Assigmnent 1

HAITIAN CASE STUDY FOR DISCUSSION

The St. Fleur family is well respected in the Haitian community because they are religious with great moral values. They moved to the United States because of political issues in Haiti. Ronald, the youngest son of this family, is 27 years old and lives at home with his mother and father. Recently, he began having fevers and subsequently developed pneumonia. He was admitted to the hospital, where laboratory tests were HIV positive. Ronald was in shock when the doctor informed him that he was HIV positive. He confessed to the doctor that he was gay but he could not tell his family. He said that he did not want to bring shame to the family. Because he couldn’t be in a formal relationship owing to his family and the Haitian community’s view of homosexuality, he has been very promiscuous over the years.

• What are Haitians’ dominant cultural views of homosexuality?
• If Ronald’s parents were to learn of his positive HIV status, how might they react if they are religious and traditional?
• Identify three specific culturally congruent strategies to address in designing HIV-prevention practices in the Haitian community?

Assigmnent 2

(Carper’s Way of Knowing)

Ways of Knowing in Nursing

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Death of a newborn: healing the pain through Carper’s patterns of knowing in nursing. By: Sherman DW, Journal of the New York State Nurses Association, 00287644, 1997 Mar, Vol. 28, Issue

Death of a newborn: healing the pain through Carper’s patterns of knowing in nursing

During a six-week childbirth education course, I teach expectant couples ways to cope with the physical changes they can expect during pregnancy and delivery, as well as the emotional changes they might go through. I encourage them to draw on personal experiences and accomplishments, which will enhance their sense of inner strength and lessen their fears. I tell my pregnant couples they can call me if they have any questions, concerns, or problems related to their birth experience or during the postpartum period. Living in rural upstate communities, many young couples have moved far from the support networks of family and friends, so I extend my role to that of a “community” nurse who offers guidance and encouragement in the early days of parenthood.

Jane and Jim Olsen enrolled in my Lamaze class to relieve their anxiety about childbirth. After several infertility work-ups and one miscarriage, this pregnancy was a testimony to their love and commitment to each other. They wanted to do everything possible to insure the health of their baby and a positive birth experience. They diligently attended class, read numerous books about childbirth, and openly discussed their fears and expectations. I promised to share with them everything I knew about childbirth. My knowledge was gained through graduate education in parent-child nursing, ASPO certification as a childbirth educator, and through my own lived experiences of pregnancy, birth, and parenthood.

Although in Lamaze classes I discuss all possible variations in birth experiences and potential birth complications, I focus on birth as a natural process, requiring intense work, which most often culminates in the joyful birth of a healthy child. The possibilities of death of a newborn or mother are approached as an unlikely reality, given the expertise and technology offered by current prenatal and obstetrical care.

Yet my work on a high-risk obstetrical unit has etched in my memory the grief and loss experienced by parents who have lost their newborns. Such experiences involve intense nurse-patient relationships requiring not only scientific knowledge and skill, but a nurse’s love, respect, empathy, obligation, and commitment. Through this work, I realized the importance of encouraging grieving parents to spend time with their critically ill newborns, and in the event of death, the opportunity to hold their son or daughter as they mourned a life that was never given a chance. Some health providers and family members express concern that this would add to parents’ pain. Yet I reamed that amid the suffering and loss, the healing process can begin. As parents hold and kiss their babies, the nightmares about deformed, monster-like children are put to rest. Looking at their newborn’s features, mothers and fathers recognize family traits and decide on names. This is not only important in coming to terms with reality, but it gives them tender memories of their precious infants to hold close to their hearts.

Jane and Jim Olsen had already experienced the grief and loss of having a first-trimester miscarriage. As we shared the excitement of childbirth through our Lamaze classes, I didn’t know that one day I would be called upon to holistically integrate empirical, esthetic, ethical, and personal knowledge to help this couple heal the pain of their newborn’s death. I realize now that my teaching and nursing practice were guided by what Carper (1978) describes as “patterns of knowing in nursing.”

Keeping a Promise

One evening early in May, my phone rang. Through his tears, Jim pleaded “Please come to the hospital. We need you right away!” I quickly made arrangements for my own children and sped off to the obstetrical unit of our community hospital. When I entered the unit, the nurses greeted me saying “Your Lamaze couple, Jane and Jim Olsen, are still in the recovery room. The delivery went okay, and the baby looked perfectly nominal, but she had trouble breathing and we couldn’t resuscitate her.” I asked if Jane and Jim had seen and held their baby. The nurse answered, “No, we don’t do that.”

I instantly asked myself, “Do you know what to do for this grieving couple?” The answer was yes. I had the nursing education and background to make a difference. I must be their advocate and do everything possible to support them in their grief and create a healing experience. As I had promised, I would share with them everything I knew about childbirth. Now I must go one step further and integrate the science and art of nursing with the ethical obligations of an advocate and my personal knowledge, all ways of knowing in nursing, in facing not only birth but death.

Ways of Knowing in Nursing

Each nurse-patient interaction is a holistic expression of different patterns of knowledge in nursing. Although nursing education provides the scientific knowledge and critical thinking skills to decide the appropriate course of action in many nursing care situations, the wholeness and complexity of human experiences require nurses’ openness and receptivity to other forms of knowing.

To provide excellent nursing care, nursing knowledge must extend beyond the descriptions, explanations, and predictions offered by the scientific method to an appreciation of patterns of knowledge involving the symbolizing, understanding, and creating of human experiences? Symbolizing is the identification of reality and description of the situation or experience as it is. Understanding involves a search for meaning van explanation of the patient’s experience. Creating focuses on the imagined possibilities, and the potentials of a given event or experience (Chine & Jacobs, 1987).

Carper’s (1978) four “patterns of knowing” are interrelated and link nursing theory and nursing practice. The patterns of knowing are identified are empirics or the science of nursing, esthetics or the art of nursing, ethics, the moral component of nursing knowledge, and personal knowledge in nursing derived from one’s own lived experiences. As distinct aspects of the whole of nursing knowledge, each is vitally important and may be communicated either through words or by a nurse’s behavior and actions.

Healing Through Empirical Knowing in Nursing

Empirics as a pattern of knowing is based on the assumption that what is known is observed through the five senses and can be verified by others. Empirical knowledge is thus factual in nature, and its processes involve describing, explaining, or predicting phenomena of concern to nursing. Empirics contributes to nursing knowledge by offering the descriptive knowledge regarding disease, illness, and technology. Empirical knowledge answers the critical question “What is this?” (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

The art of nursing engages nurses in the critical life events of those for whom we care. I hoped that through my presence, Jane and Jim felt a sense of comfort and support. I held them both and cried with them. I listened as Jane sobbed, “This is not the way it’s supposed to be!” I gently wiped her tears.

I knew what this baby meant to them. They had been trying to conceive for the past four years, and this baby was a source of joy and fulfillment. Jane had done everything possible to ensure the health of her baby. She ate well, avoided alcohol, got plenty of rest, and vigilantly kept her prenatal appointments. Jim was extremely proud and protective of his wife, taking over any of her strenuous household chores, working two jobs so that lane could reduce her work hours, and rubbing Jane’s belly as he talked to his unborn child. Even Jane’s mother attended a class with her daughter and son-in-law, expressing her excitement about becoming a grandmother.

After six weeks of class, I had developed a supportive relationship with this couple and I understood the importance of offering them the opportunity to see and hold their baby. I said, “I know you’re both in pain right now. I’ve reamed that it helps many couples work through their grief if they spend time with their baby. If this is your choice, I will be there for you. I will bring you your baby.”

In caring for this couple, I entered as fully as I could into their experience. Understanding the meaning of this experience for them, both as individuals and as a couple, guided my nursing conduct, attitudes, and actions. Imagining the possibilities, I envisioned the beginning of a healing process made possible by physical, emotional, and spiritual support. Through my nursing actions, they would be able to caress her little body, hold her close to their hearts, tell her of their love and hopes of being good parents, choose her name, and even possibly plan a funeral which would celebrate her short life and lay her to rest. With knowledge and support, Jane and Jim would be empowered to act, based on their own personal values and choices.

Healing Through Ethical Knowing in Nursing

Ethical or moral knowledge in nursing includes not only ethical codes of behavior, but a focus on what ought to be done in a situation. The symbolic dimension of ethics is the process of clarifying a situation or experience, while the understanding dimension is rooted in one’s own philosophic beliefs and values. Through the creating dimension of ethics, guidelines for advocacy are developed to promote or protect the rights and interests of others. Thus, ethical knowledge involves actively confronting conflicting values, norms or standards. Rather than prescribing the ways things should be done, ethical knowledge provides insights into possible alternatives or decisions, with an emphasis on individuality and human respect. Ethical knowledge involves such critical questions as “Is this right? For whom? Is this responsible?” (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

From the moment I asked the nurses if my couple had seen and held their baby and was told “No, we don’t do that,” it was clear that I had a responsibility to advocate for their rights and best interests. In responding to the issue of what ought to be done, I knew that this couple must be given options in their grief, and opportunities that might enhance their ultimate healing and sense of wholeness and dignity. I have argued many times from an ethical perspective that dying people should have the right of unlimited access to their loved ones. In the event of neonatal death, it is ethically just that loved ones, such as Jane and Jim, also have the opportunity to spend time with their baby, if they so desire. Through confronting the norms or standards in the care of parents experiencing neonatal death, I needed to clarify with the nurses my role, giving reassurance of the value of my knowledge and experience, and assisting both the nurses and my couple in recognizing the potentials of all the alternatives and decisions.

In speaking with the nursing care coordinator of the unit, I reamed that many of the nurses on this unit were uncomfortable and inexperienced in caring for grieving parents. Since I had worked at that hospital in a supervisory position in previous years, I had developed collegial relationships with the nursing supervisor and staff. We agreed that I would accompany the nursing care coordinator to the morgue and take responsibility for bathing, dressing, and bringing the baby to her parents if they so wished. I would then spend as much time as needed with the family during the visit. I assumed the responsibility of providing holistic nursing care in this situation. I also accepted the nursing staff’s request to conduct an in-service program on coping with neonatal death.

Healing Through Personal Knowing in Nursing

Personal knowledge in nursing evolves from a nurse’s inner knowledge of self with the symbolic dimension described as an opening to the fullness of the life and a conscious awareness of life experiences. The understanding dimension of personal knowledge involves introspective awareness of the meaning of the patient’s experience based on the nurse’s own personal life experiences. Through the creative dimension of realizing, nurses are able to express an authentic, genuine self in interactions with others. Personal knowledge therefore allows nurses to enter the world of their clients through a deep understanding of their experience and with an intuitive sense of its importance. The critical questions asked by the nurse are “Do I know what to do? Do I do what I know?” (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

The next morning, Jane called me to ask if I would bring them their baby.

Her parents and Jim were on their way to the hospital. Once again, I asked myself “Do I know what to do?” With knowledge, courage, and conviction, I answered yes.

With the nursing care coordinator, I went to the morgue and cared for the baby. Wrapping her tightly in a pink blanket, and placing a pink-bowed hat on her head, I covered any evidence of the autopsy. I went upstairs by the back elevator, holding this dead baby girl in my arms, realizing how much she felt like the doll I used in Lamaze classes. With a prayer for strength, I brought her to her parents and grandparents. As they took her from my arms, I cried. As a mother myself, I felt their pain and anguish. Yet over the course of three hours, as I came in and out of their room, I saw them begin to accept their baby’s death. Their faces revealed a sense of peace and comfort. They remarked on her beauty as they gently touched her face and stroked her hands. They took turns holding and rocking her, caring for her as if she were alive. With their eyes and hearts filled with love, they named her Mary, a sweet and holy name for “their little angel.”

The greatest sorrow that I have experienced as a nurse was taking this baby from her mother’s arms. All I could leave with them was a lock of her hair, and the blanket in which she was wrapped. This was my gift of love for a couple entrusted to my care. To this day, I cry when I recall that moment.

The symbolism, understanding, and creating dimensions inherent in Carper’s patterns of knowing in nursing were made clear to me through this extraordinary nursing experience. Through years of nursing education and practice, I had acquired the knowledge, values, courage, and strength which enabled me to care for this family. The ways of knowing in nursing had become an integral part of who I was and how I practiced. I resumed home weary but with a sense of fulfillment. I believed that I had made a difference in the lives of this couple and family.

• Discuss how the “death of a newborn” illustrates Carper’s four ways of knowing (Empirical, Aesthetic, Personal, and Ethical Knowledge). as discussed by the author.
• Based on a clinical nursing experience of your own, identify in your case study Carper’s four ways of knowing. (Explain each of Carper’s ways of knowing and relate it to your example).

Assigmnent 3

(Case of Mrs. Mendez related to Interprofessional Theories)

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Interdisciplinary Philosophies and Theories

Read the case of Mrs. Mendez Case Study.doc

Family Theory Case Study

“Mrs. Mendez”

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

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

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

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

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

Approximately one week later, the nurse receives a call from Gloria reporting that her mother has seemed to decline rapidly over the weekend. Mrs. Mendez awoke during the night with difficulty breathing and has been terrified of the possibility of suffocation. On exam, the nurse notes that Mrs. Mendez has developed extreme shortness of breath. She is also increasingly fatigued and the combination of exhaustion, dyspnea, and general decline has resulted in minimal intake of foods or fluids. José called this morning with strict orders that his sisters continue to feed their mother at all costs. He hopes to be able to come up from San Diego the following weekend to visit. Mrs. Mendez relates to the nurse that she knows she is dying and does not want to continue being a burden to her family.

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

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

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

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

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

Mrs. Mendez Case Study Questions

1. Assess each family member.
2. Assess the functioning of the whole family
3. Identify the larger suprasystem and the subsystems and discuss their interactions.
4. What are the positive and negative feedback loops?
5. Is this family self-reflective working toward goals?
6. Is the family able to create a balance between change and stability?
7. What patterns are observed for the family?
8. Is Gloria self-differentiated?
9. What communication and interaction patterns are observed?
10. What constitutes first and second order change in this family?
11. What are the contextual constraints for change in this family?
12. What values are being passed down through the generations?
13. How you would describe this family based on Olson’s Model of family?
14. What plan would you develop for this family based on Theory Based Family problem solving?
15. How is this family responding to stress? Are they crisis prone?
16. What behavioral therapies may be of value to this family? )

As an advanced practice nurse, identify the various knowledge bases that you draw upon from the physical, emotional, spiritual, cultural, and social sciences in the care of Mrs. Mendez and her family.

For example, Which science bases tells you about how cancer develops; which science bases tells you about pain and pain management; which science bases tell you about grief and loss or emotional states; which science bases help you understand the importance of spiritual assessment and care; which science bases help you to assess and intervene with the family both as individuals at their own developmental age and the family as a system; which sciences bases help you understand the cultural perspectives?

• Make a list of key concepts relevant to the case study. IDENTIFY PHYSICAL, EMOTIONAL, SOCIAL OR SPIRITUAL CONCEPTS RELATED TO MRS MENDEZ AS WELL AS VARIOUS FAMILY MEMBERS
• Identify from the middle range theories presented in your textbooks, one interprofessional or middle range theories associated with your concepts of interest, and give a rationale for its selection. GIVE INFORMATION ABOUT THE THEORY SELECTED AS YOU DISCUSS THE RATIONALE FOR SELECTION.
• Discuss how the selected theory guides both your clinical assessments and interventions for Mrs. Mendez or her family. (MAKE SURE YOU DISCUSS HOW IT INFLUENCES YOUR ASSESSMENT QUESTIONS AND THEN DISCUSS HOW IT INFLUENCES YOUR SELECTION OF INTERVENTIONS FOR MRS. MENDEZ AND HER FAMILY MEMBERS.
• Explain how knowledge from interprofessional health-related sciences informs advanced nursing practice. PROVIDE REFERENCES FOR THIS QUESTION.

Assigmnent 4

(Students Clinical Interest and Related Theories)

Conceptual Frameworks or Theories Relevant to your Clinical Problem and Population of Interest

As change agents, Doctors of Nursing Practice identify clinical problems within the context of a population of interest.

Your clinical problem could be a disorder or condition (e.g., HIV/AIDS, hypertension, depression, chronic illness, adolescent pregnancy) or a psychosocial or physiological characteristic (e.g., social support, health related quality of life, resilience, family communication patterns, mother-infant attachment, self-esteem).

Your target population could be a cultural group (e.g., Hispanic elders, African American women), a diverse group (e.g., urban/rural Cuban Americans, low income women), or a vulnerable group (e.g., incarcerated adolescents, sex workers, IV drug abusers, severely mentally ill adults).

Provide an introduction to the clinical problem of interest in your specific patient population, include:

• Your perceived need for change in practice and the rationale for such change
• Discuss the incidence and prevalence of the clinical problem
• Discuss the significance of the problem.

(This introduction must be referenced from the literature).

Identify two conceptual frameworks or theories that may be applied to the study of your clinical problem within the context of your target population.

• Discuss how the conceptual framework or theory is relevant to your clinical problem and target population.