The Client Experience Model

The Client Experience Model is a middle-range nursing theory that is broad-based and aimed to guide nursing practice, facilitate positive healthcare experiences and improve health outcomes according to Holland, Gray, and Pierce (2011, p. 36). The theory suggests that when each of the concepts, which includes security, communication, interaction and expectation are used analogously to the patient’s needs it will result in the patient having a positive experience and health outcomes will be positive (Holland et al. , 2011). On the opposing view, if there were to be a negative experience within the paradigm it would result in negative health outcomes (Holland et al. , 2011). The impact of the theory is that by nurses assessing any one of the four concepts and noting a barrier the goal would be to remove the barrier to provide better care and experience for the patient.

Internal Criticism of the Theory

Adequacy

The theory presented in the text by Holland et al. (2011) introduces a great topic to be discussed; The Client Experience Model. It addresses a fundamental topic that is vital to all healthcare professionals and applicable to all areas of care. Which is in essence similar to Maslow’s Hierarchy of Needs because it includes fundamental assessments of things including: security, communication, interaction and expectation. Although this particular study uses African American’s with Multiple Sclerosis through clinical observation in an acute care setting as its population this does not adequately account for all areas that nurses would engage with these patients. Additionally, there is no correlating information provided on how the concept’s influence the patient’s experience. According to the Agency for Healthcare Research and Quality (2017), patient experience in healthcare is related to satisfaction, which has triggered the use of surveys as a method of measurement.

Clarity The Client Experience Model lists clearly the components to be discussed security, communication, interaction and experience and how these components work together to provide a positive experience which leads to a positive outcome (Holland et al. , 2011). What is not understood with clarity or described is the nursing assessment. The assessment is discussed as a assessment via conversation with questions, but only examples of generalization with no specifics are given. Additionally, the intervention varies on the information gathered in the assessment with tailored ideas on what interventions can be implemented. However, there are not clear definitions on how the interventions should be implemented or what to do if your assessment should vary from this example.

Consistency

The description of the theory’s main concepts of security, communication, interaction and experience are consistently upheld throughout the article. Additionally, the theory congruently uses the same terms, interpretations and principles throughout the article. One gap of inconsistency that is noted however is that the theory is based on the use of African Americans with multiple sclerosis in a clinical observational acute care setting, but the assessment and intervention portion focus on nurses in a community setting (Holland et al. , 2011, p. 39).

Logical Development

The Client Experience Model is compared to Kolcaba’s Comfort Theory (Holland et al. , 2011, p. 38-39), and both of these theories are based off of a holistic natural care approach which can be applied to bedside care. The concepts mentioned have been proven to be effective through many previous studies. According to an article published by Jha, Frye and Schlimgen (2017, p. 34-37) patient safety, communication, interaction and expectations are all factors that influence patient experience and satisfaction. Essentially, Jha et al (2017, p. 37-38) theory is that the patient experience is all encompassing throughout the continuum of care. The additional research provided by this team solidifies that the concepts discussed by Holland and associates would lead to positive outcomes which is supported by this additional literature.

Level of theory Development

The Client Experience Model discussed by Holland et al appears to be in a very beginning stages of development and the basic concepts are discussed (Peterson & Bredow, 2017, p. 15). Furthermore, the theory itself is well explained by the four concepts within the theory having been investigated utilizing nursing research. Upon researching the CINAHL database with these keywords: multiple sclerosis and client experience model, no additional research articles were discovered.

External Criticism Complexity

The Client Experience is based on the concept of creating a positive patient experience which will result in improved health outcomes (Holland et al. , 2011). The theory consists of four concepts security, communication, interactions and expectations that are not complex in comprehension. In addition, they are easy to read and understand in the text of how they should work together.

Discrimination

The Client Experience Model hypothesizes that utilization of the component’s security, communication, interactions and expectation will lead to positive patient experiences and improve outcomes (Holland et al. , 2011). Although the concepts discussed are very unique they are not distinctive enough that they could not be arrived at by using another method. As discussed by Holland et al. (2011) the Kolcaba’s Theory of Comfort also uses the concepts of relief, ease, and transcendence by hypothesizing that improving the patient experience will lead to improved outcomes. The theories are well-defined that the use of the key concepts for assessment will lead to interventions that result in favored outcomes (Holland et al. , 2011).

Reality convergence

The assumptions of this theory are literal in the real world of nursing and do represent a real-world nursing scenario. Building trusting relationships, or rapport, with patients will result in a higher ratio of patient follow through (Berkowitz, 2016, p. 4). Accomplishing trusting relationships includes providing a safe and caring environment to foster open communication (Holland et al. , 2011, p. 39). The theory’s concepts are expressed in bedside nursing but are also pertinent in the outpatient setting as well.

Pragmatic

This theory can be operationalized in real-life nursing. Due to the flexibility and broad spectrum of this theory it can be tailored to fit any nursing or healthcare setting. Nurses should be coached on the fundamentals of building patient rapport with additional communication skills on diversity instruction to be provided depending on the population of patients being served to ensuring that all patients are being served equally (Khan, Williams, Amezcua, Javed, Larsen, and Smrtka, 2015, p. 133-134). Again, as mentioned, ensured that a safe and caring environment for patients to feel comfortable opening to communicate (Holland et al. , 2011p. 39).

Scope

The theory is narrow since the focus is on a primary issue, outcomes. The concepts discussed in this theory are narrow enough individually to be discussed as one or can be merged and discussed together. In this framework, application of these concepts works to create positive patient outcomes. Due to the narrow range of scope allows it to be consisted a middle-range theory.

Significance

The concepts discussed in this theory will make a direct impact on how nurses interact with their patients. Research that is conducted on how nurses interact and deliver care is vital and essential to the current and future generations of nursing.

Utility

The theory discussed by Holland and associates is realistic for many different healthcare settings. The four concepts can produce hypotheses that are applicable to other settings based off of patient populations and desired outcomes specified to that setting. Because of the grounds of the middle-range theory it makes it functional and adaptable to all areas of care.

Description of Practice Setting

The Client Model Experience is formed from a clinical observational acute care setting among African Americans diagnosed with multiple sclerosis (Holland et al. , 2011, p. 37). Due to the commonality of the key concepts, this theory can be applied to most any setting that involves patient-provider care. Nursing is much more than science, it is treating people how you would want to be treated. African Americans are at a 47% increased risk of developing multiple sclerosis as compared to other demographics and additionally are more likely to develop a more aggressive disease course (Khan et al. , 2015, p. 133-134).

According to a study conducted by the North American Research Committee on Multiple Sclerosis (NARCOMS), which included 21,557 enrolled patients with multiple sclerosis, concluded that African Americans were found to have increased disease severity levels, lowest income, lowest education levels, and less likely to have private insurance which additionally leads to poorer health and worse outcomes (Khan et al. , 2015, p. 137). Acting as a nurse navigator and ensuring that these individuals unique needs are being met to ensure compliance can be the difference between outpatient therapy with an increased quality of life versus a life of pain and suffering (Khan et al. , 2015, p. 139). These acts can provide excellent bonding between patient, provider and nurses while simultaneously providing satisfaction to the patient and improving patient outcomes (Jha et al. , 2017, p. 35). Jha et al. (2017) discusses that experiences are highly personal and vary per individual but should happen as it builds the impression of being cared for.

Application of the Theory of Practice

This theory was applied to African Americans diagnosed with multiple sclerosis (Holland et al. , 2011). This population is especially vulnerable because disease progression is higher in African Americans (Khan et al. , 2015, p. 133). Additionally, African Americans are found to be more likely at the lowest income and education levels and less likely to have private insurance (Khan et al. , 2015, p. 137). Furthermore, a study conducted by Newland, Riley, Foerster, and Thomas (2015) discusses that participants in a study showed some evidence that nurses caring for African Americans with multiple sclerosis need to understand how symptoms manifest in this racial group. The application of the Client Experience Model can prove beneficial during the initial consultations with this patient population.

Case Study

Mr. Tyrone Billings is a 38-year-old African American single male. He has two adolescent children who live with him and works full-time as a delivery driver. He is a one income household, as he does not have the support of his children’s mother. Tyrone stays active in the community at events with his children and attends church weekly. He was diagnosed at the age of 32 with multiple sclerosis after he went to the emergency room with sudden onset of blurred vision and loss of bladder control. After several expensive tests and in-house consults, he was introduced to a neurologist who recommended he have a lumbar puncture to confirm what he was suspecting. Neurologists in his area are particularly scarce, but this particular neurologist is board-certified and a partner in care with the National Multiple Sclerosis Society. Tyrone was prescribed a steroid to get through the current exacerbation period, the neurologist has the in-house nurse schedule the lumbar puncture and a follow up in his outpatient practice about 1 month later, due to the lengthy time it takes to get the results back from the lab. In the meantime, the neurologist reviews Tyrone’s chart notes to review his demographics.

About 1 month later, the neurologist sees on his daily schedule that Tyrone is due to come see him for a follow-up regarding his lumbar puncture results. As suspected, Tyrone’s labs come back positive for oligoclonal bands (NMSS, 2017). However, unexpectedly Tyrone does not show up for his appointment. The neurologist has his nurse call him to make sure he is okay. He does not answer the phone, so she leaves a message. A few days later the call is left unreturned, so she calls again. About one month goes by and there is no word from Tyrone despite several attempts to reach him by phone and by mail. Then, one day Tyrone calls the office while the provider is out of the office. The nurse returns his call to find him complaining of lower limb pain, spasticity, blurred vision and bladder incontinence.

An appointment is made with the nurse practitioner expeditiously. Before arrival the nurse practitioner concludes that for application of the Client Experience Model, assessment of security, communication needs, level of interaction and his expectations for the visit need to be addressed (Holland et al. , 2011). Upon arrival assessment of security includes financial, emotional or employment support (Holland et al. , 2011) ensues. Tyrone has a full-time job as a delivery driver which provides benefits. He has support from his children and church community. Next, assessment of communication includes access to healthcare information and educational level (Holland et at. , 2011). Tyrone has a high-school diploma but does not have the financial means or the time to acquire higher levels of education. He does have a cell phone but does not answer it often due to his job as a delivery driver. He does not have a computer. He obtains his healthcare information from utilizing urgent care or emergency rooms as he does not have a primary care provider. Next, the level of interaction which includes degree of social interaction, social support or isolation, disregarding of symptoms, and degree of trust (Holland et al. , 2011) that Tyrone displays.

Tyrone frequents activities with his children in the community often as well as participation in church activities. Nevertheless, due to the recent symptoms caused by his multiple sclerosis has caused him to miss work which has caused a damper in his social interactions and increased stress. He often dismisses his symptoms and has little trust in the healthcare system due to diversity issues and misconceptions from hearsay. Lastly, assessment of Tyrone’s expectation for the visit including disease knowledge, health perception and need for selfcare (Holland et al. , 2011). Tyrone is currently in a denial state with his diagnosis and does not think that treatment is necessary, he also is concerned about insurance coverage and cost of treatment. However, he also knows that he cannot continue to miss work. He says he came to the visit because he got a letter in the mail reminding him of the missed visit. He has mediocre expectations for the visit. As with all patients, after this assessment, an individual care plan is developed to address this patient’s unique needs.

Interventions to increase Tyrone’s client experience include ensuring a safe and caring environment to ensure effective communication (Holland et al. , 2011). Additionally, financial security can be provided by ensuring that sources of support are provided which can include patient assistance and charitable funding information. Communication should be provided at a knowledge level that is understood by Tyrone on disease symptoms, progression, exacerbations and disease management (Khan et al. , 2015, p. 140). Lastly, providing interventions for interactions include providing education regarding multiple sclerosis to the community such as support groups (Holland et al. , 2011). Tyrone’s expectations for the visit are mediocre, based on ideas that he has gathered from hearsay. Due to this, the practitioner will need to pay extra attention to make sur that Tyrone is involved in his plan of care to meet his individual needs (Holland et al. , 2011). Application of the Client Experience Model will help ensure a positive patient healthcare experience and increase positive outcomes (Holland et al. , 2011).

Conclusion

To conclude, the Client Experience Model is comprised of four concepts: security, communication, interaction and expectation which can be utilized as a framework for the delivery of nursing care to provide positive patient experience to improved patient outcomes (Holland et al. , 2011). Throughout this critique the internal criticism detailed how the theory shows the four key concepts fitting and working together (Peterson & Bredow, 2017). The external criticism presents how the theory correlates to nursing, patients and health (Peterson & Bredow, 2017). The case review explains how the theory can be applied to a real-world vulnerable population of patients, in this case African Americans diagnosed with multiple sclerosis. Lastly, additional research is necessary to test the theory in relevant healthcare settings and patient populations.