Proposal for Immunization in Senior Citizens: Theoretical Background

This segment of the proposal relates the project’s objectives to theoretical backgrounds and structures. The theories discussed within the scope of this project are: Quality Improvement Model, Evidence-Based Practice Model, and Nursing Theory. Each will be explained in terms of how their guiding principles are used as the framework for this project.

Quality Improvement (QI) Model

According to McDonald, Graham, and Grimshaw (2004), quality improvement research is defined as the study of how research findings can be translated into practice aimed towards improving upon the way services are delivered and practiced in order to increase the quality of the services to the patient. Also, the behaviors of healthcare workers are studied within this inquiry frame to understand how their behavior factors into optimization incorporating the best research findings into practice. As McDonald et al. stated, there are a variety of descriptive theories available within the QI framework, but are unproductive at times because of their descriptive nature, whereas a more prescriptive nature would be more productive. Theory constructs describing and forecasting behaviors assist in constructing effective interventions.

As McDonald et al. (2004) explained, the lack of theoretical construct to solve problems in practice aimed to improve quality care is problematic because the why of many studies are not explained. Understanding theoretical constructs behind studies aimed to improve quality of care provides a rationale for the study, which are lacking in a majority of studies. For instance, one could broach a study from a cognitive standpoint, where one tries to understand the rationales for existing barriers, or a behavioral standpoint, where an intervention is imposed to test the effectiveness of implementing change within an established system. Each standpoint can change the focus and purpose of the study.

The quality improvement model used to improve the uptake of immunization in senior citizens for this project is Roger’s (1995) diffusion of innovation theory describing the five-phase adopting of improvements to existing standards: awareness of the improvement, forming optimistic opinions of the improvements, deciding to implement the improvement, utilization of the implementation, and deciding to continue utilizing the implementation. This immunization project will use education to increase awareness within the staff of the problem of under-immunization in geriatric patients and the importance of immunization in patient safety. The educational materials will hopefully persuade the staff at the site to adopt new standards of practice. The data collected and analyzed for the study will provide the researcher and the staff with benchmarks to demonstrate the effectiveness of the new office practice to encourage the staff to continue using the new improvements.

The theory that compliments this model is the Plan, Do, Study, Act (PDSA) Model, described by Institute for Innovation and Improvement (2013), each reflecting a phase in the process to implement changes to improve quality of patient care. After a plan is decided upon, the plan is implemented on a small scale, if possible. Once the plan has been put into practice, the effects of the change are studied. If the evidence demonstrates improvement in the quality of care, the plan is used as a regular basis of ongoing practice. This model encourages the continuous interrogation, study, and monitoring of implementation to ensure success and positive patient outcomes. This plan will be utilized to drive the objectives and directives of this study.

Evidence-Based Practice (EBP) Model

The above description of the theory describing the driving process in this study compliments the EBP model of the study. Titler (2011) and Nieva, Murphy, Ridley, Donaldson, Combers, Mitchell, et al. (2005) described the Agency for Healthcare Research and Quality (AHRQ) method of EBP:

Steps of knowledge transfer in the AHRQ model represent three major stages: (1)knowledge creation and distillation, (2) diffusion and dissemination, and (3) organizational adoption and implementation. These stages of knowledge transfer are viewed through the lens of researchers/creators of new knowledge and begin with determining what findings from the patient safety portfolio or individual research projects ought to be disseminated. (p. 2)

The AHRQ model follows the same process as Roger’s (1995) theory of adopting innovation. The information will be presented to the staff in educational materials and training, then implemented. A more sophisticated model also fits within the parameters of the focus of this study, the Iowa Model of Evidence-based Practice to Promote Quality of Care (Titler, Kleiber, Steelman, Rakel, Budreau, Everett, Buckwalter, et al., 2001), which is endorsed by the AHRQ and other supportive organizations interested in improving quality of care. The model looks through the lens of the healthcare workers and their organizations when taking into consideration quality of care delivered to patients, focusing upon the end product - delivering of highest possible quality care to patient, maximizing health outcomes and patient safety. This model also takes into account the dissemination of the information, which is important to each practice, and to the healthcare industry in general (Wilson, Petticrew, Calnan, & Nazareth, 2010). The best way to do this, the theory assumes, is to base implementations of practices and practice improvements upon research-evidenced information. 

As Titler et al. (2001) explained, the model encourages healthcare organizations to prioritize the issue being studied, compose a team of stakeholders, gather and analyze the evidence, recommend implementations based upon the evidence, weighing pros and cons, determine if the implementations can be used within the organization’s practice, test the implementations, implement the innovations, analyze the data gathered to observe benchmarks in progress, continuously monitor and report progress to the stakeholders. In this manner, patient-focused changes in practice are implemented for the betterment of quality in healthcare delivery. This process is said to save time and resources, freeing the researcher to concentrate upon the issue being studied, carry out the implementations, and evaluate ongoing progress.

This study has already implemented the Iowa Model of Evidence-based Practice to Promote Quality of Care model to conduct the needs assessment. Those efforts helped produce the data demonstrating the necessity for healthcare change within the practice. The stakeholders were kept in mind as the research was conducted. A plan was formulated to educate the healthcare staff within the office and implement strategies to educate the patients to encourage higher rates of immunization uptakes. The researcher will monitor progress of implementation effectiveness through data tracking, collection, and analysis.

Nursing Theory

Nursing theories are guiding principles for the field of nursing. This study depends upon the efforts of the nurse practitioner to assess and implement strategies to improve quality care within the healthcare setting for this study. The guiding principle behind this study is the caring theory. According to Tonges and Ray (2011): “Caring theory postulates that nurses demonstrating they care about patients is as important to patient well-being as caring for them through clinical activities such as preventing infection and administering medications” (p. 374). The goal is to actualize “caring theory across a healthcare organization by systematically incorporating interventions that link nursing actions, caring processes, and expectations” (p. 374). The caring theory is based upon ethical principles. The model demonstrates that not only should the nurse’s actions and intentions be caring, meaning words and deeds that convey caring and their outcomes,  but also work in an environment that allows the nurse to be ethical and conduct oneself in an ethical manner. This study demonstrates caring for the patients that visit this clinical setting because the intention is to improve patient well being in helping them prevent infection through the staff increasing its efforts to have all its geriatric patients immunized. Moreover, this project will be conducted with the full support of the stakeholders. This will allow the researcher to freely conduct the investigation and implement the strategies aimed to increase geriatric immunization, which will in turn increase the well-being and health outcomes of the patient. 

On the patient end, this study operates within the Health Belief Model. As the Boston University School of Public Health (2013) stated, the model is an expression of the patient’s belief system and the health outcomes these beliefs produce for the patient. For instance, a patient might refuse a vaccination because the person does not believe in the effectiveness in immunizations’ role in disease prevention. The patient education program in this study will address the barriers that could prevent seniors from accepting vaccinations, thereby improving vaccination uptakes. 

All the theories in this study are aimed towards one outcome – improve geriatric patient health by increasing immunization rates and preventing infection from preventable diseases. Each of the theories described orient the purposes and intentions of this study, as well as compliment each other in purpose and guiding principle. The guiding theories described for this study provide consistency between good intentions, improving health outcomes, and bring these intentions to practice, conducting the necessary research in an ethical manner and changing practices to ensure positive outcomes. 

References

Boston University School of Public Health (2013). The health belief model. Retrieved from http://sph.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models2.html

Institute for Innovation and Improvement (2013). Quality and service improvement tools. Retrieved from http://www.institute.nhs.uk

McDonald, K. M., Graham, I. D., & Grimshaw, J. (2004). Toward a theoretic basis for quality improvement interventions. In K.G. Shojania, K. M. McDonald, R. M. Wachter et al. (Eds.), Toward a Theoretic Basis for Quality Improvement. In Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 1: Series Overview and Methodology): Technical Reviews, 9.1(3), Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK43917/

Nieva, V., Murphy, R., Ridley, N., Donaldson, N., Combers, J., Mitchell, P., et al. (2005). From science to service: a framework for the transfer of patient safety research into practice. In Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality.

Rogers, E. (1995). Diffusion of innovations (4th ed.). New York, New York: Free Press.

Titler, M. G. (2011). Chapter 7: The evidence for evidence-based practice implementation. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/TitlerM_EEBPI.pdf 

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., Buckwalter K.C., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am, 13(4), 497- 509.

Tonges, M. & Ray, J. (2011). Translating caring theory into practice: The Carolina Care Model. JONA, 41(9), 374-381.

Wilson, P. M., Petticrew, M., Calnan, M. W., & Nazareth, I. (2010). Disseminating research findings: What should researchers do? A systematic scoping review of conceptual frameworks. Implementation Science 5:91. doi:10.1186/1748-5908-5-91