NNS511 Nursing Science 1


Introduction: Patients, their families, and the health care system want to listen to them. They want comprehensive, integrated, coordinated and coordinated services across all areas (Richards and Bodenheimer, 2007).

Expert patients possess knowledge and experience. However, some patients are viewed as a dream’ and others as a nightmare’ (Shaw & Baker 2004, 2004).

Don’t use plagiarized sources. Get Your Custom Essay on
NNS511 Nursing Science 1
Just from $8/Page
Order Essay

Degeling (2006); Sheridan and al., 2009). It is becoming increasingly clear that patients have to be heard and their experience with long-term conditions must be understood if care is to suit and respond to their needs.

Scope: The student must demonstrate an understanding:

People and their whanau centred collaboration care. The challenges and benefits of this approach for people with long-term disabilities

The current journey through health care for a group, with special attention to their experience with person-centered collaborative care.

Answer to Question: NNS511 Nursing Science 1


There are many challenges facing the global healthcare industry in order to ensure high-quality and affordable patient care.

Zatta, Mcginnity (2016) point out that these issues can be external or internal depending on who the healthcare providers are.

Study results show that older adults, people living with disabilities, and patients with long-term conditions are on the rise. These issues require urgent strategic solutions.

Austrom (2016) indicates, on the other hand that there is increasing pressure on social care budgets.

To provide effective, high-quality healthcare that allows patients to enjoy the best quality possible of life, it is necessary to rethink the relationship between the healthcare organizations and patients that receive the care (Caughan (2016)).

The person-centered approach to healthcare is often customized and tailored to individual needs. It ensures that each person is treated with dignity, respect, and compassion.

Zachos (2013) notes that this model of care can be seen as a common vision for all healthcare forms, but is rarely a standard practice among healthcare providers.

The same study shows that the majority of healthcare providers are unable to work with people, but rather do so ‘for or ‘to’.

As services are intended to attain a particular clinical outcome, this results in difficulty for patients to be included in their views, goals, decisions and opinions.

He found that patients living with long-term medical conditions, such as diabetes or depression, are often faced with difficult situations.

This paper will focus on the evaluation of patient-centered collaborative care for patients with long-term conditions such as stroke and depression.

The Concept Of Person Centred Collaborative Care

Slowther (2011) explains that person-centered, collaborative care is a way of making decisions, as well as doing so in a manner where the individuals receiving the care are considered equal partners in developing, planning and monitoring the care.

This means that patients and their loved ones are central to the decision-making process and they are seen as experts working with healthcare professionals in order to ensure the best outcome.

Mcginity (2016) supports this assertion. Zatta and Mcginity (2016) highlight that person-centered, collaborative care isn’t only about providing the best care, but also considering patients’ values, wants, and lives.

Zachos (2013) says that person-centered collaborative care is one that treats the patient as an integral part in the process. It works together to provide the right solutions for the patient’s health issues.

It requires compassion from healthcare professionals while making decisions, while also considering the views of patients.

Berg (2017) states that in the past patients were expected to conform to and follow the routines and practices of social services.

With increasing awareness and patient’s awareness about the importance of their health, person-centered care demands that healthcare providers make decisions with patients. Creasy et al.

(2015) state that current services are evolving to better meet the needs and preferences of patients.

The process involves working with the patients and their families in order to make the right decisions about the patient’s healthcare.

Fox (2013) and Sidani (2012) point out other terms such as patient-centered (user-centered), personalized, individualized, family-centered collaborative healthcare, and individualized care.

The idea behind collaboratively including patients is the same regardless of how the term is used.

A study by the same organization found that there are several aspects to person-centered, collaborative care.

We can all work together to ensure effective communication and education.

For emotional support, involve family members and friends

It is important to ensure continuity within and among services while still taking into consideration the expressed preferences and needs.

Integrating and co-ordinating care that is respectful of patient values and places them in the centre of care

Assuring patient safety and comfort when they seek appropriate care.

Creasy et.

Creasy et.al. (2015) emphasized that person-centered and collaborative care are important. This is a recognized global principle of high-quality care delivery.

Global health professionals have made it a priority of their efforts to make healthcare providers and other healthcare professionals person-centered.

A similar study found that person-centered, collaborative care increases the quality of healthcare services and helps patients get the right care whenever they need.

It encourages patients to be more proactive in taking care of their health, even with the complications associated with stroke and depression.

It reduces the burden on social services as well as health for chronic long-term conditions.

People living with Stroke and Depression

Slowther (2011) found that depression is often a result of stroke.

It is well-known that stroke victims are not only going through a recovery process, but also learning new skills.

Many stroke survivors experience sadness, angers, fear, anxiety, and hopelessness on a variety of levels.

These emotions are common post-stroke and cause depression in more than half of stroke survivors.

Patchell (2013) concluded that the emotional well-being of an individual is as important as their physical health. This can lead to stroke discovery or disruption.

Healthcare provided to such patients should be tailored to their individual needs and coordinated with their families.

Patients with stroke need to be treated using high-tech therapy equipment. This helps them recover as independently as possible and supports their return to productive lives.

Bailey and Gordon (2016) point out that depression can strike days, weeks, months or even years after stroke and can affect the patient’s ability to recover and rehabilitate.

The result can have a negative impact on a person’s quality life and their families.

Slowther (2011) also states that strokes are often sudden and can have a dramatic impact on one’s life.

Stroke-related brain damage can often have a profound impact on the person’s ability to exercise their social, emotional, and psychological responsibility. This can cause depression.

Miller et.al. state that symptoms vary widely in their duration, severity, frequency, and duration. (2011).

These symptoms include sadness, anxiety and emptiness, insomnia, changes in appetite and eating habits, loss of interest or hobbies, withdrawal from society, and irritability.

Barriers and enablers in person-centered collaborative care for people living with depression

Post-stroke Depression is often defined as feeling depressed and hopeless after strokes. This can lead to a slower recovery and may cause patients to feel more helpless.

Creasy et.al. states that it is often accompanied depression and stress as patients struggle with accepting their new medical condition. (2015).

Lutz et.al.

(2011) note that there are many hurdles that may prevent the adoption and use of this model for healthcare in the care of a patient with long-term brain damage.

One example of the clinical barriers to person-centered collaboration care for stroke and depression is a complex mix of ethical considerations as well as attitudinal and interpersonal factors.

Grobe (2011) notes that the primary unit of healthcare is often the family.

Healthcare providers should ensure that the rights of the patient and their family are not compromised.

When this happens, providers face the dilemma of who is to be served: the family unit, or the patient. This will impact the responsibility strategies of such individuals.

There are also specific barriers to person-centered collaborative healthcare that can affect providers. This indicates the need for providers to be involved before any success with the implementation of the personcentered approach (Valois (2014)).Steinberg et al.

(2014s). Steinberg and colleagues. Creasy et al.

(2015) also note that there is often mismatch and disagreement between patients’ needs and the goals for collaborative care.

The study also identifies inconsistency and miscommunication as major factors in the process of reaching decision-making regarding expectations and roles of care providers.

Orlin et.al.

(2014) suggests that resources and organizational support are equally important.

If such systems are not changed, providers might have difficulties delegating their responsibilities.

Young (2011) states that good communication can lead to better patient self-management and stay.

Effective communication, which is considered an enabler, allows the patient and their family to express their feelings regarding the stroke and depression to the friends, family, and healthcare providers.

Even though relationships might change after strokes, social detachment is an inevitable consequence of post-stroke. Counseling is needed to help the patients accept that they are not responsible for the condition and to openly share their feelings with the caregivers.

Billinger (2010) has done a systematic review of this study and concluded that communication facilitates effective monitoring of the progress of the patient as well as the steps needed to get better treatment.

The role of an interprofessional team in providing patient-family-centered collaborative care for long term conditions

Galvin, Valois, Zweig (2014) claim that patients suffering from long-term health conditions have a large economic impact. This places significant financial burdens on providers, patients, caregivers, and the healthcare delivery and delivery systems.

It is imperative to explore other healthcare options that are effective for this patient group.

In order to address long-term health conditions and promote person-centered healthcare, the national plans and reforms need to incorporate preventive and medical services. Quality care should be incorporated to best serve the patient’s needs and the family’s wishes (Halili, Hall & DeLuca,2014).

Often, an interprofessional team is composed of several people who coordinate to ensure patient-centered collaboration care for those with long-term conditions.

They are social workers, doctors, psychologists, occupational therapists, and psychiatrists. Each one has a particular duty during the healthcare provision process.

Galvin and Zweig (2014) point out that the central component of person-centered, collaborative care is the initial evaluation. It provides expert clinical evaluations, patient diagnosis and needs and caregiver assessments. Supportive counseling provision is also provided.

It requires referrals to community resources and planning for an efficient development strategy with short-term, medium-term, and long-term goals (Pascoe, et al. 2013).

These components can only happen if the team has members that bring in their unique perspectives and expertise, which can then be integrated into the person-centered collaboration care model.Role Of Physicians

When the care plan is initiated, the doctor will conduct a diagnosis to determine the initial condition of the patient.

Review of laboratory results and brain imaging for indication

Patients with unanticipated changes in a condition that is unusual or atypical should be evaluated

Assistance for patient emergencies

Referring to Hospice or Home Care depending on federal regulations

Role Of The Nurse Practitioners and Physician Assistants

Re-evaluating the plan of care and providing assessment progress regarding cognition and symptoms

Coordinate care with other medical professionals and disciplines

Referring patients to other services

Follow-up on all imaging results and testing

Patient and family education regarding both non-pharmacologic (and pharmacologic) interventions

The clinician who may make the initial diagnosis.Role Of Health Educators

Coordinate the distribution and collection of relevant information about healthMaintaining health records for health information

Training for neuropsychological testing performance

Prepare individuals for training in counseling and social services.

Role of the Occupational and Physical Therapists

Evaluate your home’s safety

Cognitive skills training

Training and fall prevention in balance

Assessment of patients’ daily activities such as exercise and nutrition.

Driving evaluation

Provide education for caregivers

Social care professionals and health professionals are able to coordinate with individuals using the services under person-centered collaborative care.

Martz (2011) and Creasy (2011) concluded that person-centered, collaborative care helps individuals to improve their knowledge, skills, and confidence in order to manage their health and make informed decisions about the services they receive.

Others have symptoms such as fatigue, irritability, trouble remembering details or concentration, aches and pains, digestive complication, suicidal thinking, and even suicidal ideation (Mueller & Hong 2016, 2016).

For patients who want to make real progress, person-centered care is the best option.

The best way to help someone with a medical condition is to collaborate with their family, friends, coworkers, caregivers, and other loved ones.

For a better stay, strengthen your self-management support

Lutz et.al.

(2011) state that in order to provide effective person-centered collaborative healthcare, nurses need to make sure that patients with depression and stroke, as well their families, are actively involved in a way that is consistent with the theoretical framework.

Creasy et.al. performed a systematic review.

(2015) also stated that the delivery and planning collaborative care should be determined by a collaborative partnership of all involved.

These strategies will help ensure positive changes in patient recovery.

The treatment of stroke and depression is not enough. Long-term complications like diabetes, such as those resulting from long-term illness, can also be treated (Lasater and coauthors, 2016).

It is important to have a range of strategies that can be used to address the emotions caused by the disease and encourage self-management. This will help the patients live longer.

Also, the patient’s health and nutrition needs must be met.

Martz and Creasy (2011) state that eating foods rich in omega-3 and complex fatty acids, vitamin A, complex carbohydrates, and/or folic acids can improve a patient’s mood when they are fighting stroke.

A similar study found that omega-3 fats are important for brain health in foods such as flaxseed and walnuts.

Brown rice and whole wheat help increase neurotransmitter chemical levels in the brains veins and blood vessels, which can impact the mood.

Dark chocolate can be used to fight fatigue and reduce stress.

Billinger (2010) showed that foods like oranges, broccoli, and beans are often deficients in folic Acid and therefore linked to depression.

Folic acid boosters are essential for stroke and depression patients. Patients who have difficulty recognizing themselves should avoid eating beans, broccoli, and oranges.

Vitamin B12 rich foods, such as liver, milk, or eggs, can increase energy levels and alertness. (Lerdal (2016)

Lutz et.al.

Lutz et. al. (2011) recommend that patients who are suffering from long-term chronic conditions such as diabetes, stroke, or depression join local support groups.

A stroke victim should join a group for support. This will help them gain skills and knowledge that can be used to improve their recovery.

Young (2011) notes that these support groups may be rehabilitation centers with rehabilitation programs depending on the severity and medical requirements of the patients.

A similar study also shows that effective person centered collaborative care is common in these rehabilitation centers. It brings together professionals with diverse ideas about how to treat different patient conditions (Gay and colleagues, 2010).

Patients can also use these support groups and rehabilitation centers to share their experience with the condition. This helps to revitalize the social life, and help them to learn how to manage it positively (Talley, et al. 2015).

Patients suffering from poststroke can also become part of the community, helping to eradicate the stigmatization and social isolation that so often affects these patients. Creasy et al.

(2015) point out that strokes and depression can be quite traumatizing. The recovery time may be longer depending on how severe the illness is.

The best way to manage stroke and depression is to get active. Stroke survivors can use braces, canes, or walkers to improve their physical condition (Lewin Jobges & Werheid 2016, 2016).

Walking, swimming, yoga, and other activities have a low impact effect that can aid recovery. It should be done with close supervision by caregivers or the family.

It is also important to limit the intake of alcohol, not just for depression or stroke but also for patients with long-term medical conditions (Kouwenhoven und al. 2013).


Person-centered, collaborative care in healthcare encourages cooperation between family members, patients and providers. It promotes partnerships and collaboration with families and patients regarding evaluation, planning and delivery.

It helps providers gain a better understanding of the potential impact of the illness on their care and how it can affect the transition.

It is clear that adopting person-centered, collaborative care as a standard business model in healthcare requires fundamental changes to how services are delivered.

The role of the patient and the healthcare professional should be considered.

Post-stroke Depression is often defined by a feeling of hopelessness that can interfere with quality and function of life. This condition can lead to a slower recovery process if not managed properly.

Patients are often struggling to accept their new situation and can be affected by depression and stress.

Although it is difficult to make the transition to person-centered collaborative healthcare, this type of care can still be achieved.

This can be achieved if more effort and resources are put into achieving patient-centered collaborative care.

Therefore, rehabilitation nurses and healthcare workers need to consider stroke and depression patients along with their family caregivers as a single unit.

Patients can be helped by nurses who use person-centered, collaborative care.

For patients to recover, treatment is only half the battle.

With the support of their families and caregivers, patients should have good nutrition and communicate well. They also need to attend rehabilitation centers and participate in support groups. Patients must be as active as possible and stop using drugs such as alcohol and smoking.

Refer toAustrom, M. G., Carvell, C. A., Alder, C. A., Gao, S., Boustani, M., & LaMantia, M. (2016).

Development of the workforce to provide person-centered healthcare. Aging & Mental Health, 20(8), 781-792. doi:10.1080/13607863.2015.1119802Bailey, W. A., & Gordon, S. R. (2016).

Family Caregiving amid Age-Associated Cognitive changes: Implications and Future Generations.

Family Relations, 65(1). 225-238.Berg, K., Askim, T., Balandin, S., Armstrong, E., & Rise, M. B. (2017).

People with stroke-induced Phasia in Norway: Participants’ experiences of goal setting. A qualitative study.

Disability & Rehabilitation, 39(11), 1200-1130Billinger, S.A. (2010).

Comprehensive Overview Of Nursing and Interdisciplinary Rehabilitation Care For Stroke Patients: A Scientific Statement From the American Heart Association. 41:2402-2448.

Caughan D (2011).

What are the most important decisions made by nurses?

Thompson C, Dowding DD, editors.

Clinical judgment and decision making in nursing.

Edinburgh: Churchill Livingstone. :95-108.Creasy, K. R., Lutz, B. J., Young, M. E., & Stacciarini, J.-M. R. (2015).

Clinical Implications of Family-Centered Treatment in Stroke Rehabilitation.

Rehabilitation Nursing?

Rehabilitation Nursing? https://doi.org/10.1002/rnj.188Doty, A. K. (2014).

The Continuum of Care to Depression: Role of a Physical Therapist.

Journal of Physical Therapy. 91(3). 143-153.Galvin, J. E., Valois, L., & Zweig, Y. (2014).

For dementia care, a transdisciplinary collaborative team approach is used.

Neurodegenerative Disease management, 4(6). 455-469. https://doi.org/10.2217/nmt.14.47Gay, A. (2013).

A cross-sectional analysis of their association to sociodemographics.

Neuropsychological Rehabilitation. 28(2), 92–97.Grob, R. (2011).

The heart and soul of patient-centered care.

Journal of Health Politics, Policy and Law. 2013;38(2):457-465.Halili, H., Hall, J., & DeLuca, S. (2014).

Historical analysis of professionalism within western societies: implications to interprofessional education and collaboration. Journal Of Interprofessional Care, 28(2), 92-97. doi:10.3109/13561820.2013.869197Hong, Z. (2011).

Restorative Care’s effect on activities of daily living dependence in long-stay nursing home residents. Gerontologist, 55S88-S98Kouwenhoven, S. E., Gay, C. L., Bakken, L. N., & Lerdal, A. (2013).

An investigation of the association between depressive symptoms and clinical factors in acute stroke.

Neuropsychological Rehabilitation. 23(5), 658-677.Lasater, K. l., Cotrell, V., McKenzie, G., Simonson, W., Morgove, M. W., Long, E. E., & Eckstrom, E. (2016).

Collaborative Falls Prevention – Interprofessional Team Formation and Implementation. Evaluation.

Journal Of Continuing Education In Nursing. 47 (12), 545-555.Lerdal, A. (2016).

A cross-sectional analysis of their associations with sociodemographics.

Neuropsychological Rehabilitation. 23(5), 658-677.Lewin, A., Jobges, M., & Werheid, K. (2013).

The influence on self-reported depressive symptoms following stroke rehabilitation of pre-stroke depression, self-efficacy, and perceived social support

Neuropsychological Rehabilitation. 23(4): 546-562.Lutz, B.J., Young, M.E., Cox, K.J., Martz C., & Creasy KR.

(2011). The crisis that is stroke: Stories from patients and their caregivers.

Topics in Stroke Rehabilitation. 18(6):786-797.

Martz C. & Creasy K. (2011). Stroke crisis: The experiences of stroke victims and their caregivers.

Topics for stroke rehabilitation. 18(6):786-797.Miller, E., Murray, L., Richards, L., Zorowitz, R.D., Bakas, T., Clark, P., Billinger, S.A. (2011).

Comprehensive Overview of Nursing & Interdisciplinary Rehabilitation Care of Stroke Patients: Scientific statement from American Heart Association. Stroke;41:2402-2448.Mueller, C. E., & Hong, Z. (2017).

Restorative Care’s Effects on Activities Of Daily Living Dependency In Long-Stay Nursing Hospitals.

Gerontologistal Analysis. 55S78 – S88Orlin, M. N., Cicirello, N. A., O’Donnell, A. E., & Doty, A. K. (2014).

The Continuum of Care to Individuals With Lifelong Disability: Role of a Physical Therapist.

Physical Therapy, (94(7)), 1043-1053.Pascoe, M. C., Crewther, S. G., Carey, L. M., Noonan, K., Crewther, D. P., & Linden, T. (2012).

As a biochemical marker for depression in older stroke survivors, homocysteine may be used. Food & Nutrition Research, 561-5.Patchell, R. (2015).

Resident to resident aggression in nursing homes: Collaboration and involvement of social workers.

Health & Social Work. 40(3). e101 – e109.Sidani, S., & Fox, M. (2014).

The specific elements of patient-centered medicine: clarification to allow interprofessional care. Journal Of Interprofessional Care, 28(2), 134-141. doi:10.3109/13561820.2013.862519Slowther, A. (2011).

Health policy, patient-centred healthcare and clinical ethics.

Journal of Evaluation in Clinical Practice. 17:913-919.Steinberg, D. d., Askew, S., Lanpher, M. G., Foley, P. B., Levine, E. L., & Bennett, G. G. (2014).

Results of a randomized controlled trial on the effects of “Maintain don’t lose” weight management strategies on depression in black women.

American Journal Of Public Health (104(9)), 1766-1773.Talley, K. c., Wyman, J. F., Savik, K., Kane, R. L., Mueller, C. E., & Hong, Z. (2015).

Restorative Care’s effect on activities of daily living dependence in long-stay nursing home residents. Gerontologist, 55S88-S98Valois, L. (2014).

Collaboration among transdisciplinary teams for dementia care.

Neurodegenerative Disease management, 4(6). 455-469.Young, M.E. (2010).

Rethinking the role of family caregivers in stroke caregiving.

Rehabilitation Nursing. 35(4):152-160Zachos, K. (2013).

Computing Technologies for Reflective, Creative Care of People Living with Dementia.

Communications Of The ACM. 56 (11), 60-67. doi.10.1145/2500495Zatta, M., & Mcginnity, B. (2016).

An overview of transition planning and strategies for deafblind students.

American Annals Of The Deaf. 161(4): 474-485.