Comm,entary
Post- Vancouver: Implications for
Nursing Practice and Nursing Research
William L. Holzemer, RN, Phi), FAAN
Key words: HIV, nursing practice, nursing research
T h e evolving understanding of the pathogenesis of
HIV infection, the new antiretroviral therapies, and the
complex issues of medication compliance demonstrate
that HIV care is a constantly moving target. The XIth
International AIDS meeting in Vancouver, British Columbia, Canada, presented for us the theme, "One
World, One Hope," and delegates left Vancouver with
a new-found commitment to the prevention of HIV and
the care of those living with and affected by HIV
disease. The splendid news of the new therapies was
at times overwhelming, particularly when one considers the cost and therapeutic regimens required. However, there was good news and we in the nursing
community have a strong obligation to understand this
good news. We also have an obligation to understand
the limitations of these therapies. And, we have an
obligation to develop solidarity regarding access to
these therapies.
To assist in the reconceptualization of HIV disease
post-Vancouver, an outcomes model is presented as a
strategy for thinking about nursing care interventions
and people living with HIV and their significant others/families. The outcomes model for health services
research (Holzemer, 1994a, 1994b) simply expands a
systems perspective from Donabedian's work of inputs, processes, and outcomes by adding a vertical
dimension that includes client, provider, and setting
(see Table 1). The systems framework of inputs-proWilliam L Holzemer, RN, PhD, FAAN, is a professor in and
the chair of the Department of Community Health Systems,
and the director of the International Center for HIV/AIDS
Research & Clinical Training in Nursing, School of Nursing,
University of California, San Francisco.
cesses-outcomes suggests that inputs are those elements that come together at the moment of a health
care encounter. These include the client's strengths and
problems, the provider's expertise and wisdom, and
the setting's resources and policies. The processes are
those things that happen during an episode of care,
including the client's self-care activities, the nursing
interventions, and any potential changes in the setting
(e.g., changes in skill-mix) that might have an impact
on the ability of the provider to deliver the intervention. Outcomes typically focus on client outcomes,
often referred to in the literature as nurse-sensitive
outcomes. These include from a nursing process perspective the desired resolution of the patient's problems. From an organizational perspective, it is also
important to explore provider outcomes (burnout of
nurses in AIDS care, nurse satisfaction, etc.) as well as
setting outcomes such as costs of care and aggregated
patient statistics like morbidity and mortality. This
model is used to examine implications of the post-Vancouver developments for nursing practice and nursing
research. The client, provider, and setting have been
added to the systems model of inputs-processes-outcomes to enhance our understanding of how components interact and have an impact on the outcomes of
care.
The client in this special issue of JANAC is the
person living with HIV/AIDS, not those at risk for HIV
infection; perhaps a future addition will focus on the
prevention research and practice issues. Client inputs
include their knowledge, attitudes, and practices
(KAP) related to HIV/AIDS (see Table 2). In reading
these tables, read down each heading of inputs, processes, outcomes, not across; items are not meant to be
linked necessarily from left to right across the three
columns. For example, KAP may or may not relate to
JOURNALOF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 8, No. 4, July/August 1997, 62-66
Copyright @ 1997 Association of Nurses in AIDS Care
