Introduce and Define the ” Nurse-Patient Relationship” theory to construct a narrative (story) about your experience in clinical or simulation with a patient.

1) Introduce and Define the ” Nurse-Patient Relationship” theory to construct a narrative (story) about your experience in clinical or simulation with a patient.

2) Explain how this theory applies to your clinical experience with the patient.

3) Must include any 3 of the following when writing about your personal experience:
Demonstration of or lack of:
*leadership
*Interprofessional collaboration
*therapeutic communication

*holistic care (social determinants / cultural considerations)

*safety for the client

For this Case Study Discussion, you will once again review a case study scenario to obtain information related to a comprehensive well-woman eval and determine differential diagnoses, diagnostics, and develop treatment and management plans.

For this Case Study Discussion, you will once again review a case study scenario to obtain information related to a comprehensive well-woman eval and determine differential diagnoses, diagnostics, and develop treatment and management plans.

Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations. Your primary diagnosis, additional questions, and types of symptoms are what this assignment and grading is focused on. Your critical thinking for this assignment

References MUST be scholarly!!! (Do not use WebMD, Clevelandclinic.org, mayoclinic.org, etc as these are public websites).

Case Study 2

Case Study: STI Investigation

Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She

works full-time as an administrative assistant, and relates she loves her job. She has no medical

or surgical history, takes no medication, and has no allergies. Family history is non-

contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day

(PPD) since age 14, / EtOH only on weekends, 6-8 hard liquor/ daily, and marijuana

smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and

using 3 tampons daily. She has some cramping during her menses for which she

takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and

“occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for

the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day

or two, but Tylenol took care of it and she thought it was allergies.

Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and

weight 118 lbs. (which was the same as last year). BMI 19.04

· HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat

appears reddened.

· Lung: clear to auscultation

· CV: regular sinus rhythms without murmur or gallop

· Abd: soft, non-tender, liver normal,

· Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge,

no adenopathy, and bilateral nipple piercings.

· VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted

· Cervix: friable, some petechia no cervical motion tenderness.

· Uterus: mid mobile, non-tender

· Adnexa: without masses or tenderness

· Perineum: wnl

· Rectum: wnl

· Extremities: full rom, skin clear, no edema, reflexes 1+.

· Neurological: CN II-12 grossly intact.

Ms. JN is a 24-year-old law student who presents to an outpatient psychiatry clinic accompanied by her husband. She feels “worried about everything!” She is “stressed out” about her academic workload and upcoming assignments.

DO NOT INCLUDE THE WHOLE CASE STUDY IN THE PAPER WRITTEN. USE SUBHEADINGS FOR EACH INFORMATION, PLEASE

Case Study

Ms. JN is a 24-year-old law student who presents to an outpatient psychiatry clinic accompanied by her husband. She feels “worried about everything!” She is “stressed out” about her academic workload and upcoming assignments. She feels fatigued and has difficulty concentrating on her assignments. She also complains of frequent headaches and associated neck muscle spasms, as well as difficulty falling asleep.

The patient’s husband describes her as “a worrier. She’ll worry about me getting into an accident, losing my job, not making enough money—the list goes on and on.”

Ms. JN reports that she has always had some degree of anxiety, but previously found that it motivated her. Over the last year, her symptoms have become debilitating and beyond her control.

Questions:Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.

  1. Summarize the clinical case
  2. Formulate a diagnosis
  3. Create a list of the patient’s problems and prioritize them.
  4. Which pharmacological treatment would you prescribe? Include the rationale for this treatment.
  5. Which non-pharmacological treatment would you prescribe?   Include the rationale for this treatment.
  6. Include an assessment of treatment’s appropriateness, cost (exact a, effectiveness, safety, and potential for patient adherence.

Instructions:

at least 500 words ( 2 complete pages of content) formatted and cited in current APA style 7 ed  with support from at least 3 academic sources which need to be journal articles or books from 2019 up to now. NO WEBSITES allowed for reference entry. Include doi, page numbers, etc. Plagiarism must be less than 10%.

Gastrointestinal Reflux Disease (GERD) Presentation

YOUR TOPIC HERE

 

 

 

 

 

OVERVIEW

Define and provide an overview of the selected topic/disease process.

 

 

 

 

 

MEET THE TEAM

Introduce your team and include any information of choice

 

 

 

 

 

RISK FACTORS

Identify the risk factors (modifiable and non-modifiable) that predisposes a patient to the selected disease process.

 

 

 

 

 

CLINICAL MANIFESTATIONS: SIGNS & SYMPTOMS

Identify the clinical manifestations that a patient with the selected disease process may present.

 

 

 

 

 

DIAGNOSTIC & LABORATORY TESTS

Identify and discuss two – three diagnostic or laboratory tests that are used to confirm the diagnosis of the selected disease process.

 

 

 

 

 

MEDICAL MANGEMENT

Identify and discuss medical management (including medication and/or surgery) that are used to treat the selected disease process.

 

 

 

 

 

NURSING INTEVERVENTIONS & PATIENT TEACHINGS

Identify and discuss nursing interventions and patient teaching that would be done and provided to the patient with the selected disease process.

 

 

 

 

 

CONCLUSION

Provide a summary of pertinent and key information presented.

 

 

 

 

 

REFERENCES

Provide a list of the references that were used in completing this presentation.

 

 

 

 

 

In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved.

NURS 6051: Transforming Nursing and Healthcare Through Technology

 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists

Nature offers many examples of specialization and collaboration. Ant colonies and bee hives are but two examples of nature’s sophisticated organizations. Each thrives because their members specialize by tasks, divide labor, and collaborate to ensure food, safety, and general well-being of the colony or hive.

Of course, humans don’t fare too badly in this regard either. And healthcare is a great example. As specialists in the collection, access, and application of data, nurse informaticists collaborate with specialists on a regular basis to ensure that appropriate data is available to make decisions and take actions to ensure the general well-being of patients NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay.

In this Discussion, you will reflect on your own observations of and/or experiences with informaticist collaboration. You will also propose strategies for how these collaborative experiences might be improved.

 

To Prepare:

  • Review the Resources and reflect on the evolution of nursing informatics from a science to a nursing specialty.
  • Consider your experiences with nurse Informaticists or technology specialists within your healthcare organization.

Post a description of experiences or observations about how nurse informaticists and/or data or technology specialists interact with other professionals within your healthcare organization. Suggest at least one strategy on how these interactions might be improved. Be specific and provide examples. Then, explain the impact you believe the continued evolution of nursing informatics as a specialty and/or the continued emergence of new technologies might have on professional interactions.

Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

 

  • Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
  • Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)

American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/

Glassman, K. S. (2017). Using data in nursing practice. American Nurse Today, 12(11), 45–47. Retrieved from https://www.americannursetoday.com/wp-content/uploads/2017/11/ant11-Data-1030.pdf

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf

Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05.

Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs

Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.12.019. NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay

Nursing is one professional that cannot survive without collaborative approach. To ensure that there is better quality in service delivery, the nurses must work together with the nursing informatics and technology specialists to ensure a smooth flow in the service delivery (McGonigle & Mastrian, 2017).  Right from when the patient visits the health facility, they are first met by the receptionist who happens to be a medical record expert and they are the ones who directs the patient on where to head next after retrieving their details. The patient is then sent to the triage, which is the most important point for a patient as the assessment by a nurse will reveal several issues including the matter of urgency for the patient treatment. NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay.

Other issues such as blood pressure, BMI and sugar levels that are important before a patient sees the doctor are monitored within the triage. The results of the same may be indicated on the patient file or in case the system is automated; they will be wired directly to the doctor of the day. The doctor or the clinical officer on duty, then examines the patient and recommends on either medication, further test or ward admission. At this stage, the nurse may take over again in case of admission or wound dressing as per the doctor’s direction NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay. This is usually the routine taken by the patients on a daily basis and requires expertise collaboration between the nurse and other professionals in order to deliver services in the right manner.

On issues to do with strategy on how these interactions might be improved, technology comes in handy as its effective application may speed up the processes and eliminate the unnecessary delays that may add up costs, or contribute to even the worst cases of loss of life (Macieria et al. 2017). From the admission to the triage up to the doctor’s room, effective online transit of the patient information will eliminate delays and hence smooth delivery of services, patient and healthcare professional’s satisfaction, as well as cost reduction.

With the continued evolution of nursing informatics as a Specialty, the future of nursing seems brighter and most manual chores are eliminated and collaborative interactions are being enhanced, hence improved quality, more productivity and eventually cost reduction (Wang, Kung & Byrd, 2018). With advanced technology, the professional interaction is bound to enter a whole new level where the processes will be executed with minimal time and at the expected quality level hence the overall improvement in the service delivery within the health facilities. NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay.

 

References

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G.

(2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge

(4th ed.). Burlington, MA: Jones & Bartlett Learning.

Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and

potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126 (1), 3–13. doi:10.1016/j.techfore.2015.12.019. NURS 6051 Wk 3 Discussion: Interaction Between Nurse Informaticists and Other Specialists Essay

This week, reflect on your level of preparedness for the national board certification exam (PMNC-PMHNP) on psychiatric. Develop a strategy for board preparation and time management utilizing the prompts below. Respond to the questions below in complete sentences.

This week, reflect on your level of preparedness for the national board certification exam (PMNC-PMHNP) on psychiatric. Develop a strategy for board preparation and time management utilizing the prompts below. Respond to the questions below in complete sentences.

· Discuss at least 3 realistic and attainable strategies that you would implement to prepare for the national board certification exam. What is your plan for implementing these strategies?

· Discuss how you plan to manage your time to include the additional preparation needed.

· Describe what challenges you anticipate as you prepare for national boards. How do you plan on overcoming these challenges?

Review the rubric for this assignment for additional details. Include at least two peer journal reviews APA style.

Rubric

Certification Preparation Plan Rubric

Certification Preparation Plan Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeContent
30 to >24.6 pts

Satisfactory

Student details 3 or more ways to prepare for the national boards and provides a comprehensive plan, with 2-3 specific strategies for time management and additional preparation.

24.6 to >0 pts

Not Satisfactory

Student does not provide a detailed strategy to prepare for the national boards or any details within a plan, with for time management and additional preparation.

 

30 pts
Total Points: 30

     The surrogate role in nursing refers to the nurse’s ability to temporarily stand in as a substitute for a patient’s family or support system.

Surrogate role in nursing

The surrogate role in nursing refers to the nurse’s ability to temporarily stand in as a substitute for a patient’s family or support system. Hildegard Peplau initially introduced this role in the mid-20th century as a part of her theory of interpersonal relations in nursing. However, despite its early prominence, the surrogate role is not frequently mentioned in recent nursing practice literature. This raises the question of whether the surrogate function, as stated by Peplau, is still relevant to nursing practice today.

The idea that nursing is an interpersonal process that involves building relationships with patients is central to Peplau’s theory. Peplau saw the surrogate role as a critical component of this process because it allows the nurse to put themselves in the patient’s shoes, understand their point of view, and provide care tailored to their specific needs (Forchuk, 2021). A surrogate is one of the four roles a nurse can play in a therapeutic relationship with a patient. Counselor, teacher, and leader are the other roles. Advocating for the patient, providing emotional support, and assisting them in navigating the complexities of the healthcare system are all part of the surrogate function.

While the surrogate function is not explicitly discussed in current nursing practice literature, it is still an essential part of nursing practice. Indeed, many of modern nursing’s core competencies, such as patient-centered care, advocacy, and empathy, are rooted in the surrogate role. Nurses must still be able to connect with their patients, understand their perspectives, and provide care that is tailored to their specific needs (Wasaya et al., 2021). The surrogate role is often assumed to be part of the nurse’s overall role in providing emotional support and holistic care to patients, which is why it is not frequently mentioned in recent nursing literature.

Furthermore, the challenges that modern healthcare systems face have only emphasized the importance of the surrogate role. Patients are more likely to have complex and multifaceted healthcare needs as chronic diseases become more prevalent and the population ages (Pecanac & King, 2019). Nurses must be able to act as surrogates for patients, guiding them through the complexities and ensuring that they receive the care and support they require.

In conclusion, while the surrogate role may not be frequently mentioned in recent nursing literature, it remains a relevant and important aspect of nursing practice today. As patients often do not have the same level of support from family and friends as they may have had in the past, nurses may need to take on the surrogate role more frequently and for longer periods of time. By providing emotional support and serving as a substitute family member, nurses can help fill the social support gap for patients and improve their overall health outcomes. However, nurses must also prioritize their well-being and set boundaries to avoid burnout.

 

200 words and one scholarly reference

The concepts are related to nursing practice, education, and/or administration. For example, if you are planning to be a family nurse practitioner, you might choose the concept of family support. In this assignment, you will review the literature related to the study of your concept from different disciplines. Doing so will help illuminate the meaning of the concept.

Concept Analysis Paper Assignment Instructions

Purpose and Process

The concepts are related to nursing practice, education, and/or administration. For example, if you are planning to be a family nurse practitioner, you might choose the concept of family support. In this assignment, you will review the literature related to the study of your concept from different disciplines. Doing so will help illuminate the meaning of the concept.

Paper Guidelines

1. Introduction (5 points): This section informs the reader of the purpose and focus of your paper. In addition, this section also explains what a concept analysis is, according to the literature. Then, describe why you chose your concept and its application to nursing research and another area in nursing, such as nursing administration, nursing practice, or nursing education.

2. Review of the Literature (15 points): This is the main section of your paper which identifies all uses of the concept. First, begin with the dictionary and lay sources, then move to academic literature. Review the nursing literature related your topic, as well as two other disciplines, such as biology, psychology, or law. The selected literature should mainly be scholarly, peer reviewed journal articles and textbooks. Provide a brief summary of each of these articles and connect them together as a synthesis. For example, for postpartum depression, you would review the literature in nursing, and two other possible disciplines such as psychology and social work. Generally, use references published within the last five years, unless there is a landmark piece of literature (for example, Peplau’s theory of interpersonal relationships). Use at least three scholarly articles from each discipline. Write a synthesis of these articles (for example, compare and contrast focus and/or findings). For more information, examine Nursing: How to Write a Literature Review.

3. Defining attributes (15 points): From your literature review of uses of the concept (sources such as the dictionary and the thesaurus [lay sources] and academic articles), determine the defining attributes of your concept. In order to accomplish this, make sure to do the following for each of your selected sources (academic articles, dictionaries, textbooks):(1) read them entirely, (2) highlight or underline the definitions in each source to keep track of the various definitions used to define your concept, and (3) extract the definitions from all sources for a comprehensive list of attributes that define your specific concept. Two or three defining attributes may exist for one concept, whereas for another concept, there could be seven or eight defining attributes. Do a comprehensive review of the literature within your selected sources prior to deciding on the final list of defining attributes, to capture the essence or meaning of your concept.

4. Definition of the Concept (5 points): Write a definition that incorporates all the concept’s defining attributes in one-to-two paragraphs.

5. Cases (35 points): Ensure your cases fit your designated case types. Also, be sure to provide a rationale for why your case meets that criterion. In the example of a model case, first describe what a model case is according to the literature, then describe your model case and why it meets that criterion. Be specific. You should follow this method with each of your cases.

a. Model Case: (15 points)

b. Borderline, Related, Contrary, Illegitimate, and Invented Cases. (Each section is worth 4 points; 20 points for this component.)

6. Antecedents and Consequences (Each section is worth 5 points; 10 points for this component.): Antecedents are the events/required elements that occur before the concept can happen. Consequences are the events/outcomes that take place after the concept occurs. Antecedents and consequences cannot be the same. They also cannot be the concept itself, but the events/required elements that take place before or after the concept is evident.

7. Empirical Referents (5 points): Describe how the concept is measured by two research tools. Define the concept that the researcher used and the purpose and structure of the tool (that is, number of items), and then note one study where the tool was used and include its purpose, sample, method, and main findings. This information can come from your literature review.

8. Summary (5 points): Summarize your paper and do not provide new information. You should not leave the reader in suspense, as if there would be a sequel.

9. Format (5 points): Your paper should use APA formatting for its all components and formal writing mechanics, and be free of spelling and grammar errors.

Other Requirements

· Your paper should be 10 to 12 pages long, typed in a Times New Roman 12-point font, and have 1-inch margins. The paper’s length does not include the title page and references list. Do not include appendices.

· You will have following three milestones for your concept analysis paper so that your instructor can provide you with feedback on its development:

1. Concept analysis outline: It includes the Introduction through Review of the Literature with at least four references styled in APA format. This outline is due in Week 3. (Counts as 10% of the concept analysis paper’s grade.)

2. Concept analysis draft: A draft of the entire paper is due in Week 5. The concept analysis draft you submit in Week 5 should be a complete version of the paper. Each part of the final paper should be present, including references styled in proper APA format. The closer that your draft is to the final paper, the more specific feedback your NU601 faculty can provide to you to help improve your final submission (submitted in Week 7). (This draft is worth 10% of the concept analysis paper grade.)

3. Final paper: The final complete paper is due in Week 7 (The final paper is worth 80% of the concept analysis paper grade)

Helpful Hints

· Ensure you review the Week 2 and Week 3 learning materials and readings on concept analysis before you begin writing your concept analysis paper. Refer to the examples in the media activities about what should be included in a concept analysis.

· Use the paper guideline headings to organize your paper. Subheadings might also be helpful, but use them judiciously.

· Reference all work that is not your own or common knowledge, such as “alcoholism is a serious problem.”

· For each section of your paper, define what each part means according to the literature, then provide your explanation. You will want to define what a concept analysis is, as well as the meaning of defining attributes, model cases, borderline cases, etc.

· You may combine your review of the literature pertaining to the three disciplines or present each separately.

· Do not use broad assumptions without data or evidence to support them.

· Write in your own words.

· Do not use colloquial statements or informal language, such as “Let’s take the car for a spin.”

· If you find a concept analysis of your concept, you may use it very judiciously. Your paper should be your own work.

· Review this example of a concept analysis paper: West, P., Abbott, P., & Probst, P. (2014). Alarm fatigue: A concept analysisOnline Journal of Nursing Informatics 18(2). It is not perfect, but it should help your understanding of how to write your paper.

· You may not use basic nursing resources (such as Registered Nurse Journal or American Journal of Nursing), nor basic nursing textbooks. You may use websites that are classified as .org or .edu websites. However, such websites should be used judiciously.

In what ways does the distance of the extended family influence this family’s approach to health promotion?

MSN 5550 Health Promotion: Prevention of Disease Case Study Module 10 Instructions: Read the following case study and answer the reflective questions. Please provide evidence-based rationales for your answers. APA, 7th ed. must be followed. Deadline: Due by Saturday at 23:59 p.m.

CASE STUDY: Preschool Child: Ricky Ricky, age 4 years, arrives in the clinic with his mother. Ricky lives with his mother and father, who both work full-time, and his infant sister. Their extended family lives in a different state more than 100 miles away. Both parents are of average height and in good health. Ricky’s mother mentions that Ricky often expresses frustration, particularly in regard to food. Conflict over food occurs every day. Mealtime is a battle to get him to eat, unless his mother feeds him. Ricky’s baby sister seems to tolerate all baby foods but requires her mother to spoon-feed. Ricky’s mother is quite frustrated and concerned that he will become malnourished. Reflective Questions

1. What additional assessment information would you collect?

2. What questions would you ask, and how would you further explore this issue with the mother?

3. In what ways does the distance of the extended family influence this family’s approach

to health promotion?

4. What factors would you consider to determine whether malnourishment is a factor in this family?

What was the impetus for the quality and safety initiatives of the last two decades?  Who or what groups were responsible for championing changes in health care delivery?  What were the most important messages from these reports?  To what extent have the IOM reports changed nursing practice?

Skim the following IOM reports:

Committee on Quality of Care in America. (2001). Crossing the quality chasm: A new health
system for the 21st century.
http://www.nap.edu/catalog.php?record_id=10027

Aspden, P., Corrigan, J. M., Wolcott, J., Erickson, S. M. (Eds.). (2004). Patient safety: Achieving a
new standard for care. http://www.nap.edu/catalog.php?record_id=10863

Page, A. (Ed.). (2004). Keeping patients safe. http://www.nap.edu/catalog.php?record_id=1085

Discussion 1

As you read the IOM reports this week, what stood out to you?

What was the impetus for the quality and safety initiatives of the last two decades?  Who or what groups were responsible for championing changes in health care delivery?  What were the most important messages from these reports?  To what extent have the IOM reports changed nursing practice?