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Dorothy as the Prototype in Looking at Client Expectations; Quality of Life and Functioning

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The nursing process focuses on the prioritization of care based on the assessment of the problem followed by the formulation of a nursing diagnosis, then planning and implementing care, and finally evaluating the process. When nursing students think of the priorities of care they generally focus on a medical model. While prioritizing such important issues as the ABCs (airway, breathing, and circulation) is inarguably vital and often the catalyst for interface with the health care system, these issues are often not the priorities identified by the client. Many times client priorities are more closely linked to quality of life issues than to life sustaining issues, especially in the case of older adults. Can a marriage of addressing the client’s expectations and the priorities of the health care teach better influence outcomes in care of the older adult? It is sometimes difficult for the nurse to take into account the complexity of issues surrounding the older adult. This teaching strategy looks at raising the awareness client expectations and at how the nurse can work with the client in addressing these expectations to ultimately maintain the best possible quality of life.

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Dorothy as the Prototype in Looking at Client Expectations; Quality of Life and Functioning

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Learning Objectives
Students will:
- Communicate effectively and consistently in asking older adults about their expectations of the health care experience and their priority outcomes.
- Develop an understanding of the need to consider the expectations of the older adult on the same level as the priorities of the health care team.
- Assess identified expectations of both the client and health care team in the context of client functioning.
- Discuss tactics for advocacy for the client’s expectations.
- Reflect on their own expectations in controlling events in their lives.
- Discuss beliefs about making reconciliation between priorities of care.
- Develop an understanding of increased vulnerability during transitions when expectations are not addressed.
Learner Pre-Work
Listen to or read Dorothy's monologue. Ask the students to consider these questions as they listen or read the monologue:
- What were Dorothy’s expectations of the hospitalization?
- What were the nurse’s expectations of the hospitalization?
- What is the connection between Dorothy’s expectations and her functioning?
- How does Dorothy define her quality of life? Do you agree?
- How could Dorothy’s transition be influenced by her expectations?
- What is the best way for the nurse to advocate for Dorothy?
- How is dignity considered when assessing Dorothy’s needs?
- What is the impact of immobility on Dorothy’s outcome?
Suggested Learning Activities
1. Student reflection outlining expectations of health care, education, and relationships or a guided class or online discussion on expectations. Consider the following questions in initiating this exercise:
- What is most important to you?
- How have you felt when your expectations were not congruent with that of others?
- How have you felt when decisions were made for you?
- When was the last time you felt helpless?
- What is significant to you when you think of your quality of life?
- Given experiences that you have had in life, how have your expectations changed?
2. Utilize Dorothy’s audience response questions from the download section to initiate a discussion on quality of life. This format will allow students to answer questions anonymously. The ethical perspective of the questions will likely allow for rich discussions. They can be easily converted into any audience technology available. The questions in this audience response activity are as follows:
- The most important part of life is?
- Health
- Family
- Money
- Mobility
- If the quality of my life was diminished I would want to die – Yes or No
- Dorothy’s mobility should be the priority – Agree or Disagree
- I think the most important question to ask Dorothy is:
“What is important to you?”
“Have you fallen in the past three months?”
“Do you want to live?”
“So you feel your heart skipping a beat?”

3. A concept map is a diagram that illustrates relationships between concepts. Assign a concept map to students after they listen to the monologue or have the students do a concept map as a group project in class/seminar, or as a post-conference activity. See the example of the concept map in the download section. This should be considered a draft. Have students start with this draft which uses decreased mobility as a concept and ask them to identify missing pieces and identify priorities of care while considering the essential nursing actions and essential knowledge domains.

4. Advanced Directives are written instructions regarding what actions an individual wants if they are unable to make decisions for themselves. In the monologue Dorothy talks about her expectations. Ask students to write their own advanced directives as an exercise to help raise their consciousness about quality of life issues and what measures they might want to sustain life in the face of illness or incapacity. This exercise lends itself to a discussion of their thoughts and decisions either in a verbal forum in person or an online forum in a discussion group.
Materials
1. ConsultGeri.org; the website of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing contains many evidence-based assessment tools. Those listed below from the Try This® and How to Try This Series® are particularly recommended for the content on geriatric syndromes. The tool, an article about using the tool, and a video illustrating the use of the tool, are all available for your use. The SPICES tool is listed first since it is an overall assessment tool; the remaining tools are listed in alphabetical order. View the list of tools. Below is a suggestion of tools that may be appropriate in assessing Dorothy: Visit ConsultGeri.org to access the Try This® and How to Try This resources. Some examples of assessment tools that can be used with Dorothy are:
2. Download Dorothy’s audience response PowerPoint slides that can be used for anonymous questioning with an audience response system as discussed as one of the activities in the Learner Pre-Work section.

3. Download Dorothy’s concept map illustrating the concept of diminished mobility which can be used in the concept map activity outlined in the Suggested Learning Activities section. Please note that this is only a sample and should be used as a draft and not considered a complete concept map related to the Dorothy case study. It includes missing pieces that students can add to in either an individual or group project.
Suggested Reading

Boltz, M., Resnick, B., Capezuti, E., Shuluk, J., & Secic, M. (2012). Functional decline in hospitalized older adults: Can nursing make a difference? Geriatric Nursing, 33(4), 272-279. doi:10.1016/j.gerinurse.2012.01.008

Spar, M.J., Nicosia,F. M. Steinman, M. A. and Brown, R. T. (2017). Current Approaches to Measuring Functional Status among Older Adults in VA Primary Care Clinics. Federal Practitioner. https://www.mdedge.com/sites/default/files/Document/September-2017/0917fed_spar.pdf

Olson E.V., Johnson, B. J., & Thompson, L. F. (1990). The hazards of immobility. American Journal of Nursing, 90(3), 43-48. [Historic Article, 1967, PMID: 2178421]
Author Information

Laureen Tavolaro-Ryley, MSN, RN
Community College of Philadelphia
Philadelphia, PA