Preface

Nursing plays a vital role in healthcare systems worldwide. It encompasses not only research and education but also compassionate care for patients and communities, promotion of health, and advocacy for overall well-being. Today, understanding and meeting patient concerns is as important as performing therapeutic interventions in the evidence-based practice of healthcare delivery.

New Research in Nursing – Education and Practice provides an overview of current nursing experience in novel clinical interventions. The authors are a group of international experts with expertise in the various clinical aspects upon which the practice components of nursing care are based. We hope that many of the therapeutic advances described in this book will allow nurses and other healthcare professionals to use best practices to improve healthcare outcomes.

This book contains a diverse range of research studies that address critical areas within nursing. These studies delve into various dimensions of nursing education and interdisciplinary collaboration. The authors have examined their findings, employing different methodologies and best practices, and I wish to express my sincere thanks to all who have contributed to this book. Each chapter focuses on specific nursing interventions and novel strategies investigating the impact of technological advancements on nursing practice and nursing education.

In Chapter 1, R.N. Hiroko Shimizu presents an evaluation of nurses' attitudes toward elderly care. In Chapter 2, Geeta Parwanda discusses reflective approaches in nursing education and clinical practice. In Chapter 3, Sarah A. Balcom focuses on advanced practice nursing in Canada. In Chapter 4, Jia Guo demonstrates the application of operation research to health care. In Chapter 5, Chandra Rekha Makanjee discusses nurse practitioners' "insider" and "outsider" roles and responsibilities enabling quality managed delivery of medical imaging services. In Chapters 6 and 7, Marvin J. Gordon and Delgersuren Gelegjamts et al., discuss palliative care. In Chapter 8, Ka-Huen Yip et al., discuss advances in burn care in Hong Kong. In Chapter 9, Razzagh Rahimpoor presents the physiological and physical effects of sleep disorders. In Chapter 10, Doris Y.P. Leung shows the effects of video-supported, nurse-led advance care planning for older adults with frailty. In Chapter 11, Priscilla Yeye Adumoah Attafuah et al., talk about reconceptualising geriatric care in sub-Saharan Africa. In Chapter 12, Serly Sani Mahoklory and Ferdinandus Suban Hoda discuss the effect of cromotherapy on decreased blood pressure in patients in Indonesia. Finally, in Chapter 13, Ehsan Garosi presents nurse work system organization through the lens of macro ergonomics.

While it is very difficult to provide an overview of all aspects of nursing, we hope that this book will be a valuable resource not only for nurses but also for other clinicians, students, and patients seeking insights into new therapies and clinical practices. In this book, you can navigate the evolving landscape of nursing practice that addresses

the challenges and opportunities faced by healthcare providers worldwide. I encourage readers from other backgrounds to read this collection of excellent publications as a source of inspiration for critical thinking and new ideas in education and clinical investigation. Finally, I would like to acknowledge the publishing team who have worked tirelessly to bring this collection to the audience.

#### **Victor Chaban, Ph.D., MSCR**

Chairman and Professor, Department of Biomedical Science Education, Charles R. Drew University of Medicine and Science,

> Professor, Department of Medicine University of California, Los Angeles, USA

**Chapter 1**

Care

**Abstract**

*R.N. Hiroko Shimizu*

which revealed a clear effect.

elderly to achieve happy aging.

**1. Introduction**

Evaluation and Cultural Influence

of Nurses' Attitudes toward Elderly

The eldery population among the 38 countries of the Organization for Economic Co-operation and Development; thus, nurses have many opportunities to care for the elderly. The elderly are more likely to suffer from diseases, such as geriatric syndrome and sarcopenia, in addition to frailty. Medical personnel is reported to have a protective attitude, but the problems of nurses' dialog attitudes include confusion, concern, prejudice, and difficulty in dialog with patients with critical illnesses. Therefore, we had developed the scale to evaluate the negative aspects of nurses' interactive attitudes toward the elderly. The validity and reliability for the scale of the 15-item and 7-law methods were determined. A comparison of the dialog orientation scales of nurses and nursing students revealed that nurses are more positive as they gain more experience. Additionally, nurses were more negative about age discrimination in dialog and the difficulty of dialog with seriously injured people than caregivers because nurses care for more severely ill elderly. Moreover, we implemented a program to conduct dialog training with the elderly from the stage of nursing students,

**Keywords:** elderly care, nurse, prejudiced attitude, cognitive bias, Japan

This chapter provides research-based insights for improving the quality of care for the elderly, particularly within New Research in Nursing – Education and Practice. The important keywords are "successful aging" and "age discrimination." Focusing on age discrimination, especially cognitive distortions in caregivers, is necessary for the

Before the 1980s, aging was viewed as a period of increasing physical and mental frailty. However, this viewpoint has clearly changed since the early 1990s and has been influenced by the notion of "successful aging" advocated by Rowe and Kahn [1]. As expressed in the terminal decline model proposed by psychologists, crystalized intelligence continues to function until just before death, and older people are capable of contributing to society, which should be considered a desirable objective [2]. Nurses involved in healthcare with older people should understand the characteristics

#### **Chapter 1**

## Evaluation and Cultural Influence of Nurses' Attitudes toward Elderly Care

*R.N. Hiroko Shimizu*

#### **Abstract**

The eldery population among the 38 countries of the Organization for Economic Co-operation and Development; thus, nurses have many opportunities to care for the elderly. The elderly are more likely to suffer from diseases, such as geriatric syndrome and sarcopenia, in addition to frailty. Medical personnel is reported to have a protective attitude, but the problems of nurses' dialog attitudes include confusion, concern, prejudice, and difficulty in dialog with patients with critical illnesses. Therefore, we had developed the scale to evaluate the negative aspects of nurses' interactive attitudes toward the elderly. The validity and reliability for the scale of the 15-item and 7-law methods were determined. A comparison of the dialog orientation scales of nurses and nursing students revealed that nurses are more positive as they gain more experience. Additionally, nurses were more negative about age discrimination in dialog and the difficulty of dialog with seriously injured people than caregivers because nurses care for more severely ill elderly. Moreover, we implemented a program to conduct dialog training with the elderly from the stage of nursing students, which revealed a clear effect.

**Keywords:** elderly care, nurse, prejudiced attitude, cognitive bias, Japan

#### **1. Introduction**

This chapter provides research-based insights for improving the quality of care for the elderly, particularly within New Research in Nursing – Education and Practice. The important keywords are "successful aging" and "age discrimination." Focusing on age discrimination, especially cognitive distortions in caregivers, is necessary for the elderly to achieve happy aging.

Before the 1980s, aging was viewed as a period of increasing physical and mental frailty. However, this viewpoint has clearly changed since the early 1990s and has been influenced by the notion of "successful aging" advocated by Rowe and Kahn [1]. As expressed in the terminal decline model proposed by psychologists, crystalized intelligence continues to function until just before death, and older people are capable of contributing to society, which should be considered a desirable objective [2]. Nurses involved in healthcare with older people should understand the characteristics of aging and be free of cognitive bias when treating older people [3]. Ageism discrimination is one of these cognitive biases.

Ageism refers to cognitive bias toward older people and is a specific form of discrimination, such as racism and sexism. Specifically, Butler [4] defined ageism as "a process of systematic stereotyping and discrimination against people because they are old." This type of bias, which results from cultural and social influences [5], is distinctive for each country and ethnic group. This may be a specific problem in Japan, with Palmore [5] observing that the general Japanese population holds feelings of respect and contempt for older people. Indeed, it can be difficult to correct through education.

In February and March 2004, the Japanese Cabinet Office performed the "Survey on Public Attitudes to Aging," which used the Fraboni Scale of Ageism (FSA) to evaluate cognitive bias against older people among 6000 Japanese respondents aged ≥20 years. Respondents who were older males living in major cities or prone to illness expressed strong feelings of avoidance and rejection toward older people. People form views about others beginning from their childhood who influenced by one's family and community. Another research in Japan indicated that views toward older people are positive in elementary school but less positive in junior high school and high school. Children frequently consider older people to be physically weak [6]. In other words, cognition changes negatively with the time affected. Therefore, Japanese culture and social influences may enhance the prejudice against older people.

#### **2. Increasing number of elderly people in the population**

#### **2.1 Japanese average life expectancy and high aging rate**

Japan's Ministry of Health, Labor, and Welfare reported a Japanese population of 122,780,487 as of October 1, 2021, following a year-on-year downward trend since 2007.

The population aged ≥65 years in Japan accounted for 36,214,000, with an increase of 188,000 from the previous year, having the highest ratio of 28.9%.

The population aged ≥75 years accounted for 18,674,000, with an increase of 72,000 from the previous year, having the highest ratio of 14.9%. The total ratio of elderly people aged ≥65 years was 42.38 in the population [7]. Hence, one in two or three Japanese people is an elderly person.

The average life expectancy of the Japanese was the highest ever in 2020. The most recent average life expectancy increased by 0.09 and 0.14 years in 2021, with an average of 81.47 and 87.57 years for males and females, respectively. The difference in life expectancy between males and females was 6.10 years, which decreased by 0.05 years from the previous year. Therefore, the life expectancy of males has relatively increased [8].

These results reveal that the elderly who need care mainly consists of people in their 80s.

Deaths in 2021 increased to a postwar high of 1,439,856 (increased by 67,101 from 1,372,755 in 2020).

The number of deaths from malignant neoplasm (tumor) was 381,505 (26.5% of the total number of deaths), and the mortality rate (per 100,000 population) of 310.7 ranked first place, followed by heart disease (14.9%, 174.9), senility (10.6%, 123.8), cerebrovascular disease, and pneumonia, in order.

*Evaluation and Cultural Influence of Nurses' Attitudes toward Elderly Care DOI: http://dx.doi.org/10.5772/intechopen.109818*

The number of deaths due to coronavirus disease 2019 (COVID-19) was 16,766.

These diseases are among the leading causes of death in the elderly. The majority of Japanese elderly patients in end-of-life care have chronic diseases, such as cancer, heart disease, cerebrovascular disease, and pneumonia, in addition to senility. However, the number of patients following an acute turning point due to COVID-19 infection has increased since 2020. Thus, many patients with chronic diseases require a long treatment period, and they have a long relationship with nurses. Particularly, nurses' attitudes possibly affect the quality of nurses.

#### **2.2 International comparison of the aging rate**

The Organization for Economic Co-operation and Development (OECD) is an international organization with 38 developed countries, mainly European countries, including Japan and the United States. The OECD database predicted Japan to have the fastest-aging population worldwide by 2021. From this point of view, Japan's approach to measures and care for the elderly may set a precedent for other countries [9, 10].

Countries with high aging rates often have low birth rates and total fertility rates. Therefore, an economic guarantee for care is important because it is accompanied by a decreased working-age population. The economic precedent for elderly care in Japan is the Long-Term Care Insurance Law [8].

The aging rate in Japan was at the bottom, middle, and highest in the 1980s, the 1990s, and 2005, respectively, compared to that of other developed countries. This high level is expected to be maintained in the future.

Comparing the number of years required for the aging rate to reach 14%, 126 years in France, 85 years in Sweden, 72 years in the United States, and 126 years in Sweden, compared to relatively short periods of 46 years for the United Kingdom and 40 years for Germany, Japan exceeded 7% in 1970 and reached 14% in 1994, 24 years later.

Conversely, some Asian countries, such as South Korea in 2018 and Singapore in 2017, are expected to have a faster aging speed than Japan [11].

#### **3. Geriatric medicine and characteristics**

#### **3.1 Physical changes in the elderly**

Many elderly people have physical decline or frailty, with age. Frailty in the elderly not only reduces the quality of life but also carries the risk of various complications.

A research group of the Ministry of Health, Labor, and Welfare in Japan defined frailty as "mental and physical vitality (motor function, cognitive function, etc.) decreases with aging, and life functions are impaired due to the effects of multiple chronic diseases, etc., and is a state in which physical and mental vulnerability has emerged." Conversely, frailty is considered a state in which maintaining and improving living functions are possible through appropriate intervention and support, and appropriate intervention by nurses is required [12].

We calculated the frailty rate of Japanese elderly people through a panel survey, because Japan has the highest aging rate worldwide. The results showed that the rate of frailty was 8.7% among all elderly people. Hence, approximately 11.3 million elderly people in Japan require appropriate intervention and support. They are the target of nursing care, including the elderly living at home, because not all of these are inpatients. Therefore, nurses should increase their knowledge of the elderly to improve the effectiveness of care because the elderly are important subjects of care [13].

Japan will have 960,000 nurses, including registered and associate nurses, by 2021, with at least one frail elderly person for every nurse. Japanese nurses work in a wide variety of fields, including clinics, healthcare facilities for the elderly, welfare facilities for the elderly, and home-visit nursing, in addition to hospitals. The attitude that nurses take toward the elderly is hypothesized to affect the quality of intervention and support because nurses provide face-to-face life support.

#### **3.2 Diseases of the elderly**

The elderly have various diseases, but these diseases are very different from patients at other developmental stages, such as adults and children. Diseases that are common among the elderly in Japan include geriatric syndrome, sarcopenia/frailty, locomotive syndrome, dementia, cancer, infectious diseases, aspiration lung disease, pneumonia, diabetes and its complications, and hypertension. A geriatric syndrome is a general term for symptoms and signs that are often seen in the elderly with aging and require a medical examination, care, and nursing care. The geriatric syndrome has >50 items of symptoms and signs and is characterized by having multiple symptoms; thus, patients are required to visit multiple clinical departments and hospitals. Physiological aging and pathological aging coexist in geriatric syndrome; thus, factors and effects for recovery should be correctly evaluated. Diseases associated with the geriatric syndrome include hormonal depletion and lacunar infarction. Hormones are associated with the decline of aging and may be treated with hormone replacement therapy [14, 15].

#### **3.3 Points to note in elderly care**

Elderly people experience a decline in activities of daily living (ADLs) when they are ill as typified by the geriatric syndrome. The risk factors that double this decline in ADL are cognition, sensory fatigue, falls, depression, and female sex. Cerebrovascular accidents increase the risk fivefold. Moderate aerobic exercise and interactive communication are necessary to avoid these.

Sarcopenia, which is common in the elderly, refers to the loss of muscle mass and muscle strength due to aging, and in October 2016, "sarcopenia" was registered in the International Classification of Diseases and is now positioned as a disease. Sarcopenia affects ADLs, such as walking and standing, requires care, and is prone to falls. Approximately 15% of the elderly aged ≥65 in Japan are considered affected by sarcopenia. As of 2019, the elderly population is estimated to be 35.89 million; hence, approximately 5 million elderly people are likely to have sarcopenia. However, exercise and nutrition are expected to improve muscles even after 70 years old; thus, so exercise and nutrition are important factors in the care of the elderly [13].

#### **4. Attitudes of nurses in geriatric nursing**

The elderly have more opportunities to receive nursing care due to symptoms and disabilities caused by aging and illness. The caregiver's dialog and attitude greatly affect the willingness of the elderly to recover and rehabilitate.

An example is based on Bandura's theory of social learning. According to his theory, the factors that influence the patient's behavior are not only the family

members but also the nurse's emotional arousal and model behavior presentation, which affect the outcome of care. Numerous studies were conducted on this issue of nurses' care attitudes in nursing the elderly, and nurses' knowledge and attitudes are considered important for high-quality care.

#### **4.1 Characteristics and problems of nurses' attitudes toward the elderly**

The author focused on the dialog between nurses and the elderly and clarified the problems and characteristics of dialog.

The research method was a questionnaire survey using the indwelling method for 833 nursing students. The questionnaire consisted of 43 items whose content validity was confirmed. The evaluation scale was a 7-point scale ranging from "strongly agree" to "strongly disagree." Exploratory factor analysis and multidimensional scaling, which are analysis methods by IBM's SPSS, were used for analysis. As a result, four factors were extracted as characteristics of conversations between nursing students and the elderly. The factors were ``confused about involvement," ``concern about involvement," ``prejudice about involvement," and ``difficulty about involvement." These factors represented the attitudes of nursing students influenced by emotions such as anxiety toward the elderly, and the values of nursing students toward the elderly. Also, the characteristic of dialog was the concept placed on the two axes of cognition and attitude. The problem of attitudes of nurses found here can be an important evaluation index for education of nurses.

#### **4.2 Evaluation of factors affecting nurses' attitudes**

Disability due to aging has been the most emphasized problem among the target elderly people. For example, ADL indicators [16], dementia-related memory ability evaluation [17], and hearing ability in the elderly [18] were used as measurement indices. They could not measure the effects of problems on the part of caregivers, such as prejudice, although they measured the extent to which disability on the part of the elderly affected dialog. Prejudices are cognitive distortions formed by nurses' internal experiences that negatively influence care and are expected to improve with education. Therefore, the following evaluation scales had been considered as indicators for the side facing the elderly.

Young people's beliefs in communication have been measured [19], but they have not addressed the influence of interlocutors' attitudes and prejudices. The use of existing social skill scales [20, 21] and communication skill scales [22, 23] was attempted in Japan. Kiss-18 is a behavioral index of social skills in dialog relationships, and communication scales developed in Japan include Nagano's [24] evaluation scale for micro-skills training and Ueno's [25] 2003 communication skills scale. Scales are available, but none of them considered the effects of aging as a problem.

The English literature presented a Kogan Scale. The Kogan Scale [26] can measure dialog attitudes influenced by prejudiced attitudes toward the elderly; hence, adopting it as the Japanese language is possible.

However, prejudiced attitudes toward the elderly consider the cognitive influence; thus, considering the kind of cultural influence the subject is receiving and causing cognitive distortion upon evaluation is necessary. Palmer points out that the Japanese view of the elderly is unique regarding the cognitive characteristics of the Japanese toward the elderly. Palmore [27] states that the Japanese government has established Respect for the Aged Day, unlike people in other countries. Concurrently, he points

out that the attitude to evaluation scales proposed by other cultures cannot be applied to Japanese people who have such ambivalent attitudes toward the elderly. Therefore, the author developed a scale to measure Japanese people's dialog attitudes with the elderly, considering culturally influenced prejudiced attitudes.

#### **5. Evaluation of care attitudes of nurses in geriatric nursing**

#### **5.1 Characteristics of evaluation scales**

Shimizu developed the Dialog Preference Scales for the Elderly (DPSE or Shimizu scale), which assesses nurses' negative cognition and attitude tendencies during their conversations with elderly individuals, to help address the problem of ageism among caregivers [28].

DPSE has four subconcepts that reliably assess respondents' relationships with older people [29] (**Table 1**). These subconcepts are bewilderment (shown through uncertainty), anxiety, cognitive bias (associated with ageism), and difficulty in communication. No other standardized scale is comparable to the DPSE. However, concurrent validity was detected for the DPSE's "anxiety in relationships" item and the "authoritative anxiety" item in the Social Anxiety Scale in Social Situations [30]. Additionally, DPSE demonstrated predictive validity for the targeted achievement level for nursing students' clinical training. The total coefficient of reliability (α) was 0.811, thereby confirming internal consistency reliability. The coefficients of reliability (α) were 0.764, 0.687, 0.671, and 0.670 for bewilderment, anxiety, cognitive bias, and communication difficulty, respectively [29]. This scale requires careful interpretation of the scores because the total score represents the degree of negative aspects of attitudes.

#### **5.2 Characteristics of nurses' interactive attitudes with the elderly: in comparison with nursing students**

We clarified the characteristics of nurses' interactive attitudes with the elderly in comparison with nursing students. This is a finding obtained from a survey of Japanese nurses and nursing students.

Data collection was conducted at hospitals and seminars in Japan. Participants were nurses (n = 186; males: 2.7%; females: 97.3%) and nursing students [n = 552; males: 2.0% (38.4 ± 10.3 years); females: 98.0% (22.9 ± 4.9 years)]. Nursing student data from a study with the same questionnaire were obtained retrospectively.

Data were gathered using the 15-item Shimizu Scale, which measures attributes and four subconcepts (bewilderment, anxiety, cognitive bias, and communication difficulty). Higher scores indicate more negative cognitions or attitudes (maximum score: 28). Data were descriptively analyzed using t-tests and secondary factor analysis of confirmatory factors. The responses of nurses were compared with the previously collected responses of nursing students who differed from nurses in their experience and knowledge.

Nurses' total scores (mean: 3.94) were significantly lower than the nursing students' scores (mean: 4.4), indicating that nurses had a more positive view of communication with older people than nursing students.

The path coefficients for dialog preferences in the subfactor for nurses were 0.48 for bewilderment, 0.36 for anxiety, 0.34 for cognitive bias, and 0.72 for communication difficulty (**Figure 1**). When comparing the fit of the subconcept analysis model,


#### **Table 1.**

*Dialog preference scales for elderly questionnaire (DPSE or Shimizu scale).*

GFI was 0.91(0.95 for nursing students), AGFI was 0.88 (0.93), and CFI was 0.94 (0.94) for nurses, indicating good model fit for nurses. However, a significant difference was seen in the apprehension score for nurses with <1-year experience compared

**Figure 1.**

*Training program for interactive attitudes with older people.*

with those with more experience (p < 0.05). Overall, compared with the nursing student data previously measured using the same scale [28], experienced nurses had more positive attitudes toward older people on the Shimizu Scale.

Moreover, a significant difference in the anxiety scores was observed between nurses with <1 year of experience and those with more experience. Experienced nurses had a more positive attitude regarding communication with older people compared with nursing students. Since this result instructed the current research results, the Shimizu Scale is appropriate for nurses.

The results of this survey show that nurses tend to have more positive attitudes toward the elderly than nursing students and first-year nurses. This is thought to be because the explanatory power of the subordinate concepts of the scale makes it possible to deal with patients with more difficult medical conditions and knowledge of the elderly, thereby reducing anxiety and preventing confusion (31).

#### **5.3 Characteristics of nurses' interactive attitudes with the elderly in comparison with care workers**

Nurses' interactive attitudes toward the elderly became more positive depending on their experience [31].

What is the difference between nurses and caregivers?

Nurses' and care workers' scores on the Dialog Preference Scales for Elderly (DPSE) created from data from nursing students in Japan are compared. For this forward-looking, quantitative, questionnaire-based study, data collection was conducted from 2010 to 2012 with care seminar participants in Japan.

Participants were nurses (n = 277; 36.96 ± 10.33 years old, males; 4.33% females; 95.66%) and care workers (n = 83; 40.52 ± 11.68 years old, males; 25.30% females; 74.69). The samples varied significantly in mean age (p < 0.05) and gender (p < 0.001). The number of years of experience was 139.94 for nurses with SD = 10.99 and 90.99 for care workers with SD = 45.44 (p < 0.001).

Data were gathered using the 15-item Dialog Preference Scales for Elderly (DPSE or Shimizu scale), which assesses nurses' negative cognition and attitude tendencies during their conversations with elderly individuals [31]. The DPSE measures attributes and the four subconcepts such as bewilderment, anxiety, cognitive bias, and communication difficulty. Higher scores indicate more negative cognitions or attitudes (maximum score: 28). Data were descriptively analyzed using Pearson's χ<sup>2</sup> test and student's t-test of confirmatory factors.

*Evaluation and Cultural Influence of Nurses' Attitudes toward Elderly Care DOI: http://dx.doi.org/10.5772/intechopen.109818*

Nurses' total scores (mean; 57.31, SD = 11.84) were not significantly different than care worker's scores (mean; 57.58, SD = 12.25), indicating that nurses and care workers had a similar view of communicating with older people. However, the subconcept of cognitive bias was significantly lower for nurses, as they likely had higher levels of ageism (p < 0.10).

Additionally, the communication difficulty subconcept also was significantly higher for nurses, possibly because they had been caring for much older patients with more severe illnesses (p < 0.01) [31].

Why do nurses have negative interactive attitudes when caring for the seriously ill elderly?

The reason is that other research results show that medical professionals have a protective attitude toward patients [32]. The protective attitude of medical staff based on the principle of health supremacy is a problem for medical staff in general. Murata et al. revealed that the possibility that nurses have this negative tendency cannot be denied. Negative views of the elderly include prejudices (Ageism) that affect words and actions [27].

#### **6. An effective interactive learning method for geriatric nursing**

Factors affecting the quality of nurses' care for the elderly include prejudiced dialog attitudes, in addition to negative views on the elderly, and protective attitudes. Therefore, learning is necessary to affirm this dialog attitude.

The next section will introduce the learning method.

#### **6.1 Program content**

The dialog training program [33] for nursing students who have completed the following pre-learning is introduced. Preparatory learning was positioned at the stage of deepening understanding of the elderly by completing the basic knowledge of basic nursing and practical training for understanding patients and receiving lectures on the elderly for 10 h.

The structure of the program consists of four elements. First, a model demonstration between an experienced nurse and a trained elderly simulated patient is viewed [33–36]. Second, students will role-play with each other. Third, a third-party evaluator and a simulated patient will evaluate the student's performance. Fourth, the performer student receives feedback from the evaluator and the simulated patient. Here, the simulated patient should verbalize and convey the patient's inner feelings. A trained simulated patient is a citizen who has the experience of being an elderly patient and who acts like a patient according to the acting scenario created under the learning objectives. Therefore, the citizen's condition is to be a learning cooperator and to express linguistically the patient-likeness of the elderly. The patient-like expression means having a sense that only the patient can be aware of and being able to verbalize it at the level of student understanding.

#### **6.2 Training method**

The following are the specific training methods.

The program consists of lectures and exercises. Lectures for 45 min focused on the involvement techniques of the micro-skills hierarchy constructed by Allen Ivey [37].

The exercise consists of three stages. The scenario is a geriatric scenario for a simulated geriatric patient. The first stage of the exercise is the actual model performance. A model performance of a nurse counselor and a simulated elderly patient is performed for 15 min according to the elderly scenario. At this time, the students will observe and the teacher will explain the involvement behavior and the use of micro-techniques after the implementation. The second stage involves small group role-plays of four students. Students take on the role of nurse, patient, recorder, and evaluator, and the entire group changes roles. The theme of the scenario is "Recently Worrying," and the performance is recorded for 5 min. The student receives 2 min of feedback from the evaluator after completing the performance. The evaluator gives feedback using the evaluation form for the frequency of use of the micro-techniques and the mayor's video images and recorded voices used by the recorder. This is done reciprocally. The third stage is a 15-min role-play between a student representative and a simulated patient. Students observe this and receive feedback from performers. Here, questions about the difference in feelings are asked and answered by the visiting students. Finally, the teacher summarizes the learning and concludes (**Figure 1**).

#### **6.3 Effects of training**

We surveyed the results of implementing an interactive learning program for the elderly with 48 nursing students [33].

After the exercise, students stated its worth because they are learning (100%), they understood the actual atmosphere, attitudes, and postures (29%), and they learned more about non-verbal communication, communication selection, and interaction. Of the respondents, 29% understood the content of the lecture through role-playing and feedback, 29% understood the content of the lecture, and 19% thought of it as a useful learning experience as it reduced their anxiety. As for the simulated patients, 95% stated a good practice experience of participating in the simulated patients. This is supported by the following statements: "the model performance gave me an atmosphere that I could not capture with videotapes or lectures," "I experienced different viewpoints through role-playing," and "feedback from a tape recorder made my reflections more effective." Additionally, "I was surprised by the simulated patient's appearance," "I could not clarify the difference between paraphrasing and closed questions," "I felt a real tension in the nurse counselor's skillful technique, Speaking," "I was able to see the depth of my habits," "I was able to see my habits objectively," and "Students' feedback helped me understand." These descriptions suggest that the program was effective.

The statistical examination revealed that the items before and after program learning were significantly "clarified clues for non-verbal communication." This is supported by the following statements: "the other person's intentions are reflected in the non-verbal communication that naturally occurs in the process of empathizing with them," "the silence that affects the first meeting and the first impression has meaning," "the anxiety of communication is reduced," etc. Therefore, through this type of learning, students will reduce their anxiety about interacting with the elderly and reduce their expressions of embarrassment.

#### **7. Conclusion**

Japan has the highest rate of the aging population in the OECD. Moreover, Japan has rapidly become an aging society in a short period compared to countries such as *Evaluation and Cultural Influence of Nurses' Attitudes toward Elderly Care DOI: http://dx.doi.org/10.5772/intechopen.109818*

France. In Asia, South Korea and Singapore are also aging faster than Japan. In 2000, Japan developed a Long-Term Care Insurance Law for the financial security of elderly care, called the Long-term Care Insurance Law. Twenty-two years have passed since its inception, and it continues to utilize the Long-Term Care Insurance Act with some modifications. Japan's elderly care methods, including the Nursing Care Insurance Law, will serve as a reference for countries that will become aging societies in the future.

In this chapter, it was explained that young caregivers requires to understand as old people who lived in an unknown past, to understand the physical and psychological changes that accompany aging, and to understand the attitudes of caregivers themselves. As a way of solving problems, the attitudes of nurses were evaluated, and improving the quality of care with undistorted attitudes was explained, as well as specific teaching methods.

I recommend that caregivers, in a country that is becoming an aging society, use this as a reference and hope that they will contribute to the successful aging of the elderly.

#### **Acknowledgements**

The Dialog Preference Scales for Elderly Questionnaire developed and described by the author in this chapter is the author's doctoral dissertation. Japan is notorious for its aging society, but there is no bachelor's degree in gerontology in Japan. However, due to the need for gerontological research, J. F. Oberlin University, a private school, established a gerontology major in its graduate school of international studies. The author's doctorate in gerontology was registered as one of the first gerontologists in Japan. Professors Masami Nojiri of the Honorary professor of Chiba University, Professor Hisao Osada and Professor Hidehiro Sugisawa of Oberin University, and Professor Masahiro Kodama of the University of Tsukuba supervised this doctoral dissertation. I would like to express my gratitude to my mentor.

This study was supported by Enago and the Program to supporting research activities of female researchers by MEXT (Ministry of Education, Culture, Sports, Science and Technology) in in manuscript submission.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

R.N. Hiroko Shimizu Faculty of Medicine, Kagawa University, Kita-Gun, Kagawa, Japan

\*Address all correspondence to: shimizu.hiroko@kagawa-u.ac.jp

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[13] Cabinet Office of Japan. White Paper on the Aging Society, (whole version 2) International Trends in Aging. 2020. Available from: https://www8.cao.go.jp/ kourei/whitepaper/w-2020/html/zenbun/ s1\_1\_2.html [Accessed:2022-Oct. 29]

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[18] Erber NP, Holland J, Osborn RR. Communicating with elders: Effects of speaker-listener distance. British Journal of Audiology. 1998;**32**:135-138

[19] McCann RM, Cargile AC, Giles H, et al. Communication ambivalence toward elders: Data from North Vietnam, South Vietnam, and the U.S.A. Journal of Cross-Cultural Gerontology. 2004;**19**:275-297

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[29] Shimizu H. Validity and reliability of dialogue preference scales for elders. Journal of Japan Academy of Gerontological Nursing. 2010;**14**:34-41

[30] Mori I, Tanno Y. Reliability and validity of creating social anxiety scale in social situations scale. Journal of Health Research. 2001;**14**:23-31

[31] Shimizu H. Comparison of Japanese nurses' and care workers' scores on the dialogue preference scales for elderly (DPSE). International Journal of Nursing & Clinical Practices. 2021;**7**:328

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[33] Shimizu H, Nojiri M. Characteristics of an educational program for elderly communication for students using simulated patients. Human Care Research. 2005;**6**:45-54

[34] Shimizu H, Yokoi I, Toyoda S, et al. Characteristics of studies on simulated patients and standardized patients in nursing education. Journal of the Japanese Society of Health Sciences. 2008;**10**:215-223

[35] Shimizu H. Utilization of simulated patients in nursing education characteristics and evaluation of simulated patients. Perspectives on Nursing. 2009a;**34**:68-70

[36] Shimizu H. Utilization of simulated patients in nursing education ingenuity and implementation method of utilizing simulated patients in nursing objective-based participatory learning of simulated patients. Nursing Perspectives. 2009b;**34**:69-72

[37] Ivey AE translated Fukuhara M, Kajiyama K, Kokubu H, Nireki M. Introduction to Microcounseling. USA: Cole Publishing Company, A Division of Wadsworth Inc; 1985. p. 8

#### **Chapter 2**

## Reflective Approaches in Nursing Education and Clinical Practice

*Geeta Parwanda*

#### **Abstract**

Today modern society is becoming more complex and constantly information is changing along with problem solving strategies, reflective learning is an ability to look **back** over an **experience** and break it down into its significant aspects, such as any factors affecting success or failure. Due to this complex and continually changing environment, healthcare professionals could benefit from a program of reflective practice. Reflective Practice (DAVIS 2012) 1 is increasing from an experience for any situation, acquisition of new knowledge and skills, further understanding of own beliefs, attitudes and values. This practice involves encouragement of self-motivation and self-directed learning in nursing education and clinical practice.

**Keywords:** reflective practice, nursing education, clinical practice, health care professional, reflective approaches

#### **1. Introduction**

Today Modern society is becoming more complex since the Covid-19 pandemic starts the information is becoming more advanced with technology and changing more rapidly leading users to constantly rethink, moving to new direction and adopt problem solving strategies.

Reflective learning is a capacity to **look back** over an **experience** and able to analysis in significant way, any factors which affect success or failure.

Learning in reflection will aid in enhancement for own human skill development and finding a clear path between the effort in development activity and outcome of it Reflection also heap in knowing are learning experiences regarding the purpose of activity and its importance (**Figure 1**). Reflecting on learning enables to link professional development to practical outcomes and widens the definition of what counts as useful activity.

Being is learner in reflective practice. One always try to apply knowledge and practice in further work as learning is always connected to the action and theoretical knowledge to clinical skills.

We can always assess our learning outcome through the feedback from peer group teachers with self assessment. As we understated that reflection is the process which aid to gain meaningful look into are professional practice.

**Figure 1.** *Learning in reflection.*

#### **2. Reflective approaches**

In nursing education reflective approaches can be used as important tool in clinical practice based where the nursing student learn from their own professional experience, classrooms lecture or mentor which is always helpful in career advancement and adopting same process is able to bring together theory and clinical practice.

As Paterson Chapman [1, 2] mentioned that reflection is vital part of learning from experience and mainly lead to develop and maintain completely across a professional's lifetime in the area of health care. John Dewey was among the first to explain about Reflective Practice with his exploration of experience, connection between incidents as shown in **Figure 2**.

Reflections helps to see and able to mark schools of thought and theory of concept within the context of our work done [3]. Important point to be noted about reflection during the practice reveals that the individual not only look back on his past activities and the action taken, but also deeply look into observation of emotions shown, previous happenings, actions taken, and its effect and thus lead to higher level of understanding [2].

The use of reflection in nursing education:

1.Enhance self awareness leader to increases understanding of the effect that past experience may have on care delivery.

**Figure 2.** *Experience and reflective process.*


#### **2.1 The various model of reflective practice**

Reflective practice applied in disciplines such as teaching, nursing, social work as a way to learn from real life experience. There are many models to explain and guide personal and situational analysis and improvement. The first stage of reflection usually start with the description what has happened and the next stage of reflective practice describe about what we know the situation and what it is impact and the final stage of reflection briefs about the change and outcome of situation as explained in **Figure 3** the co-relation of Reflection, learning and action. The structure and format of these modals may have difference but mostly all reflective modals have many common features.

#### *2.1.1 Gibbs' reflective cycle or Gibbs' model of reflection (1988)*

One of the most common cyclical models of reflection which consist of following six distinct stages of exploring the experience [4].


Gibbs reflective cycle allows to reflect upon ones experience as they happen and it helps to enhance our performance and for better improvement in future.

#### *2.1.2 Rolfe 2001*

**Figure 4.** *Rolfe reflective framework.*

#### **2.2 Adaptation of the Rolfe reflective model**

Rolfe's reflective model is based on three simple questions what happened, (self awareness) and how it happened (critical analysis and evaluation), and what will be next plan (action oriented), so what and what next (As shown in **Figure 4**). A simplistic cycle composed of three questions which asks the practitioner, by introducing the problem that they are reflecting on before making their observation about the issue and finally concluding what they would change next time Through this analysis, a description of the situation is given which leads into the scrutiny of the situation and the construction of knowledge that has been learn through the experience. The most important advantage of Rolfe model relates to its clarity and simplicity. It often produce meaningful solutions.This models not only consider reflection after the moment but when the event is taking place so that the corrective measure can be taken.

To conclude Rolfe model describe that reflections does not remain superficial but it is comprehensive by completing the simple action plan with key pointers about what we will do and how will decide that our practice has improved.

#### *2.2.1 Ganshirt 2007*

The reflective model Christian Ganshirt 2007 was prepared on the concept of the design cycle and the Ganshirt design cycle is explained with the first step begin with any innovative thoughts and next step is using visual and audio aids through same ideas is expressed and transfer in cyclical way with the critical rethinking and the same process goes on.

To summarize these models provide a useful guide or mode to begin but reflection is a unique and innate process and nursing professional will perceive it in a different way. Everyone takes some time to try different reflective approaches until it works

positive and effective.As the time passes and as a reflective practitioner that we may try to practice different methods to handle the current situation.

The main four level of reflection can be described as:-


#### **2.3 Application of reflective learning for health professional**

Reflective Practice is always connected with learning from previous experience, and is considered as an important strategy for nursing professionals who believes in learning process in all phases of lives and it is known fact there is always changes in context of healthcare practices leading to continuous progression in medical knowledge hence there is a always remarkable need for experts in medical and nursing education.

Reflective practices seem to be important tool for healthcare professional because of rapid changes in healthcare facilities. Price explained in 2004 [5] about the benefits of reflective practices for healthcare practitioner by understanding his or her own motive,thoughts,moral and feelings connected with client care and to promote solution to practice situations and meet challenge with existing ideas, response of action taken with positive or negative feeling and also to rethink how the practice situation can be handled in different way.

In the field of nursing profession there is always a concern that actions taken in any situation may have the risk of habitualization, thus dehumanizing client care and their needs. Reflective Practice always aids to nurses are to plan their process of nursing care and keen monitoring the action to ensure it is beneficial to the clients.

The act of reflection is seen as a way of promoting the self decision, qualified and professionals with leadership quality. Involving in Reflective Practice leads to the improvement of the quality of nursing care, enhancing personal and professional growth and reducing the gap between theory and practice. Reflective practices are now being introduced into undergraduate, postgraduate and continuing nursing education. Mann [6] expressed in her research that in nursing professional in clinical practice reflection process is multi factorial and to include different aspects. All experiences during anticipation of a difficult situation also added to reflection. Practicing professionals always have variation in their attitudes and capability to reflect. Denner [7] mentioned that reflection has meditation aspect which causes a change in brain alpha and theta wave activity and also increases the right hemisphere brain activity which is connected to our insights and leads to sudden awareness of correct answer to any verbal problem and leads to creativity. Many researchers have proved that self reflection involves the brain's cortical midline structures (CMS) any disturbance to the CMS causes difficulty in evaluating the difficult situation and there is tendency to overestimate one's personal abilities [8].

#### **3. Conclusion**

To prevent burnout, nursing professional need to have passion of their profession. Nursing professional at every level after this covid 19 pandemic will need to be more

perseverant and passionate with excellence in clinical practice [9]. Thus reflective learning is important tool to learn and enhance skill competency over time and evaluates our learning experience towards nursing care. Self reflection enhances skills which involve motivation and temperament which are necessary for success in the health care professional.

#### **Acknowledgements**

I would like to acknowledge the extraordinary debt I owe to the editor and my special thanks to Paula Gavran, Author Service manager for her continual support. I also thanks to all my reader.

### **Conflict of interest**

I declare no conflict of interest.

### **Further reading**


### **Author details**

Geeta Parwanda Faculty of Nursing, Swami Vivekananda Subharti University, Meerut, Uttarpardesh, India

\*Address all correspondence to: parwandaa@yahoo.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Samantha D. Embracing reflective practice. Education for Primary Care. 2012;**23**(1):9-12

[2] Chapman P. Enhancing skills of critical reflection to evidence learning in professional practice. National Library of Medicine. 2013;**13**(3):133-138

[3] McBrien B. Learning from practicereflections on a critical incident. Accident and Emergency Nursing. 2007;**15**(3):128-133. DOI: 10.1016/j. aaen.2007.03.004 Epub 2007 May 30

[4] Gibbs G. Learning by doing: A guide to teaching and learning methods. London: Oxford Centre for Staff and Learning Development, Oxford Polytechnic, Further Education Unit; 1988

[5] Price A. Encouraging reflection and critical thinking in practice. Nursing Standard. 2004;**18**(47):46-52, quiz 53-4. DOI: 10.7748/ns2004.08.18.47.46.c3664

[6] Mann K. Reflection and reflective practice in health profession education. Advances in Health Sciences Education Theory Practice. 2009;**14**(4):595-621

[7] Denner SS. The science of energy therapies and contemplative practice. A conceptual review and application of zero balancing. Holistic Nursing Practice. 2009;**23**(6):315-334

[8] Van der Meer L, Costafreda S, Aleman A, David AS. Self-reflection and the brain: A theoretical review and meta-analysis of neuroimaging studies with implications for schizophrenia. Neuroscience and Biobehavioral Reviews. 2010;**34**(6):936-946

[9] Turale S et al. Challenging times: Ethics, nursing and the COVID-19

pandemic. International Nursing Review. 2020;**67**(2):164-167. DOI: 10.1111/ inr.12598

#### **Chapter 3**

## Starting Somewhere: Advanced Practice Nursing in Canada

*Sarah A. Balcom*

#### **Abstract**

Many countries are capitalizing on nurses with advanced degrees or practice experience to increase patients' access to healthcare. In Canada, there are two advanced practice nursing roles – nurse practitioners (NPs) and clinical nurse specialists (CNS). While both NPs and CNSs are knowledgeable nursing leaders who make important contributions to the healthcare system, only NPs have a protected title and are separately licensed from registered nurses (RNs). In this chapter, the author explores how entry-level-competencies (ELCs) are essential to the separate licensure of NPs. The author also argues how ELCs may increase NPs' role recognition and effective use in the Canadian healthcare system.

**Keywords:** nurse practitioners, clinical nurse specialists, registered nurses, nursing education, teaching and assessment

#### **1. Introduction**

"If you don't start somewhere, you're going to go nowhere." – Bob Marley.

Globally, registered nurses (RNs) with advanced degrees or specialized qualifications often take on important clinical leadership and advanced practice roles, which can increase patients' access to quality healthcare [1]. However, the context and implementation of these roles varies between countries, with some countries showing slower acceptance and/or implementation than others [1, 2]. In one study, Jean et al. [2] explored advanced nursing roles in Canada and Spain, and found that, while both countries needed these roles, each country was at a different implementation stage. Similar barriers to implementation were found in both countries, including lack of role clarity, opposition from other health professionals (e.g., concerns about 'scope creep' or the scope of practice expansion of one health profession through legislation into the scope of practice of another), education/training issues, and regulatory concerns [2]. These findings are similar to those of other researchers [3, 4].

Entry-level competencies (ELCs), written collaboratively by advanced practice nurses, regulatory bodies and other stakeholders, including other health professionals and patients, increase the role clarity and integration of one advanced practice nursing role, that of the nurse practitioner (NP), into the healthcare system [5]. These statements describe the abilities/knowledge/judgment entry-level practitioners need to provide safe care [6, 7]. ELCs provide the 'somewhere' to start for other advanced

practice nurses seeking to better define and promote their roles and receive greater recognition for their contributions to quality patient care.

#### **2. Canada's advanced practice nursing and nurse practitioners**

The ICN [1] uses the term 'advanced practice nurse' to describe "a generalist or specialist nurse who has acquired, through additional graduate education (minimum of a master's degree), the expert knowledge base, complex decision-making skills and clinical competencies" for an expanded role in patient care (p. 6). In Canada, advanced practice nursing began in the 1890s with outpost nurses who worked in isolated, rural, and northern areas [8]. Over the years, Canadian advanced practice nursing has evolved, and today, there are two widely recognized advanced practice nursing roles – NPs and clinical nurse specialists (CNS) [9]. While NPs and CNSs are both knowledgeable nursing leaders who contribute significantly to patients' care, only NPs have a protected title and are separately licensed from RNs [10]. The first NPs in Canada appeared in the 1960s and were viewed as a solution to physician shortages, and a way to increase patients' access to primary healthcare and lower costs [11]. By 1972, a national report (the Boudreau report) recommended the implementation of NPs to meet Canadian primary healthcare needs [8]. The recommendations were not followed, and the Canada-wide implementation of NPs has remained inconsistent [12, 13].

There is strong evidence supporting NPs' effectiveness as care providers in a variety of settings. Stanik-Hutt et al. [14] reviewed 37 articles published between 1990 and 2009 and determined that NP-provided care was on par with physician-provided care in primary care clinics. Kleinpell et al. [15] reviewed 53 articles between 2008 and 2018 and concluded that the evidence supported the inclusion of NPs in the care of acute and even critically ill patients. Despite the number of studies illustrating the value of NPs as care providers, the implementation of the role Canada-wide has been variable [13]. The role is most widely implemented in Ontario [16]. In 2021, there were 7400 active NP licenses in Canada, with over half practicing in Ontario [16].

#### **3. Barriers to implementation**

Several studies have identified barriers or factors that impede the implantation of the NP role across Canada [17–21]. The most common barrier noted in these studies relates to role clarity. For example, Kilpatrick et al. [18], who evaluated the integration of NPs into a cardiology healthcare team in Quebec, found NPs struggled to practice to their full scope due to unclear role definition. They noted that this may also have contributed to tension between NPs and other team members, particularly physicians [18]. As Rickards and Hamilton [19] note, a lack of role clarity can lead to confusion among patients and other team members, hindering collaboration and effective implementation of the role. Role confusion is understandable. In Canada, NPs' roles are determined by both their legal and individual scopes of practice. The legal NP scope of practice (i.e., what NPs are authorized to do) is defined through provincial legislation (i.e., nursing acts), with NP roles expanding in many provinces over the years [9]. In Ontario, for example, NP's authority to prescribe prior to 2010 was restricted to a pre-approved list of drugs or renewing drugs first prescribed by physicians [22]. Since then, their prescribing privileges have expanded to more classes of

*Starting Somewhere: Advanced Practice Nursing in Canada DOI: http://dx.doi.org/10.5772/intechopen.110245*

drugs, including controlled drugs/substances [22]. Today, all provinces and territories have NP legislation in place [9]. Although there is some variation, generally, NPs can autonomously diagnose/treat diseases, order/interpret tests, prescribe medications, and perform procedures [9].

Individual NPs' scopes of practice may differ from their legal scopes of practice; and may be influenced by many factors, particularly their clinical competence [23]. For example, Medical Assistance in Dying (MAiD) was legalized in Canada in 2016 [24]. In most provinces, NPs are authorized to prescribe substances that cause death for eligible patients [25]. In these provinces, however, each NP must determine their clinical competency to participate in MAiD [24]. If an NP does not feel competent to participate, they may develop this through additional education/clinical experience. The concept of clinical competence is difficult to define [26]. Benner [27] defines clinical competence as the ability to perform a task to a desirable outcome under certain circumstances within a clinical context. Other authors argue that this concept needs to be considered more holistically [28, 29]. For example, Nabizadeh-Gharghozar et al. [28] explain clinical competence as "the combination of knowledge, skills, attitude and ability" which are used to provide safe patient care without supervision (p. 2). NPs' competence can be visualized as a balloon that expands and changes shape throughout their careers as they gain clinical experience and the context of their practice changes [5].

#### **4. Enablers to implementation**

Some studies have identified enablers or factors that facilitate the implementation of the NP role. Unsurprisingly, a scoping review by Torrens et al. [21], found that role clarity and a positive attitude by other healthcare professionals toward the clinical competency of NPs promote role implementation. Similarly, Brault et al. [30] found it was essential to clarify roles when NPs joined primary care teams to mitigate power struggles, facilitate integration, and foster intra/interprofessional collaboration.

One effort by NP-advocates and supporters to clarify the NP role was the development of ELCs for NPs. In 2012, the Canadian Council of Registered Nurse Regulators (CCRNR) began a project to establish national ELCs to standardize NP practice and improve NP mobility [6]. The resulting ELCs were organized into four categories: (1) patient care, (2) quality improvement and research, 3) leadership, and 4) education, and were adopted, with some adaptions, by nearly all provincial/territorial regulatory bodies [31]. Each of the categories is supported by specifically written statements, which describe the minimum expected levels of performance required for newly graduated NPs to practice safely in a variety of settings [7, 31]. The ELCs articulate, using standardized language, NPs' role and how their practice differs from that of other nursing professionals, such as RNs [6]. Notably, the ELCs are not static and are revised/modified to respond to current issues, needs, and trends in NP practice, such as increasing concerns about mental health and problematic substance use [31] or the recommendations from the Truth and Reconciliation Commission of Canada [32].

The ELCs increase the standardization of NP education, which is also essential for role clarity and development [33]. As Bryant Lukosius et al. [33] argue, the standardization of NP education is needed to achieve consistency and ensure curriculums align with current and expanding NP scopes of practice. In countries like Canada, where generalized nursing education is at the baccalaureate level, NPs currently require a masters degree from an accredited program. This was not always the case, as a 2010

environmental scan by the Canadian Association of Schools of Nursing [34] found that only 75% of the 27 NP programs in Canada were at the masters level. The ELCs are both a guide for curriculum development and a way for accrediting and regulatory bodies to assess NP education programs [35]. Increased standardization means that NP educators must prove to accreditors/regulators how they prepare their students to meet the ELCs [36]. Consequently, many NP educators use curriculum mapping to provide evidence that their curriculum/courses demonstrate alignment. The ELCs also inform the development and revision of the Canadian Nurse Practitioner Examination [35]. Thus, they are an essential link between formal educational programs (like master's programs) and licensing bodies (i.e., the provincial/territorial nursing regulatory bodies).

The ELCs guide both curriculum development in NP programs and entry-level exam test plans and so are critical to the NP licensure process [35]. Provincial/territorial legislation allows nursing regulatory bodies to protect the public by setting NP licensure requirements and ensuring all NPs practice at an acceptable level [37]. The NP licensure process is similar in most provinces and territories, and involves an assessment of applicants' experience, education, and competence [38]. Specifically, applicants need to prove they (1) were previously registered as an RN, (2) completed an NP educational program, and (3) passed the Canadian Nurse Practitioners Examination [38]. Licensing assures patients that they are treated by qualified professionals who will provide a safe standard of care.

#### **5. Clinical nurse specialists**

NPs are often confused with CNSs, the other widely recognized advanced practice nursing role [10]. Although there are similarities between the two, such as requiring advanced degrees and/or qualifications, there are important differences [33]. As Bryant-Lukosius et al. [33] emphasizes, NPs usually provide more direct patient care, while CNSs support excellence in clinical practice. The CNS title is not protected. Also, only NPs must meet ELCs specific to their role and are licensed separately from RNs [10]. Arguably, the implementation of CNSs in Canada has been even more inconsistent than NPs [10]. As Bryan-Lukosius et al. [33] notes, "the profile and deployment of CNS roles… have fluctuated … and the full benefit of the role has yet to be realized" (p. 140). Several studies reported role confusion and role overlap with NPs as barriers [39]. Some CNS-advocates argue that ELCs specific to the CNS role may help with its advancement and the standardization of CNS education [8, 40]. However, opponents argue that ELCs are unnecessary because CNSs do not write a different licensing examination and have separate licenses from RNs [40]. These opponents also worry ELCs may not capture the multifaceted aspects of this role, which is perceived as more varied than the NP role, with more involvement supporting other healthcare providers and leading evidencebased practice, quality assurance and program development activities [40, 41].

In 2014, CNA published the "Pan-Canadian Core Competencies for the Clinical Nurse Specialist" to clarify the role. In the future, there may be separate ELCs, which describe the minimum expected levels of performance required for all CNSs new in their roles. ELCs may be 'somewhere' to start for those looking to further standardize CNS education (e.g., a specialized masters degree or certificate/diploma program), develop CNS certification exams (similar to those in the United States), or set up other special credentialing [40]. If CNS-advocates advance the role in any of these directions, ELCs will be a needed starting point.

### **6. Directions for the future**

The CCRNR [35] is updating the national NP ELCs, which will guide the development of a new entry-to-practice exam. This will further increase the standardization and quality of Canadian NP educational programs. The COVID-19 pandemic showed the multiple vulnerabilities of the healthcare system and the vital role NPs can play [42]. The number of NPs grew by 10.7% between 2020 and 2021 [16]. Although the future looks bright, a shortage of qualified nurse academics may limit future student enrollments [43]. Canada, like many countries, is plagued by a recurrent nursing faculty shortage [34]. As CASN [34] report found, Canadian nursing schools could not fill 46 faculty positions, representing a 2% vacancy rate. To fully implement the NP role, qualified nursing academics are needed to educate the next generation. Future research is needed to address the factors contributing to the nursing academic workforce shortage and to develop innovative strategies to promote faculty recruitment and retention [43].

#### **7. Conclusion**

In Canada, implementation of the NP role has yet to be fully realized, primarily due to role confusion. This confusion has led to less awareness about the role, which has made healthcare regulators slow to take advantage of these skilled professionals. The establishment of national ELCs provides a means to articulate the role of newly graduated NPs and to ensure acceptance of their role by other health professionals and the patient community. The ELCs increase the standardization/quality of NP educational programs, guide curriculum development, are a way for accrediting and regulatory bodies to assess NP education programs and inform the development and revision of the entry-to-practice exam. Consequently, they are an essential link between formal educational programs (like masters programs) and licensing bodies (i.e., the provincial/territorial nursing regulatory bodies). CNS-advocates who want to advance the role through more standardized education or other special credentialing may want to develop similar ELCs as 'somewhere' to start.

#### **Author details**

Sarah A. Balcom University of New Brunswick, Canada

\*Address all correspondence to: o295d@unb.ca

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 4**

## Application of Operations Research to Healthcare

*Jia Guo*

#### **Abstract**

Operations research (OR) is significantly important to healthcare. OR techniques can make efficient use of medical resources to enhance patients, providers and agencies'satisfaction. Given limited medical resources and high demand from patients, the primary goal of OR is to use optimization models to quantify the problem and apply mathematical algorithms to obtain a close-tooptimal solution. For example, OR has been widely used to scheduling problems by minimizing the number of nurses or maximizing demand coverage, while keeping service regulations satisfied. In this chapter, we first give a brief introduction of optimization models, followed by the application of OR to healthcare problems such as nurse scheduling, home healthcare delivery and transportation services for patients.

**Keywords:** operations research, mixed integer linear programming, mathematical models, healthcare optimization, nurse scheduling, home healthcare delivery, transportation service

#### **1. Introduction**

Operations research (OR) plays a critical role in healthcare of both rich and poor countries, especially when the medical resources are limited and the patient demand is high. OR techniques could be applied to optimize the use of medical resources, signicantly improve service quality and reduce operations cost. For example, techniques such as mixed integer linear programming (MILP) algorithms, heuristics and data analytics could be used to design nurse schedules, patient-provider assignment and transportation routes. The past experience has shown that it is possible to obtain high-quality solutions to the most difficult planning and scheduling problems by applying mathematical modeling and advanced decomposition techniques in conjunction with intelligent heuristics.

The general idea of OR application to healthcare is to make decisions by mathematical optimization models. Examples of mathematical formulation on a nurse scheduling problem and a routing problem will be presented in Sections 2 and 3, respectively. Before making decisions, we must have several components that pass on to the optimization model our requirements. Components include:

#### 1.Objective function

The objective function is the goal we wish to achieve. It can be the minimization of "cost" (such as the number of hired nurses, overtime hours, or patients' travel distance), or the maximization of "profit" (such as hospital revenue, patient demand coverage, or satisfaction level). Some problems require a multiobjective function. For example, hospitals aim to achieve maximum patient demand coverage with a minimum number of nurses.

#### 2.Constraints

Constraints are the rules and regulations we must obey. For example, nurses cannot work 20 hours a day, even though the violation of this rule can cover more patient demand with fewer nurses. Constraints that cannot be violated are considered "hard." In addition to hard constraints, there are "soft" constraints that can be violated with a penalty cost added to the objective function. For instance, nurses are not encouraged to work more than 40 hours per week, but overtime is allowed if all the demands must be covered. If a nurse works overtime for an hour, then the one-hour penalty cost is added to the objective function. That means all demand is covered at the cost of overtime.

#### 3.Decision variables

Decision variables indicate what we are supposed to decide. For example, in a home healthcare delivery problem, we need to decide on nurse-patient assignment, nurses' travel routes, and service start time at each patient's location.

#### 4.Parameters

Parameters are given as constants. For instance, when designing nurses' travel routes, we know the distance between every two locations. In real-life problems, however, some parameters are uncertain, such as patient demand and travel time, which may vary during different periods of the day. In such cases, robust optimization will be involved to address uncertainty.

In practical cases, a mathematical optimization model usually contains thousands, even tens and thousands of decision variables, making it extremely time-consuming for commercial solvers (such as CPLEX or Gurobi) to get a good solution within a reasonable amount of time. In reality, a lot of health institutes are reluctant to purchase the license of commercial solvers due to the high price. Therefore, mathematical algorithms (optimization-based heuristics or metaheuristics) are developed to solve large-scale problems. Optimization-based algorithms usually require solutions to mathematical models, but instead of solving the large-scale problem directly, the problem can be decomposed or transferred to smaller and easier problems. Common optimization-based algorithms include but are not limited to Lagrangian Relaxation, Column Generation, Benders Decomposition, Cutting Plane Algorithm and so forth. Metaheuristics do not rely on the type of the problem, but it must keep all the hard constraints satisfied while searching for a close-to-optimal solution. Metaheuristics include but are not limited to Genetic Algorithm, Greedy Algorithm, Tabu Search, Ant Colony Algorithm, Simulated Annealing, and Memetic Algorithm. Even though optimization-based algorithms and metaheuristics can find good feasible solutions within a limited amount of time, they are both at the cost of optimality. The quality of solutions obtained from the algorithm significantly depends on the algorithm parameters, such as time limit and the number of iterations for each step.

The remainder of this chapter displays several examples of OR application to healthcare, such as nurse scheduling, home healthcare delivery, and transportation services for patients.

#### **2. Nurse scheduling**

Nurse scheduling is a critical branch of OR application to healthcare. Nurses are of vital essence in hospital and clinic operations, generally accounting for more than 50% of the budget [1]. The efficient use of nursing resources can directly impact a healthcare system's financial well-being. This is true for both public and private facilities, and especially true for those that serve economically disadvantaged areas [2].

#### **2.1 Problem description**

In a nurse scheduling problem, the goal is to assign nurses to different shifts over a one-or-several-week planning horizon. A shift usually lasts 6–12 hours with a fixed start and end time. For example, the start and end time of the morning, evening, and night shifts are (7 am, 3 pm), (3 pm, 11 pm), (11 pm, 7 am), respectively. The union of all shifts covers the entire planning horizon.

The stakeholders in a nurse scheduling problem include nurses and patients. On the side of patients, the demand should be covered as much as possible. That means a sufficient number of nurses should be assigned to each shift, so that patients can receive necessary medical treatment. Also, nurses'skill qualification is of vital significance. For example, a nurse for a blood test cannot be assigned to help a patient with her physical therapy.

On the side of nurses, the laws and regulations are mostly on hours of service. For example, for each nurse, there is an upper and lower limit on the number of working hours and working days per week, the number of consecutive working days and days off, the number of consecutive working hours, the number of overtime hours per week, the number of shifts per day, and the number of weekend shifts. In addition, each nurse must rest for at least 8 hours between any two shifts assigned to her.

Furthermore, some clinics and hospitals allow nurses to report on their preference for days and shifts before the schedule is decided. For example, if a nurse reports her preferred working day is Sep. 28, and she will not be available on Oct. 1, then a "profit" will be added to the objective function if a shift is assigned on Sep. 28, and a "cost" will be incurred if she is scheduled to work on Oct. 1. Other factors contributing to nurses'satisfaction level include shift transition, work-day transition, and equity. The shift transition happens if a nurse is assigned different shifts on two consecutive days (e.g., morning shift on day 1 and evening shift on day 2). Shift transition makes it harder for nurses to keep a regular life schedule. Work-day transition involves two cases: (i) 1-0-1 schedule: work on day 1, rest on day 2, work on day 3; and (ii) 0-1-0 schedule: rest on day 1, work on day 2, rest on day 3. Neither 1-0-1 nor 0-1-0 schedule is beneficial as they add an interruption to nurses' work or rest. Equity means the number of overtime hours, 1-0-1 schedules, 0-1-0 schedules, or any other preference violations should be evenly spread among nurses. For example, it is not ideal to assign nurse A 20-hour overtime, while asking nurse B not to work overtime at all.

#### **2.2 Mathematical optimization model**

The requirements for nurses and patients can be either "soft" or "hard" constraints, depending on the hospital or legal regulations. In this subsection, a mathematical formulation for the nurse scheduling problem (Model 1) is presented. For simplicity, we assume the planning horizon is 1 week. The objective function is to minimize the number of uncovered demand hours, 1-0-1 violations, 0-1-0 violations, and violation differences among nurses. The hard constraints include the upper and lower limits on the number of working hours for each nurse in a week. Each nurse can work at most one shift per day.

*Sets and indices*


#### *Parameters*


#### *Decision variables*


*Application of Operations Research to Healthcare DOI: http://dx.doi.org/10.5772/intechopen.109919*

Model 1

$$\text{Minimize}\quad a \sum\_{d \in D} \sum\_{h \in H} U\_{dh} + \sum\_{i \in N} \sum\_{a=1}^{V\_{\text{max}}} r\_a \, V\_{ia} \tag{1}$$

subject to

1.Demand constraints

$$U\_{dh} \ge D\_{dh} - \sum\_{i \in N} \sum\_{t \in T} F\_{ht} X\_{idt} \tag{2}$$

2.Upper and lower limits on the number of working hours for each nurse in the planning horizon

$$\sum\_{d \in D} \sum\_{t \in T} h\_t X\_{i dt} \le \overline{H}\_i \qquad\qquad\qquad \forall \ i \in N \tag{3}$$

$$\sum\_{d \in D} \sum\_{t \in T} h\_t X\_{idt} \ge \underline{H}\_i \tag{4}$$

3.At most one shift per day for each nurse

$$\sum\_{t \in T} X\_{idt} \le 1 \tag{5}$$

4.Definition of 0-1-0 and 1-0-1 violations

$$\sum\_{t \in T} \mathbf{X}\_{idt} + \left(\mathbf{1} - \sum\_{t \in T} \mathbf{X}\_{i, d+1, t}\right) + \sum\_{t \in T} \mathbf{X}\_{i, d+2, t} + P\_{id} \ge \mathbf{1} \tag{6}$$

$$\left(\mathbf{1} - \sum\_{t \in T} \mathbf{X}\_{idt}\right) + \sum\_{t \in T} \mathbf{X}\_{i,d+1,t} + \left(\mathbf{1} - \sum\_{t \in T} \mathbf{X}\_{i,d+2,t}\right) + \mathbf{Q}\_{id} \ge \mathbf{1} \tag{7}$$

5.Violation computation

$$\sum\_{d \in D} (P\_{id} + Q\_{id}) = \sum\_{a=1}^{V\_{\text{max}}} aV\_{id} \tag{8}$$

#### 6.Variables definition

*Xidt*, *Pid*, *Qid*, *Via* ∈ f g 0, 1 ∀ *i* ∈ *N*, *d*∈ *D*, *t*∈ *T*, 0≤ *a*≤*V*max (9)

$$0 \le U\_{dh} \le D\_{dh} \qquad\qquad\qquad \forall\ d \in D,\ \ h \in H \tag{10}$$

Objective function (1) consists of two terms. The first term is the weighted demand uncoverage, that is, sum of the number of nurses required but not supplied in each hour every day. If the hospital requires 10 nurses on Monday between 8:00 am and 9:00 am, but only 7 nurses are assigned to this hour, then we have uncovered a demand of 3, that is, *U*Mon,8 ¼ 3. Instead of adding 3 directly to the objective function, we add 3*α* to quantify the significance of demand coverage. The weight for an uncovered demand (*α*) is usually larger than 1 because we give demand coverage a higher priority. The second term is the penalty for 1-0-1 and 0-1-0 violations. Binary variable *Via* ¼ 1 if nurse *i* has *a* 1-0-1 and 0-1-0 violations throughout the planning horizon. Note that *ra* is usually a constant exponential of *a*. For example, if nurse *i* has 3 1-0-1 and 0-1-0 violations, then a penalty cost of *e*<sup>3</sup> will be added to the objective function. We use a constant exponential of *a* because we would like to improve equity among nurses, that is, not to assign one particular nurse a large number of violations, while giving other nurses few violations.

Constraints (2) define the number of uncovered demands in each hour every day. On the right-hand side of (2), *Ddh* is the number of nurses required in hour *h* on day *d*. The term P *i* ∈ *N* P *<sup>t</sup>*∈*<sup>T</sup> FhtXidt* indicates the number of nurses scheduled to work in hour *<sup>h</sup>* on day *<sup>d</sup>*. We use " <sup>≥</sup>" instead of "¼" in this set of constraints due to the following reasons:


Constraints (3) and (4) force each nurse to work between *Hi* and *Hi* hours in the planning horizon. Constraints (5) require a nurse should work at most one shift per day. Constraints (6) and (7) indicate whether nurse *i* has a 0-1-0 or 1-0-1 violation P starting on day *d*. Take constraints (6) for example, if nurse *i* rests on day *d* (i.e., *<sup>t</sup>*∈*<sup>T</sup> Xidt* <sup>¼</sup> 0), works on day *<sup>d</sup>* + 1 (i.e., <sup>P</sup> <sup>P</sup> *<sup>t</sup>*∈*<sup>T</sup> Xi*,*d*þ1,*<sup>t</sup>* <sup>¼</sup> 1) and rests on day *<sup>d</sup>* + 2 (i.e., *<sup>t</sup>*∈*<sup>T</sup> Xi*,*d*þ2,*<sup>t</sup>* ¼ 0), then to make constraint (6) satisfied, binary variable *Pid* must equal 1, indicating nurse *i* has a 0-1-0 violation starting on day *d*. Constraints (8) calculate the total number of 0-1-0 and 1-0-1 violations. Constraints (9) and (10) give variables definitions.

#### **3. Home healthcare delivery**

Home healthcare (HHC) delivery plays an important role in medical service, especially for patients with chronic illnesses and ambulatory disabilities. Instead of requiring patients to travel to hospital for medical treatment, hospitals schedule qualified nurses to provide service for patients at their place of residence. The quality of the weekly and daily schedules assigned to the nurses can impact the level of service patients receive, as well as nurse productivity and job satisfaction. Efficient patientnurse scheduling and routing can significantly reduce the cost and improve the service quality of HHC.

#### **3.1 Problem description**

In a home healthcare scheduling and routing (HHCSR) problem, nurses are scheduled to provide medical treatment for patients who reside in different locations of a city. On each day of the planning horizon, a nurse starts from home (or a depot), visits patients that are assigned to her, and returns home. Decision variables include (i) nurse-patient assignment, that is, which nurse should be assigned to visit each patient; (ii) the travel route of each nurse (i.e., visit sequence of patients for each nurse); and (iii) nurses' arrival time at patients' home. The objective of an HHCSR problem includes but is not limited to the minimization of nurses' travel distance and the maximization of patients'satisfaction level. Details of each stakeholder will be discussed in the remainder of this subsection.

#### *3.1.1 Patients*

Before the agency (clinic or hospital) designs nurses' assignments and routes, patients request visits with specific service dates, time windows, and skill requirements. Nurses'schedules and routes are designed based on the information from patients. In addition to meeting the requirements on time and skill qualification, the agency should try to keep the continuity of care (CoC) for patients with multiple visits in the planning horizon by assigning the same nurse to a patient. CoC has the benefit of maintaining treatment consistency as the nurse becomes more familiar with the patient's physical condition and treatment details.

#### *3.1.2 Nurses*

To ensure the nurses can provide high-quality service for patients, the daily workload of each nurse is limited to a specified range. The workload can be associated with the number of working hours, the number of patients serviced, and the type of medical treatment offered by the nurse. In addition, nurses usually have agreements with the agency on the start and end time of each day. However, in some cases, nurses are allowed to work overtime to complete more requested visits. Moreover, the differences in workload among nurses with the same skill level should be minimized to achieve the objective of equity. Finally, to provide a healthy working environment, a lunch break is taken into account.

The requirements from patients and nurses can be either "hard" or "soft" constraints in the optimization problem, depending on the agreement among patients, nurses, and the agency. If a constraint is relaxed as a "soft" constraint and is violated in a schedule, then we should add a penalty cost to the objective function.

The above paragraphs describe the basic version of a HHCSR problem. In practice, the problem can be extended and involve more stakeholders. For example, in some cases, on each day of the planning horizon, nurses start from pharmacies, visit patients to drop off medicine, provide medical treatment, and collect biological samples (such as blood or tissue). After visiting all the scheduled patients, nurses deliver all collected biological samples to laboratories for tests [3]. In such cases, besides decisions in the basic version of a HHCSR problem, patient-pharmacy assignment and pharmacy-laboratory assignment should be made. Furthermore, vehicle capacity must be considered due to the transportation of medicine and biological samples.

#### **3.2 Mathematical optimization model**

In this subsection, we assume the nurse-patient assignment is completed by clustering based on the geographical locations of patients. Model 2 decides the sequence of requested visits assigned to nurse *w* on day *d*, as well as the service start time of each visit. The objective is to minimize the travel time, the number of hours a visit is completed outside of the patient's time window, and the number of hours nurse *w* works overtime. Model 2 makes use of following notation.

*Sets and indices*


#### *Parameters*


#### *Decision variables*


#### Model 2 (for fixed nurse *w* on day *d*)

$$\text{Minimize}\quad a\sum\_{i\in I\_{dw}}\sum\_{i'\in I\_{dw}}\tau\_{ii'}X\_{dii'w} + \sum\_{i\in I\_{dw}}\left(Y\_{div}^{\text{VS}} + Y\_{div}^{\text{VE}} + Y\_{div}^{\text{WS}} + Y\_{div}^{\text{WE}}\right) \tag{11}$$

subject to.

Each visit has a predecessor and successor on a route

$$\sum\_{I\_i' \in I\_{dw}} X\_{d\text{if } w} = \mathbf{1} \tag{12}$$

$$\sum\_{i \in I\_{dw}} X\_{d \text{if } w} = \mathbf{1} \tag{13}$$

Violation of patient time windows

$$Y\_{\rm div}^{\rm VS} \ge h\_i^s - T\_{\rm div} \tag{14}$$

$$Y\_{\rm div}^{\rm VE} \ge T\_{\rm div} + \mathfrak{t}\_{\rm i} - h\_{\rm i}^{\rm e} \tag{15}$$

Violation of shift start and end times

$$Y\_{div}^{\rm WS} \ge h\_{dw}^{s} - T\_{div} \tag{16}$$

$$Y\_{div}^{\rm WE} \ge T\_{div} + \mathfrak{t}\_i - h\_{dw}^{\mathbf{e}} \tag{17} \\ \tag{17}$$

Subtour elimination constraints

$$T\_{\rm div} + (\tau\_{\rm if} + t\_i) - M(\mathbf{1} - X\_{\rm dii'w}) \le T\_{\rm di'w} \tag{18}$$

Variables definitions

$$X\_{di'w} \in \{0, 1\} \qquad \qquad \forall \ i \neq i' \in I\_{dw} \tag{19}$$

$$\begin{array}{ccccc} \mathbf{Y}\_{\mathit{d}lw}^{\textup{VS}} & \mathbf{Y}\_{\mathit{d}lw}^{\textup{VE}}, & \mathbf{Y}\_{\mathit{d}lw}^{\textup{WS}}, & \mathbf{Y}\_{\mathit{d}lw}^{\textup{WE}} \geq \mathbf{0} \end{array} \tag{20}$$

$$T\_{div} \ge 0 \qquad\qquad \forall \ i \in I\_{dw} \tag{21}$$

Objective function (11) contains two terms. The first term minimizes the travel time. The second term minimizes four components. The first two components represent the length of time window violation for an early or late arrival of nurse *w* for visit *i* on day *d*. The third and fourth components are the number of hours outside of the start or end time of a shift for nurse *w* on day *d*.

Constraints (12) and (13) ensure that each requested visit has exactly one predecessor and successor on a route, assuming there is a dummy origin and destination. This makes the route a closed loop. Constraints (14) and (15) calculate the number of hours a visit is completed outside of its time window. Constraints (16) and (17) compute the number of hours nurse *w* works overtime. Constraints (18) prevent the model from creating subtours among the requested visit locations. Constraints (19)–(21) define the variables range.

#### **4. Transportation services for patients**

Transportation services for nonemergency medical appointments are of vital importance, especially to financially disadvantaged patients. In urban communities, a lot of poor patients cannot afford a car, and thus they have to rely on public transportation to keep medical appointments. However, public transportation is insufficient and inconvenient for people with ambulatory issues. As a result, clinics experience high cancelation/no-show rates. Moreover, many patients do not have the means to pick up their medicine after appointments, which makes their situation even worse. Good transportation services can significantly help patients to keep appointments and save operations costs of the clinic [4].

Unlike the problem described in Sections 2 and 3, offering transportation services for patients can hardly be integrated into one single optimization model but involves

multiple problems such as the prediction of no-show rate, the decision on transportation mode, and the assignment of transportation services. The remainder of this subsection introduces details of each problem.

#### **4.1 Prediction of no-show probability**

When designing transportation services for patients with nonemergency medical appointments, we first need to investigate the impact of transportation barriers on no-show, and predict the no-show probability assuming the transportation service is not available. This can be achieved by collecting patients' historical data, such as home address, transportation difficulty level, transportation mode, ambulatory issue, and travel time, whether they have chronic diseases, and whether they kept their appointments. Then, statistical analysis can be conducted to predict the no-show probability based on those factors, and verify whether the transportation barrier significantly impacts the no-show probability. Logistic regression models can be applied to predict the probability. This step shows whether providing transportation services is necessary, and recognizes the group of patients that need transportation services [5, 6].

#### **4.2 Decision on transportation mode**

Unlike regular urban transportation, transportation services for patients must be uniquely designed due to patients' weak physical conditions. Therefore, the transportation mode should meet the following requirements. First, the transportation mode should allow patients to either sit or stand. For example, it is improper to offer free bicycles to patients. Second, some patients have ambulatory issues, so the transportation mode must have enough capacity to hold wheelchairs. Third, some clinics or hospitals do not have bus stations nearby, so the transportation service should give patients a ride to their destination. Finally, the transportation mode should allow patients to receive service without long waiting, especially in areas of severe weather. Based on the above requirements, taxis and shuttle buses with short intervals are common transportation services provided for patients.

#### **4.3 Vehicle routing-based optimization problem**

The vehicle routing-based optimization problem is a crucial branch of transportation services if shuttle buses are offered. In a regular vehicle routing problem, vehicles depart from a depot, visit several locations and return to the depot. In a medical situation for patients, each vehicle starts from the clinic, visits several stops to pick up and drop off patients, and goes back to the clinic. In this optimization problem, we need to decide the number of vehicles, the route of each vehicle, and the vehicle's arrival time at each stop. With a rough estimation of the number of patients at each bus stop, we should also take vehicle capacity into consideration. Moreover, the shuttle interval and travel time must be restricted to an upper bound for the sake of patients' health conditions. The objective can be minimization of vehicles' fixed cost, travel cost, patients' waiting, or travel time. Examples of vehicle routing problem models can be found in Luo et al. [7] and Guo et al. [4].

*Application of Operations Research to Healthcare DOI: http://dx.doi.org/10.5772/intechopen.109919*

#### **5. Summary**

Operations research has been widely applied to healthcare by maximizing the benefits of all stakeholders with a limited amount of medical resources. In addition to nurse scheduling, home healthcare delivery, and transportation services for patients, other problems such as operating room and surgeon assignment, inventory management of medical material, and healthcare project prioritization can also be addressed by mathematical models and algorithms.

Besides knowledge and skills in healthcare management, mathematics, and computer, expertise in other fields plays a crucial role in OR application. For example, topology and network theories are of vital importance in transportation design, and inventory techniques can significantly improve the order and storage decisions of medical material. The OR application to healthcare is a combination of mathematics, computer skills, medical knowledge, and a variety of interdisciplinary expertise.

### **Author details**

Jia Guo Operations Research and Industrial Engineering, Cockrell School of Engineering, The University of Texas, Austin, TX, United States of America

\*Address all correspondence to: jia.guo@utexas.edu

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Chiang B. Estimating nursing costs— A methodological review. International Journal of Nursing Studies. 2009;**46**(5): 716-722

[2] Guo J, Bard JF. A column generationbased algorithm for midterm nurse scheduling with specialized constraints, preference considerations, and overtime. Computers and Operations Research. 2022;**138**(2022):105597. DOI: 10.1016/j. cor.2021.105597

[3] Bahadori-Chinibelagh S, Fathollahi-Fard AM, Hajiaghaei-Keshteli M. Two constructive algorithms to address a multi-depot home healthcare routing problem. IETE Journal of Research. 2019;**68**(3):1-7. DOI: 10.1080/ 03772063.2019.1642802

[4] Guo J, Bard JF, Morrice DJ, Jaén CR, Poursani R. Offering transportation services to economically disadvantaged patients at a family health center: A case study. Health Systems. 2022;**11**(4): 251-275

[5] Mohammadi I, Wu H, Turkcan A, Toscos T, Doebbeling BN. Data analytics and modeling for appointment No-show in community health centers. Journal of Primary Care & Community Health. 2018;**9**:1-11

[6] Topuz K, Uner H, Oztekin A, Yildirim MB. Predicting pediatric clinic no-shows: A decision analytic framework using elastic net and Bayesian belief network. Annals of Operations Research. 2018;**263**(1–2): 479-499

[7] Luo Z, Liu M, Lim A. A two-phase branch-and-price-and-cut for a dial-aride problem in patient transportation. Transportation Science. 2019;**53**(1): 113-130

### **Chapter 5**

Nurse Practitioners "Insider" and "Outsider" Roles and Responsibilities Enabling a Quality Managed Delivery of Contemporary Medical Imaging Services

*Chandra Rekha Makanjee*

#### **Abstract**

Nurse practitioners (NPs), as key healthcare professional, play a critical role in the provision and coordination of care, prevention of adverse events, health service throughput, and patient outcomes. Patient experience is considered as one of the pillars of quality in healthcare, along with patient safety and clinical outcomes. Based on the aforementioned, nurse practitioners have a vital role in providing clinical nursing care to patients within or outside of the immediate medical imaging (MI) working environment. Their evolving role expansion in medical imaging is documented in the literature. The purpose of this chapter is to create further awareness of the nurse practitioner in medical imaging.

**Keywords:** quality, management, contemporary, services delivery, nurses

#### **1. Introduction**

In health care organizations, nurse practitioners (NP) play a pivotal role in serving as a liaison between multi disciplines including the temporary team membership in medical imaging (MI) enabling patient care management that strives to achieve consistent, high-quality care [1]. The principle of quality is implicit in healthcare and includes aspects of accessibility, appropriateness, affordability, availability, effectivity, efficiency, integratedness, and safety [2]. Additionally, the continuity of care and wellbeing concept which goes beyond the healthcare complex is essential. Continuity is conceptualized as multidimensional, encompassing three specific domains—relational, management, and informational continuity—with emphasis placed on their interrelations. Continuity of care (CoC) is an important aspect of quality, safety and efficient manner. CoC implies the delivery of services in a coherent, logical, and timely fashion [3]. These NPs form an integral part in the continuity and holistic care

using the nursing process of assessment, diagnosis, planning, implementation, and evaluation. Including nursing care to individuals' families, communities, or populations by using critical thinking, skill, professional competence, and evidence-based knowledge.

MI technology is a healthcare resource intertwined and shared across the multilayered healthcare delivery, medical specialties, and patient care. Their services are crucial in the management of various diseases contributing toward CoC, ranging from primary prevention, timely detection, and diagnosis to treatment and post-therapy rehabilitation or palliative care and as well as for fluoroscopic real-time visualization of different types of pathology and image-guided diagnostic tumor sampling for pathology work-up and therapeutic interventions. It aligns with the recent endeavor on the role of medical imaging in value-based healthcare. Including the timely diagnosis highly reliant on the accessibility, effectiveness, efficiency in utilization of the imaging technology [4, 5]. It consists of both ionizing and non-ionizing imaging modalities. The ionizing modalities are general radiography, fluoroscopic imaging examinations, mobile radiography, portable radiography, mammography, computed tomography, angiographic and interventional angiographic imaging examinations, diagnostic nuclear medicine whereas non-ionizing imaging modalities include diagnostic ultrasound and magnetic resonance imaging. The different examination types with its respective imaging modalities and the interpretation of the imaging series are used to diagnose, monitor, or treat medical conditions [4, 6]. From an NP perspective technology form an integral part of the nursing profession and it is expected of them to have that specialized knowledge and insight to recognize, prevent and care for possible complications related to MI examination types [7].

The purpose of the chapter is to provide a bird's eye view of the roles and responsibilities of the NP in MI as an "insider" and "outsider" as the patient journeys through the various points within the healthcare system.

#### **2. The nurse practitioner's scope of practice and diagnostic decision-making processes**

Quality of care improvement within a healthcare team differs in terms of education, expertise, and competencies. For example, a rich mix of qualified staff with postgraduate qualifications is associated with better clinical outcomes. Globally, there is a widening gap between the supply and demand of healthcare workers indicating a need for an urgent response. Within the bigger picture at the global level bridging, this gap is complex and complicated. Several factors impact the balance of demand and the supply of timely and appropriate care. Within this context, the number of healthcare professionals is only one aspect impacting access to care. In this regard, NPs are positioned in settings such as government roles, public health, academia, clinical care, leadership, and private industries with the ability to develop a creative and effective network to respond to multifaceted problems. Dynamic NPs practicing to its full scope can assist in addressing health system demands [8].

Before this can occur, a clearer understanding and national application of the NP scope of practice is required [9]. Any ambiguity surrounding the practice scope of NP impacts the profession's ability to respond to health system challenges. NP scope of practice is defined and regulated among others by their education, training, clinical experience, registration standards, endorsements and notations, positions of employment, clinical protocols, and guidelines. Efforts to recognize new professions

#### *Nurse Practitioners "Insider" and "Outsider" Roles and Responsibilities Enabling a Quality… DOI: http://dx.doi.org/10.5772/intechopen.111423*

or modify the scope of practice for existing health professions usually require the enactment of or amendment to state law, a process that is typically slow and, at times, adversarial. For example, in the United States of America, states often solicit input on proposed changes from stakeholders, including professional associations and, to a more limited extent, consumer groups [10]. According to Gleason et al. the scope of practice laws is not the barrier as perceived to be [11]. These authors advocate that NPs to be prepared and accountable for playing an active role in the diagnostic process, not that they assume accountability for making medical diagnoses. However, a challenge is a false perception that scope of practice laws prohibits NPs from participating in the diagnostic process. The lack of consistency across states' scope of practice laws and terminology used to describe the role of NPs in medical diagnosis could contribute to the confusion. Therefore, encouraged to adopt clear and common regulatory language that contributes to the medical diagnostic process, is within the NPs scope of practice [11].

However, the reality is that these professionals significantly contribute to the medical diagnostic process, in terms of observations, diagnostic thinking, clinical judgment, reasoning, and interpretations of findings. Gleason and others believe that NPs are essential members of the diagnostic team. Though there is a clinical medical diagnosis by medical healthcare professionals assigned based on a syndrome or disease based on a set of signs, symptoms, and other findings. One could argue that a nursing diagnosis is based on a clinical judgment based on a holistic approach not only isolated to their health conditions but expands beyond the immediate clinical context including family members and community. However, these practitioners also function in acute, chronic, and high-pressure critical medical environments and expectation to identify and intervene through an action plan. This process of diagnostic decision-making encounters includes diagnostic tests like medical imaging encounters that NPs are directly or indirectly involved [11].

From a MI quality management perspective, MI service refers to an understanding of the importance of quality as a determining factor in competitiveness such as globalization, technological evolution, increased competition, changes in the profile of patients in these services [5]. Like any health service, it is an open system and suffers the action of the environment that constantly changes, while it contributed to the emergence of a new way of seeing its internal and external relations to meet new demands of imaging service. Quality of services that occupy an important place in health care is imbued to seek excellence and sustainable development with a focus on risk management, quality of exams, reports, and patient safety improvements [12]. Nursing influences and adds value to the practice in radiology and imaging diagnosis by incorporating assessment skills and initiatives of evidence-based practices, and the nurses' specialization in MI is recognized. Disseminating this specialty and producing knowledge, as well as the methodology of nursing accreditation in this space, require attention, as they are associated with the redefinition of the roles of NPs and other members of the health team [6].

The quality of service regarding the CoC for instance includes on-MI NPs who are responsible for the handoffs and safe transition of patients between inpatient wards and MI departments. CoC occurs through verbal and written reports. That CoC was disrupted because of breakdowns in verbal and written communication. In a study by Carley and others several participants echoed the limited communication about what happened in the MI procedure during handoff. Information shared verbally between the sending and receiving nurses varied. To overcome this shortcoming, a suggestion was to focus on the specifics about the procedure when interacting with medical imaging NPs [13].

#### **3. Nurse practitioner referrer and medical image interpreter role**

MI studies usually come from referring clinicians during a medical encounter who seek radiological input, and directly receive the output (reports). Referring clinicians can be considered as "intermediate customers". Similarly, it is not unusual for NPs to complete a request order, initiate an imaging referral, varying from country to country. For example, within an Australian primary healthcare context, NPs scope is limited to completing referrals for chest and pelvis radiographic examinations. Restrictions also apply to other imaging examinations such as Dopplers and Dexa scans. These are essential for NPs to be able to access if they are to provide appropriate primary health care and address often urgent health needs without the delay. For example, there are legislative changes proposed by the Australian Capital Territory Government with regard registered NP registered by the Nursing and Midwifery Board of Australia with regard to advanced practice. Like working independently and collaboratively within the ambit of expert critical care context. Includes among other like core activities, such as diagnosis and treatment of medical conditions, prescribing medicine and requesting and interpreting diagnostic examinations (e.g., blood tests and MI examinations) [14].

One of the arguments is the fear of over or under diagnostic tests that would or would not have been ordered by the medical officer. Though the potential benefits of NPs in terms of saving time and satisfaction, there are also excessive requests that could potentially result in additional time, additional expense and increased resource utilization, unnecessary radiation exposure, and potential morbidity. Risk of additional tests following the physician's examination. Additional projections of the same/adjacent or different regions can be ordered because the first projection did not demonstrate the problem, or another injury was discovered during the consultation. The "to and froing" like unnecessary trips to imaging become necessary, resulting in both the time constraints for treatment and the inconvenience to the patient [15, 16].

The request order is an effective and efficient medium of communication between the refer and the recipient on behalf of the patient. The request order is an essential part of the justification for the examination, a medico-legal requirement, provides the cue for the type of MI examination through verification and confirmation with the patient, the planning of the MI examination, compiling a radiological interpretation and report triggering an action plan and form part of the medical record keeping. For example, often MI services are rendered outside of the immediate MI section, such as intensive care units, emergency and trauma settings, and ward settings. In these instances, the justification expands beyond the imaging justification principle. These requests ideally are restricted to patients on life-support machines or those with medical conditions where nursing care and treatment could be seriously affected if transported to the imaging section. If the examination requested could be done in the MI section with a better outcome, the MI team should consult the referring doctor and nurse looking after the patient regarding the advisability of moving [17]. In other words, the referring doctor should always consent to any changes to the mobile imaging service requested. A chore in the element is quality of the information and processing the referral in a timely manner in achieving a high impact quality MI outcome. Bearing in mind that multiple patients and patient acuity levels can prevent the attentiveness needed to process orders in a timely manner. A good working relationship between the doctor, radiographer, and nurse is cardinal in acquiring quality diagnostic images [18].

#### *Nurse Practitioners "Insider" and "Outsider" Roles and Responsibilities Enabling a Quality… DOI: http://dx.doi.org/10.5772/intechopen.111423*

In most instances, the refer could make a request electronically through the radiology information system (RIS) or paper-based and especially in an emergency by telephone and or bleep system. Digital patient records enable and ensures seamless communication between the departments. If this record is not available and configured in a way that the MI professionals can access and utilize. Inaccessibility and timely access could result in errors, impact safety, compromise the quality of examination, accuracy of results, or potential for delays. It is essential for NPs as referrers to liaise with all involved parties in establishing the information that should be shared at this stage. For example, documenting not only the presence of an intravenous line but also the size of the line can be essential information for MI sections like contrast media-related imaging examinations. Considerable time can be lost if MI staff must track down the referring NP to find out if an intravenous line is capable of the high flow required for some intravenous MI contrast agents.

With modern MI computer science and technological advancement, a chore component of clinical practical applications such as medical diagnosis, treatment planning, and for instance surgical navigation [17, 19]. Including a wide array of technological networks among other social media and e-health data use has resulted in a massive progression in the way MI services are delivered [20]. An essential element throughout these processes is the filtration of the quality documented information in the delivery of quality, evidence-based nursing practice. Since NPs accountability, roles, and responsibilities expand across settings from the micro-level clinical bedside to an administrative office role at the meso and or macro level in an organization. According to Zadvinskis et al., and Abuzaid and others recognise the value of artificial intelligence (AI), like health information system, electronic health records; and digitised order entry and decision aid support in medical imaging and robotics. These cognitive technologies are less invasive and more accurate tools for diagnosis and treatment. The recommendations are for organizations to invest in these technologies, refine the policies and align with nursing practice and integration into nursing education and professional development [21, 22]. Clinical data provide a holistic and collaborative understanding of the clinical condition and the management of patient care. Digital management systems can be of value in terms of data storage which can be transformed into stored electronic clinical data for utilization to provide safe and effective patient care. The design of these clinical systems should address workflow and must be done on a continuous and iterative approach based on identified needs. Good record-keeping is an integral part of patient care. Documentation should extend beyond the confines of the diagnostic report. An integrated "event details" section would allow important information to be recorded through an integrated clinical environment platform. As part of the patient clinical notes and discharge summary, thus reducing the risk of conflicting information between patient information held on the RIS and information in the patient notes. Thereby, maintain consistent continuity of patient care and help to inform future decisions regarding patient management and MI examinations [23].

The professional NPs in a study by Makanjee et al. were eager to expand their scope of practice, specifically to include the interpretation of radiographs [24]. Based on their wish to provide feedback to patients who are anxious or in transition between MI and another point of contact and to compile evidence-based nursing notes. NPs are usually the first to prepare the patient for MI examinations, read the radiological interpretation report, and provide the interpretation to the clinician. Hence, it is very important for the NPs to have a basic understanding of Chest radiographic findings to sharpen their assessment skills, promote patient safety, and alter their actions to

benefit the patient [25]. Several studies have shown evidence that NPs can interpret plain radiographic, CT, and ultrasound images through experiential learning or formal training [25, 26]. The evolving nature of this role has occurred in response to emergency departments' necessity to discover innovative ways to improve service delivery also linked to other subspecialties within the hospital is the timeliness of the accessibility and delivery of these images. A solution could be to device process metrics to provide an indication on aspects of the value of delivery in terms of the timeliness of the information delivery and its applicability to appropriate levels of specialization and subspecialties to interpret [5].

#### **4. NP roles and responsibilities in the immediate MI environment**

NPs caring for patients in MI started in the 1970s because of multimodality, cutting-edge imaging technologies. Thereby, the potential to improve efficiency, grow service lines, and improve the visibility of MI departments. A challenge in the immediate MI working environment could be adapting from having stable nursing care plans and routines to the frequency of changing plans when a patient is a switch between modalities. In close collaboration with multidisciplinary teams in imaging services, ensuring also that policies, guidelines, and protocols are complied with and contribute toward enhancing effective improvements [24, 27, 28]. For example, during the general or plain radiographic examination depending on the patient's characteristics, the competency of the radiographer and equipment ensuring the patient's comfort while in the MI examination room, the orienting and supporting the patient's immobility during the exam, interdependent on patient cooperation, such as holding breath for a while. Providing a calm and relaxed environment for the patient is indeed vital. Complexities may arise when patients require sedation, especially in the pediatric population group. Often requires scheduling in coordination with the hospital's specialized nursing care center and medical specialist. According to Ruess and the authors, there were inconsistencies in terms of the method of administration and type of medications. A confounding factor was the variable levels of experience [29]. To resolve this issue representatives from nursing staff and physicians from pediatric radiology, pediatric, anesthesia, and quality services representatives, formed a multidisciplinary team. The review entailed using institutional and national regulatory authorities' guidelines and protocols to standardize the ordering process, pre-sedation history and physical examination, physician training and staffing, and sedation medication protocols. Implementing a sedation pathway enhanced the safety, effectiveness, and efficiency of sedation medication for routine diagnostic imaging procedures [29].

Another area is the fluoroscopic imaging procedures where NPs play a chore role whether it be outside or within the immediate MI section. The Fluoroscopy MI technique uses ionizing radiation to obtain real-time moving and or static images of internal structures and functions on a display screen and guide the procedures [30]. NPs take on numerous roles during fluoroscopically guided interventions (FGI) procedures ranging from working in a radiation environment to operating fluoroscopy equipment where permissible by law. The patient care processes pre-, during post-fluoroscopic examinations. For instance, to improve the quality of the images and to obtain a safe report, before starting the exam, the nursing professional checks if the patient has prepared as requested when scheduling the exam. Fluoroscopic examinations like other modalities such as CT, MRI, and US include the administration of contrast agents associated with the patient's physiological condition. During this process, NPs together

#### *Nurse Practitioners "Insider" and "Outsider" Roles and Responsibilities Enabling a Quality… DOI: http://dx.doi.org/10.5772/intechopen.111423*

with MI professional team include safe medication management in contemporary clinical practice. Record keeping is central for risk management (e.g., contrast reactions and extravasations) and medico-legal reasons. Knowledgeable of the associated risk with contrast agent administrations include the knowledge of characteristics of the type of contrast agents and its suitability among other in conjunction with the catheter selection, cannulation site, etc. [7]. Occupational risks include radiation exposure, slips, trips, falls, and potential head injuries, along with potential exposure to chemotherapy, bodily fluids, and other pathogens, which are the most common risks faced by multidisciplinary team members including medical imaging NPs [31].

#### **5. Nurse practitioner roles and responsibilities outside the immediate MI environment**

Most hospitals are equipped with the provision of MI services away from the immediate MI section. In this section, the focus shifts toward, critical care units, theater, ward MI examinations, and remote mobile MI services [17]. As already mentioned, NPs are vital in the management of patients for ionizing and non-ionizing MI examinations. In the previous section, the role of non-medical imaging NPs was briefly touched upon in terms of handovers and the importance of an effective efficient manner of communication information exchange. An integral component is the competency, roles, and responsibilities of the contemporary multidisciplinary team members in aligning, coordinating, cooperating, collaborating, and communicating in critical decision-making processes and procedures regarding MI examinations protocols in maintaining and sustaining the seamless clinical medical CoC and wellbeing of the persons. For example, peripherally inserted central catheter insertion by NPs under fluoroscopy guidance has been shown to be a safe and suitable alternative to radiologist insertion with similar technical success and similar long-term complication rates. It could have flow-on effects in terms of cost reduction, provision of technical ward support, and allowing radiology medical staff the time to perform other fluoroscopic or angiographic procedures [32]. Central to and interwoven is technology as an enabler, facilitator, and mediating the network of interactional processes in achieving these seamless quality outcomes in patient management. The overarching and golden thread to be considered, is the holistic care and safety culture.

Pros could be ease of access where transferring a patient to the MI section could result in compromised care in terms of their unstable medical condition affecting both the treatment and nursing care. Also, requires careful consideration in terms of radiation safety and the quality of the completeness of an MI examination. For example, one needs to ensure that the physical environment is radiation safety compliant, like the thickness of the walls in theater and critical care units. Considerations include radiation protection control measures during mobile radiography such as bed distancing and protecting patients, themselves, and members of the public visiting the ward/unit. So, the timing of an MI examination, if possible, can be negotiated to avoid unnecessary exposure to the public unless critical. Some of the most common MI examinations performed is the chest radiographic imaging examinations. The most common indications for performing portable MI examinations are to check for positions of tracheostomies, nasogastric tubes (NGs), central lines or central venous catheters (CVCs), trauma injuries, pacemakers, and other medical conditions of patients who require special care. Other MI examinations can also be performed, but dependent on the type of MI equipment and its characteristics, the quality of radiographic images, and safety [17].

Prior to commencing a MI examination, a written MI request should be made. Apart from the medico-legal requirement and justification aspect, the radiographer needs to plan the imaging examination, select an appropriate image receptor, ensure the equipment is optimally functioning and appropriate imaging exposure parameters are selected and may require additional accessories such as immobilization aids. Assess the patient's condition in liaison with the NP. The NPs are responsible for the patient knowing condition and patient's needs. The radiographer and NP collaboratively coordinate the immobilizing, positioning of the patient, and the image receptor device to acquire the required radiographic projection of the body part of interest. At the end of the imaging examination, the NP or referring doctor should be informed of when the outcomes of the imaging examination are likely to be available [17].

#### **6. An overview of shared roles and responsibilities on safety culture**

An important aspect throughout any MI examination is aspects of infection control and cross-contamination. Any infection control measures should be communicated to the MI professionals and infection control protocols always be adhered to. Include the MI equipment and its accessories and radiation safety protective gear. For instance, theater and mobile MI equipment and its accessories should ideally be dedicated units kept on site. During an imaging examination, it is advisable to cover the image receptor with a suitable cover material (double-bagged if required) to prevent contamination from body fluids. Also, take into consideration that the material used will not create an artifact and is radiolucent. As would compromise the quality of the MI examination and risk the safety of the patient. When dealing with highly contagious infections wear appropriate personal protective equipment (PPE). All contaminated gear such as the covers and PPE placed in the correct waste bins. Occasionally, NP would be required to assist in the imaging of these patients. The principles of barrier nursing techniques of infection control are necessary. During this process, the role and responsibility of the radiographer and NPs knowledge of body part positioning, aligning of the image receptor, and following instructions from the radiographer is important in ensuring that safety is maintained without compromising the quality of the MI examination.

Following the MI radiation safety guidelines are significantly important. NPs should be knowledgeable about radiation safety rather than learning on the job from hearsay. Practical errors and feedback and annual training on radiation protection and safety and should be included in an occupational dose monitoring program. Basic radiation protection principles can be summarized as, time, distance, and shielding. All radiation protection strategies are fundamentally related to one or more of these rules. Using personal dosimeters ensures the management of the duration of stay in an area with high radiation levels and the monitoring of accumulated doses. Use radiation protective gear such as lead aprons, thyroid shields, and lead glasses. Justified by the role of the NP during fluoroscopic guided intervention who is in proximity monitoring the patient, an advocate for the patient, and reporting back all pertinent information related to potential safety concerns. A mobile lead shield that is transparent, at least on the upper half, can be used to create a protected area at the nurse workstation. NPs who take on the role of a procedure assistant will move around the room and therefore will require the same thickness apron in the front and back. Ceiling-suspended shields are also very effective at reducing radiation dose to the upper body and the lenses of the eyes [17, 33].

*Nurse Practitioners "Insider" and "Outsider" Roles and Responsibilities Enabling a Quality… DOI: http://dx.doi.org/10.5772/intechopen.111423*

Like their MI professional counterparts, medical imaging NPs who are pregnant or planning to become pregnant do not need to modify their duties related to working in radiation environments [34]. Pregnant radiation workers should declare their pregnancy to a radiation safety officer and acquire a fetal dosimeter in addition to the occupational dosimeter worn under PRE at the level of the conceptus, used to monitor the dose to the conceptus. The dose to the conceptus is restricted to a much lower level than that of the worker [31].

#### **7. Conclusions**

In conclusion, this chapter provided a snapshot of the NPs integrated roles and responsibilities as part of the contemporary MI team both within and outside of an evolving technological medical imaging environment and service delivery. This chapter adds to the contribution, performance, and recognition of their work. Essentially, MI professionals (radiologists and radiographers) should acquaint themselves with the scope of practice of NPs and vice versa to achieve an optimal quality outcome for the patient. This could be achieved through sharing teaching, research, continuous professional development, evidence-based practice forums; working collaboratively in developing quality management improvement plans, protocols, and guidelines in the management of the patient. Lastly, at the regulatory professional level, the scope of the profession and practice to enhance the capabilities and standards of practice, and to provide Continuing Professional Development (CPD) to NP to keep up-to-date with any developments in the safety area.

#### **Conflict of interest**

None.

#### **Author details**

Chandra Rekha Makanjee University of Canberra, Bruce, Australia

\*Address all correspondence to: chandra.makanjee@canberra.edu.au

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[15] Ghanes K, Jouini O, Wargon M, Jemai Z. Modeling and analysis of triage nurse ordering in emergency departments. In: 2015 International Conference on Industrial Engineering and Systems Management (IESM). Seville, Spain: IEEE; 2015. pp. 228-235. DOI: 10.1109/IESM.2015.7380163

[16] Hughes DR, Jiang M, Duszak R. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following officebased evaluation and management visits. JAMA Internal Medicine. 2015;**175**(1):101-107. DOI: 10.1001/ jamainternmed.2014.6349

[17] Bwanga O. What nurses need to know about mobile radiography. British Journal of Nursing. 2020;**29**(18):1064-1067. DOI: 10.12968/bjon.2020.29.18.1064

[18] Solheim J, Storm R, Whitney J. Radiological imaging and the emergency department: Teamed for success. A patient-centered approach to emergent imaging practices. Journal of Radiology Nursing. 2018;**37**(2):69-72. DOI: 10.1016/j.jradnu

[19] Li Q, Yuan Y, Song G, Liu Y. Nursing analysis based on medical imaging technology before and after coronary angiography in cardiovascular medicine. Applied Bionics and Biomechanics. 2022;**2022**:3279068.

DOI: 10.1155/2022/3279068. PMID: 35465185; PMCID: PMC9033406

[20] Ranschaert ER. The impact of information technology on radiology services: An overview. Journal of the Belgian Society of Radiology. 2016;**100**(1):93, 1-6. DOI: 10.5334/ jbr-btr.1184

[21] Zadvinskis IM, Smith JG, Yen PY. Nurses' experience with health information technology: Longitudinal qualitative study. JMIR Medical Informatics. 2018;**6**(2):e8734. DOI: 10.2196/medinform.8734

[22] Abuzaid MM, Elshami W, Fadden SM. Integration of artificial intelligence into nursing practice. Health Technol (Berl). 2022;**12**(6):1109-1115. DOI: 10.1007/s12553-022-00697-0. Epub 2022 Sep 14. PMID: 36117522; PMCID: PMC9470236

[23] Walton ER, Gandhi S. Record keeping in radiology: Are we doing enough? The British Journal of Radiology. 2016;**89**(1068):20160586. DOI: 10.1259/bjr.20160586

[24] Makanjee CR, Bergh AM, Hoffmann WA. "So you are running between"—A qualitative study of nurses' involvement with diagnostic imaging in South Africa. Journal of Radiology Nursing. 2014;**33**(3):105-115. DOI: 10.1016/j.jradnu.2013.12.005

[25] Singh J, Sharma T. Unveiling the basics of chest radiography for nurses. Journal of Primary Care Specialties. 2022;**3**(3):45. DOI: 10.4103/jopcs.jopcs\_9\_22

[26] Swamy V, Brainin P, Biering-Sørensen T, Platz E. Ability of nonphysicians to perform and interpret lung ultrasound: A systematic review. European Journal of Cardiovascular Nursing. 2019;**18**(6):474-483. DOI: 10.1177/1474515119845972

[27] Murphy A, Ekpo E, Steffens T, Neep MJ. Radiographic image interpretation by Australian radiographers: A systematic review. Journal of Medical Radiation Sciences. 2019;**66**(4):269-283. DOI: 10.1002/jmrs.356

[28] Schlunegger MC, Aeschlimann S, Palm R, Zumstein-Shaha M. Competencies and scope of practice of nurse practitioners in primary health care: A scoping review protocol. JBI Evidence Synthesis. 2021;**19**(4):899-905. DOI: 10.11124/JBIES-20-00554

[29] Ruess L, O'Connor SC, Mikita CP, Creamer KM. Sedation for pediatric diagnostic imaging: Use of pediatric and nursing resources as an alternative to a radiology department sedation team. Pediatric Radiology. 2002;**32**(7):505-510. DOI: 10.1007 /s00247-002-0712-9

[30] Hunter T, Jayasekera N, Roach R. Safer mobile fluoroscopy in the trauma theatre: A survey of orthopaedic registrars and theatre staff. The Bulletin of the Royal College of Surgeons of England. 2014;**96**(6):206-208. DOI: 10.1308/rcsbull.2014.96.6.206

[31] Jones AK, Ramirez JA III. The role of the radiology nurse in managing radiation dose during fluoroscopically guided interventional procedures. Journal of Radiology Nursing. 2022;**41**(3):201-206. DOI: 10.1016/j. jradnu.2022.05.006

[32] Askey J, Clements W. A single-center experience of fluoroscopic-guided peripherally inserted central catheter insertion by nursing staff: Rationale and clinical outcomes. Journal of Radiology Nursing. 2019;**38**(3):155-157. DOI: 10.1016/j.jradnu.2019.06.004

[33] Chida K. What are useful methods to reduce occupational radiation exposure among radiological medical workers,

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[34] Dauer LT, Miller DL, Schueler B, Silberzweig J, Balter S, Bartal G, et al. Occupational radiation protection of pregnant or potentially pregnant workers in IR: A joint guideline of the Society of Interventional Radiology and the cardiovascular and interventional radiological Society of Europe. Journal of Vascular and Interventional Radiology. 2015;**26**(2):171-181. DOI: 10.1016/j. jvir.2014.11.026

## **Chapter 6** Palliative Care

*Marvin J. Gordon*

#### **Abstract**

Palliative care bridges the gap between medically focused care with case management support, and hospice with focus on comfort only in the last 6 months of life. A multidisciplinary palliative team provides support, both medical and psycho-social, regardless of time to end of life. Patients do not forego any treatments or interrupt any current physician relationships when enrolling in palliative care. Programs may be in-patient, clinic based, home based, telehealth or a combination of venues. 24-hour availability is encouraged. Coordination with the existing medical team and the health plan is a key to success. Periodic rounding between the palliative providers and the health plan team facilitates making the managed care system seamless for members and providers. The most common adult diagnosis is cancer, but severe progressive disease of any organ system may be appropriate for referral. Some patients may stabilize or even improve. Pediatric palliative care is somewhat different with the diagnosis more likely being genetic, developmental, or neurologic. Severe diseases in children may be chronic and end of life discussions difficult. Communication skills facilitate advance care planning discussions whether advance directive or POLST. Palliative care is a cost-effective program that improves patient care without the patient relinquishing existing benefits.

**Keywords:** palliative care, hospice, advance care planning, severe progressive disease, patient support

#### **1. Introduction**

Palliative care is a relatively new field that has expanded over the past 15 years. Palliative care uses a specially trained team to support patients with severe progressive disease and their caregivers. The World Health Organization describes palliative care as " … improves the quality of life of patients and that of their families who are facing challenges associated with life-threatening illness, whether physical, psychological, social, or spiritual" [1]. This includes addressing practical needs and providing bereavement counseling. It offers a support system to help patients live as actively as possible until death.

Palliative care is indicated for a wide range of severe progressive diseases. The most common diseases needing adult palliative care include cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%) [1]. Other conditions include kidney failure, chronic liver disease, autoimmune diseases, neurological disease, dementia, and congenital anomalies.

Symptoms encountered during palliative care most commonly include pain and difficulty in breathing. Opioids are essential for managing pain and other symptoms. Palliative care is about the quality of living, recognizing that dying is a normal process, and palliative care does not hasten nor postpone death.

A landmark randomized controlled study of patients with metastatic non-smallcell lung cancer demonstrated that the addition of early palliative care, as compared to standard oncologic care alone, not only resulted in less depression, improved quality of life, fewer hospitalizations and emergency department visits, and less aggressive interventions, but the palliative group lived significantly longer [2]. Although this is not meant to imply that palliative care will always prolong life, it does suggest that palliative care certainly does not hasten death.

Palliative care integrates the psychological and spiritual aspects of patient care and offers a support system for the family, the caregivers, and the patients. The patient does not "give up" access to existing providers or any existing benefits including therapies intended to prolong life, such as chemotherapy or radiation therapy, and other disease focused investigations or therapies as well as treating any clinical complications. Palliative care is based on the needs of the patient, not on the patient's prognosis. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.

#### **2. Defining palliative care versus hospice versus case management versus community care coordination with community health workers (CHW)**

For **Palliative Care**, the patient retains all of their disease focused benefits, adding support in addition to disease focused treatments. Palliative care does not require a prognosis shorter than 6 months. Hospice is a program in which the member foregoes curative focused treatment and focuses on comfort only for the hospice diagnosis.

**Hospice Care** is defined by Medicare as being for the terminally ill (with a life expectancy of 6 months or less) for members having Medicare Part A (Hospital Insurance), for which you accept comfort care (palliative care) instead of care to cure your illness.

Medicare-certified hospice care is usually given in the home or other facility where they live, like a nursing home. Patients can also get hospice care in an inpatient hospice facility if needed. "Original Medicare" will still pay for covered benefits for any health problems that are not part of your terminal illness and related conditions. Once the patient chooses hospice care, the hospice benefit will usually cover everything needed.

Specific for patient's illness, the hospice team will create a plan of care that can include any or all these services:


#### *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*


Initial certification is done by the patient's usual doctor or the hospice doctor. After 6 months, hospice care can be continued provided that the hospice medical director or hospice doctor recertifies (at a face-to-face meeting) that the patient is still terminally ill.

As a hospice patient, the patient always has the right to stop hospice care at any time.

Medicare will not cover any of these once the hospice benefit starts:


**Hospital outpatient care (like in an emergency room), hospital inpatient care, or ambulance transportation** must be arranged by your hospice provider unless it is unrelated to your hospice diagnosis.

**Case Management** is process of assessment, evaluation, care coordination, education, and advocacy to meet an individual's and family's comprehensive health needs. This includes continuity and transition while promoting quality and cost-effective outcomes. Clinical as well as psycho-social issues are addressed. Several types of case management exist:


The case management team may include


Another growing trend is the use of **Community Health Workers (**CHW)**,** nonlicensed trusted members of the community, to navigate and assist patients in obtaining community services to address social determinants of health (SDoH) and coordinate with traditional health care. Typical SDoH would include:


*Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*


CHW programs are for any patient in need of navigation and support regardless of prognosis or severity of illness. CHWs do not manage symptoms since they are not licensed to provide medical care. Some CHWs may be specially trained to handle advance care planning.

**Figure 1** compares case management, palliative care, and hospice.



#### **Figure 1.**

*Comparison of case management to palliative care to hospice.*

distribution of ACP documents. Coordination between the palliative team and the usual medical team is an imperative. The patient is receiving both diseasefocused/curative treatment and intensive supportive treatment.


### **3. Referral criteria**

The most common referral criteria for adult palliative care include


### **4. Models**

The most common models used to deliver palliative care include


• Telehealth: the home visits are virtual using audio-video or audio only. A hybrid model can be used in which the nurse or community health care worker does the home visit and oversees a telehealth visit with a physician, nurse, or social worker.

#### **5. Sources of referrals**

Most referrals are made by in-patient case managers, discharge planners, health plan case managers, concurrent review nurses, transition care management nurses, or hospitalists. Other common sources of referrals include primary care physicians, specialty care physicians such as oncologists and nephrologists, or out-patient clinic staff. Although emergency rooms see many palliative candidates, referrals from the ED (emergency department) are less frequent unless special support staff are available to the emergency room for consultation. Data mining looking for high cost and high-risk members through claims data is limited since there is a significant lag time between claims data being processed and the actual sentinel events that indicate the need for palliative support.

Data mining for high-risk members usually requires risk stratification programs such as I Pro (Impact Pro®). A population is stratified from the sickest of the sick down to healthy members. Data mining looks at claims including cost, pharmacy, inpatient utilization, ED utilization, age, sex, diagnosis, demographics, and even social determinants of health. Another tool is the Charlson Co-morbidity Index which looks at multiple co-morbidities to create a score. In any case, prognostication is difficult. Even though these tools may stratify, there is no guarantee that the prediction for any single patient will be correct. Prognosticating the timetable for end of life is even more difficult. Although studies do show the efficacy of palliative care in the last several months of life, predicting when that end-of-life period begins is not always accurate.

The types of patients referred to palliative care may vary and include end-of-life, chronic illness, catastrophic illness, and/or being inpatient. Social determinants of health may also require significant attention. Different illnesses may have different patterns of functional decline (**Figure 2**). Cancer members may remain quite

**Figure 2.** *Trajectory of functional decline variation by type illness.*

functional despite significant disease. When the functional decline begins, the rate of decline may be fairly rapid, not allowing much time for interventions at end of life. Chronic diseases such as heart failure may have a slower decline with episodic acute exacerbations. Although they may recover from the exacerbation, they are not recovering back to their previous state of health. The decline is often not noticed since the focus is on the miraculous improvement from of the exacerbation. The exacerbations may increase in frequency and have a slower recovery until the final exacerbation occurs, from which the patient does not recover. The third type of functional decline is exemplified by dementia. In the absence of an acute complication, the course is a slow steady decline which may last for years. These varying scenarios make prognostication difficult.

An interesting tool for prognostication is the "surprise question". Rather than asking how long a patient is expected to live, the question is "would you be surprised if this patient died within the next 1-2 years?" The efficacy of this tool is debatable and does vary by disease category.

### **6. Pediatric palliative care**

Pediatric palliative care is different than adult palliative in many ways.


#### *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

Identifying children for referral to palliative care is difficult since they often have disease that is chronic but may have exacerbations for which palliative care is appropriate. The California Department of Health Care Services did define criteria for pediatric palliative for Medicaid members [3]. The criteria were:

	- "Conditions for which curative treatment is possible"
	- "Conditions requiring intensive long-term treatment"
	- "Progressive conditions for which treatment is exclusively palliative"
	- "Conditions involving severe non-progressive disability"

#### **7. Structure**

The palliative team personnel can vary. Some programs emphasize the physician and nurse practitioner. This is very important in cases in which control of symptoms and disease management are a major factor. In some cases where there is a behavioral health concern or social determinants of health play a major role, the social worker may play the key role. Looking at both health care and social issues, the nurse, either licensed vocational or registered nurse may play the key role. Often the patient will express a preference for nurse or social worker visits rather than physicians and nurse practitioners. For telehealth, having a community health worker may be helpful to assist the patient in setting up a telehealth video visit in the home with the physician or nurse. The approach to staffing may vary depending on other lines of business that the vendor performs. Those vendors who also do hospice may have more physician involvement. Organizations who do home health, may be more nurse centered.

The frequency of visits can be flexible since not every member has the same needs. A "typical" frequency of home visits may be 1 physician/NP visit every 1–2 months, a nurse every week, a social worker once a month, and coordinators and spiritual advisors as needed. These services are supplemented with phone communication. Obviously, not every week would be the same with more visits some weeks and less visits some weeks. If monthly case rates (fixed fee per month) are used, the rate can be adjusted for different levels of care. Those averaging the predetermined number of visits specified in the contract may get paid the full fixed fee per month; but if the average number of visits decreases, the case rate payment can be decreased proportionally. Case rates can also allow fee for service visits above and beyond the case rate services if exceptional services are required. The palliative provider can also work under a fee for service contract. However, the fee for service contract may require more prior authorization or documentation. Case rates can also be adjusted if the

member only was enrolled for part of the month. For in-patient and clinic visits, palliative services are often billed as hospital consults or office visits respectively.

The actual provider of the palliative care, the vendor, has several different models. The payer can contract directly with local vendors. This has the advantage of using vendors known in the community. Depending on the size of the service area, home visits may be relatively easy. Larger national companies can be contracted, but then that company needs to either contract with local vendors or set up a network of employed providers if face to face visits are needed. The use of telehealth with or without community health worker making home visits does allow the palliative provider to cover a much larger service area.

#### **8. Outcomes and disposition**

Overall, studies have shown that there is very high satisfaction with home based palliative care programs [4]. In general, utilization of the hospital and emergency department (ED) decrease, overall health care cost decreases (mostly due to in-patient and ED savings), savings are greater when the patient is closer to end of life, and certain diagnoses like cancer are more likely show savings than chronic illness like dementia [5]. Cost reduction does vary by insurance product with largest savings seen in the commercial product, probably because the unit cost is highest compared to Medicare and Medicaid.

Some patients referred to palliative care will choose hospice instead once they understand their options. Of patients qualifying for palliative care, about 15–20% of members will refuse the program. Reasons for refusal include misunderstanding despite explanations, fear that they will receive less care, cultural beliefs, fear of talking about death, family disagreement, or wanting privacy without anyone in their home. Physicians may not make the referral due to a misunderstanding that existing benefits continue, fear that they are giving up, not wanting to discourage the member, or not having the time for a series of end-of-life discussions. Often the physician does not understand the referral process or even the availability of the program.

Patients referred to palliative care may subsequently transfer to hospice, die, move out of the area, change insurance coverage, refuse services after enrollment, or actually improve such that they do not need further palliative care.

#### **9. Advance directives**

Advance Care Planning (ACP) is a process of discussing and then documenting a patient's wishes for health care. If the patient becomes incapable of making his/her health care decisions, then two questions arise. First, who can make those decisions for the patient (i.e. who is the patient's legal agent), and second, are the patients preferences known (and preferably documented)? Part of the discussion is an education of the patient and any family or significant others who the patient may want to be included in this process. The goal is to make informed decisions and then document before a catastrophic event occurs that leaves the patient unable to make their own decisions. Without written preferences, family members may disagree as to what the patient would really want. The patient and family may not understand all of the options. For example, a DNR (do not resuscitate) order may mean do nothing if the heart stops, or do only electrical stimulation, or administer drugs but no chest

#### *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

compressions. The patient may want CPR (cardio-pulmonary resuscitation) but would not want to remain on a ventilator (breathing machine) if there is no hope of recovery. Decisions could also include feeding tubes, dialysis (artificial kidney), surgery, hospitalization, or certain other treatments. The patient may refuse a certain treatment or agree to a limited trial of a treatment to be discontinued if recovery is not expected. If the directions are not clear, the designated agent would have the authority to intervene and make decisions.

ACP documents fall into two categories. The advance directive (AD) asks the patient to name the person, the agent, who would make medical decisions on their behalf should the patient be unable to do so. This gives the agent Durable Power of Attorney for Health Care. An alternate agent may also be named should the first choice not be available. The AD would also contain a general statement whether the patient's preference is to do anything possible to prolong life, or to limit interventions if there is no hope of recovery or regaining consciousness. A second question is whether the patient wants relief from pain even if it may hasten death. Other requests may be made such as type of burial or religious preferences. The AD can be notarized or signed by two witnesses who are not the agent.

The second document is the POLST (Provider Order for Life Sustaining Treatment). If the state does not allow nurse practitioners or physicians assistants to sign this order, the POLST is referenced as a Physician Order for Life Sustaining Treatment. Some states call this a MOLST (Medical Order for Life Sustaining Treatment). The POLST or MOLST is a specific order signed by the patient or his/her agent, and a physician or nurse practitioner (NP) or physician's assistant (PA) if allowed. The exact form may vary by state, but the content is similar. Does the patient want to be resuscitated? Does the patient not want to be on a ventilator (breathing machine) at all, or only for a limited period? Does the patient not want a feeding tube at all, or just for a limited period? The form also addresses wishes for hospitalization, intravenous fluids, or antibiotics. The POLST or MOLST must be signed by the patient (or his/her agent) and the physician (or NP or PA if allowed).

ACP discussions may require a series of meetings, since there is a lot of education, and the decision making may not be simple. Even if documents are created, periodic review is helpful since the patient's clinical status may change or multiple parties involved may forget what was said. The ACP documents can be revoked or amended at any time. If documents are generated and signed, it is important to distribute the documents to the appropriate parties like the patient, the agent, other participating family members, primary care physician, specialist physicians, and hospitals. For cases closer to the end of life (EOL), a copy of the advance directive may be placed on the refrigerator door in the home so the paramedics would have access to it. Some states have created a registry where the advance directives can be stored for easy access by medical personnel.

The logistics of ACP conversations can very. The primary care physician or specialist may have the conversation. However, the physician must be willing to devote time to this process including follow up meetings, be familiar with the process, and be willing to initiate what may be perceived as an uncomfortable subject. In the hospital, case managers or social workers may work with the patient and family, but usually when end of life or limiting interventions is the current issue. There are companies who specialize in doing advance directives. Usually, they take a telehealth approach. However, the personnel making the calls may vary between being a physician, a nurse, or a behavioral health trained person. Some community health workers are trained on doing advance directives.

#### **10. Rounding**

Communication concerning palliative care patients is critical because most of these patients are quite complex. On the other hand, not everything about a palliative patient can necessarily be addressed at one sitting since there are so many aspects to palliative care that can be discussed. Therefore, the communication or "rounding" has two aspects. One is the structure of the presentation, and the other is the content of the conversation.

The structure of the communication follows the SBAR format. This is a communication method developed in the airline industry to improve communication between pilots and co-pilots to avoid airplane accidents. The technique should shorten the conversation by "getting to the point". The acronym is:


In the medical world, this may be the typical emergency phone call at 3: 00 AM from the nurse to the doctor on call. If the conversation goes on for more that 3– 5 minutes, the doctor usually interrupts with "why are you calling and what do you want me to do?" This suggests that the nurse is giving too much detail on the background and is not getting to the assessment and recommendation.

An example of SBAR in the world of palliative members for non-emergent presentation (such as nurse to medical director), would be:

S: I have a 63 year old male with hepatocellular cancer complicated by portal vein thrombosis and end stage liver disease with a prognosis 3–6- months.

B: The patient's course has been complicated by pain, altered mental status due to liver disease, portal vein thrombosis, endocarditis, and a stroke. Lactulose is being titrated for encephalopathy. Morphine is being given for pain. Trans-arterial radio embolization has been used in the past for pain remediation. Patient is on anticoagulation.

A: The patient agrees to a DNR but is not ready for hospice. His vision is failing due to cataracts and he really wants to see the Superbowl. Pain is not well controlled on morphine. Lactulose is effective and diarrhea is minimal. He has a supportive family and wants to be with them as much as possible.

R: We need to evaluate the pain … repeat radio-embolization is a consideration. The patient states it worked before. The patient wants cataract surgery. We should evaluate him for that. We need a signed POLST for the DNR. Continue the lactulose, morphine, and anticoagulants.

That is a very complicated patient presented in a relatively short-focused format. This allows plenty of time for the physician and nurse to further discuss the nurse recommendations and see if the medical director has any additional recommendations. *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

Looking at the content presented, the information falls into five categories.

	- Diagnosis
	- Prognosis
	- Symptoms
	- Medications and treatments
	- Current medical team
	- Hospitalizations and ED visits
	- Level
	- Trend
	- Family
	- Caregivers
	- Spiritual
	- Housing
	- Financial
	- Food security
	- Transportation
	- Safety
	- Behavioral health
	- Advance directive
	- POLST
	- Series of discussions

The key to the conversations with the patient and family is not being judgmental, listening, asking open ended questions, showing empathy, and building a trusting relationship. The patient does have a right to determine how much they want to know, when they want to make their decisions, and what those decisions are.

#### **11. Many faces of palliative care**

Case Study 1: 63-year-old with hepatocellular cancer complicated by portal vein thrombosis and end stage liver disease. His prognosis was 3–6- months. The course was further complicated by endocarditis and a stroke. The patient's goal was to see the Super Bowl and he was not ready for hospice. He did agree to a Do Not Resuscitate (DNR) order. He did undergo cataract surgery. Lactulose was adjusted to control hepatic encephalopathy. Due to increasing pain the patient underwent trans-arterial radioembolization (radioactive microspheres injected into the hepatic artery) with improvement. Over 2 years he had 2 emergency admissions and 2 elective admits. Despite his poor prognosis, he survived for 2 years. He did convert to hospice 2 days before his death at home. He did get to see 2 Super Bowls.

This case exemplifies a patient with end stage cancer requiring both supportive and medical care such that he outlived his prognosis and enjoyed a high quality of life despite his diagnosis.

Case Study 2: 54-year-old with an Intracerebral bleed, currently on tracheotomy, ventilator, ventriculoperitoneal (V-P) shunt, and gastrostomy tube (G tube). She is in a long-term care subacute facility and had several acute-stay admits over the past year. She is scheduled for an elective admit for decubitus ulcer surgery. She never regained consciousness during 30-day acute hospitalization. She is full code, divorced with two daughters, ages 18 and 22, and has two siblings out of state. The case was presented to the palliative medical director at rounds, discussed with the subacute attending and case manager, the goals of care were reviewed, and POLST (Provider Orders for Life Sustaining Treatment) discussions were started with family.

The issue was raised why member is full code and whether family is aware that member will not wake up. The family was not aware that member will not wake up. The family expresses the wish to not keep mother alive "like this" recognizing the that decubitus ulcers can be painful.

The subacute attending concurred with decision to discontinue the ventilator. Palliative care arranges to discontinue vent with a palliative case manager, social worker, and spiritual advisor present. Time was allowed for the out of state relatives to join the daughters to be present when the ventilator was discontinued.

This is a case of palliative care addressing end of life wishes, advance care planning, and avoiding futile medical care.

Case Study 3: A 45-year-old presented with multiple emergency visits and admissions for abdominal wall infection. Five months prior, the member had undergone an abdominal hernia repair with placement of a mesh into the abdominal wall. The patient is having ED or acute admits 1–2 times per month. The member has abdominal pain and infection of an open wound at the hernia repair site. Oxycodone has been prescribed fairly regularly along with frequent antibiotics.

The member has filled all prescriptions for antibiotics and kept follow-up appointments with her surgeon and PCP. The surgeon was consulted as to why the mesh, the foreign material in the wound, has not been removed. The surgeon agrees that

#### *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

removal of the mesh is indicated, but he feels the surgery is too difficult for him to do due to obesity and scar tissue. The palliative team contacted a university-associated bariatric surgeon who agreed to do surgery, which was successful, and the wound healed. The course has been complicated by clostridium difficile, recurrent diarrhea, intermittent nausea and vomiting, and depression but with only occasional emergency department visits or admits.

This case seems to be a patient with severe progressive disease, but it is curable disease if the medical condition is treated properly. In this case the key intervention by the palliative team was to make the appropriate specialist referral.

Case Study 4: 65 year old, homeless patient with severe COPD requiring intermittent oxygen, continues smoking, and with multiple visits to the ED and hospital is referred to palliative care.

He had lost his job as a caretaker about 6 months prior. He now lives in his Lincoln Navigator SUV and he likes living there. He has portable oxygen and still smokes. He goes to senior centers for warmth, food, and socialization. He keeps some PCP (primary care physician) appointments at an FQHC (Federally Qualified Health Center) and intermittently attends AA (Alcoholics Anonymous) meetings. The palliative assessment was that the member needs structure and support. He does need regular PCP visits. Ideally, he should stop smoking and get permanent housing, but member not currently interested.

The palliative team arranged weekly visits at his car, at a senior center, or at other designated area. Phone call reminders were a key to providing structure and support. He was reminded of PCP appointments and to take his meds. His Friday "tuck in call" avoided weekend emergencies. The team continued discussion of housing and smoking and maintained phone contact.

No hospitalizations or ED visits occurred over 10 months. The patient is willing to talk to someone about permanent housing.

This case emphasizes the value of addressing social determinants of health through support and structure. Coming to the patient, gaining his trust, and being creative in providing support far outweighed the effect of the medical interventions.

#### **12. Bad news conversations**

Delivering bad news or discussing end of life issues is not always a pleasant event. The most common barriers to delivering bad news is:


Proceeding with planning cannot occur until you get through the emotions:


Although no one likes to deliver bad news, it is an essential component of quality medical care and may be the most remembered event by the patient and family. You cannot proceed with planning unless your patient has been informed.


Show your concern:


Basic techniques for the Bad News Conversation (Adapted from Baile, Buckman, Lenzi, et al., The Oncologist, 2000; 5: 302).

Validation- we respect your feelings.

"Many other patients have had similar experiences"

"I can understand how you felt that way"

*Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

"You were correct to feel that way"

Empathy- we care

"I'm sorry to have to tell you this" "This is difficult for me" "I can see how upsetting this is to you"

Probe further- we need to talk more

"Tell me more about it" "Could you explain what you mean" "Could you tell me what you are worried about"

Ask the patient to summarize what they heard. Discuss next steps and follow up.

#### **13. Helpful hints**

Acceptance of palliative care has been a slow process. It can be time consuming and uncomfortable, despite its benefits. Some of the key factors in having a successful program include:


#### **14. The elevator speech**

Trying to explain palliative care to someone within one to two minutes may not be easy, but here is an elevator speech. The two versions are similar, but one is written in prose, and one is in bullet point format. There are some variations between different palliative programs. The health plan may or may not provide a palliative care benefit. The program may or may not be offered at no cost. The health plan may or may not require prior authorization. The plan may or may not have its own palliative team to review referrals and serve as a liaison between the referring party, the palliative provider, and the patient. The referring party may have contact directly with the actual palliative provider. Not all palliative teams provide phone access or emergency service after hours.

Version 1: Palliative care is a service which may be provided by your insurance company usually at no cost to the member or doctor (check this since palliative care may or may not be a benefit). A team of physicians, nurses, social workers, and coordinators provide an extra layer of support to your members with severe progressive disease in need of symptom control, advance care planning, or psycho-social support. These are members who are frequently in the hospital or emergency room. The member retains all their normal health plan benefits which are coordinated between the doctors, the medical group, the health plan, and the palliative care provider. The palliative care providers usually have an after- hours call line (check this since some palliative care providers may not have an after- hours call line or provide services after-hours) and can provide services after hours. To make a referral, just complete the referral form, and fax or e-mail it to the health plan or palliative provider (the insurer may require prior authorization). For questions, just call the health plan palliative team (check that the plan does have its own palliative team). A contact list and referral form is attached. All referrals will be reviewed by health plan palliative medical directors. Palliative care is a program for the living … to provide the highest quality of life despite serious illness. Please remember that palliative care is not hospice. With palliative care the member may continue their disease focused treatment and there is no 6-month limitation. The palliative program has improved members' quality of life and reduced their usage of the hospital and emergency department to manage their illness. Our members and our doctors appreciate the extra layer of support that has been coordinated for them.

Version 2: Elevator speech in bullet point format.

#### *Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*


#### **15. Final thoughts**

"You can't control the wind, but you can adjust your sails." Yiddish Proverb "Life is like riding a bicycle. To keep your balance, you must keep moving." Albert Einstein.

#### **Acknowledgements**

The author wishes to acknowledge Dr. Tao Le for his input for this publication and his assistance as co-founder of the Health Net, Inc. Care Connections© palliative care program.

#### **Conflict of interest**

The author declares no conflict of interest.

#### **Notes/thanks/other declarations**

The author wishes to thank Carole Nathanson, R.N. and the Health Net palliative care nursing team for their dedication in developing the palliative care program. The author also wishes to thank LightBridge Hospice and Palliative Care, San Diego, California, USA for their collaboration in caring for the case study patients referenced in this publication.

### **Author details**

Marvin J. Gordon Department of Medical Affairs, Health Net, Inc, Cypress, California, USA

\*Address all correspondence to: marvingordonmd@cox.net

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.109390*

#### **References**

[1] Online: Who.int. Available from: https://www.who.int/news-room/ fact-sheets/detail/palliative-care)put

[2] Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. The New England Journal of Medicine. 2010;**363**:733-742

[3] California Department of Health Care Services, All-Plan Letter (CA DHCS APL 18-020 December 7, 2019)

[4] Gordon MJ, Le T, Lee EW, Gao E. Home palliative care savings. Journal of Palliative Medicine. 2022;**25**(4):591-595

[5] Cassel JB, Kerr KM, McClish DK, et al. Effect of a home-based palliative care program on healthcare use and costs. Journal of the American Geriatrics Society. 2016;**64**:2288-2295

## **Chapter 7** Ethics in Palliative Care

*Delgersuren Gelegjamts, Khulan Gaalan and Batbagana Burenerdene*

#### **Abstract**

The cases of ethical issues (new and unfamiliar daily circumstances) are increasing every day in palliative care services. The role of the codes of ethics is to help with these problems. The goal of end-of-life care for dying patients is to prevent or relieve suffering and respect the patient's wishes and values. The benefits of ethical decision-making are relief of pain, improving the patient's recovery, reducing the side effects of treatment, prevention of depression, and increasing quality of life. An essential component of the ethical decision-making processes may concern patients' family members and society. However, physicians, healthcare teams, and nurses are facing difficulties in ethical challenges in end-of-life care. It should also protect the patient's rights, dignity, beliefs, and religion. Healthcare professionals should understand the principles of ethics, ethical legal documents, advanced care planning, and ethical conflict to help patients make the best decision possible. The ethical principles guide healthcare professionals in the management of these situations and the problem they face in end of life care. In this chapter, we will cover the consideration regarding the ethical principles, ethical issues, ethical challenges, and dilemmas during the palliative care. The cases of ethical issues are increasing every day in the palliative care service.

**Keywords:** end-of-life care, ethics, advance directives, ethical dilemmas, decision-making

#### **1. Introduction**

Palliative care (PC) alleviates the distressing symptoms in a terminal stage of diseases, avoids harm of intention, and improves the quality of life (QOL). The goal of PC should be to let the patients maintain their dignity and hope while they are alive [1]. The PC team should be knowledgeable enough to provide appropriate care, respect patients, rights, and avoid conflicts [2]. It involves a multi-disciplinary team that provides medical care, pain management, and emotional and spiritual support to a person and family members [3]. The QOL of life of a cancer patient has a direct connection with the professional and nonprofessional caregiver's knowledge of supportive care and attitude toward end-of-life (EOL) care [4].

Many people at the EOL experience unnecessary difficulty and suffering [5]. Death is an inevitable part of life and death and should be peaceful, pain-free, and without any suffering [1]. Advanced medicine and modern technologies have both prolonged life expectancies and transformed the natural norms of death. Although, those new treatments and technologies do not cure chronic diseases. Medical interventions such as artificial nutrition and respiratory support can extend their life and provide secondary support [5].

The difficulties of ethical issues and moral solutions in palliative care services ethical principles recognized universally are autonomy, beneficence, non-maleficence, and justice [5]. A good understanding of medical ethics will contribute to the health professional's decision-making and the daily practice of medicine for EOL patients [2].

#### **2. Palliative care and related ethics**

#### **2.1 Ethics of palliative care and hospices**

Worldwide only about 14% of people who need PC currently receive it, and each year an estimated 56.8 million people, including 25.7 million in the last year of life, require palliative care [6]. The goal of the PC is to improve the QOL for both the patient and their family members. Many people have difficulties and suffering at the end of life EOL experience. EOL helps with anxiety and distressful emotions, such as fear of the future and being a burden to loved ones. They worry about pain management and the loss of control over the quality of their lives [7].

WHO: " PC is an improves the QOL of patient and family members facing the problems related with life-threatening illness, through the prevention and relief of suffering using of early identification and complete assessment and treatment of pain and other needs specially physical, psychosocial and spiritual" [8].

PC is a specialized medical care for people living with a serious illness [9]. Hospice and PC were established in the middle of the year 1900 and the founder who is Dame Cicely Saunders. She opened the first modern hospice (named St. Christopher Hospice-1965) and published a book about death (On Death and Dying-1969) [10].

PC improves the QOL of patients and their family members and most importantly is the reduction in symptoms of burden [11]. PC is explicitly recognized under the human right to health. It should be provided through person-centered and integrated health services that pay special attention to the specific needs and preferences of individuals [8]. Advancements in the development of medicine and technologies have both prolonged life expectancies and transformed the natural norms of death [5]. However, modern technologies and treatments do not cure chronic diseases, and medical intervention is providing secondary support such as artificial nutrition and respiratory support that can prolong lives [5, 12].

PC is specialized care provided to terminally ill patients by a multidisciplinary team. "Terminally ill" is defined as a patient who is affected by an incurable disease associated with a prognosis defined by an amount of months, days, or even hours of life. The multidisciplinary team is aimed to respect the dignity of human and improves their QOL, through pain control and relief of other symptoms.

PC is best for controlling the symptoms in these difficult situations [11] and focuses on the best quality of life for patients and family members [13]. Family members feel anger, blame, loss of hope, and weakness when they cannot relieve the suffering of their terminally ill loved one [14]. Terminally ill patients will have a hard time deciding because of sadness and stress [5]. The delivery of palliative services to patients and their loved ones should be managed in an ethical manner [6]. EOL is both a clinical and ethical challenge [15].

#### **2.2 Ethics of healthcare team of palliative care**

PC is provided by a specially trained team of doctors, nurses, and other specialists who work together with a patient's serious illness. PC is comprehensive, also interdisciplinary services [16], and total care concentrates primarily on the comfort and support of patients and families who has a serious illness like cancer, heart failure, advanced lung disease, and neurodegenerative disorders [17]. The team's palliative and supportive care is especially and serves them with holistic services including as emotional, spiritual, functional, and physical support. Healthcare professionals play crucial roles in the delivery of PC for cancer patients as they have to provide healthcare services with a positive attitude and also be prepared mentally [4].

Physicians and nurses face difficulties in their clinical practice of PC, and they need to understand ethical principles and standards well [2, 18] because health professionals need the right decision-making and the daily practice of medicine for terminally ill patients [19]. The PC experts and team members should carry out their responsibilities with honesty and dignity Palliative care, therefore, requires many different competencies, not only clinical but also relational, communicative, and ethical [20].

Essential skills needed for PC teams and clinicians who provide clinical care for EOL patients are education on medical ethics, understanding ethical principles, focusing on serious illness, learning about advanced care planning, ethics conflict, ethics committees, and specialist palliative care teams' goals [21].

Nursing as a profession was created by society to meet specific perceived health needs [13]. Their daily ethical challenges influence those factors as spiritual beliefs, religious practice, and cultural norms of the patient. The patient's culture like beliefs about disease treatment, and attitude affected their health and healing process [22].

The roles of the nurse are to work as a member of the interdisciplinary team so the patient/family can make fully informed decisions with full knowledge of the consequences of those options. In addition, PC nurses play a pivotal role in ethical issues.

Nurses are the most essential to the patients for ethical decision-making in PC because the nurses spend more time with patients and develop communication of intimacy and trust inherent in the nurse-patient relationship [14]. Andrew Jameton [23], a philosopher and author of nursing ethics, confidently states that "Nursing is the morally central health care profession". Ethical leadership in nursing requires fundamental nursing values such as respect for patients, harmless, and justice.

According to the international code of ethics for nurses by the International Council of Nurses (ICN) [24], nurses are responsible for promoting health, preventing illness, restoring health, and to alleviate suffering. Professional code of ethics states "consistent with existing professional codes of ethics, conflicts of interest, scopes of practice, and standard of care for all relevant disciplines [21], and both codes state that nurses should provide respectful and equitable care to all individuals, families, and communities needing nursing care regardless of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race, or social status [25]. The ethics of PC often conflicts with clinicians, nurses, other healthcare team members, patients, and family members about what constitutes care, particularly as death approaches [26]. Healthcare organizations can work toward developing and implementing guidelines & policies for EOL care decision-making, especially policies for withholding or withdrawing the treatment options so as to avoid ethical dilemmas.

#### **2.3 Palliative care patients**

PC is available to anyone regardless of age as long as they have been diagnosed with an illness that causes suffering or is untreatable such as cancer, multiple chronic conditions as long as the patient or family members need or who want to relieve their suffering. In any setting where patients receive EOL care such as a home, palliative units, hospice units, PC clinics, and nursing homes. A professional team provides clinical care. However, primary health services are possible with a family physician, internist, geriatrician, cardiologist, pulmonologist, intensivist, and nurses [3].

PC offers physical, emotional, social, and functional support to people who need end-of-life care. PC teams and especially nurses face death and take care of people who are affected by death regardless of the terminal illness and settings where they work [27]. However, most Asian patients like to spend their valuable time at home and with their family members. PC patients have to follow principles for decisionmaking in their own life.


#### **3. Ethical issues and palliative care**

Common ethics issues in PC include the goal of care, advanced directives issues, patient and family goal conflicts, physician and patient goal conflicts, transitioning focus of care, pain and symptom management, and PC and hospice treatment [3]. Most stressful ethical and patient care issues were protecting patients' rights, autonomy, and consent form to treatment, staffing patterns, and surrogate decisionmaking [28]. The staffing issues include physicians, nurses, teams, and volunteer [3]. The communication-related issues include the staff and patients/family members, physicians, patients, etc.

#### **3.1 Ethics and moral attitudes palliative care profession**

Moral philosophy is considered essential in moral issues, an important discussion about whether something is good or bad and right or wrong [14]. Ethics discipline is the study of the rational justification of moral principles and moral behavior [29].

#### *Ethics in Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.110756*

Ethics is a process for making logical and consistent decisions based on social morality and philosophical reflection [14].

Both ethics issues and PC have always been a part of Medicine [11]. PC is a holistic approach, and ethical issues are an essential part of the principles of PC. The ethical principles and values in clinical practice refer to the importance of respecting all of a person's values, needs, and wishes in the context of health care, and that is the benefit to the person with an advanced chronic or terminal condition [30]. The morality of PC recognizes the moral principles; moral dimension, communication; and moral dilemmas as individual conflicts [31].

#### **3.2 Ethical principles of palliative care**

The principle was originally proposed by Beauchamp and Childress [32]. They included autonomy in the principles, beneficence, and justice. An ethical principle include: Autonomy (an individual has the freedom to make their personal choices), Beneficence (to do together, sharing knowledge and listening they thought), Nonmaleficence (without harm to people), and Justice (to encourage honesty and equality in individual). These "four principles" are common in Eastern and Western cultures, but their application and weight may differ [5].

Autonomy is careful about a patient's right to independence. Everybody has the right to decide the differences of treatment they receive unless they are proven to be unable to. Patients' autonomy should be respected and is one of the fundamental principles of medical ethics [33].

The beneficence requires the patient's charge of choosing the needs and preferences of the patient's treatment options and care. These should be regularly reviewed; recognized and acted upon so the patient can live as comfortably as long as possible with their inalienable human dignity always respected [5].

Non-maleficence is an obligation not to inflict harm intentionally [21]. Nonmaleficence is the most important principle out of the four guiding principles of ethical decision-making.

Justice requires that those who are ill and all other people involved in their care families, careers, and even the wider community are treated fairly and that limited resources are used responsibly and wisely. Additionally, dignity (the patients and the persons have to respect their dignity) and truthfulness and honesty (the concept of informed consent and truth-telling) [2].

#### **4. Ethical challenge in palliative care**

Schofield et al. [34] analyzed a systematic review of the ethical challenges in PC practices. The researchers identified the daily practice of the ethical challenge, and the ethical issues and problems related to ethical principles, delivery of clinical care, working with family members, navigating societal values and expectations, and philosophy of PC.

"Decision-making" for EOL care has earned paramount importance as it has capability to prolong the human life with the support of medical technologies or can let the natural death process continue by foregoing the treatment option [35].

Many of these dilemmas are associated with decisions made concerning continuing, limiting, or withdrawing life-sustaining treatments [36]. The ethical dilemmas surrounding the provision of patient care include clinical decision-making. Honest communication about the diagnosis and prognosis of a fatal illness, which fully respects patients' wishes and preferences, positively affects their QOL and improves symptom management [37].

#### **4.1 Decision-making and ethical principles**

Each principle relates to each of the other three principles; therefore, they should be ordered according to the criteria of priority for each case, with the ultimate aim of "the best interests of the patient". The patient who is in the PC unit should make decision about his/her treatment and services. The patient's ability of the person to choose and act for one's self free of controlling influences such as coercion from physician, nurse, consultant, family members, and pressure from religious groups. Ability to make decisions based upon our personal values and wishes [3]. Autonomy was highly respected in EOL care and decision-making Nurses communicated major concerns in considering patients' preferences, wishes, and promoting advance care planning [38]. Beneficence is acting in the best interest of the patients. That was the best-case scenario and worstcase scenario. In the best-case scenario, we help the patient understand what QOL is and respect their values. In the worst-case scenario, the nurse or person taking care of the patient treat the patient with paternalistic interactions and does not respect their beliefs and values [3]. Non-maleficence is an important requirement in morality and palliative care ethics (do not harm) [39] and make no knowing act or decision, or lack of information sharing which will cause direct harm to the patient [3].

Justice is considered an individual's decision of what is better for the better of the patients and society. These decisions impact more than our own personal sphere and are responsible for the health status of the community [3].

#### **4.2 Communication and decision-making**

Issues of communication involve disclosure, confidentiality, informed consent, and decisional capacity. The most common reasons are conflicts in values between physician and patient or patient and his family [1]. The decision-making process presented has important elements such as the patients have to understand relevant information about his/her problem, respecting their choices, personal and patient's benefit, and ability to reason and to deliberate about available choices [13]. A nurse is the key person in the decision-making process between physicians and patients or surrogates.

#### *4.2.1 Disclosure includes*

The patient's present medical condition, likely course of treatment or what might happen if no treatment, if provided potential treatments will that may help the patient in prolonging their life or saving them as well as their risks and reduce unwanted burden. A professional opinion is suggested to patients on alternative treatments and recommendations based on the professional best clinical judgment [40].

#### *4.2.2 Confidentiality*

Sensitive personal information disclosed by a patient to their nurses is legally guarded by confidentiality, and should not be divulged and the necessary steps to ensure it should be taken [40]. The confidential information should be applied to non-autonomous and deceased patients as well. The only exception to this is if it is used to avoid harm in any way possible to either the patient or a third party [41].

#### *4.2.3 Informed consent*

When a patient goes to the health profession for a medical problem, the health profession is expected to make a diagnosis, inform them of all possible treatments and recommend one of them explaining the reason its pros and cons so they can make the most informed choice and express a preference for one of the suggested options given. The patient must understand the information, consider the treatment choices, and expresses a preference for one of the options planned by the physicians. This denotes the practical use of respect for the patient's autonomy [40].

#### *4.2.4 Decisional capacity*

The patient can make their own decision unless proven that they cannot. The patient should be able to understand relevant information, the medical situation; possible risks communicate a choice even if it is as small as a nod or the shake of a head as well as engage in relation deliberation with their values in the recommended treatment [40]. The patients have a right to refuse to make a decision and refer the decision-making process to another person.

#### **5. Ethics dilemmas in palliative care patients**

#### **5.1 Dilemmas of ethics**

Ethical dilemmas on macro- and micro-levels emerge daily as the debate continues on extending life versus postponing death [20]. Changes in social/family systems have added to the complexity of EOL and PC [15]. Ethical dilemmas surface as those comparisons draw attention to the insufficiencies of practice. For an ethics standard to be meaningful, it must reflect a comprehensive approach that simultaneously allows for each individual's particular needs. The extraordinary spectrum of requisites, from the most basic of physical care concerns to the broad issues of existential distress, reflects the daunting ethical responsibilities which are integral to PC. Ferrell's QOL model, which identifies the essential components of physical, psychological, social, and spiritual wellbeing, is comprehensively reflected in the Five Principles of PC. These principles can serve as a "checklist" for any healthcare professional caring for persons at the EOL.

Ethical dilemmas emerge across the spectrum of care as nurses endeavor to provide the best possible physical and psychological care, communicate appropriately and honestly with the patient and families in making decisions to withhold or withdraw treatment, and respond to requests for interventions that may conflict with their value systems [42]. Medical professional obligations are confidentiality, advance directives, DNAR, euthanasia and PAS, research, patient competence, "right to die," and power of attorney [41].

#### **5.2 Advanced care planning**

Advanced care planning (ACP) is a process that helps patients in any stage of health in understanding and share their values, life goals [43], and preferences and wishes regarding future treatments [44]. Substituted judgment refers to a guide for decisionmaking when a patient has difficulty decision-making and doctors, nurses, and family members try to make the decision that the patient would have made if his/her were able to make decisions [42]. ACP involves identifying a surrogate decision-maker to action if the patient is no longer able to make decisions about their care [45]. Surrogate decisionmakers try to understand the patient's beliefs and values on the patient's behalf [21].

ACP is dependent on the patients' health whether they have a mild, or moderate chronic illness or advanced life-threatening [29]. ACP should be integrated into routine care and should be discussed frequently and every time the patient's condition changes [45].

The principle of the advanced care planning approach is commonly used for patients who are close to death to discuss with them about their future care and how they wish to be treated. However, these processes are not always been done, especially if; the patient is urgently admitted to the hospital or disagreement among family members about what is appropriate treatment [46].

Honoring Choices North Dakota (HCND) is defined as "Advance Directives are legal documents that allow patients to put their healthcare wishes in writing or to appoint someone they trust to make decisions for them if they become incapacitated" [21]. Types of advance directive names have Living will, personal directive, medical directive, advance decision, and mental health advance directive types of health care agent names are medical power of attorney (POA), health care power attorney, health care representative, health care surrogate, surrogate decision maker, and guardian and conservator [21].

#### **5.3 Euthanasia and physician-assisted dying**

Euthanasia on the conflicting can be both passive and active. Passive euthanasia mentions to hastening the death of an individual by taking away a form of support and agreeing for the patient to die naturally without support; active euthanasia is affecting the death of someone through direct action at an individual's request. Proponents claim that the suffering, anguish, and pain of the patient and family could be more. Finally, the public, individuals, families, and healthcare providers need to openly and honestly discuss all aspects of this approach to disease management at the end of life [7]. As of 2022, euthanasia is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Spain, and several states of Australia (New South Wales, Queensland, South Australia, Tasmania, Victoria, and Western Australia) and seven states in the US (Wikipedia, 2022). PAD is an ethical argument regarding voluntary euthanasia and it is from a utilitarian perspective [47].

#### **5.4 Death**

Professor Alexander Fitzthum [48] recorded that death is classified into five groups, natural, accidental, suicidal, homicide, and unknown death. Natural death is an internal factor that causes the body to shut down (chronic diseases such as cancer, heart diseases, diabetics.) and an external factor such as traumatic injuries.

Many physicians, particularly those in the fields of oncology and PC, will be faced with a request for such assistance sometime in their professional lifetimes. In recent years, much of the developed world has seen the emergence of EOL debates and increasing pressures for the legalization of physician-assisted dying (PAD). It is challenging because of the inherent uncertainty of making predictions and because dying is not an easy topic to discuss [49].

Physician-assisted dying in utilitarian theory is considered ethically right as its decision is in the interest of the patient. Their family's interest should not be included and they should only be allowed to give their opinion on the patient's choice [9].

#### *Ethics in Palliative Care DOI: http://dx.doi.org/10.5772/intechopen.110756*

From the perspectives of patients, there is considerable debate regarding the ethical implications of physician-assisted dying; the patient's self-determination rights, competence, beliefs, and values form the basis for these decisions [9]. The physician-assisted death is a more respectful and dignified way for terminally ill patients to die. Most people including physicians agree with physician-assisted death; however, there is a need for training, support, and implementation of physician-assisted death. Ethics committees may help fill this gap and provide resources and mediation of value conflicts [9].

#### **6. Conclusion**

The conclusion of this chapter is palliative care is to prevent or relieve suffering available while respecting end-of-life patients. Ethical issues in palliative care increasing day-to-day in clinical care due to modern therapy and technology, and it is making life expectancies to increase. Healthcare professionals face difficult ethical challenges in daily work. The most important part of professional ethic appears to be communication, decision-making process, consent form, and ethical conflicts. Healthcare professionals should understand ethical principles, bioethical codes, legal documents, and end-of-life care. These can be prevented from ethical conflicts and ethical problems.

#### **Author details**

Delgersuren Gelegjamts1,2\*, Khulan Gaalan3 and Batbagana Burenerdene4

1 Chosun University, South Korea

2 Mongolian National University, Mongolia


\*Address all correspondence to: degijulie@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 8**

## Advances in Burn Care in Hong Kong: Reflecting on a Decade of Expert Experiences from Local Practice with an International Perspective

*Tze-Wing Wong, Ka-Huen Yip, Yuk-Chiu Yip and Wai-King Tsui*

#### **Abstract**

The nursing implications of burn injuries extend beyond the immediate health concerns over the loss of skin integrity, the presence of scarring, and the psychological impacts on patients due to disfigurement. Non-fatal burns may lead to long-term disabilities, hence advanced nursing care may be required to prevent such outcomes. In Hong Kong, advances have been made to ensure that sophisticated nursing services and care are in place for affected patients. This chapter discusses how burn injuries are managed at different levels within a publicly funded acute care framework, explains how professional competencies regarding burn care are developed among burn care nurses, delineates the roles of medical technology in supporting wound assessment, explains the application of novel dressing materials for various burn wound conditions, and outlines how the establishment of nurse-led clinics can promote the continuity of care for patients with burn injuries. Written with an international perspective with the authors' practice experiences in Hong Kong (China), this chapter provides evidence-based reference for registered nurses in general, specialty nurses, nurse practitioners, and nurse consultants worldwide.

**Keywords:** burn care, burn care team, burn care nurses, nurse-led clinic, medical technology in burn care

#### **1. Introduction**

Burn injuries are life-threatening and cause significant functional and cosmetic morbidity [1, 2]. Managing patients with burn injuries remains challenging, particularly in severe cases [3].

The most common are scald burn injuries that occur in home settings [4]. Toddlers and children are accidentally scalded by hot fluids due to the carelessness of parents

*New Research in Nursing – Education and Practice*

and caregivers [5]. Furthermore, most burns in older adults occur at home since they stay alone, are more prone to medical comorbidities, and are at high risk for burn and scald injury [6–9]. Nevertheless, over the past decade, significant advances in training and development, burn wound assessment, burn wound closure technologies, and continuity of follow-up have been made [10–12].

#### **2. How burn injuries are managed at different levels within a publicly funded acute care framework**

In Hong Kong, under the governance of the Hospital Authority in the acute burn care framework, patients with burn injuries are managed in hospitals with recognized standards and trained specialty healthcare professionals [13–15]. This organizational structure provides a more coordinated care by centralizing patients with severe burn injuries, thereby facilitating the delivery of quality medical and nursing services and early transfer to a burn unit/facility. There remains no universal naming criteria as to what qualifies burn treatment premises to be "burn unit" or "burn facility"; hence, in this chapter, we follow the existing terms of the current treatment premises determined by the Hospital Authority, which is the central governance body of all publicly funded hospitals in Hong Kong. In Hong Kong, some burn units are a major acute hospital among a cluster of regional hospitals caring for patients with major burn injuries, while burn facilities care for patients with moderate sized of burn injuries. According to the severity degree of burn injuries, burn surgeons in accident and emergency unit transfer patients to burn unit or burn facility following consultation when burn injuries meet the referral criteria (**Figure 1**) [15, 16].

Healthcare professionals including burn surgeons, nurses, physiotherapists, and occupational therapists deliver rehabilitation interventions such as medical treatment, therapy, or care for patients with minor burns categorized as Level 1. These patients are stabilized in general surgical or orthopedic units in different hospitals with designated facilities and healthcare professionals with the support of the

**Figure 1.** *Networking of burn Service in Hong Kong.*


#### **Table 1.**

*Burn facility referral criteria at level 2.*

multidisciplinary team. In Hong Kong, senior burn surgeons act as the directors of the receiving burn units/facilities and coordinate the transfer management for all exposures of vulnerable populations to further risks in burns injuries. At the accident and emergency unit, patients with burn injuries are stabilized prior to transfer to the burn/facility to optimize the quality of care and treatment. Moderate-sized or complex burn injuries categorized as Level 2 are managed in a burn facility (**Table 1**) [17–19]. In Hong Kong, there are 3 burn facilities that care for patients namely Queen Elizabeth, Kwong Wah, and Tuen Mun Hospitals.

Patients with extensive and complicated burn injuries are categorized as Level 3 (**Table 2**) and managed or transferred to the burn unit [13, 17–19]. There are 2 burn units considered as the major acute hospital among a cluster of regional hospitals caring for patients with major burn injuries in Hong Kong. However, immediate resuscitation and intensive care support are mandatory. Therefore, optimal treatment of patients with extensive burn injuries requires advanced healthcare resources, implementation of multidisciplinary acute care collaboration, and planning for long-term rehabilitation.

#### **2.1 Enhancing professional competencies regarding burn care are developed among burn care nurses**

James et al. have previously reported a total of 8,991,468 patients with burn injuries in 195 countries and territories from 1990 to 2017 [20]. Previous studies have also reported that an estimated 180,000 deaths annually are attributed to burn injuries combined with electrical injuries, structural collapse, fire escape, airplane


<sup>•</sup> Burns greater than 20% and 10% of total body surface area for adult patients and children ≦12 years old, respectively

crashes, scald burns during assaults, and explosions with airborne flames [21–26]. At the global level, the age-standardized mortality due to burn injuries has significantly decreased from 1990 to 2017; only 3 out of 21 regions reported a significant increase in the incidence rates of burn injuries, and delineated rising rates by more than 30% of age-standardized incidence rates especially in China [20]. The reported indicated that most middle- and high-income regions have invested in resources and safety measures and established access to care to reduce/combat incidence of burn injuries.

A comprehensive burn team approach is important when providing burn care to patients with burn injury by burn care nurses with multidisciplinary care; a burn team consists of burn surgeons, nurses, physiotherapists, occupational therapists, dietitians, and psychologists [10, 27]. Burn care nurses play a crucial role in caring for patients with extensive burns [28] and disaster management, mainly in handling patients with burn injuries [29]. Competency-driven, high-quality, and evidencebased education training programs related to burn injuries are essential when preparing nurses for the full continuum of burn care management [30–32]. The number of burn nursing education and training programs has gradually expanded over the past 20 years [33]. Therefore, most existing training programs in Hong Kong focus on burns injuries management comprise preparedness, response, and recovery phases. Furthermore, most nurse training programs related to burns injuries, especially those targeting registered nurses, have adopted different teaching approaches (online and face-to-face) to ensure flexibility in time, location, and cost effectiveness [34, 35].

In the United States, different burn centers incorporate competencies within the educational nursing curriculums of training programs with examination aligned with the American Burn Association burn nurse competencies (BNC) [36]. Training programs establish interactive, evidenced-based, comprehensive, preceptor workshop, online learning, and skill practice module consistent with BNC domains. Domains of BNC consist of wound management, and other relevant supports (psychosocial, nutritional, discharge planning, and aftercare) [36].

Meanwhile, in the United Kingdom, registered nurses must complete specific burn courses and be competent in burn care by the end of their second year in burn centers and units [37, 38]. According to the framework of burn care for a burn-injured patient, training programs align with the National Burn Care Standards, and nurses require to attend an accredited course in the emergency management for severe burn [37, 38]. Moreover, lead nurses for the Burn Care Services must complete a specific burn care course to demonstrate competences and require attending burn specific training programs annually [38].

In Hong Kong, registered nurses with three-year experience are considered burn care nurses in different public hospitals and must complete an emergency management of severe burns course [13, 15]. Continuing professional education is vital for the future role of burn care nurses. However, to advance their practice, the *"Post-Registration Certificate Course in Advanced Surgical Nursing"* and *"Post-Registration Certificate Course in Burn and Plastic Surgical Nursing (PRCC in Burn & Plastic)"* are training programs recommend for burn care nurses to increase their competence in burn care nursing and facilitate the development of burn teams in a burn unit to meet the complexity of managing different levels of burn injuries by in-service training in Hong Kong [15].

*"Post-Registration Certificate Course in Advanced Surgical Nursing"* is an annual training program consisting of different surgical nursing specialties components (breast, urological, stoma and wound, hepatobiliary and pancreatic, head and neck and plastic, and burn and plastic care) with theoretical and practical components.

#### *Advances in Burn Care in Hong Kong: Reflecting on a Decade of Expert Experiences from Local… DOI: http://dx.doi.org/10.5772/intechopen.110319*

According to the burn patient population, conduction of *PRCC in Burn and Plastic* is affected by the demand of clinical services (e.g., held in 1997, 2016, and 2019). This program is an 8-month structured training program with examination. The core content of this program emphasizes the theoretical (210 lecture hours) and practical (6 weeks practical attachment) components to enhance the knowledge of burn care nurses in delivering burns nursing interventions [39]. Currently, becoming an experienced burn care nurse requires being a nursing burn team leader that helps to facilitate patients with burn injuries to the optimal level of physical and psychological health and social function [40]. The effect of stimulation training on the development of burn care nurses can positively affect the perceptions of nurses managing patients with burns injuries [32, 41]. The advancement of burn education through simulation training tools aimed at the emerging role of simulation for training to promote knowledge and significantly advance the delivery of burn education. It is crucial for competence enhancement of burn care nurses, such as providing experience with rare and critical incidents, problem-solving skills, decision-making, and team dynamics [13, 42–44]. Debriefing sessions during the simulation training program are critical for nursing education since they provide the opportunity for self-recall and insight into improving learning outcomes (critical analysis and personal growth) following simulation training workshops. This program can enhance the clinical skills critical in assisting new burn care nurses in their transition to practice.

Given the increased occurrence of disasters, including burns injuries, enhancing the readiness of burn care nurses caring for the physical and psychological health of patients is urgently needed [35].

To sustain the standard and competence of clinical practice, *"Advanced Nursing Standards and Specialty Nursing Practice Guidelines"* related to burn and plastic surgical nursing have been adopted in public hospitals and are regularly developed for burn care nurses to enhance their comprehensive knowledge and skills, as well as the guidelines in the whole spectrum of burns injuries management in Hong Kong [15]. All standards and guidelines for advanced nursing practices are designed to support evidence-based practices to ensure the quality and appropriate pathway for nursing professionals to meet the burn injuries challenges [32].

Caring for patients with burn injuries certainly requires teamwork both within and outside the hospital. However, nursing colleges developed a platform between burn care nurses and other health professionals useful for sharing the knowledge and experience of caring for this unique group of patients (such as introduction and elementary understanding of basic burn knowledge and wound dressing technique), thereby reinforcing the roles and functioning of burn care nurses. In Hong Kong, such a network exists; the Hong Kong College of Surgical Nursing (HKCSN) facilitates networking among local surgical professionals and is a good support source. Serving as a platform for healthcare professionals to share experiences in burns nursing, the HKCSN invites both local and international experts to deliver lectures and run courses and seminars for its members [45].

Burn care nurses frequently attend different faculty/organizational development conferences, both local and international, e.g., Burn and Plastic Forums organized by local burn unit and burn facilities and International Burn Conferences and Annual Scientific Meetings organized overseas [13, 15, 46]. These conferences help burn care nurses caring for patients with burn injuries to learn new strategies and information regarding the global insight of nursing education and practices on burn management. In addition, conferences have been held on the ability of nursing professionals to transfer new knowledge into their nursing practices for patients with burn injuries

in clinical settings. Knowledge transfer may benefit from a better understanding of professional development related to burn care in clinical settings [47], which includes best practices in non-boundary burn and plastic specialty, advanced technology in burn care, and wound dressing techniques that can be integrated into local practice.

#### **2.2 Roles of medical technology in supporting wound assessment**

Patients with burn injuries benefit from early wound closure with local treatment consisting of cleansing, debridement, and routine burn wound dressing changes to minimize or control infection and improve wound healing [48, 49]. However, at the early stages of injury, it may be difficult to accurately define the depth of burn wounds. In Hong Kong, burn care nurses use laser Doppler imaging (LDI) (**Figure 2**) with non-invasive and non-contact devices for more accurate assessments that deliver a two-dimensional image of the burn area as an early objective determination of wound depth (depth analysis of the dermal circulation).

**Figure 2.** *Laser Doppler imaging device.*

*Advances in Burn Care in Hong Kong: Reflecting on a Decade of Expert Experiences from Local… DOI: http://dx.doi.org/10.5772/intechopen.110319*

This technique also helps to predict the healing outcome of burn wounds before providing initial burn patient management [50–53], while the wound depth assessment is commonly determined and diagnosed by experienced burn surgeons using this imaging technique. This diagnostic intervention can be performed on patients with burns; hence wounds can be assessed early, between 48 hours to 5 days post-burn for diagnostic and therapeutic management [49, 52, 54].

There is a mandatory requirement to complete the LDI training qualification, which provides assessment knowledge and application skill essential for nursing clinicians in using this technique for therapeutic decisions for patients with burn injuries [51, 52, 54]. The completion requirement in operating LDI includes scanning technique, interpretation of results, awareness of safety practice, and elimination of confounding factors, including the presence of infection or tattoos [53–56]. However, the low power of the LDI laser light can penetrate the burn wound and detect circulating blood cells in capillaries, arterioles, and venules [49, 52, 55]. Moreover, LDI can identify a color-coded blood flow map showing microcirculatory blood perfusion in patients with burn injuries. LDI can differentiate superficial dermal burns, mid to deep dermal burns, and full-thickness burn wounds [51]. The utilization of LDI provides an early accurate assessment, thereby facilitating early burn treatment strategies, which can reduce costs, patient morbidity, length of hospitalization, and unnecessary surgery for patients with burns [55].

#### **2.3 Application of novel dressing materials for various burn wound conditions**

Burn care nurses perform routine burn wound dressing changes for patients with burn injuries, and their healing outcomes have been previously reviewed [48, 50, 57]. Burns can be classified by the depth of injury into either superficial, superficial dermal, deep dermal, full-thickness, and deeper injury [58–60]. According to the depth of the burn, various specialized management and treatment modalities are available and focus on specific anatomic sites; different therapeutic wound dressing materials are applied for the recovery of the underlying physiological processes in tissue repair such as antimicrobial agents, including gauze, non-adherent films, and antimicrobial agents [39, 61, 62]. The selection and application of dressing materials and topical agents are based on the nature of and benefits to the burn wound, a specific wound quality or presence of contamination or infection, and patient allergy.

Superficial burn wounds comprise superficial dermal and partial-thickness wounds that are pinkish in color, with blister formation, epidermis slough off, and excruciating pain [63]. Wound care promotes wound epithelialization and prevents infection. Furthermore, biological dressings, including porcine skin and amniotic membrane, are applied to relieve wound pain and enhance epithelialization [62, 63].

Deep burn wounds consist of deep partial thickness, full thickness, and deeper injury, and require burn wound excision and graft coverage. Mid- and deep-dermal burn wounds are mottled pinkish or whitish, have a dull sensation, and are sloughy [63]. The aims of wound care for deep burn wounds are minimizing necrotic tissue and preventing wound infection. First, wound irrigating disinfectant (e.g., Granudacyn® irrigation solution) is used to cleanse and moisturize the wound; it contains hypochlorous acid, a reliable cleansing solution [64] and can prevent the proliferation of Gram-positive and -negative bacteria. Subsequently, nurses should thoroughly cleanse and debride sloughy and necrotic tissue on a burn wound. A single-use sterile cloth, "UCS® debridement cloth", is pre-moistened and used for wound cleansing and debridement of the surrounding wound areas. Furthermore,

enzymatic debridement agents (e.g., Iruxol® mono ointment dressing) are used to remove slough and promote burn wound healing and achieving a significant therapeutic effect [13].

Moreover, full-thickness burn wounds require eschar debridement and/or excision and original autologous meshed skin grafting for charred and leathery wound [63]. The use of skin grafts on full-thickness burn wounds results in no or minimum hypertrophic scar formation [65]. Simultaneously, burn care nurses require additional knowledge and skills to care for patients with burn injuries and guide the appropriate care of both the recipient (burn area with skin graft) and donor sites (donation skin site) [66].

#### **2.4 Advancement of wound management for preventing hypertrophic scarring**

Biodegradable temporizing matrix (BTM) is used for full or deep burn wounds [67–69] to cover excised deep burn wounds for at least 3 weeks, aiming at temporary wound closure and supporting the reconstruction of the dermis. BTM intergradation into the wound bed through cellular infiltration is time consuming. New blood vessels grow and become full of fibroblasts production; therefore, when the neodermis becomes vascularized, a thin skin graft can be applied to a deep burn wound [67, 70].

Dermal regeneration templates (e.g., Nevelia®) used for full or deep burn wounds or reconstructive surgery are made for collagen layering, which promotes dermal regeneration [71, 72]. First, it is used to cover an excised burn wound or excised scarring for approximately 3 weeks [73] and consists of a matrix of bovine collagen, which facilitates integration into the wound tissue [74]. Next, a split-thickness skin graft is required to cover burn wounds, provides better functional and esthetic outcomes, and reduces hypertrophic scar formation [65, 75].

#### **2.5 Nurse-led burn clinics promote continuity of care for patients with burn injuries**

Hong Kong has only one nurse-led burn clinic in public hospital, which plays a crucial role for patients with burn injuries by function-limiting sequelae such as contractures, scarring, thermoregulatory anomalies, amputation, and nurse-led burn clinic by promoting the continuity of care, quality of life, and psychosocial well-being during their rehabilitation and return home within the long-term recovery period, and by decreasing the length of hospitalization [39]. The aims of nurse-led burn clinics include: independent burn care nurses with delegated authority to make decisions regarding patients with burn injuries; delivering full support while maintaining continuity of care after discharge; implementation of multidisciplinary acute care collaboration and planning for long term rehabilitation and burn wound management; evaluating the patient's response to both physical and psychological treatments and counseling; referring the patient to the appropriate resources for support; assessing and evaluating the patient's ability to perform activities of daily living and self-care; providing educative advice on rehabilitation for patients with burn injuries [57]. Nurse-led burn clinics and services also provide healthcare (e.g., ability to prescribe optimal wound management) to referrals with minor burns from the Accident and Emergency Unit [76, 77]. In addition, burn care nurses at nurse-led burn clinics have the authority and autonomy in performing burn wound management recognized by hospitals in the provision of care for patients with burn injuries based on the assessed needs of patients and caregivers.

*Advances in Burn Care in Hong Kong: Reflecting on a Decade of Expert Experiences from Local… DOI: http://dx.doi.org/10.5772/intechopen.110319*

#### **3. Conclusion**

Despite the recent developments in caregiving approaches for patients with burn injuries, morbidity and mortality continue to increase worldwide. Several comprehensive programs related to burn care have been implemented to enhance nurse's competency to care for patients with burn injuries in the acute care framework. In Hong Kong, burn care nurses at nurse-led clinic educate patients with burn injuries and their families/caregivers throughout the hospitalization period, discharge planning, and rehabilitative journey to ease their anxiety and promote recovery. Moreover, burn care nurses attend continuing education programs, in-service training programs, and both local and international conferences to enhance their knowledge and readiness to respond to burns injuries, as well as management and leadership in local practice with a global perspective. Nurse-led clinic and referral pathway can reduce patient hospitalization and foster better long-term rehabilitation and return home. The incentives of Hospital Authority to increase the number of nurses attending burn care training courses to enhance high quality care to patients with burn injuries. No LDI study has objectively assessed the different severity of burn depth of perform by nurses; therefore, we recommend that burn care nurses conduct a study focusing on the objective LDI assessment of diverse severity of burn depth.

#### **Funding**

This research received funding support from the Institutional Development Grant of the Caritas Institute of Higher Education, grant number IDG220225.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Notes/thanks/other declarations**

None.

*New Research in Nursing – Education and Practice*

### **Author details**

Tze-Wing Wong1 , Ka-Huen Yip2 \*, Yuk-Chiu Yip3 and Wai-King Tsui<sup>2</sup>

1 Princes of Wales Hospital, Shatin, Hong Kong, China

2 Caritas Institute of Higher Education, Hong Kong, China

3 Hong Kong Metropolitan University, Hong Kong, China

\*Address all correspondence to: khyip@cihe.edu.hk

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Advances in Burn Care in Hong Kong: Reflecting on a Decade of Expert Experiences from Local… DOI: http://dx.doi.org/10.5772/intechopen.110319*

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#### **Chapter 9**

## Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses

*Razzagh Rahimpoor*

#### **Abstract**

Poor sleep quality as one of the mental problems caused by shift working can lead to psychological disorders (i.e., depression; adult attention deficit; memory, cognitive, and performance deficit; reduced job satisfaction, quality of life, and sex drive; and mood change) and physiological disorders (immune system, obesity, cardiovascular risks, hormone imbalance, fertility, and aging). The main scope of the proposed chapter is to describe the various dimensions of psychological and physiological disorders caused by poor sleep quality among shift-working nurses. Also, educational programs will be described for early detection of physiological and psychological symptoms of poor-quality sleep and improvement of sleep quality among shift-working nurses.

**Keywords:** nurses, sleep disorders, night shift work, circadian rhythm, health status

#### **1. Introduction**

Sleep plays a vital role in brain function and systemic physiology across many body systems [1]. Sleep is controlled by the Supra Chiasmatic Nucleus (SCN) of the hypothalamus, the endogenous clock that regulates the production of melatonin, a hormone that induces sleep [2]. Sleep plays an essential role in brain function, and also, the quantity and quality of sleep affect the systemic physiology of the body, including appetite regulation, metabolism, and the function of the immune, cardiovascular, and hormonal systems [3, 4].

Normal sound sleep is defined by adequate duration, good quality, suitable timing and arrangements, and no sleep disturbances [5]. Sleep is one of the most important parameters in night cycles, which plays a key role in restoring physical and emotional strength [6]. Around a third of human life is spent on sleep, and more than thirty percent of the world's people suffer from sleep disruptions because of mental-psychological illness, physical diseases, night work, second employment, and so on. The health care system is one of the most important areas of sustainable human health development where nurses are the main occupational group in the therapeutic system. Nurses usually make up forty percent of the hospital staff, and more than half of the total personnel costs are allocated to them [7–9]. At night, employees of public service-providing areas are working, so that 36.9% of the hospital staff are nightworking individuals, and they are often nurses [10].

The results of decades of research have indicated that sleep disruption or insomnia is a widespread problem among people bearing depression; most of them complain of difficulty in starting and maintaining sleep, waking up early in the morning, difficulty in returning to sleep, and insufficient quality of sleep [11–13]. Problems with sleep are widely prevalent and include deficits in quantity and quality of sleep; sleep problems that impact the continuity of sleep are collectively referred to as sleep disruptions [1]. Sleep deprivation is used to refer to acute total sleep deprivation (typically short periods of wakefulness (<72 h) accompanied by a nearly complete loss (>90%) of both non-Rapid Eye Movement [REM] sleep and REM sleep). The non-REM sleep is often caused by occupational demands as experienced by emergency workers, shift workers, and medicine physicians on 36–48 h work shifts by clinical conditions or in military personnel due to insomnia [14].

Sleep disorders tend to occur in one of three ways: inability to obtain a sufficient amount or quality of sleep (called sleep deprivation), unable to maintain sleep durability (difficulty maintaining sleep, called disrupted sleep or sleep fragmentation, and middle insomnia), and what events happen during sleep (for example, restless legs syndrome or sleep apnea) [1, 3].

Sleepiness is the desire or inclination to sleep, whereas fatigue is the lack of desire or disinclination to continue performing the task at hand [15]. Numerous factors contribute to sleep disruption, ranging from lifestyle and environmental factors to sleep disorders and other medical conditions. Sleep disruptions have substantial adverse short- and long-term health consequences [1]. Several studies have shown that the mortality rate in people with a sleep time of fewer than 3.5 h and more than 8.5 h is higher than in those people with a sleep duration of 7 h a day [10, 16, 17].

Physiological systems that follow circadian rhythms like the sleep-wake cycle, hormone secretions, and core body temperature are influenced by signals from the environment especially light [18]. Altered circadian rhythm results in physiological and psychological variables [19, 20]. Shift work results in a conflict between days-oriented circadian physiology and the requirement for work and sleeps at the wrong biological time of day. Internally driven circadian biological clocks regulate the periods of sleepiness and wakefulness [20]. Sleep deprivation affects the ability of health workers who are involved in a multitude of life-saving tasks that need more attention and concentration. Quality of sleep is compromised in those who are frequently involved in extended working hours and shift work, which is found to be more common among nurses [21].

#### **2. Shift work**

Rotating and scheduling are the main characteristics of shift work, and nurses are largely locked into schedules that provide 24-h care and include night-shift work [22, 23]. The "shift workers are creators and victims at the same time" of this new work organization [24].

Nursing professionals being one of the most vulnerable populations with chronic work stress due to the high degree of relationship between nurses and patients and the strong emotional involvement that this requires [25]. Nursing is inherently a stressful profession requiring comparatively high levels of physical and mental activity [26]. There are several stressful situations in the nursing profession that can cause problems, including dissatisfaction, low efficiency, and retirement. These situations result in physical and mental health issues that irreversibly damage the

#### *Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

nursing system [27]. Previous studies have shown that high stress among nurses has affected their quality of professional life [28, 29].

Continuous and extended work in close proximity to patients, numerous and strenuous work shifts, poor levels of independence, dissatisfaction with occupational responsibilities, and unprepared to deal with emotional events are some specificities innate to the work of nursing technicians and nursing assistants that make them more prone to developing sleep disorders [30]. Shift work disorder is distinguished as a sleep disorder specified by insomnia in a person's daily scheme [31]. Working on the night shift has been inverse to human nature and induces various disturbances in the nighttime rhythm (circadian rhythm: biological clock) and other undesirable health effects, such as digestive disorders, cardiovascular disorders, and reproductive system disorders, and raises accident rates and decreases efficacy among employees [32, 33]. The nature of the nursing job and their occupational stress, along with the harmful physical factors, are the reason for sleep disorders and drowsiness during the daytime [34].

In addition to adverse health consequences and diminished quality of life at the individual level, shift work disorder incurs significant costs to employers through diminished workplace performance and increased accidents and errors [35]. Recent scientific findings have provided insight into individual differences in tolerance for shift work and expanded cure options for persons with shift-related work disorders. At the same time, attempts to diminish the burden of shift work among employees are still at an early stage. Despite the insufficient data, from an organizational standpoint, reducing the costs related to shift work has the potential to generate significant financial benefits [35]. Furthermore, occupational demands are frequent causes of insufficient sleep and may elevate the risk of accidents at work [36].

Cognitive impairment leads to fatigability and a decline in attention and efficiency in the workplace, which puts nurses' health and patients' health at risk. Cognitive performance is impaired among shift-working nurses, due to poor sleep quality and decreased alertness during the wake state [20]. Night work worsens the well-being of the employee and accelerates the accumulation of fatigue, which is the cause of lower quality and efficiency of work and numerous absences of the employee. Working at the night shift is attended by excessive stress, which makes it very hard to rest and sleep adequately [37, 38]. The result of this is the occurrence of many diseases, including diabetes, hypertension, ischemic heart disease, neurosis, anxiety disorders, and depression, which subsequently lead to various sick leaves, occupational burnout, and incompatibility with the environment and with families [39].

Working at night disrupts all of the physiological processes of the body, as well as causes an increase in the stress hormones adrenaline and cortisol, which are the main representatives of glucocorticoid hormones. Sleep deprivation raises the level of cortisol in blood serum, which subsequently arranges the body to a constant state of readiness. Because of this, higher levels of cortisol hormone cannot go back to normal levels in spite of sleeping at night [38]. It is thought that a long-term adaptation to night-shift work is extremely restricted or even inevitable [40].

#### **3. Psychological disorders**

Nurses work rotating shifts and extended hours, which can change the circadian rhythm, occasionally leading to abuse of caffeine and benzodiazepines and nurses needing to use their days off and free time to recover from lost sleep hours. On the other hand, the consequences that arise from nurse burnout are numerous, such

as absenteeism; lack of motivation; concentration difficulty; poor organization; increased errors; decreased patient safety; lack of energy; and feelings of frustration, anxiety, and depression; and insomnia. This scenario leads to poor sleep quality, which plays a critical role in emotional regulation and mental well-being, creating a cyclical issue underlying nursing work [25, 41].

One of the responsibilities of a nurse is prescribing the right drug on time to the right patient by the correct route. Therefore, it is obligatory that nurses clarify obscure orders; have the requisite knowledge and strength of character to question orders that are inappropriate; doubly and triply verify the medicinal product, dosage, and identity of the patient; administer the drug at the correct time and through the right route; and carefully monitor the patient [42]. Administering drugs is part of everyday nursing practice. Patient safety is a key concern in today's healthcare delivery systems. Errors in medication administration can pose a threat to patient outcomes and patient safety [43].

Research conducted among night-shift residents' and nurses reported that poor concentration hindered their efficient, decision-making capacity and also caused increased error rates. Better cognitive ability was reported among nurses who had never been exposed to shifting work compared to those who had been exposed to sleep deprivation, altered circadian rhythm, and extended shift work duration [11, 44]. Chronic fatigue, emotional exhaustion, cognitive anxiety, and worse sleep quality are more common among shift-work nurses than other nurses, and it is associated with the duration of their work shift. In other words, the increase in days of rest for 12-h shift nurses does not seem to be sufficient to neutralize the accumulation of adverse effects during extended workdays [45]. Due to the high incidence of medical mistakes and significant gaps in healthcare quality (medication errors and patient deaths), patient safety is a key concern of today's healthcare delivery systems, and medication administration errors are frequently used as an indicator of patient safety. Several studies have shown that failure to obtain adequate sleep is an important contributor to medical errors, and sleep deprivation can make many healthcare workers, including nurses, more susceptible to irritation and anger toward those they care about. It often causes feelings of guilt, depression, and anxiety and more sleep disorders. Difficulty in sleeping significantly increases the risk of depression even in someone who hasn't had a history of depression before [32].

Several studies have investigated the effect of sleep loss on the development of these neurons [46]. Disruption of sleep for one night appears to have little effect on the rate of cell production, but chronic sleep restriction or disruption of sleep has cumulative effects that lead to a reduction of neuronal development [47, 48]. Additionally, sleep restriction interferes with the normal increase in neurogenesis that occurs with hippocampus-dependent learning tasks (e.g., spatial learning) [49]. It is hypothesized that decreases in cell production are related to a decrease in REM sleep commonly seen in total sleep deprivation and sleep restriction [50].

Partial sleep deprivation reduces response inhibition during the night shift and frontal-lobe vulnerability. Working memory and episodic memory are related to temporal-lobe function, and therefore, relative sleep deprivation has detrimental effects on the psychiatric health of nurses on duty, which is responsible for impaired memory, concentration, and thinking ability [20]. A medical error is defined as a situation when a healthcare professional chooses the wrong method of care or a situation in which the healthcare professional selects the right method of care but performs it incorrectly; so medical errors are frequently described as human errors in the healthcare system [51, 52]. Shift work leads to experiencing circadian disturbance,

#### *Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

particularly working overnight shifts or rotating shifts; also, shift work schedules increase the risk of accidents and injuries [53]. Working during the evening or night can lead to aggravating fatigue in employees because the circadian cycle is disrupted, and on the other hand, fatigue can increase the rate of human errors as a part of medical errors [54]. The cognitive deficits associated with total sleep deprivation have been well described by many studies.

Various studies have continually shown a deleterious effect of total sleep deprivation on vigilant attention. Other cognitive domains aside from attention have also been found to deteriorate with total sleep deprivation. These include spatial working memory, verbal memory, constructive thinking, and cognitive throughput [55–58]. Total sleep deprivation can result in task perseveration with reduced creative thinking and an inability to perceive the likelihood of making errors [57, 59]. Results of previous studies revealed that wrong time and wrong rate were the most frequent medication errors committed by nurses. These errors may be due to either oral or written miscommunication, name confusion, similar or misleading container labeling, or performance or knowledge deficits [15, 60]. People's instability starts when the biological mechanisms affecting the sleep initiation process interfere with cognitive functions. This makes cognitive functions more variable and dependent more and more on intentional efforts to stay awake. The aftereffects of state instability are manifested by increasingly frequent errors of commission (responding when not required) and errors of omission (not responding when it is required) [50, 61].

The most frequent complaints among nurses have been reported as insufficient sleep, short sleep duration, and insomnia [62]. External, environmental, and social factors may also act as predisposing factors for poor sleep. During periods of stressful events and changes in routine, sleep quality may be negatively affected [63]. Sleep plays a fundamental role in learning, memory consolidation, and motor learning, as well as in the immune system and cardiovascular and liver metabolism [25]. Deficits in attention, learning & memory, sensory perception, emotional reactivity, and higher-order cognitive processes, such as executive function and decision-making, have all been documented following sleep disruption in humans [14].

Short-term consequences of sleep disruption include increased stress responsivity; somatic problems; reduced quality of life; emotional distress; mood disorders and other mental health problems; cognition, memory, and performance deficits; and behavior problems in otherwise healthy individuals [1].

Stress and emotional tension from exhausting working conditions can cause burnout syndrome. Burnout is an emotional disorder with symptoms such as stress, fatigue, and physical exhaustion resulting from very stressful work associated with a high degree of responsibility or competitiveness [64]. Burnout groups also show greater sleep fragmentation, lower sleep efficiency, less slow wave and Rapid Eye Movement sleep, lower delta power density in non-REM sleep, and finally lower subjective sleep quality [65].

Burnout can have severe impacts on patients and healthcare professionals. This not only leads to negative mental and physical health outcomes, absenteeism, poor morale, and lack of incentive among personnel but also results in a decline in the quality of care delivered by the affected personnel, resulting in inferior consequences for patients [66].

Inadequate sleep or circadian changes can reduce mental performance and cognitive function, decrease levels of concentration and attention, slow down complex coordination, increase the risk of accidents, increase psychiatric morbidity,

impair the cardiovascular autonomous response system, and also increase physical fatigue [67, 68]. Sleep anxiety can also mediate between depressive symptoms and sleep disorders. Sleep anxiety can be defined as a 24-h phenomenon originating from worries created by insufficient and uncontrollable sleep. Another noteworthy finding is that emotional exhaustion and sleep anxiety have successively caused the association between sleep disorders and depressive symptoms [44, 69]. Previous studies confirm that there is a significant relationship between low earnings and stress in clinical workplaces and the rate of medication errors.

Patient safety outcomes, including medication errors, have been related to occupational burnout in nurses, which is related to staff shortage, unfavourability of nursephysician relations, and further work-life factors [43, 70].

Emotional exhaustion, job dissatisfaction, and depersonalization are significant factors that influence sleep disorders. Emotional exhaustion, which causes burnout, significantly affects the occurrence of sleep problems. Exhaustion can make work at night more tiring, while the body's ability to regenerate worsens, which may directly cause health problems [38]. Emotional exhaustion is an enduring state of physical and emotional depletion that is caused by personal demands, excessive work, and continuous stress [71]. Clearly, providing services or care, like nursing, can be a very challenging profession, and of course, emotional exhaustion is a usual response to this job overload [72]. Emotional exhaustion is a stress-related and social problem, whereas depression is a pervasive and individual problem [73]. Emotional exhaustion can be an important mediator in the relationship between sleep disturbance and depressive symptoms. Empirical studies have shown that sleep disturbance leads to increased emotional exhaustion. Emotional exhaustion represents the basic individual stress dimension of burnout, which is defined as a psychological state resulting from prolonged emotional or psychological stress on the job [70].

Nurses also typically travail from high workloads and face problems balancing work and family life. These personal workplace conflicts lead to the formation of occupational stress and burnout. In addition, the aftereffects caused by the prevalence of burnout among nurses are multiple, including lack of motivation; reduction in work performance and communication between co-workers; increased absenteeism; grown errors; deficient organization; loss of energy; reduction in patient safety; feelings of frustration, depression, and anxiety; and insomnia [73]. Several studies show that sleep pattern disorders, daytime sleepiness, and burnout are more common among shift-working nurses with 12-hr shifts or more and discontinuous or badly organized shifts than other nurses. These variables are most influenced by the fixed night shift and the rotating shift [25, 74].

Sleep deprivation raises your risk of depression, even for someone without a history of depression. Depression is a syndrome with multiple symptoms, in particular changes in one's behavior (isolation), mood (guilt and sadness), thinking and perception patterns (less focus and lower self-respect), physical complaints (sex, sleep, and hunger), and a high potential of suicide [75]. Previous studies reported significant correlation between sleep parameters and sleep quality, as well as daytime impairment [31, 76]. Several studies have demonstrated that sleep disturbance leads to symptoms of worry, which later develop into depressive symptoms and mood disorders [77, 78]. Generally, the self-reported mood is also affected by sleep deprivation. In the majority of sleep deprivation studies, there is an increase in negative mood states, with reports of fatigue and confusion as well as reduced energy and enthusiasm. Sleep restriction also affects mood [79] and sociability and has been found to exacerbate psychosomatic symptoms, including feelings of muscular pain,

#### *Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

nausea, headache, and generalized body pain. As such, sleep restriction may degrade long-term well-being [80].

The impact of sleep disturbance on depressive symptoms has been strongly mediated by emotional exhaustion. Furthermore, sleep disorders were related to sustaining and emotional exhaustion [81, 82]. The increase in sleep disorders has been sequentially associated with increased emotional burnout and sleep-related anxiety, leading to elevated depressive symptoms. Nurses who rotated between day and night shifts were found to have more health complaints and were less satisfied with their working hours than their colleagues who worked 8-h shifts. The positive correlation between depression and the frequency of medication errors, in a way, indicates the increase of medication errors with the increase in depression [15]. These symptoms are often underestimated by professionals, who self-medicate instead of asking for help in medical or psychological consultation. Furthermore, it has a strong impact on the quality of care [83].

To increase productivity at work, a minimally stressful work environment is necessary. To deal with job stress, temperament control, intervention with control of depressive symptoms and mood, and good sleep quality of a worker, particularly for female nurses, might create an improved and more efficient work environment [84]. Female physicians, like nurses, are at risk of increased occupational stress. An increased workload can lead to severe psychological problems, such as sleep disorders and depression among female doctors, and subsequently affect their occupational and personal lives [85]. In general, shift work can lead to problems in the personal and professional lives of female workers due to the need to work at unusual hours and increased physical activity at work. As a result, woman shift workers have a higher risk of stroke than other workers [86].

#### **4. Physical disorders**

The tendency to sleep is regulated by the interaction between a "homeostatic pressure" to sleep and a "circadian alerting signal" that encourages wakefulness. The homeostatic pressure for sleep increases with each hour of wakefulness and dissipates with sleep. Also, the circadian alerting signal is controlled mainly in the suprachiasmatic nucleus of the anterior hypothalamus. This intrinsic coordinator of the circadian rhythm lasts approximately 24.2 h, which regulates not only sleep and wakefulness but also variable physiological functions such as blood pressure, body temperature, and hormone secretion (cortisol and melatonin) [35].

The natural light-darkness cycle is the is the strongest controller of the circadian rhythm. After light waves enter the eye (or through closed eyelids), photic stimuli are transmitted to the suprachiasmatic nucleus through the retinogeniculo-hypothalamic and retinohypothalamic pathways in the hypothalamus, and this suppresses the secretion of melatonin from the pineal gland [87].

Following nighttime work, these two opposing processes are uncoupled, and the balance of sleep and wakefulness is disturbed. It means that working at night or artificial "day" is not compatible with low melatonin secretion and high alertness. For instance, night-shift workers often fall asleep during the daytime, while at the same time, the circadian alarm signal is at its highest. Therefore, daytime sleep is fragmented and short, resulting in a lack of homeostatic sleep and low circadian excitement at night. In contrast, night work is expected to occur exactly when circadian alerting signals are weakest and sleepiness is at its strongest [35, 88].

Medical complications include increased risk for cardiovascular disease [89]; cerebrovascular events and stroke [86]; obesity [90] and metabolic disorders [91]; gastrointestinal complaints [92]; poor sexual health, including reduced fertility and problems during pregnancy [93]; and multiple forms of cancer [94]. The night shift has been associated with a higher incidence of varicose veins, appetite disturbance, and sleep disorders. Sleep deprivation has considerable consequences on people's personal life as they often postpone many personal and social activities. Inadequate sleep may jeopardize health professionals' efficacy to handle critical situations. Poorquality sleep has been identified as a risk factor for nursing turnover [40].

The distress associated with sleep loss can create additional stress to maximize sleep, which, in turn, contributes to worsening (rather than improving) sleep disruption. Insomniacs have been shown to have increased EEG activity, abnormal hormone secretion, increased metabolic activity, and increased sympathetic nervous system activity throughout the day and night [1, 95].

The greatest change in blood pressure during the sleep period among those who work shifts is a relevant finding because blood pressure is expected to decrease during the sleep period, called a drop [96]. The lack of a drop and the severity of blood pressure is linked to sleep apnea, autonomic dysfunction, nightly overload, increase in mortality, decreased myocardial diastolic function, developing lesions in target organs like left ventricular hypertrophy, and increase in the prevalence of diabetic retinopathy and subsequent decline of glucose tolerance [97].

Sleep abnormalities affect immune function in a reciprocal manner, leading to changes in prion inflammatory cytokines, such as tumor necrosis factor, interleukins 1 and 6, and C-reactive protein. During both brief and extended arousals during sleep, increased metabolism is evidenced by increased oxygen consumption and carbon dioxide production. Chronic persistent insomnia is associated with increased secretion of adrenocorticotropic hormone and cortisol, which is present throughout a 24-h sleep-wake cycle [98–100].

Long-term consequences of sleep disruption in otherwise healthy individuals include hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, and Type 2 diabetes mellitus. The increased activity of the sympathetic nervous system that is associated with sleep deprivation has substantial longterm consequences for adults and adolescents. Adults who experience sleep disruption have elevated blood pressure and an increased risk of developing hypertension. Sleep loss appears to affect energy metabolism primarily by impairing insulin sensitivity and increasing food intake. Disrupted sleep has been associated with weight gain and other weight-related issues. Sleep fragmentation can alter glucose homeostasis and decrease insulin sensitivity [1]. Shift work is also associated with a disturbed lipid profile; high triglycerides and low HDL levels are often noticed among shift workers. High triglycerides and low HDL cholesterol findings among shift workers are associated with metabolic syndrome compared to non-shift workers [91, 101].

Previous studies have documented the numerous gastrointestinal signs and disorders related to shift work for over two decades, including gastritis, dyspepsia, colitis, indigestion, peptic ulcer, appetite disorders, constipation, pain, heartburn, abdominal rumblings, inconsistent bowel movements, gastro-duodenitis, and flatulence [92, 102]. Several factors may be involved in the gastrointestinal symptoms reported among shift workers: altered circadian rhythm of stomach functions (enzyme activity, gastric secretion, and intestinal motility), drugs, types of foods eaten, psychosocial stress, and changed menstrual cycle (in women) [103].

#### *Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

Inflammatory markers such as C Reactive Protein (CRP) and leukocyte counts are higher in shift workers and are associated with cardiovascular diseases, atherosclerosis, stroke, and Type 2 diabetes mellitus (T2DM) [104, 105]. An increase in leukocytes is a major risk factor for ischemic stroke and a risk and prognostic indicator for cardiovascular diseases [106, 107]. Nightwork is one of the risk factors for diabetes management since A1c hemoglobin is higher in night shift workers with T2DM than in daytime workers [108]. Several studies have been published for investigating the probabilistic effects of shiftwork on the cardiovascular system without providing deterministic results [109]. Some studies have pointed out that night-shift workers have a higher relative risk of cardiovascular diseases than day workers [89, 110]. In a cohort study, it has been shown that mortality due to various causes, including cardiovascular diseases, among female rotating night-shiftwork nurses was higher than that among day-work nurses, which reflects the potentially adverse effects of rotating night shift on health and life expectancy [111]. A decade ago, the International Agency for Research on Cancer (IARC) confirmed that there was sufficient evidence to consider shift work along with circadian rhythm disturbance as a possible carcinogen (breast cancer) [112].

The occurrence and prevalence of breast cancer among woman shift workers are higher than woman daytime workers. The reason for that is the suppression of melatonin secretion due to excessive exposure to light during the night shift, and considering that the secretion of melatonin at night has an antioxidant role in the pathological and physiological functions of the body, it will ultimately lead to the susceptibility of women shift workers to breast cancer [113]. The biology and growth of normal breast tissue are controlled by genes affected by the circadian rhythm, so a disturbance in the circadian rhythm can cause breast cancer [114]. Female shift workers are at a higher risk of breast cancer compared to non-shift workers because of the disturbance of their circadian rhythms. The decrease in the secretion of cortisol and melatonin hormones causes the diffusion of a series of inflammatory indicators like as TNF-α, IL-1, and IL-2 and subsequently makes women prone to breast cancer [114, 115]. Light exposure at night among shift workers suppresses the normal release of melatonin from the pineal gland and can also stimulate the production of estrogen from the ovaries, which, in turn, can result in breast cancer [10]. Prolonged work as a shift worker is a risk factor for the occurrence of breast cancer due to circadian rhythm disturbance [116].

However, a cohort study reported that there was no significant difference in cortisol levels and any of the immune system indicators between daytime and shift workers [117]. Women are more susceptible to breast cancer if they begin shift work at a very early age and work for a long time period [118].

#### **5. Operational and educational suggestions**

The sleep disorders cause burnout in nurses who work shifts. This science can be used to develop strategies to prevent sleep disorders and burnout in nurses, which will also better the quality of nursing services. Identifying the key factors affecting nurse burnout can play an important role in countering this destructive phenomenon by carrying out targeted treatment actions. An efficient system of monitoring shift working schedules should be set up to decrease the occurrence and prevalence of burnout and sleep disturbances. Monitoring the statistic of night shifts, forbidding

nurses from working the day after the night shift, and controlling the long adequate rest breaks all can be effective in reducing the adverse effects of night work as the major reason for sleep disorders and insomnia among shiftwork nurses [38].

In many cases, it is impossible to change the work team's organization; thus, it is necessary for these professionals to adopt measures to reduce variations in the sleepwatch rhythm, using a system of daytime naps and adjusting their personal and family rhythms to their varying work schedules and days of payment. The relationship between sleep and burnout must be taken into account to improve nurses' working conditions. Developing tunicity strategies that limit alternate in circadian rhythm and improve sleep quality can be positive [25]. The distinction between scheduled and unscheduled time worked (time that is planned in advance versus time that is unanticipated) may be more important than the actual number of work hours [15].

Shift work schedules, choosing proper nurses for shift work, and how they remedy them are main factors in the management of shift worker issues. A half-hour nap helps to effectively reduce stress levels of nurses, which allows them to return home safely at the end of their shift with less sleepiness. Making proper work schedule policies among nightshift-working nurses and their implementation can provide better healthcare to the patients and also give better sleep quality and a healthy working environment to nurses [119].

An organized ergonomic turnaround can be less detrimental to the health of nurses and more beneficial for healthcare providers. A 2 × 12 rotation (day-night) had fewer sleep disorders, and the duration of sleep was more balanced and less segmented than in the rotation of 3 × 8 (AM–PM–AM). In addition, it appears that a clockwise rotation 2 × 12 provides better recovery, in spite of 50% increase in the turnaround time. A night shift in the weekly schedule does not change the circadian rhythm and nature of cortisol level of the nurses. Sleep disturbances are especially reported among nurses in morning shifts with a 3 × 8 turnaround pattern. Shift rotation pattern, if it coincides with travel time, causes the deprivation of needed rest and sleep. In the case of an early-phase rotation (afternoon, morning, night, rest, rest, rest), difficulties related to tiredness and anxiety are linked to the fear of waking up in time the next morning [120].

Using warmer lights during night shifts can be of significant help in hospital work environments, as white light can play a key role to improve sleep quality. Furthermore, if possible, the fixed night shift should be eliminated due to its adverse effects on circadian rhythm [25]. Exposure to daylight at least 3 h a day was found to cause less stress and higher satisfaction at work. Daylight exposure has a curative effect on burnout parameters because there are a lot of studies reporting this effect of daylight on mood disorders [121].

Insomnia can be treated pharmacologically; melatonin can help in the facilitation of normalizing the aberrant circadian rhythm. Benzodiazepine receptor agonist response is good among several insomniac patients, and remission rates are very low. The National Institute for Occupational Safety and Health (NIOSH) guides workers on how to cope with stressful work-related situations and manage their daily healthy physical and mental health [119, 122].

Related mental health promotion services, such as mind-based intervention and cognitive control strategies, can be useful for improving the sleep and mental health of nurses during their work [44]. According to the principles of occupational health, proper sleep as an important category should be included in the plans to improve the workplace. Screening for sleep disorders can be utilized to triage nurses to an acceptable level of treatment based on risk (for example, clinical assessment or public health

#### *Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

education). In this regard, health services for night-shift workers should be provided by the employer during night-shift hours. This can help healthcare providers correctly diagnose the occurrence of shift-work disorders. Treatments that focus on increasing circadian adaptation, reducing sleepiness, and improving sleep can improve the quality of life in shiftwork disorder patients. Clinicians are strongly advised to incorporate family and social support to maximize patient adherence [35].

Disturbance in the circadian rhythm can lead to insufficient sleep and subsequently to cognitive impairment and poor work performance, and to overcome it, good social support and providing a supportive work environment can be used. Preventive acts to minimize psychosocial stress at workplaces like social support, family support, and providing a favorable work environment can reduce sleep problems and also increase worker efficiency within working hours. Stress management training and techniques can help cope with sleep disturbance in certain professions such as nursing. This training can last longer and be beneficial for one's future professional career life. Controlling self-temperament and a cooperative environment among employers, employees, and colleagues can help to decrease sleep disturbance and can increase the work performance and life quality of workers. Switching night work and rotational work can improve sleep disturbances, compared to sticking to the same shift schedule. Blood pressure control and napping can also play an important role in the management of hypertension related to shift work.

### **Author details**

Razzagh Rahimpoor Faculty of Health, Department of Occupational Health Engineering, Student Research Committee, Larestan University of Medical Sciences, Iran

\*Address all correspondence to: razzaghrahimpoor@yahoo.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Physiological and Physical Effects of Sleep Disorder among Shift Work Nurses DOI: http://dx.doi.org/10.5772/intechopen.110417*

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#### **Chapter 10**
