment measures In assessing NP practice, instruments for measuring holistic care are necessary. Such instruments have been developed and validated for both comfort and sense of coherence. To assess comfort, Kolcaba (1992) developed the General Comfort Questionnaire, a 48-item Likert scale on which a higher score indicates a higher level of comfort. In its first use with 206 hospital and community-dwelling adults, Chronbach’s alpha was calculated at .88, indicating good reliability. Face validity was established through its representation of the attributes of comfort as described in the theory (Kolcaba, 1992, 1994, 2001). Other researchers developed a shorten version of the instrument because the original length was a barrier for some individuals (Kolcaba, Schirm, & Steiner, 2006). The resultant 28-item scale was used in a sample of 60 participants and had reported Chronbach’s alpha scores of .86, .83, and .82 at three different points in data collection (Kolcaba et al., 2006). Several other measures of comfort derived from Kolcaba’s theory have been developed, and these include a visual analog scale for both adults and children (Kolcaba, 2003). To assess sense of coherence, the Sense of Coherence Scale has been used for over two decades in at least 32 countries and in over 33 languages (Eriksson & Lindstrom, 2005). Originally developed by Antonovsky and reported in 1985, the first Sense of Coherence Scale had 29 items presented in a Likert scale. Later, Antonovsky shortened the original Sense of Coherence Scale to 13 items. In 1993, Antonovsky presented a report of the use over a 5-year period of both scales confirming their reliability and validity. At that time (1993), the 29-item scale had been completed by over 10,000 individuals and the 13-item scale has been completed by over 4000 persons. Antonvsky (1993) reported an average Chronbach’s alpha score of .91 and .82 for the longer and shorter versions, respectively. He cautioned that the instrument was developed to measure sense of coherence as an indivisible outcome rather than a discrete measure of components, thus it is difficult to assess content validity accurately. Ericson and Lindstrom (2005) noted that the instrument has been used extensively since 1993. Others report that the Sense of Coherence-13 is equal to the longer version (Kattainen et al., 2006), thus making it appropriate for use among people with complex health needs. We are unaware of any assessment of NP practice that has made use comfort or sense of coherence theories. In spite of this, we argue that using theories, such as these, to explicate patient-centered outcomes, we can better understand the “value added” holistic quality of NP practice, thereby adding to the growing list of NPs sensitive outcomes. Therefore, we plan to use these two mid-level theories in a study evaluating the integration of
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NPs into the province of British Columbia. Our intent is to measure patients’ sense of coherence using the Sense of Coherence-13 scale and the General Comfort Questionnaire to determine if patients cared for by NPs have a greater sense of coherence and comfort.
Conclusions and implications for nursing The theories we have discussed, sense of coherence and comfort, have several implications for evaluation of NP practice. In this article, we have situated NP practice in the realm of theory-informed nursing care. All too often, theories are not overtly reflected in discussions of NP practice and outcomes. Yet theories of and for NP practice are gaining recognition for their importance in evaluation. NP practice is, and should be, a holistic endeavor in the same way as any practice of professional nursing. Use of mid-level theories can provide patient-centered outcomes that are sensitive to NP practice, potentially altering the dominance of provider-centered discourses around evaluation. Such patient-centered outcomes allow for consideration of the complex lives of patients, shift the focus away from providers, begin to demonstrate the value-added benefit of patient care provided by NPs within a holistic nursing framework, and highlight the nursing in NP practice.
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