1.Thought Question

:

The thought questions were developed related to the instructional materials in the

course


modules

. They are meant to focus your attention on the essential ideas presented in the readings and to engage in self-dialogue regarding your perspectives on the question as nursing theorists and scholars. Below is the thought question for this module:

• Should there be a single paradigm, co-existence of complementary paradigms or the creation of an integrated paradigm to advance nursing knowledge to guide research and practice?

2.

Critique knowledge that arises from four definitions of nursing: Nursing as a Health Science, Practice Discipline, Caring Discipline, and Health-Oriented Discipline

3. Module Learning Objectives:

• Explain what theory does in relationship to nursing knowledge development as a discipline and science.
• Discuss theoretical thinking in terms of questions asked and answers.
• Apply Carper’s Way of knowing in clinical practice.
• Discuss nursing theories focused on human existence and caring.
• Explain how theories relate to health and planned change which guides nursing practice.
• Discuss the deliberative nursing process and AACN Synergy model guide practice.

4. Thought Questions

:

The thought questions were developed related to the instructional materials in the

course


modules

. They are meant to focus your attention on the essential ideas presented in the readings and to engage in self-dialogue regarding your perspectives on the question as nursing theorists and scholars. Below are the thought questions for this module:

• How have historical trends in the philosophy of science influenced the development of nursing knowledge?
• How does the role of the DNP-prepared nurse advance the development of nursing science?

5. Thought Questions

:

The thought questions were developed related to the instructional materials in the

course


modules

. They are meant to focus your attention on the essential ideas presented in the readings and to engage in self-dialogue regarding your perspectives on the question as nursing theorists and scholars. Below are the thought questions for this module:

• How can the care of the Mendez family be viewed from the lens of complex adaptive systems?
• What are the implications for theories and methods in ethics in the care of the Mendez family?
• Does change in your organization occur according to the theory of change? What are the implications for changes in the organization related to nursing?
• According to Lewin?s Theory, what are the driving and opposing forces to initiating a palliative care or wound care service at an in-patient facility?

6. 2 different replies needed for the

discussion

below

Cuban Communication Patterns

For a healthcare provider, it is essential to understand and apply appropriate communication patterns with the client. Several elements define typical communication patterns for Cubans. First, Cubans show awareness of good interpersonal relations through courtesy and respect (Brown, 2021). Based on this, I will ensure I focus on relationships rather than rules and positions while maintaining a positive attitude. Specifically, notable patterns I will be aware of during our engagement include maintaining eye contact when talking to her and shaking the patient?s hand when introducing myself. Furthermore, it is essential to accept hugs from Mrs. Hernandez, particularly after finishing my clinical intervention. Hugging is a specific way of showing appreciation among Cubans, hence the need to oblige (Brown, 2021). Conclusively, understand the patterns of communication will be vital in managing cultural barriers during the interaction and ensure the appropriate delivery of quality care to Mrs. Hernandez.

Assisting Mrs. Hernandez Develop a 1500-calories Diet

Primarily, I will assist Mrs. Hernandez in developing a 1500 calories diet and regular exercise plan by equipping her with the requisite skills and knowledge that she can implement on her own. For instance, I will inform the patient that the 1500-calories diet must entail consistently consuming selected foods, such as yams, yucca, grains, vegetables, plantains, and boniato. The selection of these foods follows a cultural understanding of Cubans (Wirtz, 2014). Additionally, it is necessary to recommend to Mrs. Hernandez a moderate aerobic exercise of about two hours weekly. Furthermore, based on her age, the patient can perform brisk walking and jogging. The exercise will run for 30 minutes daily. More importantly, I will motivate the patient to regularly exercise to generate enough desire to conduct it on her own volition. In essence, regular exercising and diet will improve the patient?s balance, strength, and flexibility.

Botanica Visit for Drugs

I will not encourage Mrs. Hernandez to go to the botanica for drugs. Although I recognize that the patient?s culture significantly influences her desire, instead, I will discourage her decision to go for buying herbs. Therefore, my approach would involve educating Mrs. Hernandez about modern medicines, particularly their benefits compared to traditional medicines (Purnell & Fenkl, 2018). First, I will emphasize the patient?s desire to practice her culture and clearly explain my admiration for it. At the same time, I will explain the critical nature of medications for her health, particularly the need for medications that will guarantee an immediate impact. Secondly, I will reiterate that traditional medications are unregulated and take long period before feeling and achieving the desired results. Conclusively, while educating Mrs. Hernandez about the benefits of modern medicines compared to her preferred herbal drugs, I will employ the Cuban communication patterns, which include maintaining eye contact, listening to her opinion, and maintaining eye contact. It is crucial to convince Mrs. Hernandez to opt for modern medicines.

Cuban Practices

Arguably, the patient?s preference for herbal medicine underscores the impact of culture on the Cuban population. Therefore, common folk practices Cuban families utilize to maintain healthy families include applying medicinal plants, which include powders, oils, incenses, and ointments (Purnell & Fenkl, 2018). In some instances, they use ornaments and animals to treat people. For instance, Cubans commonly use Chaya leaves to control diabetes and keep blood pressure stable. Furthermore, traditional healers are known to have the conviction to tell specific ailment a patient has by simply touching them. This alternative diagnosing provides vital information that traditional healers used to prepare an herbal medicine that would remedy a health problem. In Cuba, special shops exist where people can purchase traditional medicines and, in some instances, government pharmacies and private entrepreneurs stock herbal medicines for people to buy (Wirtz, 2014). Nonetheless, I will educate and convince Mrs. Hernandez to choose modern medicines because they have a better and quicker response, hence being more effective.

7.

2 different replies needed for the

discussion

below

Arab Culture Case Study: Mrs. Nasser and Samia

1) How should the nurse respond to Mrs. Nasser?s request?

The nurse?s initial interaction with Samia and Mrs. Nasser did not portray cultural competence. Mrs. Nasser is now agitated and requesting a prescription from the doctor for her daughter?s infection. Before responding, the nurse must consider both the medical complaints of Samia, the patient, as well as the concerns of her mother, Mrs. Nasser. Mrs. Nasser is extremely agitated and threatening to leave immediately if the provider does not write a prescription for her daughter?s infection. The nurse should respond in a calming manner in an attempt to deescalate the situation prior Mrs. Nasser and Samia leaving against medical advice, prior to even getting the chance to speak to the provider. The nurse should respond by acknowledging Mrs. Nasser?s cultural concerns and assure her that the provider, nor anybody else in the clinic, will perform a vaginal

exam

without her consent. The Arab culture views verbal agreements to be more important than written contracts, so the nurse assuring Mrs. Nasser of this will help calm her down (Kulwicki, 2021). The nurse should apologize for insisting on the vaginal

exam

and approach the remainder of the encounter differently. She should combine expertise with warmth, being mindful of her manner and tone when speaking (Kulwicki, 2021). She should clarify her role, perform a comprehensive

assessment

, and explain alternative tests that could help properly diagnose Samia?s physical complaints (Kulwicki, 2021).

2) Identify culturally congruent strategies that may be most effective in addressing the needs of Mrs. Nasser

Arab culture values modesty, so to ask Samia to get undressed for a vaginal

exam

prior to establishing a relationship and explaining the indication for the

exam

, is not an effective approach. Arab women are often reluctant to seek care due to shyness about disrobing for examination or even fear that the diagnosed illness will bring shame to the family (Kulwicki, 2021). Vaginal exams and related tests are regularly performed for only Arab married women and single, unmarried women are likely to decline because it could compromise a virginal female status (Attum et al., 2021). The patient is 16 years old and of legal age to agree to any STI testing if she wishes, however, Arabs greatly respect their elders and allow family members to oversee care and make decisions on their behalf (Kulwicki, 2021).

The nurse and provider should take a few additional things into consideration: Arab culture has profound respect for science and medicine, seldomly challenging or questioning the authority of physicians (Kulwicki, 2021). While many view medicine as the most respected and prestigious profession, the same cannot be said about the nursing profession (Kulwicki, 2021). Older Arab immigrants do not recognize the higher status of nurses in the US, and are more likely to think of nurses as similar to medical assistants and housekeepers (Kulwicki, 2021). Nurses should take the time to get acquainted and establish a personal relationship with the patient and family before expecting them to share any personal information (Kulwicki, 2021). Regardless of Somia?s culture, the patient is a 16-year-old female who has never had symptoms like this before, indicating she likely has never had a vaginal

exam

. Rather than telling an adolescent girl to get undressed to prepare for a physical examination, she first should have formed a trusting relationship with the patient and then explained what to expect from the visit today, including a vaginal

exam

by a female provider if she were to consent to that. Additionally, Arab culture values cultural sensitivity, so Mrs. Nasser having to explain beliefs of their culture is a clear indication that she can tell the nurse is not culturally competent.

The nurse should notify the provider of the patient and her mother?s concerns and allow the provider to develop an appropriate plan of care for the patient. Due to Arab culture?s high respect for physicians, having a female physician speak with Mrs. Nasser and Samia regarding her vaginal symptoms is likely a better outcome than the nurse or a male physician continuing this conversation (Alsharif, 2019; Kulwicki, 2021). By informing the provider of the situation prior to her entering the room, the provider can address this case differently. Obtaining a thorough history from the patient regarding her complaint could help to come to a diagnosis without even needing to do a vaginal

exam

. Arabs often avoid discussing problems with sexual relationships or concerns, however, the provider should explain that it is necessary to obtain a full history to aid in making an accurate diagnosis and proper treatment of her symptoms (Attum et al., 2021). The provider should ask Mrs. Nasser to step out of the room at some point during the encounter to clarify with Samia questions she may be hesitant to answer in front of her mother, such as sexual activity. The provider could do a urinalysis in the office to determine the extent of the UTI, if present, and then send the urine for a culture and sensitivity, following up with the patient once the culture results. If worried about STIs, the provider could

test

the urine for chlamydia and gonorrhea and obtain blood tests in the office if concerned about HIV, Herpes, or Syphilis. The provider should still offer vaginal

exam

services and explain that it does not imply any shame or specific type of behavior but more for accurate diagnosis and treatment (Attum et al., 2021). If Mrs. Nasser and Samia still decline the vaginal

exam

, their wishes should be respected.

3) How might the nurse ensure that Mrs. Nasser?s concerns are addressed appropriately and that Samia has received the appropriate care?

To ensure Mrs. Nasser?s concerns are addressed appropriately, the nurse should be generous with her time to establish a non-judgmental, trusting relationship with Mrs. Nasser. The nurse should never criticize Arab cultural practices and make accommodations in the plan of care as needed (Cultural Atlas, 2022). Discussing the plan of care with Mrs. Nasser directly will help establish trust as well. Arab patients often allow family members to oversee healthcare decision making (Kulwicki, 2021). Mrs. Nasser may come across as demanding and overly protective to American culture, but it should actually be interpreted as a measure of concern (Kulwicki, 2021).

Arabs are likely to be more expressive of pain with their family and more restrained with health-care providers (Kulwicki, 2021). The nurse should tell Mrs. Nasser to notify the provider if dysuria and other symptoms do not improve within a few days or worsen following treatment initiation. Arab family members may also omit certain symptoms out of shame to their family (Kulwicki, 2021); Gaining trust from the beginning of the encounter will make the patient and family more comfortable and likely to be honest about the patient?s symptoms. Obtaining a history and performing as much of a physical

exam

as Samia and Mrs. Nasser allow are essential to Samia receiving appropriate care. She presents with a high fever and dysuria, which could indicate the infection has become more extensive since onset of symptoms and when she decided to seek medical care. Checking for CVA tenderness is important as well as asking about personal hygiene practices, such as if the patient wipes from front to back or back to front. She should also ask about any vaginal discharge or bumps/lesions present in a nonjudgmental approach. Samia and Mrs. Nasser may stop the provider from asking too many questions, but questions that could best diagnose the problem should be asked. The provider also can collect a urine sample and blood sample to check for possible causes of the infection or presence of a STI. The patient could be started on a broad-spectrum antibiotic and adjusted if needed once the culture results. Asking Samia these questions alone, without Mrs. Nasser in the room, is important to obtain any additional history she may not have told her mother. If, for example, Samia admits to being sexually active and exposed to a STI, such as chlamydia or gonorrhea, the provider can treat the patient accordingly without disclosing the likely pathogen to her mother. This would ensure Samia has received appropriate care. It would also ensure that Mrs. Nasser?s concerns are addressed appropriately because Samia would receive a prescription for her daughter?s infection without the provider performing a vaginal

exam

, unless of

course

Mrs. Nasser changed her mind when speaking to the provider. This case study scenario is an excellent portrayal of how cultural sensitivity and competence could make the difference between a patient getting necessary care and walking out to seek care elsewhere.

References

Alsharif, N. Z., Khanfar, N. M., Brennan, L. F., Chahine, E. B., Al-Ghananeem, A. M., Retallick, J., & Sarhan, N. (2019). Cultural sensitivity and global pharmacy engagement in the Arab world. American Journal of Pharmaceutical Education, 83(4).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC65813…

Attum, B., Hafiz, S., Malik, A., & Shamoon, Z. (2021). Cultural competence in the care of Muslim patients and their families. StatPearls Publishing LLC.

https://www.ncbi.nlm.nih.gov/books/NBK499933/#_NBK…

Kulwicki, A. D. (2021). People of Arab heritage. In L. D. Purnell & E. A. Fenkl (Eds.), Transcultural health care: A population approach: Cultural competence concepts in nursing care (5th ed., pp. 251-276). Springer.

The Cultural Atlas. (2022). Saudi Arabia culture. https://culturalatlas.sbs.com.au/saudi-arabian-culture

(Case of Mrs. Mendez related to Interprofessional Theories)

Read the case of

Mrs. Mendez Case Study.doc

Family Theory Case Study

“Mrs. Mendez”

(Mrs. Maria Mendez is a 72-year-old Hispanic patient with advanced left breast cancer with metastasis to the lungs and bones. She is referred to your home care agency for wound care services. She has seven children: five daughters and two sons (all living in California). Her five daughters live within the Los Angeles area. Her eldest son lives in San Diego and the younger son has been distant from the family and has not had contact with the family for the last 18 months. Mrs. Mendez’s husband died seven years ago of lung cancer. Since that time she has lived with her youngest daughter, Maria.

Initially, Mrs. Mendez discovered the breast lump herself but did not seek medical care for over a year. When Mrs. Mendez was diagnosed, her disease was considered advanced. She refused to have a mastectomy based in part by her cultural belief that the soul resides in the breast and should not be removed. At the urging of her children, she did undergo chemotherapy but recently has experienced increased bone pain and decided to discontinue the treatment regimen. The tumor in the left breast is now approximately the size of an orange with malodorous, purulent drainage. Home care was initiated for wound care and other symptom management services. Under the terms of her managed care/Medicare insurance plan, her care is referred back to her family care practitioner in her local community rather than her oncologist since she is no longer receiving cancer treatment.

Mrs. Mendez’s condition continues to decline and her physician encourages her to seek hospice care. Mrs. Mendez has become very close to the home care nurses who provided the wound care and requests that her care continue with the home care agency rather than a referral to hospice. At this time, changes in her living arrangements are also made. Living with Maria over the last seven years has been very positive, but Maria has three young children and the intensive care of her mother at this stage of the illness is becoming a problem. The family emphasizes that Mrs. Mendez should move in with her eldest daughter, Gloria, who no longer has children living at home. Although her daughters have always been close to their mother and more involved in her care, the eldest son of the family, Jos?, who resides in San Diego, is consulted for all decisions and has been the father figure of the family since Mr. Mendez’s death. Mrs. Mendez’s managed care plan allows for only two RN visits per week and must be reevaluated every three weeks by the case manager. In addition to the symptom management provided by the home care agency, Mrs. Mendez and her daughters use many alternative therapies which includes “cat’s claw”, herbs, and visits by a healer. Mrs. Mendez is religious and uses prayer to help cope with her illness. Her middle daughter, Christina, is devout in her religion and is in absolute denial that her mother will die. Christina comes nightly and holds a prayer vigil with her mother and also brings herbs and remedies that “will cure the disease”. Mrs. Mendez becomes increasingly withdrawn as conflicts arise among her children. Gloria and Christina are at odds because Gloria is most accepting of her mother’s impending death. Gloria was also the primary caregiver during her father’s illness with lung cancer.

After three weeks of care by the home care agency (HCA), Gloria calls requesting that a nurse come as soon as possible because her mother?s pain is worse. On physical

assessment

, the nurse notes that the breast tumor remains dry, however the tumor mass has increased and the breast is inflamed. The pain is described by Mrs. Mendez as an intense pressure pain at the site of the tumor in the base of the breast. She also describes a sharp stabbing pain in the left upper quadrant of the breast. In addition, Mrs. Mendez complains of intense pain in her mid-back which has made it very difficult to lay in bed and she has been unable to sleep for the last week. She has been taking one to two Vicodin every four hours PRN although yesterday Gloria reports that out of desperation the Vicodin was given approximately every two hours until Mrs. Mendez became extremely nauseated. The nurse recalls that morphine was ordered for the patient a few weeks ago in anticipation of increased pain not controlled with the Vicodin. Upon questioning, the daughter states that they have not used the morphine as they were “Saving it for the end.” Gloria also reports that the family is trying to minimize the use of the medicine since their mother is extremely constipated. Gloria continues to relate that the reason her mother is constipated is because Mrs. Mendez has not been able to continue her herbal remedies due to nausea. Mrs. Mendez appears very stoic with minimal expression of pain. Her only complaint is that she no longer is able to have her grandchildren over to visit due to her declining condition.

Mrs. Mendez is initiated on a regimen of long-acting morphine, 60 mg at bedtime with 15 mg morphine immediate release (MSIR) for rescue dose. Over the next week, the long-acting morphine is increased to 120 mg BID supplemented with Imipramine 50 mg BID and Ibuprofen 800 mg TID. Christina has now moved into Gloria’s home and continues her evening prayer vigils. Jos? calls several times a day to dictate his wishes regarding his mother’s care but has not been able to visit often from San Diego as he is in risk of losing his job. Gloria seems increasingly burdened with her mother’s care and her siblings’ involvement. Gloria follows the home care nurse to the car weeping because of the stress.

Approximately one week later, the nurse receives a call from Gloria reporting that her mother has seemed to decline rapidly over the weekend. Mrs. Mendez awoke during the night with difficulty breathing and has been terrified of the possibility of suffocation. On

exam

, the nurse notes that Mrs. Mendez has developed extreme shortness of breath. She is also increasingly fatigued and the combination of exhaustion, dyspnea, and general decline has resulted in minimal intake of foods or fluids. Jos? called this morning with strict orders that his sisters continue to feed their mother at all costs. He hopes to be able to come up from San Diego the following weekend to visit. Mrs. Mendez relates to the nurse that she knows she is dying and does not want to continue being a burden to her family.

Mrs. Mendez’s physical condition has greatly improved due to aggressive symptom management by the HCA. The morphine dose has increased to 240 mg BID supplemented with 40 mg of MSIR approximately every two hours for dyspnea. With her breathing improved, she as been able to take sips of water and occasional amounts of other liquids. Mrs. Mendez’s condition, however, continues to decline and the home care nurse anticipates that she will die within the next two weeks. The HCA schedules a meeting with the primary nurse and social worker to discuss the growing tension in the family. Four of the daughters are now present in the home taking shifts to be at Mrs. Mendez’s bedside at all times. To make the family situation more difficult, Jose has learned that the young brother Pablo is living in Los Angeles and asks Pablo that he please visit his mother before she dies. Christina continues her prayer vigils and has asked members of her church to visit daily to hold prayer meetings with her mother. Mrs. Mendez tells the nurse that she cannot discuss her impending death with her family because they do not want to talk about it or hear that she is dying. At this point, Mrs. Mendez is very withdrawn and has little interaction with her family. Mrs. Mendez has now developed a pressure ulcer on her buttocks and requires a Foley catheter due to incontinence, which has intensified the physical care demands of her care.

The HCA receives a call on Saturday evening requesting

assistance

with Mrs. Mendez as her condition is declining rapidly. The younger son, Pablo, arrived two days ago and has had a very tearful reunion with his mother and his sister, Gloria. The social worker and the nurse were very successful in the family meeting with facilitating communication among the children and establishing common goals for Mrs. Mendez’s comfort. All of the children with the exception of Christina, seem accepting of the impending death. Gloria’s husband, Michael, has been quite supportive of his mother-in-law’s care throughout her illness, but has strong feelings against death occurring within his home.

The priest is called to give Mrs. Mendez communion and the Anointing of the Sick. The extended family is at Mrs. Mendez’s bedside, except for Christina who is in the kitchen crying.

Source: HOPE: Home care Outreach for Palliative care Education Project. (1998). Funded by the National Cancer

Institute. B. R. Ferrell, PhD, FAAN, Principal Investigator.