Nursing Mental Health and Community Concepts Textbook PDF
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Chippewa Valley Technical College
Kimberly Ernstmeyer, Dr. Elizabeth Christman
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This textbook is an open educational resource for prelicensure nursing students. It covers mental health and community health concepts, emphasizing stress management, coping strategies, and community resources. The text is based on a Wisconsin-based curriculum, and the NCLEX-RN Test Plan.
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Introduction This textbook is an open educational resource with CC-BY licensing developed specifically for prelicensure nursing students. The e-book and downloadable versions are free. Affordable print versions are published in collaboration with XanEdu and available on Amazon and in colleg...
Introduction This textbook is an open educational resource with CC-BY licensing developed specifically for prelicensure nursing students. The e-book and downloadable versions are free. Affordable print versions are published in collaboration with XanEdu and available on Amazon and in college bookstores. Content is based on the Wisconsin Technical College System (WTCS) statewide nursing curriculum for the Nursing Mental Health and Community 1 Concepts course (543-110), the NCLEX-RN Test Plan, and the American Psychiatric Nurses Association Education Council’s Crosswalk Toolkit: Defining and Using Psychiatric-Mental Health Nursing Skills in 2 Undergraduate Nursing Education. Mental health and community health concepts are discussed while emphasizing stress management techniques, healthy coping strategies, referrals to community resources, and other preventative interventions. Nursing care for individuals with specific mental health and substance use disorders is examined, and the nurse’s role in community health needs assessments and caring for vulnerable populations is introduced. The following YouTube video provides a quick overview of how to navigate the online version. One or more interactive elements has been excluded from this version of the text. You can view them online here: https://wtcs.pressbooks.pub/nursingmhcc/?p=4#oembed-1 1. NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm 2. American Psychiatric Nurses Association Education Council, Undergraduate Branch. (2016). Crosswalk toolkit: Defining and using psychiatric-mental health nursing skills in undergraduate nursing education. https://www.apna.org/resources/undergraduate-education-toolkit/ Introduction | 1 Preface The Open RN project is supported by a $2.5 million grant from the Department of Education to create five free, open-source nursing textbooks. However, this content does not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the federal government. More information about the Open RN grant can be found at cvtc.edu/OpenRN. The first three textbooks of the Open RN textbook series, Nursing Pharmacology, Nursing Skills, and Nursing Fundamentals, received a Best OER Award from OE Global in 2020 and 2021. Usage Survey and Feedback We would love to hear if you have integrated some or all of this resource into your course. Please use this short survey to report usage information that will be shared with the U.S. Department of Education. Please use this short survey to provide constructive feedback or report errors. Editors Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC Dr. Elizabeth Christman, DNP, RN, CNE Graphics Editor Nic Ashman, MLIS, Librarian, Chippewa Valley Technical College Developing Authors Developing authors remixed existing open educational resources and/or developed content based on evidence-based sources and experience in the mental health field: Dr. Elizabeth Christman, DNP, RN, CNE Dawn Barone, MSN, RN, Chippewa Valley Technical College Sue Dzubay, MSN, RN, CHSE, RN-BC, Chippewa Valley Technical College Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC, Chippewa Valley 2 | Preface Technical College Jeanne Green, EdS, MSN, RN, CNE, CHEP, RN-BC, Chippewa Valley Technical College Deb Johnson-Schuh, MSN, RN, CNE, Mid-State Technical College Rorey Pritchard, EdS, MEd, MSN, RN-BC, CNOR(E), CNE, Senior RN Clinical Educator, Allevant Solutions, LLC Dr. Miriam Sward, DNP, PMHNP, APNP, Psychiatric Mental Health Nurse Practitioner Alicia Tays, MS, LPC, Counselor Contributors Contributors assisted in creating this textbook: Jane Flesher, MST, Proofreader, Chippewa Valley Technical College Shronda Green, MSN, RN, Gateway Technical College Vince Mussehl, MLIS, Open RN Lead Librarian, Chippewa Valley Technical College Joshua Myers, Web Developer, Chippewa Valley Technical College Kelly Nelson, MSN, RN, Mid-State Technical College Amanda Olson-Komisar, CSW, Social Worker; Pupil Services Teacher Assistant, Pepin Area Schools Andrea Olson, MSN, RN, Trempealeau County Healthcare Center Meredith Pomietlo, BA, Retail Design and Marketing, University of Wisconsin – Stout Dominic Slauson, BA, Open RN Instructional Technologist Dr. Jamie Zwicky, EdD, MSN, RN, Moraine Park Technical College Advisory Committee The Open RN Advisory Committee consists of industry members and nursing deans who provide input for the Open RN textbooks and virtual reality scenarios: Jenny Bauer, MSN, RN, NPD-BC, Mayo Clinic Health System Northwest Wisconsin, Eau Claire, WI Preface | 3 Lisa Cannestra, Eastern Wisconsin Healthcare Alliance Travis Christman, MSN, RN, Chief Nursing Officer, HSHS Sacred Heart and St. Joseph’s Hospitals Sheri Johnson, UW Population Health Institute Dr. Vicki Hulback, DNP, RN, Dean of Nursing, Gateway Technical College Jenna Julson, MSN, RN, NPD-BC, Nursing Education Specialist, Mayo Clinic Health System Northwest Wisconsin, Eau Claire, WI Brian Krogh, MSN, RN, Associate Dean – Health Sciences, Northeast Wisconsin Technical College Hugh Leasum, MBA, MSN, RN, Nurse Manager Cardiology/ICU, Marshfield Clinic Health System, Eau Claire, WI Pam Maxwell, SSM Health Mari Kay-Nobozny, NW Wisconsin Workforce Development Board Dr. Amy Olson, DNP, RN, Nursing Education Specialist, Mayo Clinic Health System Northwest Wisconsin, Eau Claire, WI Gina Petrie, MSN, RN, Dean of Nursing, Chippewa Valley Technical College Rorey Pritchard, EdS, MEd, MSN, RN-BC, CNOR(E), CNE, Senior RN Clinical Educator, Allevant Solutions, LLC Kelly Shafaie, MSN, RN, Associate Dean of Nursing, Moraine Park Technical College Dr. Ernise Watson, PhD, RN, Associate Dean of Nursing, Madison Area Technical College Sherry Willems, HSHS St. Vincent Hospital Reviewers Dr. Caryn Aleo, PhD, RN, CCRN, CEN, CNE, CNEcl, Pasco-Hernando State College Dawn Barone, MSN, RN, Chippewa Valley Technical College Lisa Bechard, MSN, RN, Mid-State Technical College Shanleigh Bechard, MS, LPC, Beloit Area Community Health Center Ginger Becker, Nursing Student, Portland Community College Nancy Bonard, MSN, RN-BC, St. Joseph’s College of Maine Dr. Joan Buckley, PhD, RN, Nassau Community College Kathleen Capone, MS, RN, CNE, EdD, Utica College 4 | Preface Lorraine Chiappetta, MSN, RN, CNE, Emeritus Washtenaw Community College Travis Christman, MSN, RN, Hospital Sister’s Health System Maria Darris, MSN, RN, St. Louis Community College Tamara Davis, MSN, RN, Chippewa Valley Technical College Dr. Andrea Dobogai, DNP, RN, Moraine Park Technical College Dr. Judith Dornbach, DNP, MSN, RN, NEA-BC, Southwestern Oregon Community College Jessica Dwork, MSN-Ed, RN, Maricopa Community Colleges-Phoenix Collège Dr. Terri J. Farmer, PhD, PMHNP-BC, University of Arizona College of Nursing Dr. Rachael Farrell, EdD, MSN, CNE Howard Community College, Columbia, MD Dr. Vivienne Friday, EdD, MSN, RN, CNE, MSOL Goodwin University Jocelyn E. Goodwin, MSN, RN, Paradise Valley Community College Kerry L. Hamm, MSN, RN, Lakeland University Julia Harelstad, MSN, RN, Mayo Clinic Health System, Eau Claire WI Deborah Harmon, BSN, RN, AdventHealth Zephyrhills/Dade City Melissa Hauge, MSN, RN, Madison College Camille Hernandez, MSN, APRN-Rx, ACNP/FNP, Hawaii Community College – Palamanui Katherine Howard, MS, RN-BC, CNE, Middlesex College New Jersey Susan Jepsen, MSN, RN, CNE, Lansing Community College Eric Johnson, MSN, RN, Chippewa Valley Technical College Dr. Kathi L. Johnson, DNP, MS, RN-BC, CNE, Howard Community College Jenna Julson, MSN, RN, NPD-RN, Mayo Clinic Health System Dr. Andrew D. Kehl, DNP, MSN, MPH, APRN, RN, Vermont Technical College Kathryn Kieran, MSN, PMHNP-BC, MGH Institute of Health Professions Lindsay Kuhlman, BSN, RN, HSHS Sacred Heart Kathy L. Loppnow, MSN, RN, WTCS Health Science Education Director (retired) Dawn M. Lyon, MSN, RN, Saint Clair County Community College Dr. Erin Micale-Sexton, DNP, MSN-RN, CNL, Lansing Community College, Madonna University, Arizona College Sara K. Mitchell, MSN, RN, Fox Valley Technical College Preface | 5 Dr. Jamie Murphy, PhD, RN, SUNY Delhi Kelly Nelson, MSN, RN, Mid-State Technical College Tram Nguyen, Nursing Student, Portland Community College Dr. Tennille O’Connor, DNP, RN, CNE, College of Central Florida Andrea Olson, MSN, RN, Trempealeau County Health Care Center Amanda Olson-Komisar, CSW, Social Worker; Pupil Services Teacher Assistant, Pepin Area Schools Dr. Grace Paul, DNP, MPhil, RN, CNE, Glendale Community College Krista Polomis, MSN, RN, CNE, Nicolet College Mary A. Pomietlo, MSN, RN, CNE, University of Wisconsin – Eau Claire Cassandra Porter, MSN, RN, Lake Land College Rachel Potaczek, BSN, RN, Chippewa County Department of Public Health Rorey Pritchard, EdS, MSN, RN-BC, NPD, CNOR(E), CNE, Allevant Solutions, LLC Dr. Debbie Rickeard, DNP, MSN, BScN, BA, RN, CNE, CCRN, University of Windsor Dr. Argie Rivera, DNP, MAN, PMHNP-BC, Polara Health, Grand Canyon University, Cara Behavioral Health Kathleen S. Rizzo, MSN, RN, St Louis Community College at Forest Park Ann K. Rosemeyer, MSN, RN, Chippewa Valley Technical College Brenda Scheurer, MS, PMP, Eau Claire City-County Health Department Cynthia Schroder, MSN, RN, FNP, Yavapai College Katherine A. Sell, MSN, RN, IBCLC, CNE, University of Wisconsin – Eau Claire Alexis Smith, MScN, RN, Western University Justine Sparrgrove, MSN, RN, Southwest Wisconsin Technical College Morgan Stock, MSN-Ed, RN, CNE, University of Arizona Dr. Miriam A. Sward, DNP, PMHNP, APNP, Northlakes Community Clinic Maria E. Thomas, MSN, MS, RN, CNE, Yavapai College Jane Trainis, MS, PMHCNS-BC, CNE, Community College of Baltimore County Jennie E. Ver Steeg, MLIS, AHIP, Mercy College of Health Sciences Emily Vergenz, MSN, RN, Lakeshore Technical College Devon Rice Weaver, MSN, RN, Clatsop Community College Dr. Nancy Whitehead, PhD, APNP, RN, Milwaukee Area Technical College 6 | Preface Licensing/Terms of Use This textbook is licensed under a Creative Commons Attribution 4.0 International (CC-BY) license unless otherwise indicated, which means that you are free to: SHARE – copy and redistribute the material in any medium or format ADAPT – remix, transform, and build upon the material for any purpose, even commercially The licensor cannot revoke these freedoms as long as you follow the license terms. Attribution: You must give appropriate credit, provide a link to the license, and indicate if any changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. No Additional Restrictions: You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation. No Warranties Are Given: The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material. Attribution Some of the content for this textbook was adapted from the following open educational resources. For specific reference information about what was used and/or changed in this adaptation, please refer to the footnotes at the bottom of each page of the book. Nursing Fundamentals by Chippewa Valley Technical College is licensed Preface | 7 under CC BY 4.0 Nursing Management and Professional Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0 Nursing Pharmacology by Chippewa Valley Technical College is licensed under CC BY 4.0 mhGAP Intervention Guide – Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 Human Relations by LibreTexts is licensed under CC BY-NC-SA 4.0 Anatomy and Physiology by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/books/anatomy-and-physiology/pages/ 1-introduction Nursing Care at the End of Life by Lowey is licensed under CC BY-NC-SA 4.0 Doing What Matters in Times of Stress: An Illustrated Guide by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO StatPearls by Orenstein & Lewis is licensed under CC BY 4.0 Psychology 2e by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/books/psychology-2e/pages/1-introduction StatPearls by Jabbari & Rouster is licensed under CC BY 4.0 StatPearls by Sheffler, Reddy, and Pillarisetty is licensed under CC BY 4.0 StatPearls by Dhaliwal and Gupta is licensed under CC BY 4.0 StatPearls by Shin and Saadabadi is licensed under CC BY 4.0 StatPearls by Wilson and Tripp is licensed under CC BY 4.0 StatPearls by Chokhawala and Stevens is licensed under CC BY 4.0 StatPearls by Ahuja and Abdijadid is licensed under CC BY 4.0 StatPearls by Padda and Derian is licensed under CC BY 4.0 Foundations of Addiction Studies by Flori and Trytek is licensed under CC BY-NC-SA 4.0 StatPearls by Vasan and Kumar is licensed under CC BY 4.0 StatPearls by Kang, Galuska, & Ghassemzadeh is licensed under CC BY 4.0 Action Steps Using ACEs and Trauma-Informed Care: A Resilience Model by Laurie Leitch is licensed under CC BY 4.0 8 | Preface StatPearls by Kisling and Das is licensed under CC BY 4.0 Community Tool Box by Center for Community Health and Development at the University of Kansas is licensed under CC BY NC SA 3.0 Daily New Confirmed COVID-19 Deaths Per Million People by Our World in Data is licensed under CC BY 4.0 The Emerging Neurobiology of Bipolar Disorder by Harrison, Geddes, & Tunbridge is licensed under CC BY 4.0 StatPearls by Fisher, Hany, and Doerr is licensed under CC BY 4.0 StatPearls by Lewis and O’Day is licensed under CC BY 4.0 StatPearls by Vasan and Padhy is licensed under CC BY 4.0 The Scholarship of Writing in Nursing Education: 1st Canadian Edition by Lapum, St-Amant, Hughes, Tan, Bogdan, Dimaranan, Frantzke, and Savicevic is licensed under CC BY-SA 4.0 Suggested attribution statement: Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0 Preface | 9 Standards and Conceptual Approach The Open RN Nursing Mental Health and Community Concepts textbook is based on several external standards and uses a conceptual approach. External Standards American Nurses Association (ANA) The ANA establishes Standards for Professional Nursing Practice and the 123 Nursing Code of Ethics. , , https://www.nursingworld.org/ana/about-ana/standards/ American Psychiatric Nurses Association (APNA) The APNA advances the science and education of psychiatric-mental health nursing. APNA is committed to the practice of psychiatric-mental health nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems, and the care and 4 treatment of persons with mental health disorders. https://www.apna.org/ American Psychiatric Nurses Association Education Council, Undergraduate Branch 1. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 2. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for- nurses/ 3. American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Nursesbooks.org. 4. American Psychiatric Nurses Association. https://www.apna.org/ 10 | Standards and Conceptual Approach The APNA created a toolkit to help define and integrate psychiatric-mental 5 health nursing content into undergraduate nursing curricula. https://www.apna.org/resources/undergraduate-education-toolkit/ Substance Abuse and Mental Health Services Administration (SAMHSA) The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation and to improve the lives of individuals living with mental health and substance use disorders and their families. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities and draws advice from public members and professionals in the field of substance 6 abuse and mental health. https://www.samhsa.gov/ The National Council Licensure Examination for Registered Nurses: NCLEX- RN Test Plans The NCLEX-RN test plans are updated every three years to reflect fair, 7 comprehensive, current, and entry-level nursing competency. https://www.ncsbn.org/nclex.htm The National League of Nursing (NLN): Competencies for Graduates of Nursing Programs NLN competencies guide nursing curricula to position graduates in a 5. American Psychiatric Nurses Association Education Council, Undergraduate Branch. (2016). Crosswalk toolkit: Defining and using psychiatric-mental health nursing skills in undergraduate nursing education. https://www.apna.org/resources/undergraduate-education-toolkit/ 6. Substance Abuse and Mental Health Services Administration. (n.d.). Strategic plan FY2019-FY2023. https://www.samhsa.gov/sites/default/files/samhsa_strategic_plan_fy19-fy23_final-508.pdf 7. NCSBN. (n.d.). 2019 NCLEX-RN test plan. https://www.ncsbn.org/2019_RN_TestPlan-English.htm Standards and Conceptual Approach | 11 dynamic health care arena with practice that is informed by a body of 8 knowledge to help ensure the public receives safe, quality care. https://www.nln.org/education/nursing-education-competencies/ competencies-for-graduates-of-nursing-programs American Association of Colleges of Nursing (AACN): The Essentials: Competencies for Professional Nursing Education The AACN provides a framework for preparing individuals as members of the discipline of nursing, reflecting expectations across the trajectory of nursing education and applied experience. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/ Essentials-2021.pdf Quality and Safety Education for Nurses (QSEN) Institute: Prelicensure Competencies Quality and safety competencies include knowledge, skills, and attitudes to be developed in nursing prelicensure programs. QSEN competencies include patient-centered care, teamwork and collaboration, evidence-based practice, 9 quality improvement, safety, and informatics. https://qsen.org/competencies/ Wisconsin State Legislature, Administrative Code Chapter N6 The Wisconsin Administrative Code governs the Registered Nursing and 10 Practical Nursing professions in Wisconsin. 8. National League of Nursing. Competencies for graduates of nursing programs. https://www.nln.org/ education/nursing-education-competencies/competencies-for-graduates-of-nursing-programs 9. QSEN. (n.d.). About. https://qsen.org/about-qsen/ 10. Wisconsin State Legislature. (2018). Chapter 6: Standards of practice for registered nurses and licensed practical nurses. Board of Nursing. https://docs.legis.wisconsin.gov/statutes/statutes/441 12 | Standards and Conceptual Approach https://docs.legis.wisconsin.gov/code/admin_code/n/6 Healthy People 2030 Healthy People 2030 envisions a society in which all people can achieve their full potential for health and well-being across the life span. Healthy People provides objectives based on national data and includes social determinants 11 of health. https://health.gov/healthypeople Conceptual Approach The Open RN Nursing Mental Health and Community Concepts textbook incorporates the following concepts: Holism. Florence Nightingale taught nurses to focus on the principles of holism, including wellness and the interrelationship of human beings and their environment. This textbook encourages holistic nursing care by addressing the impact of social determinants of health (SDOH) on mental health. Evidence-Based Practice (EBP). Evidence-based practices are referenced by footnotes throughout the textbook. To promote the development of digital literacy, hyperlinks are provided to credible, free online resources that supplement content. The Open RN textbooks will be updated as new EBP is established and after the release of updated NCLEX Test Plans every three years. Clinical Judgment. Associated unfolding case studies are written to reflect the NCSBN Clinical Judgment Measurement Model used on the NCLEX-RN. Formative assessments encourage students to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, 12 and evaluate outcomes. 11. Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health 12. Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the national council of state boards of nursing Standards and Conceptual Approach | 13 Cultural Competency. Nurses have an ethical obligation to practice with cultural humility and provide culturally responsive care to the clients and 13 communities they serve based on the ANA Code of Ethics and the ANA 14 Scope and Standards of Practice. Safe, Quality, Patient-Centered Care. Content reflects the priorities of safe, quality, patient-centered care. Clear and Inclusive Language. Clear language is used based on preferences expressed by prelicensure nursing students to enhance 15 understanding of complex concepts. “They” is used as a singular pronoun to refer to a person whose gender is unknown or irrelevant to the context of the usage, as endorsed by APA style. It is inclusive of all 16 people and helps writers avoid making assumptions about gender. Open-Source Images and Fair Use. Images are included to promote visual learning. Students and faculty can reuse open-source images by following the terms of their associated Creative Commons licensing. Some images are included based on Fair Use as described in the “Code of Best Practices for Fair Use and Fair Dealing in Open Education” presented at the OpenEd 2020 conference. Refer to the footnotes of images for source and licensing information throughout the text. Open Pedagogy. Students are encouraged to contribute to the Open RN project in meaningful ways by reviewing content for clarity and assisting 17 in the creation of open-source images. clinical judgment model into nursing educational frameworks. Journal of Nursing Education. 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03 13. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for- nurses/ 14. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 15. Verkuyl, M., Lapum, J., St-Amant, O., Bregstein, J., & Hughes, M. (2020). Healthcare students’ use of an e- textbook open educational resource on vital sign measurement: A qualitative study. Open Learning: The Journal of Open, Distance and e-Learning. https://doi.org/10.1080/02680513.2020.1835623 16. American Psychological Association. (2021). Singular "They." https://apastyle.apa.org/style-grammar- guidelines/grammar/singular-they 17. The Open Pedagogy Notebook by Steel Wagstaff is licensed under CC BY 4.0 14 | Standards and Conceptual Approach Supplementary Material Provided Several supplementary resources are provided with this textbook. Supplementary, free videos promote student understanding of concepts and procedures. Online, interactive, and written learning activities provide formative feedback. Critical thinking questions encourage the development of clinical judgment as students apply content to realistic patient scenarios. Free downloadable textbook versions are available for offline use. Affordable soft cover print versions are published by XanEdu and available on Amazon and in college bookstores based on the finding that over 65% 18 of students prefer a print version of their textbooks. 18. Verkuyl, M., Lapum, J., St-Amant, O., Bregstein, J., & Hughes, M. (2020). Healthcare students’ use of an e- textbook open educational resource on vital sign measurement: A qualitative study. Open Learning: The Journal of Open, Distance and e-Learning. https://doi.org/10.1080/02680513.2020.1835623 Standards and Conceptual Approach | 15 16 | Standards and Conceptual Approach