BEHAVIOR CHANGE COVER SHEET(150 POINTS)
Due July 8, 2008 10:00 PM

My behavioral change was the removeal of Red Bull. I did do so then I completely removed myself from caffinie all together! I would liek to see the research of withdrawl, addiction, and relaspe. I will add in my own journal to the essay as well. thank you
NAME:_________________________________ Date________________

Behavior Change Assignment: Identify an activity or a substance that you use on a regular or daily basis, preferably something that helps you cope with life. You will be asked to discontinue use and then refrain from this activity or substance for two weeks of June 26 July 20th. During this period of time, journal your experiences and then prepare a written paper of your adventure. (You do NOT need to turn in the journal. The journal is meant to simply be a tool for you to better write your paper).

Your papers should include information and your experience as related to:
2) Stages of change,
2) Symptoms of Post Acute Withdrawal,
3) Relapse Prevention Strategies,
4) Incidences of relapse and how you tried to intervene,
5) Your thoughts/feelings about giving something up,
6) What you learned and how it applies to the overall concept of addiction.
7) Did you have symptoms of addiction?
8) Was your behavior change easy or difficult and why?
9) What did it teach you about people who have to give up chemicals?
10) Did it change your view of addiction and willpower?

In order to receive all your points you must cover all 10 objectives listed above!!

(1) Have you completed the learning objective as indicated above? Yes / No

(2) Is your paper 5 typed pages, double-spaced, 12-font? Yes / No

(3) Have you checked spelling, punctuation, and grammar? Yes / No

(4) Are you turning your paper in on time? Yes / No

(5) Review your paper and indicate the grade you believe your work reflects based on the degree to which you completed the assignment with resourcefulness, effort, & creativity.



POINTS AND RATIONALE: _______________________________________________




INSTRUCTOR COMMENTS_______________________________________________




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It is in the field of psychology, about a behavior I would like to change. I chose about i should start to go to the gym and exercise. Write about the process and how I lost two pounds each week for going to the gym 45 ,minutes everyday.you can imagine yourself doing that and write it on my behalf. please find the steps of the paper below,


Here are the steps:
1. Select a behavior that you would like to change, one that you?d like to increase or
decrease or modify in some way (Examples: eating junk or high-fat foods, chewing gum, smoking, getting angry, studying, exercising, spending money, worrying, etc).
2. Define your specific goal, consider the benefits and barriers, and choose a behavior modification plan.
3. Design a method of tracking your daily progress. This could be a tallying form, a data table, etc. This device should allow you to record the frequency and/or duration of your behavior on a daily basis. (if your behavior is something that is done several times a day, you might want to create a data tracking device that you can carry along with you).
4. Record your behavior, following the procedures you have developed, throughout the term. Write a 4-5 page report that includes the following points:

Goal-Setting and Monitoring
? What behavior did you try to change? What was your precise goal? (for example, to increase/decrease the frequency and or duration)
? What were the benefits that you perceived to changing your behavior? In other words, why did you want to change your behavior?
? How did you keep track of (record) your daily progress? Very briefly describe the type of tallying sheet (or recording device) that you used.


Motivation
? Where do you think your goal would fall on Maslow?s hierarchy of motives and why? What types of counter-motives made it difficult for you to accomplish your goal (example; hunger, pleasure, etc.) Where would these counter-motives fall on Maslow?s hierarchy?
? Did you feel more intrinsically or extrinsically motivated to change this behavior and why?
? Did your goal involve the behavioral activation system (BAS) or the behavioral inhibition system (BIS) and why? Was your goal more approach- or avoidance-oriented and why?
? Do you think that your motives contributed to your outcome? How and why?
Learning

Emotions, Barriers, and Social Support
? What types of emotions did you feel when trying to change your behavior? How did you feel along the way and how were these emotions related to the amount of effort you invested in trying to change your behavior?
? What were some of the barriers that you encountered while trying the change the behavior? Did you expect these barriers when you started or did they surprise you along the way? What did you do to overcome these barriers?
? Did you enlist the help of family and friends in trying to change your behavior? Was this helpful or harmful?

Conclusion
? Did you reach your goal or not? How do you feel about the outcome? What could you do differently in the future to be even more successful at changing your behavior? If you do not reach your goal, that is okay. The purpose of this assignment is to make you aware of the psychological principles involved in behavioral changes and to get you to think critically about the course material and readings related to your behavioral change attempts.
? How did you go about trying to change your behavior? Did you use any of the behavior learning strategies that we discussed in class such as classical or operant conditioning?
? How did you use these strategies? Did they work or not?

This essay paper should reflect the Transtheoretical Model of Prochaska ( Change Theory)

a. Write an overview of change theory ( Transtheoretical Model of Prochaska, )
http://www.youtube.com/watch?v=8XUaq2iqzA0 (one of the sources)
b.Then write about clients individual situational factors you may consider prior to developing the behavioral change plan of how one can quit smoking (assume that client is 30 y.o female nursing student, who have been smoking for at least 10 years 5-6 cigarets a day)
c.Based on Transtheoretical Model of Prochaska , write step-by-step plan for this client on how to quit smoking.
d. Evaluate the results ( assuming that client followed the created plan)



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This course is wellness and this paper is Behavioral change contract report (3 pages)
I am considering (improve my cardio reps & Gain some muscle) as long term goals
Please make up a paper matching the guideline. If you have other suggestions about the goal assessment please let me know.

Here's the guideline:

Behavioral change
Final Report
I. introduction (long term goals, assessments)
II. Results of wellness assessment
III. Seven steps for successful change (Robert Allen)
Steps :
1. Understand the culture
2. Get the facts and separate fact from fiction (5 research articles)
3. Set reasonable objectives and action plan (obstacles and benefits)
4. Find or develop your support group
5. Keep track and tune in
6. Reward yourself and have fun
7. Research out to others
IV. Conclusion (quantitative and qualitative)
VI. Self Evaluation (30 points)

Keep a journal about your health behavioral change experience. The journal is an opportunity for you to express and process your personal reactions to this experience. Your entry should include four componets: An OBJECTIVE measure of your progress your stage of readiness according to the Transtheoretical and the ratio of pros to cons for your behavior. Please respond to this question: How do you anticipate your intervention will work?
1single-spaces page.

Quit smoking is what I want to change.
Please read my proposal before you start writing.





Research Proposal to Quit Smoking over the Next Eight Weeks

Smoking is one of Americas largest silent killers behind heart problems. The American people, once glamorized through the thick wall of smoke, are now realizing how serious the complications related to smoking actually are. The 2005 National Health Survey (NHIS, 2005), reported staggering numbers of Americans, 29.5 million males and 20.7 million females, were smoking and thus considered themselves as smokers. Having been a smoker for a decade now, I see the need to drop the habit in hopes of preventing serious disease and pain in my future years. I no longer have much of a decision in the act of quitting, its either I quit, or I give myself a death sentence. With that in mind, I am proposing to change my dangerous habit, and over the course of the next eight weeks completely eliminate smoking from my daily life.
Quitting smoking is much more difficult than most might imagine. Of the thousands of people who try to quit each year, only a few remain successful in their fight against nicotine. Most smokers quit for a period of time, only to regain their habit after a brief separation. In fact, it is the first few months which prove the most critical, Most patients relapse within the first six to 12 months of a smoking cessation attempt, (Mallin, 2002). Through other peoples failures, physicians have also discovered that quitting without any plan of action leads to an even higher percentage rate of ex-smokers succumbing to their old habits. An overwhelming 95% of smokers who quit without implementing any sort of program to assist in their endeavors, actually stay smoke free, (Reynolds, 2002). These drastic figures attest to the importance of formulating a plan unique to ones position as the most efficient way to quit smoking. More important to creating that plan, is the eventual follow through.
The adverse health affects are a justifiable reason to quit smoking. An astounding 90% of lung cancer is directly associated with long term smoking, (Centers for Disease Control and Prevention, 2008). Other adverse health risks include cardiovascular disease, and other respiratory diseases. These haunting reminders of the adverse affects of smoking only increase as the user smokes for a longer period of time. Both lung and heart disease rates for smokers explode as smokers continue smoking throughout their lives. The risks just get higher as the years continue to pile up, If you smoke for a lifetime, there is a 50% chance that your eventual death will be smoking-related - half of all these deaths will be in middle age, (BBC News 2003).
I am now almost thirty years of age, and have been smoking for at least ten years. As I have continued to smoke over the years, I have added to my risk of being forced to endure the harmful affects related to cigarettes. Rather than continuing such a harmful habit, I have decided to change my behavior and lifestyle and so erase nicotine and tobacco from my life. I now realizing through assessing my need for change, (DiClemente, 1991) that I dont have much of a choice if I want to prevent myself becoming one of those terrifying statistics. I have found myself in the passing through the contemplation stage and now in the preparation phase of my desired change, (Mallin 2003). I no longer believe that the affects of smoking are overrated or that they will never extend to disrupt my life, which is associated with the precontemplation stage.

Research has shown than quitting without treatment usually has grim hopes of success. Quitting cold turkey will most likely just delay my cigarette smoking rather than abolishing it. Therefore, I need a strategic plan of action as a way to fully ensure my success in the attempt to kick the butt. Consulting with a physician alone can improve the chance to remain smoke free, (Mallin, 2002). Therefore I have decided to follow researchers advice and blend a combination of life style choices and proper medical care as a road to success.
Robert Mallin, in his 2002 work Smoking Cessation: Integration of Behavioral and Drug Therapies, expresses the importance of implementing a blended strategy. This change needs to be a conscious choice, but heavily backed up by medical help. Therefore, I will plan to implement a strategy in several steps with aid from a physician if the need for such help arises. Without either of the two, my endeavor would most likely end in failure.
The first crucial step is thorough preparation for the drastic life style change which is about to take place. The first step is planning a pre-determined date in the near future to quit, which I have chosen to be March 1, 2008. Now, I must attend to other preparation necessities, such as involving family and friends. Several studies have shown that with the support of loved ones, smokers are less inclined to cheat in their attempt to quit. Therefore, I have begun telling friends and family members that I plan to quit, and that I will be my attempt on March 1st of this year. Now that the idea has begun to saturate in my mind, I have to begin the task of removing objects which either remind me or encourage me to smoke. I have to rid my environment slowly of lighters, ash trays, matches, empty cigarette cartons, and any cellophane. All these items, even if encountered randomly might trigger an urge to smoke; therefore I need to try and remove as much as possible to lower the risk of encountering an object which might trigger a craving. Along with removing objects, I must slowly recognize what images, sounds, or smells remind me of smoking. Identifying these occurrences now may help prevent the risk of temptation and relapse when encountered later.
The next stage is moving out of preparation and entering into action. On February 29, 2008 I will smoke my last cigarette. It is truly my luck that this year is a leap year, and I get one extra day of February to enjoy smoking before my quit date. During this stage, support is key so I will rely on my family and friends to keep me going. If my cravings get too bad, I plan to visit support groups for further encouragement, and will resort to nicotine replacement drugs as prescribed through a physician if absolutely necessary. Hopefully, this will not be the case and I will be able to quit without the use of further medication. During this time period, I also plan to switch my smoking with a healthier substitute, (Mallin, 2003). I am planning on running in the mornings when I know I will crave the most as a deterrent for a cigarette. Running will give me an adrenaline rush and prevent laziness after not waking up with the first cigarette of the day, which normally wakes me up.
Using preparation, support, and replacement, I believe that I will be successful in my attempt to quit smoking. This research paper will document my endeavor through the preparation stage into the action stage. By adhering strictly to my plan and relying on support from outside in my network of family and friends, I hope to ensure myself success.

This is a literature review for a dissertation. It should include a historical perspective of autism as well as address current current programs and treatment. There should be no more then two/three direct quotes per page.

Below is the perspectus.

Historically, documented disruptive behaviors displayed by residential students diagnosed with Autism and other developmental disabilities include noncompliance, physical and verbal aggression, inappropriate verbalizations not characterized as aggression, poor social skills, as well as deficits in attention to task (Green, 1996; Luce, 1981; Maurice, 1996). These behaviors require residential treatment and preclude participation in community based activities, (Luce, 2004). Educators generally agree that deficits in academic skills result from a decrease in on-task behaviors because of disruptive off-task behaviors (Skinn, Ramsey, Walker, Stieber, & O?Neill, 1987).

Frequently used techniques to decrease these disruptive behaviors include reinforces such as verbal praise, token economies, time out, and self-contained classrooms. Autism affects one in 1,000 individuals in the United States (World Health Organization, 2001) and warrants further investigation to examine the use of daily activities to decrease these inappropriate behaviors. This quantitative dissertation study will examine the effectiveness of an everyday activities-based protocol (Holm, Santangelo, Fromuth, Brown & Walter, 2000) for managing challenging and disruptive behaviors of 13-23 year old residential students (male and female) with Autism and other developmental disabilities to reduce two out of three inappropriate behaviors as identified by residential staff.

Purpose
The purpose of this quantitative dissertation study is to test the effectiveness of an everyday activities-based protocol (Holm, Santangelo, Fromuth, Brown & Walter, 2000) for managing challenging and disruptive behaviors of 13-23 year old residential students (male and female) (dependent variable) with Autism and other developmental disabilities who live at Melmark Homes, Inc., of southeastern Pennsylvania, and attend school or adult day programs. Applied behavior analysis and a focus on everyday occupations (activities) (independent variable) will be combined during the intervention phase. Reinforcement will be for subtask completion and duration of participation, not for absence of target maladaptive or disruptive behaviors. A single-subject, multiple-baseline, across-subjects design with 50 subjects will be used to evaluate change in behaviors under alternating conditions. Data will be analyzed using graphical, semi-statistical, and statistical techniques, including celeration lines, slopes, 2 standard deviation bands, and the C-statistic.

Research Question
Will participation in Activities of Daily Living (ADL?s) reduce or extinguish inappropriate behaviors displayed by individuals with Autism or other developmental disorders who currently reside in residential facilities?

Significance
Clinically significant behavioral changes in this area have the potential to lead to the expansion of residential programs, implementation of new programs, and the identification of, and access to, additional community funding resources for curriculum improvement and development; in addition to the development of more comprehensive community-based programs. The proposed dissertation study replicates the results found by Holm et al. (2000), which successfully combined behavioral and occupational therapy interventions with dually diagnosed subjects in Community Living Arrangements (CLA)/School environments. Should a study such as this be successful, a full protocol can be developed for residential staff so that they too can be taught how to break down everyday tasks into manageable units so that residents with Autism are able to increase their participation in everyday activities at school and in their communities-be they residential or non-residential (home-based) living communities (WHO, 2001).

When evaluating community based programming for individuals with Autism and other developmental disabilities, community, school, and healthcare leaders, must utilize data that is not only clinically significant but data that will drive cost effective programming to ensure the appropriate utilization of private and governmental financial resources (McConnell, 2004). The study will have significance to the consumer community because of the intervention's potential to enable greater participation of individuals with Autism in lived in environments. The study will have significance to the care-giving community because it promotes a novel approach to care-giving, using an intervention that combines a behavioral approach with enabling of everyday activities. To community healthcare leaders, this reduces the financial resources needed for community based programming (WHO, 2001).

Here is additional information that may be incorporated, but should only serve to provide a basis.

Abstract
The purpose of this dissertation study is to test the effectiveness of an everyday activities-based protocol (Holm, Santangelo, Fromuth, Brown & Walter, 2000) for managing challenging and disruptive behaviors of 13-23 year old residential students (male and female) with Autism who live at Melmark Homes, Inc., of southeastern Pennsylvania, and attend school or adult day programs. Applied behavior analysis and a focus on everyday occupations (activities) will be combined during the intervention phase.

Reinforcement will be for subtask completion and duration of participation, NOT for absence of target maladaptive or disruptive behaviors. Behavior analysts, however, will document the frequency/duration of the target behaviors during each condition. Interventions will occur daily, Monday through Friday. A single-subject, multiple-baseline, across-subjects design with 9 subjects will be used to evaluate change in behaviors under alternating conditions. Data will be analyzed using graphical, semi-statistical, and statistical techniques, including celeration lines, slopes, 2 standard deviation bands, and the C-statistic. The projected outcome of the study is the validation of an activities-based protocol to enable greater participation of individuals with Autism in everyday activities (WHO, 2001), and in their communities, be they residential or non-residential (home-based) communities.

Background
The World Health Organization?s International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001, see Figure 1) provides a model for describing and studying functioning (positive state) and disability (negative state) of individuals and populations, including residential students diagnosed with Autism and other conditions. ICF performance qualifiers differentiate between performance in the actual or ?lived in? home environment, and the student?s ability to execute tasks or actions in a standard or uniform environment such as the classroom (WHO, 2001). Thus, the ICF provides a guide for examining and documenting a student?s functioning and disability and the impact of the environment and participation on the functional outcomes of everyday activities-based behavioral interventions.

Because Autism creates a disabling impact on functioning and full participation, in February 2002 the National Institutes of Health (NIH) and the Department of Health and Human Services prepared a report to Congress addressing Autism and Pervasive Developmental Disorders (PDD); the report authorized both money and research to ?conduct activities relevant to Autism and Pervasive Developmental Disorders". It indicates, "Families coping with this devastating illness are searching for answers about these causes, diagnoses, prevention, and treatment? (NIH, 2002; Strock, 2004).

Historically documented disruptive behaviors displayed by residential students diagnosed with Autism and other developmental disabilities include noncompliance, physical and verbal aggression, inappropriate verbalizations not characterized as aggression, poor social skills, as well as deficits in attention to task. Educators generally agree that deficits in academic skills result from a decrease in on-task behaviors because of disruptive off-task behaviors (Skinn, Ramsey, Walker, Stieber, & O?Neill, 1987). These behaviors continue to be seen today in educational and residential programs. Frequently used techniques to decrease these disruptive behaviors include reinforcers such as verbal praise, token economies, time out, and self-contained classrooms (Luce, 2004).

In order to increase the frequency of an individual?s appropriate behavior, it is most often recommended that such behaviors be praised or otherwise rewarded when they occur (e.g., with a natural consequence). Attempts to increase the frequency of positive behaviors are based on the belief that, by doing so, behaviors that are more appropriate will gradually replace less desirable (e.g., disruptive) behaviors. The literature suggests that teacher or caregiver consideration should provide attention to the individual when he/she is engaged in positive rather than negative behaviors (Green, 1996). Token economy systems involve awarding tokens, stickers, points, or other items to individuals who demonstrate targeted behaviors. Students usually exchange tokens for rewards, which may consist of preferred food or other activities. Token economies can be effective for those individuals who are resistant to other types of behavior management techniques. The benefits to using this system are ease of administration, immediate reinforcement (tokens) while teaching delayed gratification (holding tokens until trade in time), satiation for the student due to the availability of a variety of back-up reinforcers, as well as lack of competition between students as they compete only against themselves (Society of Treatment for Children, 1998).

Over the last several years, Applied Behavioral Analysis (ABA) has become the most preferred and utilized behavioral intervention. ABA, in brief, "involves a breakdown of all skills into small, discrete tasks, taught in a highly structured and hierarchical manner." This is accompanied by differential reinforcement, and data are recorded systematically and regularly so that interventions can be adjusted as needed based on the student's progress or lack thereof. ABA is designed to help those with Autism learn how to learn (Luce & Christian, 1981; Maurice, 1996, p. 8).

Consistent with the ICF (WHO, 2001) view of the impact of the environment on functioning and disability, another perspective is that ?the origin of challenging, disruptive behaviors is not within the person with the disability, but rather the interaction of the person, environment, and task? (Holm, Santangelo, Fromuth, Brown & Walter 2000, p. 362). In fact, one profession, namely occupational therapy, ?was founded on the belief that engaging in occupation (everyday activities) brought about mental and physical health? (Trombly, 1995, p. 970). One of the tenets of occupational therapy related to disruptive behaviors displayed by individuals diagnosed with Autism and other developmental disabilities is that engagement in everyday functional activities has the potential to decrease incidents of inappropriate disruptive behaviors. However, to date there is limited documented research supporting such a statement. In 2000, Holm, Santangelo, et al., conducted a seminal study that used everyday activities- (or occupation-) based interventions with two dually diagnosed students who attended school and lived in a CLA. The everyday activities-based intervention focused on enabling the students? participation in everyday AM and PM activities such as bed making, selecting clothes for school, helping prepare the food for dinner, setting the table, and selecting the games and crafts for after-dinner activities. Overall, the disruptive and challenging behaviors of the two students were significantly reduced when they participated in the everyday activities based tasks, even though the focus of the intervention was NOT on their behavior as in the school environment, but rather on their active participation in everyday activities.

The references below are provided to help provide a focus and can be used as references but should not be counted as part of the 50-75. 80% of the references used should be within the last 5 years.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, IV-TR. (4th ed.). Washington, DC.
Bianchi, S. M. & Robinson, J. P. (1997). What did you do today? Chiltern Jews of time, family composition, and the acquisition of social capital. Journal of Marriage and Family, 59, 332- 344.
Christiansen, C. H. (1999). Defining lives: occupation as identity: and as they own competence, coherence, and the creation of meaning. American Journal of Occupational Therapy, 53, 547-558.
Christiansen, C. H. (2000). Identity, personal projects and happiness: self construction in every day, action. Journal of Occupational Science, 7(3), 98-107.
Christiansen, C. H. (2004). Occupation and identity: becoming who we are through what we do. In C. H. Christiansen, and E. A. Townsend (Eds.) Introduction to occupation: The art and science of living. Upper Saddle River, New Jersey: Prentice hall.
Franklin, R., Allison, D., & Gorman, B. (1996). Design and analysis of single-case research.
Mahwah, NJ: Erlbaum.
Green, G. (1996). Early Behavioral Intervention for Autism: What does research tell us? In C. Maurice, G. Green, & S.C. Luce (Eds.), Behavioral Intervention for Young Children with Autism. Eds. (29-44). Austin: Pro-Ed.
Hasselkus, B. R. (2002). The Meaning of Everyday Occupation. Thorofare, New Jersey: Slack.
Henry, A. D., & Coster, W. J. (1996). Competency beliefs and occupational role behavior among adolescents: Explication of the personal causation construct. American Journal of
Occupational Therapy, 51(4), 267-266.
Hofferth, S. & Sandberg, J. (2001). Howell American children spend their time. Journal of Marriage and Family, 63, 295-308.
Holm, M. B., Santangelo, M.A., Fromuth, D., Brown, S. O., & Walter, H. (2000). Effectiveness of Everyday Occupations for Changing Client Behaviors in a Community Living Arrangement. American Journal of Occupational Therapy, 54(4) 361-371.
Kielhofner, G. (2000). Model of Human Occupation: Theory and Application. (3rd ed.) Baltimore: Williams and Wilkins.
Larson, E. A. & Verma, S (1999). Count children and adolescents spend time across the world: work, play and the developmental opportunities. Psychological Bulletin, 125, 701-736.
Larson, E. A. (2004). Chiltern?s work: the less considered childhood occupation. American Journal of Occupational Therapy,58(4), 369-379.
Luce, S., & Christian, W. P. (1981). How to reduce autistic and severely maladaptive
behaviors. Austin, TX: PRO-ED.
Luce, S., (2004). Personal Communication. Vice President of Clinical Programming, Training
and Research, Melmark, Inc. Berwyn, PA.
Maurice, C. (1996). Early Behavioral Intervention for Autism: What does research tell us? In C. Maurice, G. Green, & S.C. Luce (Eds.), Behavioral Intervention for Young Children with Autism. Eds. (29-44). Austin: Pro-Ed.
National Institutes of Health as and the Department of Health and Human Services. (2002). Report to Congress on Autism. Retrieved May 8, 2004 http://www.nimh.nih.gov/publicat/autism.cfm.
Nelson, D. L. (1998). Occupation: form the performance. American Journal of Occupational Therapy, 42, 633-641.

Ottenbacher, K. J. (1986). Evaluating clinical change: Strategies for occupational and physical
therapists. Baltimore: Williams & Wilkins.
Skinn, M. R., Ramsey, E., Walker, H. M., Stieber, S., & O?Neill R.E. (1987). Antisocial behavior in
school settings: Initial differences in at risk and normal populations. Journal of Special
Education, 21, 69-84.
Society for Treatment of Autism. (1998) General Behavioural Educational Suggestions for Autistic Children. Retrieved May 8, 2004 from http://www.autism.ca/educsugg.htm
Spitzer, S. L. (2003). Using participated observation to study the meaning of occupations of young children with autism and other developmental disabilities. American Journal of Occupational Therapy, 57(1), 66-76.
Strock, M. (2004). Autism Spectrum Disorders (Pervasive Developmental Disorders). NIH Publication No. NIH-04-5511, National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD, 40 pp. Retrieved May 8, 2004 from http://www.nimh.nih.gov/publicat/autism.cfm
Trombly, C. (1995). Occupation: Purposefulness and the meaningfulness as therapeutic mechanisms. The American Journal of Occupational Therapy, 49, 960-972
Wicks, A. A. (2001). Comment. Occupational potential: a topic worthy of exploration. Journal of Occupational Science, 8, 32-35.
World Health Organization (September, 2001). International classification of functioning, disability, and health: ICG. Geneva: WHO. Retrieved on May 10, 2004 from http://www3.who.int/icf/icftemplate.cfm

Thanks

This paper has been written but was rejected by the professor and needs to be re-written. Below are the comments and the entire paper but I can upload the complete paper as a word document if necessary. It needs to be re-written to the professors specifications and comments:

"I am impressed with your engagement in a more difficult and demanding topic area. But I am disappointed at your stringing together vast quotes. As a doctoral student, there is need to develop a stronger presentation of research information that is drawn upon your selection and integration of ideasnot sources.
I am requesting that rewrite and redevelop this paper based upon a more thoughtful engagement and presentation that both draws upon your sources ??" but more so demonstrates your ability to synthesis and differentiate ideas from sources. Further, I dont want to see full paragraph citations from sources.
This presentation is not appropriate for doctoral student work So, I want you to model expected doctoral writing in a scholarly paper
I recognize that you may have had limited time to write the paperbut I want you to demonstrate your doctoral understandings of developing and presenting a research focused paper.

Criteria:
1) the use of current and varied scholarly resources representing adult development and learning - 10 points
You have drawn upon a variety of current and scholarly resources focused upon both the neuroscience of the brain as well as key elements that influence memory and learning in adults.

2) coherent organization of material - 5 points
The first few pages of your paper for a bit meandering. I think you started two far beyond the focus of your paper. I suspect you may have wanted to focus on the nature of adult development and its relationship to neuroscience. However, the initial introduction isnt that effective in establishing that connection.
The section on the biology of the brain and nervous system is amazingly complex and well-presented.
The section on Implications and development of neuroscience and adult Learning is also very good. However, you draw upon full paragraph quotes ??" in an excessive fashion. It is evident that you dont know how to paraphrase and only draw on select sentence quotes. It is also evident that you need to develop your own thinking in relation to the ideas presented across a number of sources. I realize that this topic area is highly complex and technical. However, as a doctoral student, you need to develop strong skills of use of sources for presentation of key ideas in a synthesis fashion. You seem to have developed a line of presentation that is coherent ??" but it appears to rely on a few key sources with significantly long quotes or paraphrasing.

3) logical and persuasive argument, - 10 points
You have developed a logical presentation of key aspects of this topic.

4) evidence of relationship to adult development/learning/education ??" 10 points
You have connected the discussion of neuroscience to concepts of adult learning ??" but have not attempted to integrate sources together ??" but rather done a rather pedestrian stringing of sources together. I would expect this presentation from a masters student, but not a doctoral student.

5) well-written in terms of style, format, - 5 points
Lack of understanding the use of APA style of reference note the comments below as primary examples.
For a citation with quote the quote follows the last word -- (author, year, page) follows. Note page 2 ??" Ulijasek modified quote mark, as well as a page number. Again, similar issue with the quote with Kastenbaum. P. 13 & p. 14 ??" quote on Hebb, same issue
p. 14-quotes ( two paragraph) from Demick & Andreoletti ??" Note APA any citation more than five lines is indented and should also have a page number. P. 16 ??" full paragraph cite from Guadagnoli ??" same issue. Same issue with the full paragraph ??" Smith quote. P. 17 ??" continuing full paragraphs as cites ???"

Below is the actual paper I submitted:

Introduction
One of the most noticeable aspects of humanity is the change in shape, size, form, and function from an underdeveloped fetus, to a full grown adult. Humans are a very successful species. Much of this success stems from the human design, which involves having a large body size, a brain that is disproportionately large relative to that body size, and an extended period of childhood (Ulijaszek, et al., 2000). The brain gives us advantages relative to other species, having the ability to think our way through problems, and the time to develop behaviors through learning and activities that will make us successful, social, problem-solving animals.
Human growth and development is very broad in nature. It covers many aspects of the human being such as structural, behavioral, physiological, humanistic, psychological, and cognitive among others. It usually provides a descriptive analysis of human development from fertilization until death, discussing each developmental stage from childhood to adulthood. Understanding human growth and development is intellectually and practically important for it can help in developing diagnostic tools as well as screening and treatment procedures for the health population.
There are many theorists who formulated growth and development models. Most theoretical models focus only on early stages of development. That is why people usually perceive the word development as child development. In an attempt to develop a concrete and viable model of development through the entire life course, some investigators attempted to extend the range of theories that focuses only on early stages of development. Disengagement theory was the first substantive and innovative theory to consider the middle and later adult years; 'mid-life' crisis emerged as an influential alternative a few years later (Kastenbaum, 1993).
Adult development, being considered by many theorists as part of their theoretical models, has become an interesting topic in the past few years. There are models that form the foundation for adult development as well as aging. One of the most important concepts developed is the life-span perspective model. It divides the human development into two phases: an early phase (childhood and adolescence) and a latter phase (young adulthood, middle age, and old age). This perspective emphasizes that it takes a lifetime for the human development to complete. It gives us an understanding of the many influences we experience and points out that each stages of the human life are equally important. Adult development is a complex phenomenon and understanding how an adult develops requires a variety of perspectives. It may include behavioral, physiological, and cognitive approaches (Cavanaugh & Fields, 2006).
Cognition is the activity of knowing. It refers to the processes of through which knowledge is acquired and problems are solved. Cognitive development refers not just to the structural development of the brain but also to the development of one's knowledge as well. Piaget indicated that the highest cognitive stage of development for adult people is formal operations. There are researches that revealed limitations in adult performance that must be explained, it suggests that some adults progress beyond formal operations to more advanced forms of thought (Sigelman & Rider, 2009).
Increasing interests and concern regarding adult development and learning has emerged in the past few years since the adult stage of development has been considered by many theorists. This study focuses on the cognitive aspect of growth and development of the adult. Specifically, this research aims to provide an in-depth discussion about the brain and neuroscience and its relation to adult development and learning.
Review of Related Literature
The Human Brain and Neuroscience
The Nervous System
All organisms receive information, process that information received, and produce an appropriate response. For most living organisms, these functions are performed b two interconnected systems namely the nervous system and the endocrine system.
The nervous system is composed of large networks of nerve cells that perform three interconnecting functions. First, the nervous system allows organisms to receive information using their senses. It allows the individual to sense what is happening in their environment. Second, the nervous system processes the information received and compares it to other senses. Lastly, the nervous system allows the individual to respond, do things, and appropriately react to the perceived stimuli primarily by controlling muscles and glands. The three functions can be accomplished within a few milliseconds. The speed of this information transmission is achieved by electrical and chemical impulses within and between nerve cells (Harris, 2010).
The nervous system can be divided into two parts: the central and the peripheral nervous systems. The central nervous system consists of the brain and the spinal cord while the peripheral nervous system is outside the central nervous system and is composed of nerves and ganglia.
The peripheral nervous system has two subdivisions, namely the sensory division and the motor division. The sensory division conducts action potentials from sensory receptors to the central nervous system. Sensory neurons transmit action potentials from the periphery to the central nervous system. The motor division conducts action potentials from effector organs such as muscles and glands. Motor neurons transmit action potentials from the central nervous system toward the periphery (Seeley, et al., 2005).
Neurons and their Electrical Activity
The nervous system is composed of millions of nerve cells called neurons. Neurons are the parenchyma of the nervous system which performs every function of the said system from simple sensory functions to complex thinking and analysis. They receive stimuli and transmit action potentials to other neurons or to effector organs. The anatomy of a neuron is composed of four main parts namely the cell body, the dendrites, the axon, and the nerve fibers (Clark, 2005).
The cell body is the central region of the neuron. It varies in diameter and contains a single large nucleus. The nucleus of the neuron is the source of information for protein synthesis. It also contains most of the organelles of the neuron. Specifically, it contains large numbers of mitochondria because of its high metabolic function and also abundant rough endoplasmic reticulums which they call Nissl bodies (Seeley, et al., 2005).
The dendrites of a neuron are cytoplasmic extensions that reach out from the cell body like arms. They contain full array of cellular organelles, such as mitochondria, chromatophilic substance, and ribosomes. The most important feature of a dendrite is its electrical activity. They receive information from other neurons and transmit them toward the cell body. They produce electrical impulses called graded potentials. Graded potentials can have varying degrees of depolarization or hyperpolarization. They arise in the dendrites or in the cell body as a result of various stimuli and are important in initiating action potentials in neurons. As the graded potential passes through a cell body, it may initiate an action potential at the base of another cytoplasmic projection which is the axon (Clark, 2005).
An axon is a long cell process extending from the neuron cell body. There is only one axon in each neuron. It has a plasma membrane which is called the axolemma, and a cytoplasm which is called the axoplasm. Unlike dendrites, there are no chromatophilic substances found in axons. Axons may branch distally into axon terminals called telodendria. These end in sacs called synaptic end bulbs. Synaptic end bulbs are parts of synapses or neuroeffector junctions. Axons also play an important role in the electrical impulse activities of neurons. They carry action potentials away from the perikaryon toward the synaptic end bulbs, and these action potentials require the axolemma to have many volt-gaged ion channels. The releases of neurotransmitters from synaptic vesicles into the synaptic cleft are caused by these action potentials. A mechanism of active movement in the axon is called axonal transport. It expends energy to move substances in both directions in the axoplasm approximately 300 mm per day. This mechanism involves the cytoskeleton, and is used to deliver organelles and wastes back to the cell body (Clark, 2005).
Nerve fibers are collections of axons or dendrites. They sometimes have additional layers surrounding them for insulation. This insulation is called myelin. Axons are surrounded by cell processed of oligodendrocytes in the central nervous system and Schwann cells in the peripheral nervous system. Myelin sheaths are repeatedly wrapped around a segment of axon to form a series of tightly wrapped cell membranes. Myelin sheaths prevent almost all electrical current flow through the cell membrane. There are gaps in between the myelin sheaths which is called the nodes of Ranvier. It can be seen about every millimeter between the oligodendrocyte segments or between individual Schwann cells. Current flows easily between the extracellular fluid and the axon at the nodes of Ranvier, and action potentials can develop (Seeley, et al., 2005).
The Central Nervous System
The central nervous system consists of the brain which is present inside the cranial cavity, and the spinal cord present in the vertebral column. The peripheral part of the brain is made up of grey matter while the medulla, which is the inside of the brain, is made up of white matter. Both the brain and the spinal cord are completely surrounded by three meninges or membranes which lie between the skull and the brain. Meninges are connective tissue membranes that protect the brain and the spinal cord from injuries. Its function is to cushion the tissues of the brain and the spinal cord when a physical trauma occurs. The three protective meninges are named dura mater, arachnoid mater, and the pia mater (Bhise & Yadav, 2008).
The dura mater is the most superficial and thickest of the three meninges. Its folds extend into the longitudinal fissure between the two cerebral hemispheres and between the cerebrum and cerebellum. The dura mater contains spaces called dural venous sinuses within its folds. The sinuses collect blood from the small veins of the brain. The dural venous sinuses empty their collected blood into the internal jugular veins, which exit the skull. The dura mater is tightly attached to the periosteum of the skull. The dura mater of the spinal cord has a space between the vertebrae which we call epidural space. The epidural space is used for administration of anesthetics in times of surgery (Seeley, et al., 2005).
The second meningeal membrane is the arachnoid mater. It is composed of very thin and wispy connective tissues that cover the brain and the spinal cord. The space between the dura mater and the arachnoid mater is called the subarachnoid space, which is normally a potential space that contains a very small amount of serous fluid. It is a delicate serous membrane that contains cerebrospinal fluid (Bhise & Yadav, 2008).
The last meningeal membrane is the pia mater. It is very tightly bound to the surface of the brain and the spinal cord. The space between the arachnoid mater and the pia mater is called the subarachnoid space, which contains blood vessels and is filled with cerebrospinal fluid. Its function is to protect the nervous tissue, and to supply blood and nourishment to the central nervous tissue (Seeley, et al., 2005).
The central nervous system contains fluid-filled cavities called ventricles. These are irregularly shaped cavities that contain cerebrospinal fluid. There are four ventricles in the central nervous system namely the right and left lateral ventricles, the third ventricle, and the fourth ventricle. Their main function is to produce cerebrospinal fluid that will nourish and cushion the nervous tissues (Seeley, et al., 2005).
The lateral ventricles lie within the cerebral hemispheres, one on either side of the median plane just below the corpus calosum. The two lateral ventricles are separated by a thin membrane called septum lucidum. Blood capillaries are present in the lateral ventricles. It is also lined internally by means of ciliated epithelium called choroid plexus where cerebrospinal fluid is derived (Bhise & Yadav, 2008).
The third ventricle is a smaller midline cavity located in the center of the diencephalon between the two halves of the thalamus. It is a ventricle filled with cerebrospinal fluid and it is connected by holes to the lateral ventricles known as interventricular foramina (Bhise & Yadav, 2008).
The fourth ventricle is located at the base of the cerebellum and is connected to the third ventricle by the cerebral aqueduct which is a narrow canal. It is present below and behind the third ventricle and between the cerebellum and pons varolii. The fourth ventricle is connected continuously with the central canal of the spinal cord. It also opens into the subarachnoid space through foramina in its walls and roof (Seeley, et al., 2005).
The central nervous system has an abundant supply of cerebrospinal fluid. Cerebrospinal fluid is produced by the choroid plexuses. These are specialized structures made of ependymal cells which are located in the ventricles. Cerebrospinal fluid fills the brain ventricles, the central canal of the spinal cord, as well as the subarachnoid space. It flows from the lateral ventricles into the third ventricle and then through the cerebral aqueduct in the fourth ventricle. Only small amounts of cerebrospinal fluid enter the central canal of the spinal cord. Cerebrospinal fluid exits from the fourth ventricle through small openings and enters the subarachnoid space. There are masses of arachnoid tissue, called arachnoid granulations, which penetrate into the superior sagittal sinus, cerebrospinal fluid passes from the subarachnoid space into the blood through these granulations (Seeley, et al., 2005).
One of the main functions of the cerebrospinal fluid is to protect and support the delicate structures of the brain and the spinal cord. Also, it maintains uniform pressure around the brain structure. The cerebrospinal fluid also acts as a cushion and shock absorber for the brain and the spinal cord especially during times of injury and severe trauma. Lastly, the cerebrospinal fluid keeps the brain and the spinal cord moist as there may be an interchange of substances between the fluid and nerve cells (Bhise & Yadav, 2008).
The Human Brain
The major regions of the human brain are the brainstem, the diencephalon, the cerebrum, and the cerebellum.
The brainstem connects the spinal cord to the brain. It is composed of the medulla oblongata, pons, and midbrain and contains several nuclei involved in vital body functions such as the regulation of heart rate, blood pressure, and breathing. This is the reason of death for people who had severe injuries of the brainstem (Bear, et al., 2007).
The medulla oblongata is the most inferior portion of the brainstem. It is also connected continuously with the spinal cord. It extends from the level of the foramen magnum to the pons. The medulla oblongata contains ascending and descending nerve tracts as well as discrete nuclei which help in the regulation of heart rate and blood vessel diameter, breathing, swallowing, vomiting, coughing, sneezing, balance, and coordination. There are two prominent enlargements called pyramids on the anterior surface of the medulla oblongata. They contain descending nerve tracts, which transmit action potentials from the brain to motor neurons of the spinal cord. They are also involved in the conscious control of skeletal muscles (Bear, et al., 2007).
The pons is immediately superior to the medulla oblongata. It contains several nuclei, and ascending and descending nerve tracts. Some of the nuclei in the pons are responsible in relaying information between the cerebrum and the cerebellum. Several nuclei of the medulla oblongata extend into the lower part of the pons which functions in regulation of breathing, swallowing, and balance. Other nuclei in the pons are responsible in the control of activities such as chewing and salivation (Seeley, et al., 2005).
The smallest region of the brainstem is the midbrain. It is found just superior to the pons. The dorsal part of the midbrain is composed of four colliculi. The two inferior colliculi are major relay centers for the auditory nerve pathways in the central nervous system. The two superior colliculi are involved in controlling visual reflexes. Also, the midbrain contains nuclei involved in the coordination of eye movements, as well as in the control of pupil diameter and the lens shape. The midbrain has a substantia nigra, a black nuclear mass that is also part of the basal nuclei, which is involved in the regulation of body movements. The rest of the midbrain is composed of large ascending tracts from the spinal cord to the cerebrum and descending tracts from the cerebrum to the spinal cord or cerebellum (Seeley, et al., 2005).
There are group of nuclei scattered throughout the brainstem called the reticular formation. They play important regulatory functions in the brain. Specifically, they are involved in regulating cyclical motor functions such as respiration, walking, and chewing. The reticular activating system is composed mainly of reticular formations. They play an important role in arousing and maintaining consciousness and in regulating the sleep-wake cycle. Damage to cells of the reticular formation can result in coma (Bear, et al., 2007).
The cerebellum literally means little brain. It is attached to the brainstem by cerebellar peduncles. These large connections provide means of communication between the cerebellum and other parts of the central nervous system. The cerebellar cortex is composed of gray matter and it also has gyri and sulci. It consists of gray nuclei and white nerve tracts on the inside. The cerebellum is involved in balance, maintenance of muscle tone, and coordination of fine motor movement. The cerebellum also compares information about the intended movement from the motor cortex with sensory information from the moving structures because action potentials from proprioceptive neurons reach the cerebellum. Another function of the cerebellum involves learning motor skills such as playing the piano or driving a car (Bear, et al., 2007).
The next part of the brain is called the diencephalon. It lies between the brainstem and the cerebrum. The main components of the diencephalon are the thalamus, epithalamus, and the hypothalamus.
The thalamus is the largest part of the diencephalon. Its shape is somewhat like a yo-yo, with two large lateral parts connected in the center by a small interthalamic adhesion. The thalamus consists of a cluster of nuclei which is responsible for most sensory input that ascends through the spinal cord. The thalamus also influences mood and registers an un-localized, uncomfortable perception of pain (Seeley, et al., 2005).
The epithalamus is a small area located superior and posterior to the thalamus. It is involved in the emotional and visceral response to odors because of few small nuclei in it. The epithalamus also contains a pineal body which is an endocrine gland that may influence the onset of puberty. The pineal body may also play a role in controlling some long-term cycles that are influenced by the light-dark cycle (Bear, et al., 2007).
The hypothalamus is very important in maintaining homeostasis. It is the most inferior part of the diencephalon and it contains several small nuclei. The hypothalamus plays a crucial role in the control of body temperature, hunger, and thirst. It is responsible for sensations such as sexual pleasure, feeling relaxed and rested after a meal, rage, and fear. Nervous perspiration in response to stress or feeling hungry as a result of depression and other emotional responses which seem to be inappropriate to the circumstances also involve the hypothalamus. There is a funnel-shaped stalk in the hyothalamus, called the infundibulum that extends to the pituitary gland. This gives the hypothalamus a major role in controlling the secretion of hormones from the pituitary gland. There are also mamillary bodies on the posterior portion of the hypothalamus. These are involved in emotional responses to odors and in memory as well (Bear, et al., 2007).
The largest part of the brain is the cerebrum. It is divided into two hemispheres by a longitudinal fissure: the left and the right hemispheres. Each hemisphere contains numerous folds called gyri which greatly increase the area of the cerebral cortex. It also has intervening grooves called sulci. Each hemisphere is divided into four lobes named for the skull bones overlying them. The frontal lobe is responsible in the control of voluntary motor functions, motivation, aggression, mood, and smell reception. The parietal lobe is the main center for the reception and conscious perception of most sensory information such as touch, pain, temperature, balance, and taste. The occipital lobe functions in the reception and perception of visual stimuli. The last lobe, the temporal lobe, is involved in smell and hearing sensations and plays an important role in memory (Seeley, et al., 2005).
Neuroscience and its Relationship to Adult Development and Learning
The Neuroscience of Learning and Memory
After having an in-depth discussion of the structures and functions of the human brain, the goal is now to relate the study of neuroscience with adult development, specifically adult learning. The field of cognitive neuroscience attempts to relate cognition to neuroscience in order to understand how thought is implemented in the brain.
The single most influential finding from the cognitive neuroscience of learning and memory is that there are a lot of relatively independent memory systems in the human brain. Long-term memory depends on different neural substances than does working memory, and working memory depends on different neural substances than sensory memory. Moreover, the executive system that controls these memory systems also depends on different neural substrates than do the core memory systems themselves.
Donald Hebb proposed one of the first neural theories of learning. Hebb's idea was that if two connected neurons are frequently active at the same time, some form of physiological change in their connectivity (learning) could render them more likely to be coactive in the future, thus providing a physiological basis for memory (Guadagnoli, et al., 2008). Evidence for synaptic strengthening was discovered in neural circuits of the mollusk Aplysia and in hippocampal neurons of the rabbit empirically supported Hebb's principle of learning. The principle of Hebbian learning provides an explicit account of how patterns of activities in a network of neurons can be stored in a pattern of synaptic connections, thereby serving as a neural substrate of memory.
Hebbian learning is a powerful mechanism, but operating in conjunction with recurrent connectivity without other constraints would be problematic for the formation of memory. The problem is that because neurons are highly interconnected, excitatory activity in a few neurons tends to spread to neighboring neurons. This problem is compounded by the presence of recurrent connectivity, which allows activity to reverberate in the network creating mutually reinforcing activity (Guadagnoli, et al., 2008). As activity progresses to a network of neurons, the more active neurons tend to increasingly excite each other and at the same time increasingly inhibit less active neurons. In this way, neurons become specialized, they specifically respond to some patterns of input.
In recent years, a number of theories and frameworks have emerged that try to address both the potentials and limitations of effective cognitive and social functioning during the adult years. Such frameworks have aided the articulation of the characteristics of adult development by integrating observations that would otherwise have been disconnected pieces of a puzzle and less meaningful. In the study of adult cognitive development, much of the available data and theory suggests that there are improvements or stability as well as declines in cognitive function during the adult years. These data are being used by researchers in the development of adult learning principles (Demick & Andreoletti, 2003).
The processes and outcomes of learning influence the nature and course of adult development, and reciprocally, developmental variables influence the processes and products of learning. The concepts of learning and development can be distinguished along two dimensions. First, in terms of the inclusiveness or scope of the behavior and of the antecedents of change, learning refers to the effects of practice or experience on behavior whereas development refers to a wider variety of influences that are associated with time-related change. It is generally determined that developmental change is multi-determined and multidirectional (Demick & Andreoletti, 2003).
Implications and Development of Neuroscience to Adult Learning
Significant advances have been made since the mid-1970s in understanding how the nervous system encodes and retrieves information. Recent researches focus on understanding adult learning and memory at the cellular level, where the information encoding process can be found and recognized to changes in the properties of neurons. This is because the encoding process is known to take place through modifications in the biophysical properties of neurons and the strength of synaptic connections among neurons (Guadagnoli, et al., 2008).
One of the emerging and famous neurobiological principles is that no single universal mechanism for learning and memory exists. Instead, different mechanisms can be used by different memory systems, and any single memory system can use a variety of cellular mechanisms. Therefore, an understanding of the general ways in which neurons are changed by learning and the ways in which those changes are maintained and expressed at the cellular level is required to have a comprehensive understanding of memory mechanisms (Guadagnoli, et al., 2008).
It was more than a century since the forerunners of modern theories of learning started their works. William James, an American psychologist, was among the first to discuss the physiological basis of the manner in which information is encoded into brain cells. James formulated the law of neural habit in 1890, which states that the formation of associations is driven by the coactivity of elementary brain processes (Guadagnoli, et al., 2008).
Other scientists were also able to identify the locus of the physiological modifications. The Italian anatomist Tanzi advanced a hypothesis in 1893, it states that the connection between neurons was the locus of the change that encodes experience. In 1911, Spanish neuroanatomist Ramon Cajal reasoned that if signaling between neurons takes place at the connections between neurons. It follows the changes in the signal strength could alter the flow of activity within the brain and, consequently, the way an organism responds to experiences. Donald Hebb later advanced the argument in 1949, that learning involved coincident pre-synaptic and post-synaptic activities which he called as the Hebb synapse (Guadagnoli, et al., 2008).
Advancement in neuro-scientific methods have stimulated a vast amount of research in cognition and aging. New findings describing linkages between behavioral and brain data require theoretical explanations. A new challenge for this field is that the same behavior can be related to different neuronal activation patterns. The question remains as to whether they are functionally equivalent, yet represent biologically different mechanisms. In addition, more theoretical and empirical work is needed to investigate whether different changes in the brain may be associated with identical or differential mechanisms. Another challenge is to study changes in the brain longitudinally to investigate causal elationships. For instance, it may well be that certain brain patterns or changes in brain patterns can predict longitudinal behavioral changes. This, in turn, may have implications for pathologies of aging (Guadagnoli, et al., 2008).
Recent interest in placing behavior in both in a socio-emotional and biological context has broadened the investigation of adult developmental theories from a one-dimensional focus on mechanisms to the consideration of multiple determinants of behavioral change. For example, changes in processing of information are not simply a function of biological decline, but instead are also influenced by social context, motivation, beliefs, emotions, and life experiences. As a result we can observe a proliferation of research examining the emotion-cognition interface in the aging mind. Motivational shifts towards an increased importance of emotional gratification have been shown to influence older adults' differential allocation of cognitive resources to positive and negative information. Another determinant of cognitive performance in adulthood is social context, for instance by activating positive and negative stereotypes of aging. Other examples of determinants of behavioral change are lifestyle interfaces with biology as reflected in the influence of health on cognition (Smith, 2009).
The discussion of neuro-scientific methods has demonstrated that cognitive functioning can be understood at new levels. These methods allow us to adequately test conditions under which structural change is associated with decline, compensation, or even improvement in functioning. Rather than using general biological deterioration as the default explanation for cognitive changes, we can identify specific biological mechanisms reflected in different structures of and activation patterns in the brain. An example is that we are now able to differentiate preserved areas of the brain, such as the amygdala, from areas that are more prone to decay, such as specific areas in the prefrontal cortex. These respective areas relate to preserved emotional processing on the one hand, and decline in other more effortful cognitive processes on the other (Smith, 2009).
The number of studies examining the interface between emotion and cognition in the aging mind has been rapidly increasing. At this stage, the empirical findings have been somewhat supportive of a shift in motivational goals on the part of older adults. Although the shift towards instantiating emotionally gratifying experience is not challenged, how this shift influences cognitive processing is still more to be fully explained. As methodologies for time sampling are becoming more accessible and reliable, emotional processing can be more explicitly examined in and generalized to an everyday life context. Furthermore, the advances in statistical procedure analyzing individual variability and the coupling of psychological constructs will allow for an on-line assessment of the coupling between emotion and cognition. More information is needed on the degree to which emotion processing is resource demanding (Smith, 2009).
The study of adult development is grounded in the principles of scientific inquiry. Therefore, it is bound to produce results that are relevant to the subject matter being discussed. Researches in the past few years on several vertebrate and invertebrate model systems have led to the development of several general principles. These principles have been used by theorists in understanding adult learning processes. The principles developed might include the following (Squire, 2003).
1. Multiple memory systems are present in the brain.
2. Short-term forms of learning and memory require changes in existing neural circuits.
3. These changes may involve multiple cellular mechanisms within individual neurons.
4. Second-messenger systems play a role in mediating cellular changes.
5. Changes in membrane channels are often correlated with learning and memory.
6. Long-term memory requires new protein synthesis, whereas short-term memory does not.
In an adult cognitive development, it was thought that Piaget's four stages of cognitive development were universal, that it happens to every human being. Current research indicates that it is not universal when it was shown that development of formal operational thought is largely dependent on the influence of secondary and post-secondary educational institutions. Evidence from researches shows that many adults do not use formal operational thinking and that others use a form of dialectical thinking that is not accounted for by Piaget's definition of formal operational thought (Squire, 2003).
It is now believed that there is a fifth stage of cognitive development that is typical of mature adult thinking which is called post-formal or dialectical operational thought. The features of this stage must take into consideration the type of thinking that is typical of an adult's daily tasks.
Theorists made use of the data from the recent researches concerning adult learning and neuroscience. They are able to develop principles that will guide professionals with their respected field of study. Together, they formulated the following principles on adult development and learning (Mackeracher, 2004).
1. Adults must transfer knowledge from one context to another, most often from a training context to a practical, applied context. Transferability involves the recognition of new instances in which existing knowledge and skills can be applied, a form of contextual intelligence and learning not accounted for in formal operational thinking.
2. Adults are called on to develop specialized knowledge and skills. In 1984, Kolb describes specialization as a powerful developmental dynamic in which adults are encouraged, through professional, occupational, and role socialization, to develop personal characteristics deemed appropriate and acceptable to their field of specialization and that increasingly become an integral part of one's self and one's personal model of reality. When these characteristics become an integral part of personality, they may affect cognition.
3. While children and adolescents spend much of their time solving problems and answering questions posed by others, adults must be able to identify and formulate problems before solving them, or invent questions before answering them. While these tasks sound simple, many adults, even those in formal educational systems, cannot do them.
4. Many adults live in work, family, and community environments where it is not clear what one's goals should be. Indeterminate situations, or ill-structured problems, call for the development of projective images of future possibilities. Such situations also require cognitive strategies allowing the individual to move back and forth between this future image and the current situation in order to monitor forward progress and modify actions before implementation.
5. Adults must be able to deal with uncertainties, doubts, and ambiguities. In 1973, Riegel criticizes the idea that formal operational thinking is the highest stage of cognitive development on the ground that uncertainty, doubt, and ambiguity cannot always be resolved through formal logic or rational thought. Therefore, it is logical to assume such situations call for cognitive strategies that represent a more advanced stage of cognitive development.
6. Most adults must live and work within complex systems of roles and relationships and must learn how to manage the interactions and conflicts among them. Systems thinking involves cognitive strategies for managing the complex interactions that typify most places of work and also the complexities of an individual's adult life.
7. Adults need to be able to reflect on their own actions and change those actions even while in the process of acting. The cognitive strategies required for learning how to learn and for reflective practice involve the development of executive cognitive strategies to guide and control other cognitive strategies. Executive cognitive strateies are not accounted for in formal operational thought.
8. Adults need to be able to identify, through critical thinking, the assumptions that underlie ideas or system of ideas. Critical thinking calls for the use of cognitive processes allowing one to think about or operate on formal thoughts. In every previous stage of cognitive development, similar shifts in ability are perceived as the beginning of a new stage of development.
9. Adults need to be able to deal with paradoxical situations. Doubt, ambiguity, uncertainty, systems thinking, and self-reflective thought tend to give rise to paradoxes. It is reasonable to assume, therefore, that post-formal operational thought must allow the adult to develop strategies for dealing with paradox. A paradox is a conundrum raised when a rule, command, or generalization appears to contradict itself. All generalizations are false, this statement is false, and be spontaneous are examples of paradoxical statements. A paradox can only be resolved by moving outside the frame of reference (or personal model of reality) that contains it, and beyond the cognitive strategies that are creating it. This requires shifting into a new frame of reference and using new cognitive strategies. This type of learning is called perspective transformation (Mackeracher, 2004).

References
Bear, Mark F., Connors, Barry W., & Paradiso, Michael A. (2007). Neuroscience: Exploring the Brain (3rd ed.). USA: Lippincott Williams & Wilkins.
Bhise, S. B., & Yadav, A. V. (2008). Human Anatomy and Physiology. India: Nirali Prakashan. Human Anatomy and Physiology
Cavanaugh, John C., & Fields, Fredda Blanchard. (2006). Adult Development and Aging (5th ed.). USA: Thomson Wadsworth.
Clark, Robert K. (2005). Anatomy and Physiology: Understanding the Human Body. USA: Jones and Bartlett Publishers, Inc.
Demick, Jack, & Andreoletti, Carrie. (2003). Handbook of Adult Development. USA: Kluwer Academic / Plenum Publishers.
Guadagnoli, Mark (Ed.). (2008). Human Learning: Biology, Brain and Neuroscience. USA: Elsevier Publishing.
Harris, Tim (Ed.). (2010). Anatomy and Physiology: An Illustrated Guide. Malaysia: Marshall Cavendish Corporation.
Kastenbaum, Robert. (1993). Encyclopedia of Adult Development. USA: The Oryx Press.
Mackeracher, Dorothy. (2004). Making Sense of Adult Learning (2nd ed.). Canada: University of Toronto Press Incorporated.
Seeley, Rod R., Stephens, Trent D., & Tate Philip. (2005). Essentials of Anatomy and Physiology (5th ed.). New York: The McGraw-Hill Companies, Inc.
Sigelman, Carol K., & Rider, Elizabeth A. (2009). Life-Span Human Development (6th ed.). Canada: Wadsworth, Cengage Learning.
Smith, M Cecil (Ed.).(2009). Handbook of Research on Adult Learning and Development. New York: Taylor & Francis.
Squire, Larry R. (2003). Fundamental Neuroscience (2nd ed.). USA: Elsevier Publishing.
Ulijaszek, Stanley J, Johnston, Francis E., & Preece, Michael E. (2000). The Cambridge Encyclopedia of Human Growth and Development. United Kingdom: Cambridge University Press



There are faxes for this order.

Each week keep a journal about your heal behavioral change experience.
The journal is an opportunity for you to express and process your personal reactions to this experience.
Your entry should include four components each week: An OBJECTIVE measure of your progress.
Your stage of readiness according to the Transtheoretical and the ratio of pros to cons for your behavior using the forms at:

In addution to writing about your personal experience during the intervention, please respond to the following questions each week:

Week 1: What obstacles do you anticipate you will encounter while making this behavioral change?

Week 2: Review ONE recent research article you did not include in your original search. Your review need to to be more than 1-2 paragraphs of this week'd journal entry

Week 3: An analysis of how you acquired the undesired behavior and what has fostered it in your life.

Week 4: How has this change influenced your self image?

Week 5: How has this behavioral change changed your social interactions?

Week 6: How do you perceive your perfomance during this intervention and int the future how might you modify your intervention to enhance success?

Your jurnal entries shoud be 1 single-spaced page.

Quit smoking is what I want to change.
Please read my proposal below before you start writing!





Research Proposal to Quit Smoking over the Next Eight Weeks

Smoking is one of Americas largest silent killers behind heart problems. The American people, once glamorized through the thick wall of smoke, are now realizing how serious the complications related to smoking actually are. The 2005 National Health Survey (NHIS, 2005), reported staggering numbers of Americans, 29.5 million males and 20.7 million females, were smoking and thus considered themselves as smokers. Having been a smoker for a decade now, I see the need to drop the habit in hopes of preventing serious disease and pain in my future years. I no longer have much of a decision in the act of quitting, its either I quit, or I give myself a death sentence. With that in mind, I am proposing to change my dangerous habit, and over the course of the next eight weeks completely eliminate smoking from my daily life.
Quitting smoking is much more difficult than most might imagine. Of the thousands of people who try to quit each year, only a few remain successful in their fight against nicotine. Most smokers quit for a period of time, only to regain their habit after a brief separation. In fact, it is the first few months which prove the most critical, Most patients relapse within the first six to 12 months of a smoking cessation attempt, (Mallin, 2002). Through other peoples failures, physicians have also discovered that quitting without any plan of action leads to an even higher percentage rate of ex-smokers succumbing to their old habits. An overwhelming 95% of smokers who quit without implementing any sort of program to assist in their endeavors, actually stay smoke free, (Reynolds, 2002). These drastic figures attest to the importance of formulating a plan unique to ones position as the most efficient way to quit smoking. More important to creating that plan, is the eventual follow through.
The adverse health affects are a justifiable reason to quit smoking. An astounding 90% of lung cancer is directly associated with long term smoking, (Centers for Disease Control and Prevention, 2008). Other adverse health risks include cardiovascular disease, and other respiratory diseases. These haunting reminders of the adverse affects of smoking only increase as the user smokes for a longer period of time. Both lung and heart disease rates for smokers explode as smokers continue smoking throughout their lives. The risks just get higher as the years continue to pile up, If you smoke for a lifetime, there is a 50% chance that your eventual death will be smoking-related - half of all these deaths will be in middle age, (BBC News 2003).
I am now almost thirty years of age, and have been smoking for at least ten years. As I have continued to smoke over the years, I have added to my risk of being forced to endure the harmful affects related to cigarettes. Rather than continuing such a harmful habit, I have decided to change my behavior and lifestyle and so erase nicotine and tobacco from my life. I now realizing through assessing my need for change, (DiClemente, 1991) that I dont have much of a choice if I want to prevent myself becoming one of those terrifying statistics. I have found myself in the passing through the contemplation stage and now in the preparation phase of my desired change, (Mallin 2003). I no longer believe that the affects of smoking are overrated or that they will never extend to disrupt my life, which is associated with the precontemplation stage.

Research has shown than quitting without treatment usually has grim hopes of success. Quitting cold turkey will most likely just delay my cigarette smoking rather than abolishing it. Therefore, I need a strategic plan of action as a way to fully ensure my success in the attempt to kick the butt. Consulting with a physician alone can improve the chance to remain smoke free, (Mallin, 2002). Therefore I have decided to follow researchers advice and blend a combination of life style choices and proper medical care as a road to success.
Robert Mallin, in his 2002 work Smoking Cessation: Integration of Behavioral and Drug Therapies, expresses the importance of implementing a blended strategy. This change needs to be a conscious choice, but heavily backed up by medical help. Therefore, I will plan to implement a strategy in several steps with aid from a physician if the need for such help arises. Without either of the two, my endeavor would most likely end in failure.
The first crucial step is thorough preparation for the drastic life style change which is about to take place. The first step is planning a pre-determined date in the near future to quit, which I have chosen to be March 1, 2008. Now, I must attend to other preparation necessities, such as involving family and friends. Several studies have shown that with the support of loved ones, smokers are less inclined to cheat in their attempt to quit. Therefore, I have begun telling friends and family members that I plan to quit, and that I will be my attempt on March 1st of this year. Now that the idea has begun to saturate in my mind, I have to begin the task of removing objects which either remind me or encourage me to smoke. I have to rid my environment slowly of lighters, ash trays, matches, empty cigarette cartons, and any cellophane. All these items, even if encountered randomly might trigger an urge to smoke; therefore I need to try and remove as much as possible to lower the risk of encountering an object which might trigger a craving. Along with removing objects, I must slowly recognize what images, sounds, or smells remind me of smoking. Identifying these occurrences now may help prevent the risk of temptation and relapse when encountered later.
The next stage is moving out of preparation and entering into action. On February 29, 2008 I will smoke my last cigarette. It is truly my luck that this year is a leap year, and I get one extra day of February to enjoy smoking before my quit date. During this stage, support is key so I will rely on my family and friends to keep me going. If my cravings get too bad, I plan to visit support groups for further encouragement, and will resort to nicotine replacement drugs as prescribed through a physician if absolutely necessary. Hopefully, this will not be the case and I will be able to quit without the use of further medication. During this time period, I also plan to switch my smoking with a healthier substitute, (Mallin, 2003). I am planning on running in the mornings when I know I will crave the most as a deterrent for a cigarette. Running will give me an adrenaline rush and prevent laziness after not waking up with the first cigarette of the day, which normally wakes me up.
Using preparation, support, and replacement, I believe that I will be successful in my attempt to quit smoking. This research paper will document my endeavor through the preparation stage into the action stage. By adhering strictly to my plan and relying on support from outside in my network of family and friends, I hope to ensure myself success.



References


BBC News. Smoking is a greater cause of death and disability than any single disease,
says the World Health Organization. http://news.bbc.co.uk/2/hi/health/medical_notes/473673.stm. 2003.

Centers for Disease Control and Prevention. Health Affects of Cigarette Smoking.
National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/tobacco/data_statistics/Factsheets/health_effects.htm. 2008.

Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality,
Years of Potential Life Lost, and Economic Costs --- United States, 19951999. Morbidity and mortality Weekly Report. April 2002.

DiClemente, C.C., Prochaska, J.O., Fairhurst, S., Velicer, W.F., Rossi J.S., & Velasquez,
M. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation and contemplation/action. Journal of Consulting and Clinical Psychology, 59, 295-304. Cancer Prevention research Center. http://www.uri.edu/research/cprc/Measures/Smoking11.htm.

Mallin, Robert. Smoking Cessation: Integration of Behavioral and Drug Therapies.
American Academy of Family Physicians. http://www.aafp.org/afp/20020315/1107.html. 2002.

National Health Interview Survey (NHIS). National Center for Health Statistics. 2005.
www.americanheart.org/presenter.jhtml?identifier=4559.

Reynolds, Patrick. PRI & The Foundation For a Smokefree America.
www.tobaccofree.org. 2002.

Smokefree.gov (http://www.smokefree.gov ). 2008.

This is a termiantion summarry paper in phychiatric nursing.
qestion 1.) What behavioral changes did you notice occuring in your assiggned client and your self as a result of your nurse-patient relationship? The patient was smilling, seemed to enjoy my company.
2.)What short term goals or long term goals or outcomes were accomplished by your assigned client. The clent remained safe.
3.) Which of your nursing orders were most effective in helping your patient achieve his/her goals or outcomes? The most effective outcomes were providing a safe enviroment orienting the client to person place and time. Making sure the client had a nutritious meal. Reduced stimule.
4.) In reviewing your interactions-noted in your process recording, which communication technique
A.)Were most effective
b.) You've seen dramatic improvement in your communication or you still need to work on? I still nned to work on non verbal cues -meaning body language
5.) Describe the termination phase of your nurse-patient relationship.
a.) If you had the oppurtunity to do it over, is there anything you would have done differently?
b.)What feelings did your client express at the time?
c.)What feelings did you have at the time.? I wouldn,t do anything differently I think that I handle the situation as good as I could have. i really do not know if my client really understand that I was leaving because of her impaired memeory state, but shee didn't seem to be upset or any thing.
d.)i felt like i really enjoyed the nurse patient relationship, but I was tired I felt drained. And I was ready to leave.
6.)what are your feelings toward the termination of this clinical experience? Im glad I had the experience, but im glad it's over at the same time.
7.Were your expectations of nu 103 fufilled in the clinical area? Yes
8.)What did you find as the most meaningful aspect of your clinical experience in this phychiatric facility? I understand that you should treat people with kindness and respect and to be therapeutic. These people are human even though somthhing is wrong with there mind.
9>0 How do you plan to apply and transfer the concept and realizations you have come to recognize into other aspects of nursing? To be therspeutic in any setting.

This is a research paper due tomorrow . I have wrote some of it but im not sure I will get finished in time.

NURS 4119 Population and Global Health
ASSIGNMENT TWO (paper)
Objective: Assess the preventive and protective healthcare needs of a community of individuals, including emergency preparedness. Develop a plan for using behavioral change techniques to promote optimum health of a community, include culturally and spiritually sensitive care. (paper)
Audience: Residents or members of the population which you selected.
1. Describe the population/community you have chosen and why you chose it.
2. Assess preventative/protective health care needs of a population from different data sources and observations.
3. Select one health care need of a population/community from your assessment and develop and present a plan for meeting that need.
4. Describe theories of motivation and behavior change which you are using.
5. Explain how you would evaluate the effectiveness of your plan/intervention.
See criteria for evaluation.
Grading Rubric
Criteria ->

Category: Excellent, complete, appropriate Adequate, mostly complete & appropriate Minimally adequate, but weak Non passing, either incomplete or inappropriate
Description of population/community chosen and reasons for choosing. (10%) 10 8-9 7 0-6
Assessment of preventative/ protective health needs of specified population (20%) 20 15-19 14 0-14
Describe data sources used in conducting population/community assessment (10%) 10 8-9 7 0-6
Plan with specifics, to meet health protection/prevention need of population. (20%) 20 15-19 14 0-14
Evaluation methods, criteria for determining effectiveness of plan/intervention (20%) 20 15-19 14 0-14
Description of theories on motivation and change used in plan. (10%) 10 8-9 7 0-6
APA format, spelling, grammar, clarity of thought, scholarly writing 10 8-9 7 0-6

this is what I have so far
Changing the Future
Describe the population/community you have chosen

In addition, why you chose it.
Medication adherence in seniors greater than 60 years of age is a primary factor for preventing serious complications from chronic conditions (Ruppar, Conn, & Russel, 2008). Cognitive and physical changes comingled with additional risk factors such as living alone, unable to drive and limited incomes all contribute to a negative outcome for medication compliance. Harkness & DeMarco, (2012) moreover cultural and spiritual beliefs perceived about healthcare can contribute to barriers to medication adherence. Some fear that they will be placed in a rest home. Many elderly lack education or and have multiple chronic conditions leading to higher rates of admissions and higher rates of death. Long, S. K., King, J., & Coughlin, T. A. (2006). The elderly are disproportionately at risk for accidental drug overdoses, falls and readmission to the hospital.
Seniors have more adverse drug responses from prescription medications complicated by complex drug regiments. With increasing age, many elderly have difficulty understanding due to hearing loss, seeing difficulties and knowledge deficits (Harkness & DeMarco, 2012).




Assess preventative/protective health care needs of a population from different data sources and observations.
Today many elderly are taking multiple medications for various chronic illnesses.
Modifiable risk factors and disease processes, as well as creating a network of healthcare individuals and volunteers that can assist the elderly, this will help them receive medical care and preventative health. Nurses can focus health promotion and disease prevention
by educating them on nutrition and encourage involvement in social events in church or the community, as well as being active and mobile for a healthy life style.




Select one health care need of a population/community from your assessment, develop, and present a plan for meeting that need. Seniors are in need of effective education about the medications they take and potential side effects to increase medication compliance. The World Health Organization defines adherence as ?The extent to which a
Person?s behavior (taking medications, following a recommended diet and/or
Executing life-style changes) corresponds with the agreed recommendations
Of a health care provider? (Sabate, 2003, p. 13) (Ruppar et al., 2008, p. 115).

To counter this knowledge deficit that has become an epidemic, leading to numerous readmissions to the hospitals nurses can collaborate with other healthcare professionals and act as liaisons for the patient?s doctors, caregivers and pharmacists. They can make home care visits and discuss medication regiments to the patient. They can screen and review medication management. Nurses can assess and educate the patient?s ability to administer medications, educate on dosages, purpose and side effects. They can also observe the medication effectiveness and monitor side effects.
Nurses collaborating with doctors and pharmacists could simplify the amount of medications needed by patients, address the possible need for puncture packs for the elderly, as well as assist patients with med lists for doctor?s appointments. This simplification could lower costs for the elderly and the community.


Describe theories of motivation and behavior change, which you are using. Health care professionals can use the Health belief model to predict behaviors along with the ecological model that incorporates the individual, people and their environment, including developmental history and culture to change behavior. According to this model, behavior is linked to the knowledge values and beliefs of a person and can be used as a way to decrease barriers. By gaining a better understanding of a culture and its values, we can influence behaviors in a positive way. This would lead to better health outcomes for the Elderly whole. (Harkness & Demarco, 2012). Evaluate and educate elderly patients sent home from hospitals during the first 6 months of drug therapy nurses can collaborate with other healthcare professionals and act as liaisons between doctors, caregivers and pharmacists. They can make home care visits, phone calls, and set up group education nights at clinics.
Nurses can assess and educate the patient?s ability to administer medications, educate on dosages, purpose and side effects. They can also observe the medication effectiveness and monitor side effects.
Educating and monitoring patients over a period can lessen the high risks of drugs. This will create a healthier informed person and lower the costs of repeated hospital admissions as well as deaths resulting in a healthier community.

Explain how you would evaluate the effectiveness of your plan/intervention.
To determine effectiveness of education questionnaires will be given to some of the patients with short answers and multiple choice, along with phone calls and home visits. Permission to obtain information from the primary
Doctor would be beneficial to find out exact statistics if readmission to hospitals had lessoned in the community after a 6-month teaching period.
Assess the preventive and protective healthcare needs of a community of individuals, including emergency preparedness. Develop a plan for using behavioral change techniques to promote optimum health of a community, include culturally and spiritually sensitive care. (paper)

Because of time restraints, health beliefs , cultural differences about healthcare and miscommunication between staff and Seniors accompanied by being overwhelming during hospital stays, research showed delegating educational activities to midlevel practitioners, pharmacists as well as designated nurses that are sensitive to Seniors and cultural sensitivity, can influence patients behavior and decrease readmissions to the hospital . Follow up visits and phone calls can assist in this education (UMORE, 2011).







References


Griffiths, R., Johnson, M., Piper, M., & Langdon, R. (2004). A nursing intervention for the quality use of medicines by the elderly clients. International Journal of Nursing Practice,

Griffiths, R., Johnson, M., Piper, M., & Langdon, R. (2004). A nursing intervention for the quality use of medicines by the elderly clients. International Journal of Nursing Practice, 166-176. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdf
Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing Evidence for practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Coughlin, T. A. (2006). The health care experiences of rural Medicaid beneficiaries. Journal of Health Care for the Poor and Underserved, 17(3), 575-91.

Answer the two questions. Be sure to answer all parts of the questions, identifying each individual segment of each response by its number and letter: for example, 1a, 1b, etc.
If possible use the following as a reference: Drugs, Society, and Human Behavior, 12th ed., by Charles Ksir, Carl L. Hart, and Oakley Ray (Boston: McGraw-Hill, 2008).
Question 1
Previous textbook readings (Chapter 2, pp. 39-42) questioned the underlying causes and nature of drug dependence. A discussion of nicotine dependence (Chapter 10, pp. 254-255) presented other important observations on a complex, incompletely understood, and remarkably controversial condition. Currently, there are several significant implications about nicotine dependence emerging from recent court actions against the tobacco industry, following charges by various states' attorneys general and selected private trial lawyers as well as by the federal government. In this context, answer the following questions:
a. Compare and discuss the two somewhat contradictory views on the nature of nicotine dependence.
b. Describe your understanding of the major social, political, and economic ramifications associated with findings of deception perpetrated by the tobacco industry and cigarette manufacturers.
c. Would American society be better off if the tobacco industry was completely destroyed? Explain your viewpoint.

Question 2
a. Describe the major concerns voiced about caffeinism and the potential toxicity of caffeine, including risks associated with its use during pregnancy. In your opinion, how serious are those risks?
b. Would the FDA (Food and Drug Administration) be justified in establishing some sort of control and/or regulatory policy with regard to products containing caffeine? Provide some examples. Explain your view.
c. Should children be restricted from caffeine use? Why? Is this a matter for government involvement? Parental guidance? Explain.
d. Discuss your own personal intake of caffeine, reporting on any noticeable effects resulting from a substantial increase and/or decrease in the amount consumed. How do any of your mood and/or behavioral changes correspond to those reported in your textbook readings? What recommendations would you make?

These assignments are NOT simply a summary of the course material. Focus more on your reactions to what youve learned, heard and read. Your written response is based on the development of your insights into/on a specific topic. It is not a log of activities but rather a short essay of your well-reasoned reflections and thoughts supported by the concepts and ideas from the video lectures, class and the textbook. In the process of completing these assignments, you are making sense of what you are learning and exploring its relevance. Common questions that arise from these reflections include:
What happened?
Why did it happen?
What can be learned from this for future actions?
The specific assignments are structured to create an arc where you increasingly engage with the course material in the context of your larger world. You will begin by reflecting on past experiences, and then plan for future ones. You will relate what you are learning to paths taken by leaders who have demonstrated success. You will observe the operation of the principles we discuss out in the wild. And, finally, you will actively apply a concept covered at some point in the term by making a behavioral change and exploring what results.

Personal and subjective comments are appropriate in these assignments, including the use of personal pronouns. These are not the types of assignments where there is a single A"right or A"wrong answer. You will be evaluated on the use and application of the course material and the thoughtfulness of your response. The due dates noted below correspond to the same Lecture HW numbers and due dates in the syllabus.

Question:
Actively apply something youve learned in class to your own life by doing something differently as a result of what youve learned. That is, select one concept from the class and put it into practice by making a concrete behavioral change. For example, you may choose to apply the guidelines for effective feedback in discussing roles and responsibilities in a team project; or you may use the results of your SAL assessments in considering summer internships or job offers
(i.e. fit); or you may have identified a specific personality trait that you need to actively manage so it doesnt have a negative effect on a situation; or you change your attitude or perception in order to be more successful in a project, task or experience; or you may make a change in your study habits to capitalize on principles of motivation. Reflect on your experience and consider: was it useful? Successful? Inconclusive? Frustrating? What do you think about the concept/idea/framework you explored now that you have personal experience with it?

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TOURISM IN NEW AFTER SEPTEMBER 11
LOOKING AT SECTORS THAT MAKE TOURISM SUCH AS RESTAURANTS, HOTELS, SHOPPING, AIRLINES, AND HUMAN BEHAVIOR. THIS REQUIRES INTERVIEWS AND QUESTIONNAIRES TO BE PUT IN THE APPENDICES.

This dissertation needs to be 10,000 words (36 pages) excluding bibliography. Appendices must be an ADDITIONAL 2,250 words (9 pages) and present my research, detailing my theory, methodology, data collection, analysis, results, and conclusion. Written submission will be assessed on the following:

-Aims Clarity of definition of research objectives
Application of area of enquiry to business environment

-Research Methodology Specification/Justification of Methodology
Identification/use of appropriate primary/secondary resources
Review past literature
Conceptual, theoretical and empirical level

-Analysis and Conclusions Understanding of subject
Evidence of objectivity and independence of thought
Success in achieving research objectives
Quality of analysis
Validity and reliability of conclusions

- Form and Style Structure
Logical progression
Clarity of expression
Acknowledgement of sources/ bibliography

LAYOUT: Word processed on A4 on one side
Times new roman 12pt, double spacing
Margins of 2.5cm on left and right, header 2cm, footer 2cm
Preliminary pages unnumbered, pagination begins with the first page of text proper
Need to include word count( excluding bibliography and appendices)
PLEASE INCLUDE MY NAME (JIMMY METTA) AT THE BOTTOM OF EVERY PAGE

REFERENCING: all written work must include bibliography, a list of relevant items I consulted, including those not directly referred to in the text including books, articles and web pages
all written work should follow the Harvard system of referencing
use Author''s name and year of publication to refer to a document
include page numbers if making direct quotations

The structure of my project should follow these lines:

-Abstract
-Table of contents
-Introduction (Introduction, Personal motivation for choice of topic, Potential readership, Central research question, Research objectives)
-Literature review
-Methodology (inductive approach, preliminary research, secondary & primary research, interviews, designing interviews, candidates, points that should have been improved, external influences etc)
- Results
-Analysis
-Recommendation for further studies on this topic
-Bibliography
-Appendices

obviously charts, figures tables would definitely need to be included as well as Dedication Page , Acknowledgments Page. But I don''t want to make it look so professional it''s obvious it wasn''t me, I want to look " amazing but not too amazing" I hope I''m not being to vague, but I hope you understand what I mean.
Anyway to help you further below is a research proposal that I wrote for my college to explain what I will be doing, hopefully giving you a clearer picture.


PROPOSAL

?What are the effects on people?s behaviors and tourism in New York city after September 11th?

BACKGROUND

Over the past few months, I have been more and more certain that the choice of my topic has been the right one. Initially, I was unsure about the topic due to its complexity of factors that contribute to this matter, factors that have economic roles, political roles, socio- cultural roles etc. But, narrowing down my research content will allow me to focus on what has interested me the most: ?what particular sectors in New York have been damaged the most due to the lack of presence of tourism?.

We could be talking about the usual leisurely activities such as dining in restaurants, playing sports in a leisure club, going to a disco, gambling in a casino etc etc

All these fields will be analyzed and given a thorough examination individually to allow us to draw up a set of conclusion into how this horrible tragedy on September 11 has changed the usage of shops, restaurants bars and so on.


Evidence of such downward trend has been shown clearly across the board by major American banks, which entitle investors to look at specific industries and their performance as a whole. Morgan Stanley Dean Witter states that the events of September 11 pose an unprecedented challenge to the American business community.

This massive terrorist act has inflicted panic, low self-confidence amongst the American citizens and investors who choose to make a living by providing services for others. However, the destruction of the World Trade Centre and the attack on the Pentagon reveal the immediate dangers facing all Americans as a result of terrorism.

For example, air travel has plunged, layoffs in the aviation industry have spread rapidly and virtually all carriers confront a threat of bankruptcy. Therefore, such acts have caused businesses as well as whole industries to make massive losses due to the lack of usage of the services offered by these businesses, which make New York City.

The sheer scale of physical and economic damage from the terrorist attacks have been compared to even the most devastating natural disaster of recent years in the US.

New York city faces the following challenges:


v The scale of devastation, with damages in New York estimated in the tens of billions of dollars, entire square blocks uninhabitable, and 30 million square feet of office space rendered unusable or destroyed.

v Its disruption of global air travel, daily commuting in a major metropolitan area, and routine business operations;

v Its reach, having implications that have touched all Americans and extend throughout the world

v It?s potential to have an impact on the international economy for a significant period of time.


Hence, I will look at all the statistics offered, so that I can demonstrate how all the damage that has occurred has disrupted major industries in the US, devastated properties that perform and contribute greatly o the American economy.

RESEARCH OBJECTIVES

My research objectives should leave the reader in no doubt as to precisely what it is that my research seeks to achieve, they are the following:

v To identify the damage made on that tragic day by displaying charts and graphs whilst looking at businesses and industries.

v To establish which businesses have been completely ruined, consequently ruining the industry,

v To examine how this will change people?s perspective of doing business in the future and whether they are cynical of starting a new business in a busy city like New York.

v To evaluate people?s behavioral changes and whether they believe that day will have an impact on the rest of their life. I will encourage people to discuss with me their weekly typical life and compare it with an average week a year ago for example.

v To examine how this business loss and slowdown has affected the global economy by looking at various industries individually.

v To draw clear conclusions on what will need to be done to change things back to the way things were or whether there is a chance things will never be the same and whether the city?s structure is debatable to permanent change.

METHOD OF RESEARCH

Inevitably, to arrive to clear conclusions for this topic, it is important to draw a plan of every single attribute that will help me deliver an answer. This plan needs to be followed and revised frequently in order to get the best methodologies available.

Due to the nature of this topic and its complexity, it is vital to abstract as much knowledge a possible, this includes data, charts, literatures, journals, interviews and questionnaires and so on. Preferably these attributes will need to be developed fully in order to gain as much response a possible. For example in the case of an interview, I will need to ask the right questions whilst making sure they are directly relevant to my topic, keeping in mind that I am seeking various objectives.

Questionnaires for example will be handed out on the streets for quick answers, this way I will be able to get as many samples as possible. Quick, clear questions will be asked expecting short and precise answers. After that, I will draw up graphs that illustrate interesting points about people?s opinions and lifestyles.

Clearly, assessing people?s opinions will not be easy as they might feel differently than others in terms of the drastic changes that have occurred in their lives, therefore it will be interesting to see how citizens from New York feel compared to people from Los Angeles, whether they feel and act differently since the incident. It is important to understand that I will be analysing tourists as well as national citizens because then we will have a clear view and analysis of how people?s lives have changed, whether tourists feel threatened just in New York or in other countries equally, whether it?s the simple act of terrorism that affects them and not the city specifically.

Therefore, this thesis will be based on people in New York as well as tourists visiting New York, because it?s the actual impact on people and their behaviour that is very interesting. So, I intend to abstract as much knowledge as possible, by looking at the important statistics of businesses and consumers.

As for the particular sectors that I will be analyzing, I feel it is more appropriate to discuss relevant sectors which have changed deeply due to this tragic incident. Restaurants, shops, airports, investments, hotels are some of many aspects that I will be analyzing to arrive to some answers, but whilst analysing the changes I will hope to arrive to some estimations for what lies ahead for these businesses and whether they will be altered for good. It is with the help and cooperation of employees in companies, shops, restaurants and hotels that I will gradually start to see some answers approaching me.

Banks will play a vital role for this dissertation as analysts examine all the effects that have changed in the economy, thereby allowing me to follow their expectations and estimates to further develop my answers.

I have chosen a few major investment banks for this aspect of the thesis, to assist me with their thoughts on various sectors and whether investors truly see opportunity for development in those sectors. For example, the airline industry is in a state of depression due to people feeling threatened by terrorists or safety issues, this lead to layoffs of employees, companies going bankrupt with little hope that the industry will come back soon. However, speaking to bankers, I will get an idea of how investors are reacting and whether they are optimistic or pessimistic of the sector, encouraging more people to fly with increased safety.

Each individual sector will be analysed by using as many sources as possible, to then find a trend that can lead us to an appropriate set of answer

NOTES

Questionnaires will need to come with appropriate names of people that have been interviewed ,date and time.
Please try to be as specific as possible with great detail, it is important that we convince the examiners of our research and points made.
Table of contents should come with page numbers and chapter numbers.
Tables and charts should be well developed and well placed to prove one''s point.
Please make sure full referencing occurs.
Please don''t hesitate to add anything I have missed pointing out in adding as long as it answers the question. Any sector that you may want to add in this is up to you.

>>

The overall goal of the lecture assignments is to have you apply the material you are learning to your own life and observe the world around you through the lens of the concepts and ideas you are learning.
These assignments are NOT simply a summary of the course material. Focus more on your reactions to what youve learned, heard and read. Your written response is based on the development of your insights into/on a specific topic. It is not a log of activities but rather a short essay of your well-reasoned reflections and thoughts supported by the concepts and ideas from the video lectures, class and the textbook. In the process of completing these assignments, you are making sense of what you are learning and exploring its relevance. Common questions that arise from these reflections include:
What happened?
Why did it happen?
What can be learned from this for future actions?
The specific assignments are structured to create an arc where you increasingly engage with the course material in the context of your larger world. You will begin by reflecting on past experiences, and then plan for future ones. You will relate what you are learning to paths taken by leaders who have demonstrated success. You will observe the operation of the principles we discuss out in the wild. And, finally, you will actively apply a concept covered at some point in the term by making a behavioral change and exploring what results.
Each assignment should be at least one page, single-spaced but no longer than two pages. Personal and subjective comments are appropriate in these assignments, including the use of personal pronouns. These are not the types of assignments where there is a single right or wrong answer. You will be evaluated on the use and application of the course material and the thoughtfulness of your response.

Question:
Read a minimum of 5 articles from the Corner Office column in the New York Times (http://projects.nytimes.com/corner-office). Of these five columns, select the profile of the person whose style of leadership you most identify with or admire and discuss why this persons leadership is particularly impressive to you. Use concepts from the class (e.g., leadership, ethics, power and politics) in discussing this persons appeal. Include a list of the 5 profiles you read noting the name, company and title of the essays.
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Customer is requesting that (infoceo) completes this order.

Directions for the Self Assessment Change Project

Individual Assignmen
This is an exciting assignment, one that will not only assist you in the present but also in the future. If you read the Wall Street Journal article, Personalities Put to the Test in Module #2, you can see how personality assessments are ubiquitous and it may not be unusual as part of the selection process the next time you seek employment. Keeping this in mind, the assignment will support you in developing a strategy to improve your OPQ scales and ultimately provide you with career growth opportunity.
The actual assignment is provided below (See Self Assessment Change Project). These are just instructions that I generally would review in class but since this section is online, I have provided some guidelines.
A few important points to keep in mind
1. General-While I have provided due date of September 25th.

2. Support Group-Your support group should be the members of your virtual office therefore you should be communicating with them weekly to discuss your progress. You will insert the actual communication into your final paper.
3. Selecting Two Sten Scores- It is not unusual for students to wonder how to select the sten scores for the assignment. While I am happy to provide you with guidance, it is even better when you consult with your employer. By doing so, you can ask them which of the scales are most important for someone seeking a supervision or management position. These are always different depending on your company and the type of job you are interested in the future. Please be future thinking. You want to be prepared for the next job, not your current one. So for example if Data Rational is really important and you did not score well in that category, that might be something you want to work on.
4. Mentor-Your mentor should preferably be your immediate supervisor as they can best provide insight as to what is important for professional growth. Sometimes students say I dont trust or like my supervisor. If this is the case find someone at work that you do trust and like, perhaps someone that will help you to network towards your next job. Be strategic!!! If you are not currently employed you can ask a professor to serve as your mentor.
9. Contemporary Research-Please refer to scholarly articles and journals, websites.

Please enjoy the project, it will get you to think a lot about yourself.



Self Assessment Change Project
Changing Behavior towards Career Growth


Background/Purpose
Alan Deutschman, author of Change or Die has written and researched on the topic of the incredible difficulty for people to change even when faced with catastrophic consequences such as death, incarceration, or other critical life changing effects.
After reading the Deutschman article, using the Three Rs model for change developed by Deutschman, including Relate, Repeat, Reframe, and develop a change process based upon two of your key areas identified in your OPQ results for professional growth."
Please identify the information requested below.
Name: Daryl
Current Employer: Military
Current Job: P-3 Analyst
Future Job: Real estate

Please identify two Attributes and Sten Scores from your OPQ that you performed low in below.
Attribute 1: Sten Score:
Attribute 2: Sten Score:

1. Describe the Sten Scores that you have identified to work on as part of your change assignment. Explain in your own words what each of the attributes mean.
a. Were you surprised that you scored weak in these areas? If yes or no, then why. Are these skills that you believe are necessary for future success as a supervisor or manager? How do you know they are or arent?
2. Mentor Opportunity-Spend some time meeting with a supervisor or manager that supervises you. If you are not currently working, interview a supervisor of a former company or friend or acquaintance that is a current supervisor. Find out what are the key behavior skills necessary for the job. Insert a review of the conversation.

3. Support Group-Discuss your two attributes with your discussion board partner that has agreed to support you. Please name the person that will serve as your support here . Be prepared to have weekly e-mail conversation with this individual and provide e-mail communication to me. You will attach this communication when you submit the final paper.

4. Contemporary Research- Review current literature by selecting a minimum of two articles for each low sten score behavior and summarize your findings.


5. Self Assessment Progress Report #1- Write up a two- page summary describing your progress. What change activities have you completed using the three r model? Submit a separate document.

6. Self Assessment Progress Report #2- Write up a two- page summary describing your progress. How successful have you been in achieving your objectives? Submit a separate document.

7. Self Assessment Progress Report #3- Write up a two- page summary describing your progress. 4. What evidence do you have that you are making progress to achieve your goals (i.e. unsolicited comments from your supervisor, coworkers, classmates, etc.)?
Self Assessment Evaluation Summary and Discussion- Refer to one of the following levels that best describe the extent of your commitment from lowest to highest levels (I-V) in attaining mastery of the attributes you identified to work on in your change project
a. Level I-New Years Resolution (Soon slips back to regular pattern of behavior).
b. Level II??"Go on a Diet (Purchase a book on a new diet and/or enroll in a seminar). You make a plan and achieve some short-term success. However, you soon slip back into regular eating habits.
c. Level III??"Join a Health Club (Pay a monthly fee for services and your amount of participation is at your discretion). You do make progress and achieve a basic level of knowledge of what you should do and some level of mastery. Requires some stretch outside of your comfort zone and some monetary investment.

d. Level IV??"Hire a Personal Trainer (Have a regular appointment and receive one on one coaching). Individual trainer holds you accountable and ensures that you stretch to attain stated goals. Requires a higher monetary investment. The more you progress your confidence builds and you attain mastery. You no longer see your goals as that big of a stretch.
e. Level V??"Learning is Internalized (Actual behavioral change occurs). No longer outside your comfort zone. Mastery is not only achieved, it becomes your preferred style.
Considering the above, what do you believe your attribute sten score(s) will be for each attribute on the post assessment? Please specify.

III. Post-Assessment Reflections??"Complete after you have been given your actual scores.

1. Record your new actual sten score(s) for each attribute on you were working on from your post assessment. Do the scores surprise you in anyway? If so, why?




2. What, if anything, would you do differently or recommend that others do to further enhance the likelihood that you would achieve mastery of the attributes that you identified?


This paper will have a cover page, including running head, short title, page numbers, and title block, but they do not count.

A. Margins: One inch on all sides (top, bottom, left, right).
B. Font Size and Type: 12-pt. font (Times Roman )
C. Line Spacing: Double-space throughout the paper, including the title page, body of the document, references, appendixes, footnotes, tables, and figure captions.
D. Spacing after Punctuation: Space once after all punctuation. This includes using one space (not two!) following punctuation marks at the ends of sentences.
E. Alignment: Flush left (creating uneven right margin)

You must also visit the schools library or submit electronically your paper through turnitin.com
Customer is requesting that (wordstress1) completes this order.

Customer is requesting that (wordstress1) completes this order.

There are faxes for this order.

Customer is requesting that (wordstress1) completes this order.

Section E: Change Model

1) In 500-750 words (not including the title page and reference page) apply a change model to the implementation plan.

2) Roger's Diffusion of Innovation theory is a particularly good theoretical framework to apply to an EBP project. However, students may also choose to use change models, such as Duck's Change Curve Model or the Transtheoretical Model of Behavioral Change. Other conceptual models presented such as a utilization model (Stetler's model) and EBP models (The Iowa Model and ARCC Model) can also be used as a framework for applying your evidence-based intervention in clinical practice.

3) Apply one of the above models and carry your implementation through each of the stages, phases, or steps identified in the chosen model.

4) In addition, create a conceptual model of the project. Although you will not be submitting the conceptual model you design in Module 5 with the narrative, the conceptual model should be placed in the appendices for the final paper.

5) Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

6) Refer to the "Change Model Holistic Assessment" located within the Additional Resources folder in Canyon Connect.

7) Submit the assignment to the instructor by the end of Module 5.

8) Upon receiving feedback from the instructor, refine Section E for your final submission. This will be a continuous process throughout the course for each section.

Section F: Implementation Plan

1) In 500-750 words (not including the title page and reference page) provide a description of the methods to be used to implement the proposed solution. Include the following:

a) Describe the setting and access to potential subjects. If there is a need for a consent or approval form, then one must be created. Although you will not be submitting the consent or approval form(s) in Module 5 with the narrative, the consent or approval form(s) should be placed in the appendices for the final paper.

b) Describe the amount of time needed to complete this project. Create a timeline. Make sure the timeline is general enough that it can be implemented at any date. Although you will not be submitting the timeline in Module 5 with the narrative, the timeline should be placed in the appendices for the final paper.

c) Describe the resources (human, fiscal, and other) or changes needed in the implementation of the solution. Consider the clinical tools or process changes that would need to take place. Provide a resource list. Although you will not be submitting the resource list in Module 5 with the narrative, the resource list should be placed in the appendices for the final paper.

d) Describe the methods and instruments, such as a questionnaire, scale, or test to be used for monitoring the implementation of the proposed solution. Develop the instruments. Although you will not be submitting the individual instruments in Module 5 with the narrative, the instruments should be placed in the appendices for the final paper.

e) Explain the process for delivering the (intervention) solution and indicate if any training will be needed.

f) Provide an outline of the data collection plan. Describe how data management will be maintained and by whom. Furthermore, provide an explanation of how the data analysis and interpretation process will be conducted. Develop the data collection tools that will be needed. Although you will not be submitting the data collection tools in Module 5 with the narrative, the data collection tools should be placed in the appendices for the final paper.

g) Describe the strategies to deal with the management of any barriers, facilitators, and challenges.

h) Establish the feasibility of the implementation plan. Address the costs for personnel, consumable supplies, equipment (if not provided by the institute), computer related costs (librarian consultation, database access, etc.), and other costs (travel, presentation development). Make sure to provide a brief rationale for each. Develop a budget plan. Although you will not be submitting the budget plan in Module 5 with the narrative, the budget plan should be placed in the appendices for the final paper.

i) Describe the plans to maintain, extend, revise, and discontinue a proposed solution after implementation.

2) Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required

There are faxes for this order.

The Owens et al. study assigned for reading this week introduces a strain of mice that have been selected for behavioral sensitivity to alcohol. These selected strains of mice are an example of evolution through selection for certain traits. Write a 2-3 page paper (excluding the reference section and title page) discussing a particular strain of animal where a particular behavior has been selected for. You can select almost any behavior and find selection studies that have been done in mice and rats. You can also use the long-sleep and short-sleep mice that have been presented in the article this week. Be sure to discuss not only the selection process and impact but also other associated changes resulting from the initial selection process. As you will find if you search the long-sleep and short-sleep mice there will be a significant number of changes that occur at the neurochemical and behavioral level as a result of the initial selection study.

An animal strain that has been selected on a particular behavior or phonotype is clearly identified.
The selection process for the phenotype or behavior is clearly identified.
Secondary behavioral changes as a result of the selection are discussed.
Secondary neurochemical changes are examined
The central theme/purpose of the paper is clear.
The structure is clear, logical, and easy to follow.
The tone is appropriate to the content and assignment.
The thoughts are clear and include appropriate beginning, development, and conclusion.
Paragraph transitions are present, logical, and maintain the flow throughout the paper.
Sentences are complete, clear, and concise.
Sentences are well constructed, with consistently strong, varied sentences.
Sentence transitions are present and maintain the flow of thought.
Rules of grammar, usage, and punctuation are followed.
The paper uses words and language that are inclusive, clear, and unambiguous.
Spelling is correct
The paper includes a summary and analysis of research materials that are relevant to the assignment, e.g. scholarly journals, professional articles, legal documents, government documents, legal decisions, media clips, software, measurement instruments websites, personal communication, etc.
Professional/scholarly journals are peer reviewed and focus on the profession/application of psychology (located on ProQuest, EBSCOHost, PsycNET, etc.). Non-scholarly articles include newspapers, periodicals, secular magazines, etc, and are not peer reviewed. Websites not approved include wilkipedia.com and about.com.
Research focuses on the most current information (past five to ten years) except when citing seminal works (e.g. Freud, Erickson, etc.).
Paper includes the appropriate number of references required by the assignment.
When appropriate, the paper addresses ethical considerations in research

Please write a 2 page discussion paper and include the References page


Organizational Foundations
As you strive to grow in your leadership skills and abilities, you will likely find that your motivation and areas of focus are influenced by the context in which you work. In a similar vein, your commitment to developing professionally can contribute toward organizational effectiveness.
To that end, it is critical to recognize the importance of organizational culture and climate. In particular, through this weeks Learning Resources, you may consider several questions: How do an organizations mission, vision, and values relate to its culture? What is the difference between culture and climate? And, how are these manifested within the organization?
For this Discussion, you explore the culture and climate of your current organization or one with which you are familiar. You also consider how the organizations mission, vision, and values are conveyed through decisions and day-to-day practices.
To prepare:
Review the information related to planning and decision making in health care organizations presented in the textbook, Leadership Roles and Management Functions in Nursing. Consider how planning and decision making relate to an organizations mission, vision, and values, as well as its culture and its climate.
Familiarize yourself with the mission, vision, and values of your organization or one with which you are familiar. Consider how these are supported, or demonstrated, through the statements and actions of leaders and others within the organization. In addition, note any apparent discrepancies between word and deed. Think about how this translates into expectations for direct service providers. Note any data or artifacts that seem to indicate whether behaviors within the organization are congruent with its mission, vision, and values.
Begin to examine and reflect on the culture and climate of the organization. How do culture and climate differ?
Why is it important for you, as a masters-prepared nurse leader, to be cognizant of these matters?
Post on or before Day 3 a description of your selected organizations mission, vision, and values. Describe how these are evidenced??"or perhaps appear to be contradicted??"in the words and actions of leaders and others in the organization, noting relevant data or artifacts. In addition, discuss the organizations culture and its climate, differentiating between the two. Explain why examining these matters is significant to your role as a nurse leader.

Foundations of an Organizational and Organizational Assessment: Program A Program Transcript
[MUSIC PLAYING]
JOAN M. MARREN: I've worked for Visiting Nurse Service of New York for over 30 years. I've worked there through transit strikes, through blackouts, through blizzards, and through 9/11. There has never been a crisis in which our staff have not made themselves available to deliver care, regardless of the emergency circumstance.
I think in home health and community nursing, the family unit is the target, so to speak, of our intervention. It's not just the individual patient, and I think that's really important. We have to provide a certain kind of service to the individual around their diagnosed health care problem, let's say, but that individual exists within the context of the family.
And that family influences the choices that that individual may or may not make about their health care problem, and, to some extent, even the larger community does. So if, for example, in the area of diet. If we are trying to encourage a diabetic, or a patient with heart failure, to incorporate certain dietary choices into their daily meal plan, but in the larger-- either in the family there isn't adequate support for that, or in the larger community it's very difficult for them to get access to fresh fruits and vegetables. That will impact, ultimately, our success in accomplishing this kind of change, or the way in which that individual is able to manage the health problem on an ongoing basis.
Behavioral change, I think, is, to a large extent, dependent upon a relationship. And so one of the basic tenets, if one is to begin to have a prayer, so to speak, of attempting to influence behavior, it has to be through the development of a trusting relationship. So a trusting relationship is also dependent upon an element of time.
It's difficult to develop trust if your opportunity for interaction with an individual or family is so severely limited that you can't get to know each other. So there has to be a certain time that you have to build trust. I think secondly, for behavior to change, the kind of interaction that takes place has to be consistent with the values and beliefs of the individual whose behavior you're attempting to modify in some way.
So that really understanding those values and beliefs is important, and understanding how they might affect an individual's choices about health care, about diet, about end of life care, for example, are really important variables in successful behavioral change. And that has to do with, I believe, recruiting staff members who share the culture and the beliefs and have greater likelihood of
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being acceptable in the home or in the community to this population group. I think it means connecting with influences in the community, such as religious groups, political groups that might be representative, or individuals that might be representative of that group. And leveraging their influence in such a way that the health care needs are addressed more consistently with the beliefs of the population.
[SPEAKING FOREIGN LANGUAGE]
We actually have a kind of a satellite, what we call the Chinatown Community Center, where people can walk in and request services of our organization, but where we also conduct blood pressure screenings, health education classes, during the season flu immunization, and so on. And are sort of very much a part of that community and visible in the community, networked with health care providers and community-based organizations, so that we are seen as a resource there. And then when people need home health care, for example, they would access it through us and would be willing to bring an organization like ours into their lives in a whole variety of ways.
So what we have done, as an organization, again, both at the individual nurse level and at a programmatic level, is to really understand what are those beliefs? What are those barriers? And what do we need to do, as individual practitioners and as a health care provider, more broadly, to make those services more accessible?
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Foundations of an Organizational and Organizational Assessment: Program B Program Transcript
KEVIN F. SMITH: Our vision, I think, is over time to be able to look at that community, look at that public, and say to them, if you come here we'll keep you safe. We'll keep you from being harmed when you're under our care. That's really our vision. And if we do that, and we do it well, we believe that all of the other elements of what one might call a business plan, a strategy, will largely fall from that, take care of themselves.
Our mission is to promote the health of the people. There are about 500,000 people who live in our service area. And when their health is threatened or it fails them, to help them address that and take care of it. That's our mission over time, to promote that health and to take care of it when it goes away in some fashion.
NURSE: Gonna strap them down. And then I'm even gonna put lead on it.
KEVIN F. SMITH: I believe what contributes to that is a shared and deep commitment on the part of everybody who works here, all 2,600 people, to that vision and that mission. The belief that they are doing good work on behalf of the community, and those community members are their family members. They are their neighbors.
I think what the staff here does day in and day out, in interaction after interaction, is make it personal. They treat one another, and more importantly, hey treat patients and families like they would want to be treated, like someone who they care about would want to be treated.
Our decision making structure here tends to be very decentralized. We believe across our management team quite strongly in the power of enabling everybody in the organization. We have a saying that we use around here frequently that we don't practice administration here, we practice medicine.
And those of us who work in support and management and leadership type positions, I think we take the opportunity to constantly remind ourselves that our job is to remove barriers and enable the folks who work at the bedside delivering patient care, and those who support that effort, to allow them to do their job, give them the resources. So I think an awful lot of that is about empowering people to do their best at doing their job.
RUTH: Good morning, greeter desk. Ruth speaking. Yes. OK, I'll connect you. Thank you.
KEVIN F. SMITH: For all of the bricks and mortar and all the technology that characterizes this hospital and all of today's hospitals, this is still at its core a
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people business. And we try to adopt that approach and use it. Not just in our interactions with patients, but as we relate to problems that need to be solved, issues that need to be addressed, as we work as a team within the organization, employee to employee.
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Foundations of an Organizational and Organizational Assessment: Program B Program Transcript
KEVIN F. SMITH: Our vision, I think, is over time to be able to look at that community, look at that public, and say to them, if you come here we'll keep you safe. We'll keep you from being harmed when you're under our care. That's really our vision. And if we do that, and we do it well, we believe that all of the other elements of what one might call a business plan, a strategy, will largely fall from that, take care of themselves.
Our mission is to promote the health of the people. There are about 500,000 people who live in our service area. And when their health is threatened or it fails them, to help them address that and take care of it. That's our mission over time, to promote that health and to take care of it when it goes away in some fashion.
NURSE: Gonna strap them down. And then I'm even gonna put lead on it.
KEVIN F. SMITH: I believe what contributes to that is a shared and deep commitment on the part of everybody who works here, all 2,600 people, to that vision and that mission. The belief that they are doing good work on behalf of the community, and those community members are their family members. They are their neighbors.
I think what the staff here does day in and day out, in interaction after interaction, is make it personal. They treat one another, and more importantly, they treat patients and families like they would want to be treated, like someone who they care about would want to be treated.
Our decision making structure here tends to be very decentralized. We believe across our management team quite strongly in the power of enabling everybody in the organization. We have a saying that we use around here frequently that we don't practice administration here, we practice medicine.
And those of us who work in support and management and leadership type positions, I think we take the opportunity to constantly remind ourselves that our job is to remove barriers and enable the folks who work at the bedside delivering patient care, and those who support that effort, to allow them to do their job, give them the resources. So I think an awful lot of that is about empowering people to do their best at doing their job.
RUTH: Good morning, greeter desk. Ruth speaking. Yes. OK, I'll connect you. Thank you.
KEVIN F. SMITH: For all of the bricks and mortar and all the technology that characterizes this hospital and all of today's hospitals, this is still at its core a
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people business. And we try to adopt that approach and use it. Not just in our interactions with patients, but as we relate to problems that need to be solved, issues that need to be addressed, as we work as a team within the organization, employee to employee.
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Nurses practicing in today's healthcare environment are confronted with increasingly complex moral and ethical dilemmas. Nurses encounter these dilemmas in situations where their ability to do the right thing is frequently hindered by conflicting values and beliefs of other healthcare providers. In these circumstances, upholding their commitment to patients requires significant moral courage. Nurses who possess moral courage and advocate in the best interest of the patient may at times find themselves experiencing adverse outcomes. These issues underscore the need for all nurses in all roles across all settings to commit to working toward creating work environments that support moral courage. In this manuscript the authors describe moral courage in nursing; and explore personal characteristics that promote moral courage, including moral reasoning, the ethic of care, and nursing competence. They also discuss organizational structures that support moral courage, specifically the organization's mission, vision, and values; models of care; structural empowerment; shared governance; communication; a just culture; and leadership that promotes moral courage.
Key words: ethical work environment; shared governance in nursing; professional practice models; leadership; evidence-based leadership; moral development; moral courage; organizational empowerment; support for moral courage; the ethic of care
"Our lives begin to end the day we become silent about things that matter." (Martin Luther King, Jr.; Barden, 2008, p. 16).
Morally responsible nursing consists of being able to recognize and respond to unethical practices or failure to provide quality patient care. Moral distress has been defined as physical and/or emotional suffering that is experienced when internal or external constraints prevent a person from taking the action that one believes is right (Pendry, 2007). Ethical dilemmas in practice arise when one feels drawn both to do and not to do the same thing. They can cause clinicians to experience significant moral distress in dealing with patients, families, other members of the interdisciplinary team, and organizational leaders. Nurses experience moral distress, for example, when financial constraints or inadequate staffing compromise their ability to provide quality patient care. These situations challenge nurses to act with moral courage and result in nurses feeling morally distressed when they cannot do what they believe is appropriate (Cohen & Erickson, 2006). Nurses who consistently practice with moral courage base their decisions to act upon the ethical principle of beneficence (doing good for others) along with internal motivation predicated on virtues, values, and standards that they believe uphold what is right, regardless of personal risk.
Ethical values and practices are the foundation upon which moral actions in professional practice are based. Morally responsible nursing consists of being able to recognize and respond to unethical practices or failure to provide quality patient care. The foundation of quality nursing care includes nurse practice acts, specialty practice guidelines, and professional codes of ethics. Familiarity with these documents is necessary to enable nurses to question practices or actions they do not believe are right. Although a code of ethics and ethical principles can guide actions, in themselves they are not sufficient for providing morally courageous care. Moral ideals are needed to transcend individual obligations and rights. The moral commitment that nurses make to patients and to their coworkers includes upholding virtues such as sympathy, compassion, faithfulness, truth telling, and love. Nurses who act with moral courage do so because their commitment to the patient outweighs concerns they may have regarding risks to themselves.
Deciding whther to act with moral courage may be influenced by the degree of conflict between personal standards and organizational directives; by fear of retaliation, such as job termination; or lack of peer and/or leadership support. In this manuscript the authors begin by describing the concept of moral courage. Next they explore personal characteristics that promote moral courage, including moral reasoning, an ethic of care, and nursing competence. Organizational structures that support moral courage, specifically organizational mission, vision, and values; models of care; structural empowerment; shared governance; communication; a just culture; and leadership are addressed.
Moral Courage in Nursing
Nurses who act with moral courage do so because their commitment to the patient outweighs concerns they may have regarding risks to themselves. Packard and Ferrara (1988) proposed that nursing is comprised of four components. These components include: (a) taking the right actions to effect health promotion and quality of life; (b) possessing the knowledge and skills necessary to discern when and when not to respond; (c) knowing what the appropriate action(s) should be; and (d) demonstrating a willingness to act, thus supporting the ethical principle of beneficence. Nurses who are morally courageous are able to confidently overcome their personal fears and respond to what a given situation requires; they act in the best interests of their patients (Day, 2007). Nurses who exhibit moral reasoning and act with moral courage demonstrate a willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way (Lachman, 2007).
Sekerka and Bagozzi (2007) have asked "What induces people to act in morally courageous ways as they face an ethical challenge in the workplace?" (p.132). They noted that nurses practice with moral courage when they confront situations that pose a direct threat to care. For example, the nurse who questions discharging home a hospitalized frail elder who lacks the appropriate level of home care services and resources, thus jeopardizing the patient's safety and wellbeing, is acting with moral courage. This nursing response is based upon a commitment to serve and advocate for patients and the profession.
Kidder (2005) has argued that an individual who acts with moral courage is committed to moral principles, cognizant of the actual or potential risk that upholding those principles may require, and willing to endure the risk. Nurses can help their colleagues develop moral courage by reaffirming their colleagues' strengths and resolve, taking risks in helping to confront obstacles, possessing vision, remaining focused and disciplined toward the intended outcome(s), and taking actions that may go against the status quo but are necessary to do what is virtuous and principled (Walston, 2003).
Purtilo (2000) identified moral courage as a necessary virtue for healthcare professionals, one that enables them to not only survive but to thrive in changing times. Purtilo noted that morally courageous individuals respond to situations that incite fear and anxiety without knowing the end result of their response because they believe in doing what is morally right. The nurse on a general medical unit, for example, who confronts the physician who is reluctant to transfer an acutely ill patient in need of intensive care to the ICU, is acting with moral courage so as to provide safe care for the patient. Purtilo stated that "a rich understanding of care includes creativity, faithfulness to one's moral foundation, and a focus on the full significance of a situation" (p. 5). Practicing with moral courage responds to the call to act with moral conviction, even when the human tendency would be to act in ways that are incongruent with one's convictions when one perceives that personal security is endangered (Purtilo).
Personal Characteristics that Promote Moral Courage in Nursing
Nurses can enhance their ability to demonstrate moral courage in nursing by advancing their moral reasoning skills, nurturing their personal ethic of care, and enhancing their professional and cultural competence. Each of these behaviors will be discussed below.
Moral Reasoning
Kohlberg's theory of moral development provides a useful framework for understanding how one's personal ability to make moral judgments is influenced over time by personal development, knowledge acquisition, experience, and the environment (Cohen & Erickson, 2006; Ketefian & Ormond, 1988). Individuals at the highest level of moral development use their conscience to determine the right course of action by independently examining and delineating moral values and principles rather than by relying on group norms (Ketefian & Ormond, 1988). Ethical environments are characterized by shared decision making, taking responsibility for the consequences of one's actions, and utilizing opportunities for collective participation that empower individuals to develop higher levels of moral judgment (Ketefian & Ormond, 1988; Murray, 2007). Nurses who work in ethical environments are "aware of an ethical culture" (Murray, 2007, p. 48). They understand their role responsibilities and how an ethical environment supports their identification of ethical issues and concerns. They engage in meaningful ethical discussions (Murray, 2007).
The Ethic of Care in Nursing
The ethic of care is characterized by attentiveness, responsibility, competence, and responsiveness. The 'ethic of care' is not a set of rules and principles. Rather, it is a way of practicing that requires specific moral qualities that facilitate taking the right action (Tronto, 1994). The ethic of care is characterized by attentiveness, responsibility, competence, and responsiveness. Resulting actions include caring for, emotionally committing to, and being willing to act on behalf of a person with whom one has a significant relationship (Beauchamp & Childress, 1994). Nursing practice that includes the ethic of care promotes moral courage. Moral courage is enhanced in situations in which the ethic of care is present as evidenced by building consensus, promoting interdisciplinary collaboration, and positively influencing outcomes that support rather than oppose moral decision making (LaSala, 2009). Consider, for example, a nurse caring for a patient with invasive ductal breast carcinoma and spinal metastases who desires to die at home surrounded by family and assisted by a hospice team, but whose husband is hesitant about taking his wife home, fearful that he will be unable to manage her care. The nurse acts with moral courage by advocating for the patient's wishes, despite the palliative care physician's recommendation that the patient remain hospitalized given the probability of imminent death. Through effective communication and collaboration with the physician, the nurse is successful in facilitating the patient's discharge home with patient-controlled analgesia and hospice care, thus responding to the patient's wishes (LaSala, 2009). The moral qualities associated with the ethic of care enable nurses to care for patients and families during times of sickness and uncertainty, provide the inner motivation to do what is right and good, and demonstrate moral courage both within the context of patient care and from the perspective of the nurses' collegial, collaborative relationships with other healthcare professionals.
Nursing Competence
Professional competence is a prerequisite for providing morally responsible care. The elements of a profession, such as formal education based on theoretical knowledge, a code of ethics, professional organizations that guide practice, and the provision of necessary service to society (Miller, Adams, & Beck, 1993), all serve to develop professional competence. Standards for ethical conduct are also necessary in order to provide morally responsible care (Maraldo, 1992).
Leininger (1991) defined transcultural nursing as a humanistic and scientific area of formal study and practice focused upon similarities and differences among cultures with respect to human care, health, and illness that are related to cultural values, beliefs, and practices (norms). These norms include the way rights and protections are exercised, and even what is considered to be a health problem (United States [U.S.] Department of Health and Human Services, 2001). Nurses need to understand and appreciate inherent similarities and differences not only locally, but regionally, nationally, and worldwide as well. In order to provide morally competent care that respects individual values and needs, it is imperative that nurses examine their own health-related values and beliefs, as well as those of the healthcare organization in which they work; it is only then that they can support the principle of respect for persons and provide the ideal of transcultural care (Bjarnason, Mick, Thompson, & Cloyd, 2009).
Organizational Structures that Support Moral Courage
McClure, Poulin, Sovie, and Wandelt (1983) observed that certain healthcare organizations seemed better able to withstand pressure on their professional environments, experiencing less upheaval and producing higher quality patient outcomes with lower morbidity and mortality rates than 'average' healthcare organizations. These same institutions showed remarkable resilience in limiting turnover and maintaining patient and staff satisfaction. These observations resulted in nursing's recognition of Magnet hospitals, a designation that recognizes organizations in which nurses want to work and patients find healing environments (Aiken & Salmon, 1994; Aiken, Smith, & Lake, 1994; American Nurses Association (ANA,) 1998). It was noted that these organizations have in place a number of structures that enhance the quality of the care provided as well as the working environment. Structures that are described below help create the context for actualizing moral courage in nursing.
Mission, Vision, and Values
Creating the foundation for an environment that fosters moral courage among nurses requires that all stakeholders have a clear understanding of the organizational mission, vision, and values, as well the philosophy of the nursing department (Lachman, 2009). Clearly stating and supporting the mission, vision, and values sets the tone for the work of nursing in the organization, pictures a state that implies a commitment to organizational improvement, and suggests the types of activities that will ensure that the organization reaches those goals. Developing a nursing philosophy allows the organization to define itself not only to its internal community, but to its external community as well.
A nursing philosophy describes professional behaviors that hold nurses responsible and accountable for exercising moral courage when acting to achieve the organization's mission and vision. According to Shirey (2005) "clarity in an organization's mission, vision, and values is key to effective management in today's increasingly complex healthcare environment. To clearly articulate mission, vision, and values, employees must experience consistency between what is espoused and what is lived" (p. 59).
Models of Care
Professional practice models include reward and recognition systems acknowledging performance improvementalong with empowerment and engagement in the workplace. Another aspect of professional nursing that promotes moral courage in the workplace includes a professional model of care that exemplifies nursing's goal of enhancing the lives of patients and colleagues. The American Nurses Credentialing Center (AACN) (2008) has defined a professional practice model as the driving force of nursing care; a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality of care for those served by the organization (e.g. patients, families, and community). Professional practice models illustrate the alignment and integration of nursing practice with the mission, vision, and values that nursing has adapted. Fasoli (2010) has noted that autonomy, accountability, professional development, emphasis on high quality care, and delivery models that are patient centered, adaptable, and flexible provide a framework for professional practice models in nursing. Professional practice models include reward and recognition systems acknowledging performance improvement, and nurses' commitment to uphold high standards of practice predicated on a strong value system, moral courage, and quality professional relationships, along with empowerment and engagement in the workplace.
Structural Empowerment
In her theory of structural power in organizations Kanter described four structural factors within organizations that lead to empowerment (Kanter, 1983; Matthews, Laschinger, & Johnstone, 2006). She explained that employees who (a) have access to information; (b) receive support from organizational leadership, subordinates, and peers; (c) are given adequate resources to do the work; and (d) have opportunities for personal and professional development are empowered to contribute to achieving organizational goals (Matthews et. al., 2006; Ning, Zhong, Libo, & Qiujie, 2009). Empowerment may come from within, collectively as in work groups, or from the work environment (Manonlovich, 2007). Nurses who are empowered take control of their practice and participate in decision making at the point of care, thus strengthening a professional practice model and promoting positive patient care outcomes.
An example of this empowerment would be that of Nurse M, who heard other nurses on the unit discussing how patients assigned to Nurse J had recently complained of not receiving pain medication when requested. The nursing staff had recently observed notable changes in Nurse J's behavior as evidenced by being unwilling to help out, less engaged, and easily angered. One evening after receiving report from Nurse J, one of Nurse M's patients stated to her that he was in acute pain and had not received any pain medication from the nurse on the previous shift. Upon reviewing the patient's medication record, Nurse M found that Nurse J had documented that the patient received narcotic analgesia every four hours that shift. This information was also recorded in the unit's automated medication system. The following day, Nurse M discussed her findings with her nurse manager, who has a reputation for supporting, developing, and empowering her staff. Nurse M did this not only out of concern for that patient's safety and wellbeing but also because of her compassion for Nurse J whom she had known in the past as a trusted colleague and competent nurse. The nurse manager recognized Nurse M's moral courage in coming forward, and spoke with Nurse J who became emotionally distraught, admitting to drug diversion and problems with substance abuse. Although Nurse J resigned her position, the nurse manager continued to offer her support and resources to assist in her rehabilitation. Organizational factors, such as those described in this example, including open and supportive leadership, adequate resources, and professional development empower nurses to act and promote moral courage in the workplace.
Shared Governance
Shared governance promotes collaborative decision making and shared responsibility; it empowers nurses to act with moral courage by taking ownership of their practice at the point of care. Shared governance has been described as "a managerial innovation that legitimizes nurses' control over practice, extending their influence into administrative areas previously controlled only by managers" (Hess, 2004, p. 2). Research has demonstrated several positive outcomes of shared governance, including increased nurse satisfaction and retention and a more motivated, engaged nursing staff (Bretschneider, Glenn-West, Green-Smolenski, & Richardson, 2010). Work environments in which shared governance is firmly embedded facilitate active involvement of frontline staff in the creation of a professional practice model that promotes quality patient care outcomes.
Practicing in a shared governanc environment enables the nurse to act with moral courage when aggressive treatment of a patient based on the family's wishes continues, despite the patient's expressed wishes that it be withdrawn. In such a situation, out of duty to the patient and to self, the morally courageous nurse will advocate for the patient by initiating conversations with other care providers, consulting with the hospital ethics committee, and utilizing other appropriate resources to engage the family and patient in meaningful discussion that can result in consensus around the goals of care. Nurses practicing in shared governance settings have access to the information and resources they need to make effective decisions, create change, and influence outcomes (Hess, 2004).
Communication
Nurses act with moral courage when they use the chain of command to share and discuss issues that have escalated beyond the problem-solving ability and/or scope of those immediately involved. The Joint Commission (TJC) requires that organizations respect the patient's right to, and need for effective communication; it directs organizations to take action to address communication needs (TJC, 2009). The strength of this directive is based upon overwhelming evidence from TJC's sentinel event database indicating that communication is cited as a root cause in nearly 70 percent of reported sentinel events, surpassing other commonly identified issues, such as staff orientation and training, patient assessment, and staffing (Joint Commission Resources, n.d.).
Every day nurses and their healthcare colleagues are confronted with challenging situations where effective communication is essential, while at the same time fraught with difficulty. Assertive communication is the act of stating a position with assurance. It is an honest, direct, and appropriate means of communicating that focuses on solving a problem (Lachman, 2009). The use of assertive communication is imperative not only to patient safety and to quality patient care, but also to invoking the chain of command. Nurses act with moral courage when they use the chain of command to share and discuss issues that have escalated beyond the problem-solving ability and/or scope of those immediately involved. Engaging the chain of command both ensures that the appropriate leaders know what is occurring and allows for initiating communication at the level closest to the event, moving the discussion upward as the situation warrants.
Just Culture
The concepts of effective communication and chain of command are inherent in a position statement recently published by the ANA. The 'just culture' model seeks to create environments that incentivize rather than punish error reporting. In a just culture, individuals are not held accountable for system problems over which they have no control. A just culture recognizes that patient care safety and quality is based on teamwork, communication, and a collaborative work environment (ANA, 2010). Just culture environments enhance moral courage in the workplace.
Leadership
Nurse leaders demonstrate moral courage when they oppose work environments that put patient safety at risk. For example, chief nurses act with moral courage when they firmly oppose cost-containment measures, such as nursing layoffs or reductions in healthcare services, that would jeopardize the delivery of safe, competent patient care. Nurse leaders can create environments that support moral courage by clearly providing guidelines for nurses to use when they observe unethical practices and by providing resources, such as ethics committees, shared governance structures, and mentoring opportunities that enable nurses to confront ethical dilemmas in practice (Murray, 2007).
All nurses can demonstrate leadership by role modeling ethical behaviors based on established nursing practice standards. They can also recognize colleagues and peers when they uphold ethical principles and demonstrate moral courage, and work to develop and implement policies and procedures that facilitate effective responses to moral distress at the point of care (Murray, 2007).
Conclusion
Nurses who possess moral courage embrace the challenge of transforming the profession and the workplace. They are the nurses who question the premature discharge of an elderly patient with no social support and limited resources, refuse to administer a medication whose efficacy or dosage they question, challenge those who treat others unjustly, or speak up when others remain silent.
Nurses who act with moral courage take risks knowing that they may encounter lateral violence, including bullying, harassment, or sabotage, as well as risk of termination. Nurses practicing with moral courage know that addressing these issues is leadership in action, the type of leadership that began with Florence Nightingale -- who role modeled moral courage on the battlefield, in the classroom, at the bedside, and among legislators in advocating for the rights of patients, colleagues, and humanity. In her writings on leadership, perhaps Nightingale said it best:
What is our needful thing? To have high principles at the bottom of all. Without this, without having laid our foundation, there is small use in building up our details. This is as if you were to try to nurse without eyes or handIf your foundation is laid in shifting sand, you may build your house, but it will tumble down (Ulrich, 1992, p.40).
the accountability and responsibility for creating environments that promote moral courageis an obligation shared by all nurses, in every role, in every specialty, in every setting. Nurses have obligations to patients, one another, and the global community to assure optimal health, personal wellbeing, and quality of life for all with whom they come in contact. In her seminal publication, Nursing Speaks for Itself, Margretta Styles (2006) described the transformation that needs to occur in nursing, writing, "There is a give and take to empowerment, so nursing must be prepared to reshape the health care environment and act as its full partner. Both the culture of the profession and the culture of the workplace must be transformed (p. 10)."
Challenges in the care environment are myriad. All professional nurses assume the responsibility for serving as patient advocates and role models. This duty exists whether nursing practice occurs at the bedside, in the classroom, in the board room, or in the research setting. Quite simply, the accountability and responsibility for creating environments that promote moral courage in practice and transform the workplace is an obligation shared by all nurses, in every role, in every specialty, in every setting.
References
Aiken L. & Salmon M. (1994). Health care workforce priorities: What nursing should do now. Inquiry 31, 318-329.
Aiken L., Smith H. & Lake E. (1994). Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care, 32(8), 771-787.
American Nurses Association (2010). Just culture. Retrieved March 31, 2010, fromwww.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/ 2010-PR/ANA-Statements-Affecting-Nursing-Practice.aspx
American Nurses Credentialing Center. A new model for ANCC's magnet recognition program. Retrieved March 17, 2010, from: www.nursecredentialing.org
Beauchamp, T. L. & Childress, J. F. (1994). Principles of biomedical ethics. (4th Ed.). New York: Oxford University Press.
Bjarnason, D., Mick, J., Thompson, J. A., & Cloyd, E. (2009). Perspectives on transcultural care. In D. Bjarnason and M. A. Carter (Eds.), Nursing Clinics of North America: Legal and Ethical Issues: To Know, To Reason, To Act (pp. 495-503). Philadelphia: W.B. Saunders.
Barden, C. (2008). Breaking down the wall of silence to create healthy work environments: An interview with author Rosemary Gibson. AACN Advanced Critical Care, 19(1), 16-18.
Bretschneider, J., Glenn-West, R., Green-Smolenski, J., & Richardson, C. (2010). Strengthening the voice of the clinical nurse: The design and implementation of a shared governance model. Nursing Administration Quarterly, 34(1), 41-48.
Cohen J. S. & Erickson, J. M. (2006). Ethical dilemmas and moral distress in oncology nursing practice. Clinical Journal of Oncology Nursing, 10(6), 775-780.
Day, L. (2007). Courage as a virtue necessary to good nursing practice. American Journal of Critical Care, 16(6), 613-616.
Fasoli, D. R. (2010). The culture of nursing engagement: A historical perspective. Nursing Administration Quarterly, 34(1), 18-29.
Hess, R. G. (2004). From bedside to boardroom -- nursing shared governance. Online Journal of Issues in Nursing. Retrieved July 18, 2010, fromwww.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/TableofContents/Volume92004/No1Jan04/FromBedsidetoBoardroom.aspx
Joint Commission Resources (n.d.). Robert Wood Johnson Foundation. Retrieved March 31, 2010, from www.dev.icps.jcrinc.com/Products-and-Services/Conferences-and-Seminars/ Robert-Wood-Johnson-Foundation-Communication/
Kanter, R. M. (1993). Men and Women of the Corporation. New York, NY: Basic Books.
Ketefian, S. & Ormond, I. (1988). Moral reasoning and ethical practice in nursing: An integrative review. National League for Nursing, New York, Publication Number 15-2250.
Kidder, R. M. (2005). Moral courage. New York: Harper Collins Publishers.
Lachman, V. D. (2009) Developing your moral compass. New York: Springer Publishing.
Lachman, V. D. (2007). Moral courage: A virtue in need of development? MedSurg Nursing, 16(2), 131-133.
LaSala, C. (2009). Moral accountability and integrity in nursing practice. In D. Bjarnason and M. A. Carter (Eds.), Nursing Clinics of North America: Legal and Ethical Issues: To Know, To Reason, To Act (pp. 423-434). Philadelphia: W.B. Saunders.
Leininger, M. (1991). Transcultural nursing: the study and practice field. Imprint, 38, 55-66.
Manojilovich, M. (2007). Power and empowerment in nursing: Looking backward to inform the future. Online Journal of Issues in Nursing. Retrieved July 18, 2010, from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/LookingBackwardtoInformtheFuture.aspx
Maraldo, P. J. (1992). NLN's first century, Nursing & Health Care, 13(5) 227-228.
Matthews, S., Spence Laschinger, H. K., & Johnstone, L. (2006). Staff nurse empowerment in line and staff organizational structures for chief nurse executives. Journal of Nursing Administration, 36(11), 526-533.
McClure, M., Poulin M., Sovie M. & Wandelt M. (1983). Magnet hospitals: Attraction retention of professional nurses. Kansas City, MO: American Academy of Nursing.
Miller, B. K., Adams, D., & Beck, L. (1993). A behavioral inventory for professionalism in nursing. Journal of Professional Nursing, 9(5) 290-295.
Murray, J. S. (2007). Creating ethical environments in nursing. American Nurse Today, 2(10), 48-49.
Ning, S., Zhong, Z., Wang, L., & Qiujie, L. (2009). The impact of nurse empowerment on job satisfaction. Journal of Advanced Nursing, 65(12), 2642-2648. doi:10.1111/j.1365-2648.2009.05133x
Nightingale, F. (1914). Florence Nightingale to her nurses: A selection from Miss Nightingale's addresses to probationers and nurses of the Nightingale School at St. Thomas' Hospital. London: Macmillan & Co. (p. 90; May 26, 1875, Address).
Packard, J. S. & Ferrara, M. (1988). In search of the moral foundation of nursing. Advances in Nursing Science, 10(4), 60-71.
Pendry, P. S. (2007). Moral distress: Recognizing it to retain nurses. Nursing Economics, 25(4), 217-221.
Purtilo, R. B. (2000). Moral courage in times of change: Visions for the future. Journal of Physical Therapy Education, 14(3), 4-6.
Sekerka, L. E. & Bagozzi, R. P. (2007). Moral courage in the workplace: Moving to and from the desire and decision to act. 16(2), 132-149.
Shirey, M. R. (2005). Ethical climate in nursing practice: The leader's role. Journal of Nursing Administration's Healthcare Law, Ethics, and Regulation, 7(2), 59-67.
Styles, M. M. (2006). Nursing speaks for itself: A declaration on the education and work environment of the nurseforce. American Nurses Association. Silver Spring, MD: Nursebooks.org.
The Joint Commission (2009). The Joint Commission 2009 requirements that support effective communication. Retrieved March 31, 2010, fromwww.jointcommission.org/NR/rdonlyres/B48B39E3-107D-496A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf
Tronto, J. C. (1994). Moral boundaries: A political argument for the ethic of care. New York: Routledge, Chapman, and Hall.
Ulrich, B. T. (1992). Leadership and management according to Florence Nightingale. Norwalk, CT: Appleton & Lange.
U.S. Department of Health and Human Services. (2001). National standards for culturally and linguistically appropriate services in health care. Retrieved June 4, 2009, from www.omhrc.gov/assets/pdf/checked/finalreport.pdf
Walston, S. F. (2003). Courage and caring: Step up to your next level of nursing excellence. Patient Care Management, 19(4), 4-6.
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By Cynthia Ann LaSala, MS, RN and Dana Bjarnason, PhD, RN, NE-BC
Cynthia Ann LaSala, MS, RN is a Clinical Nurse Specialist in general medicine at Massachusetts General Hospital (MGH). Ms. LaSala has extensive experience in clinical and educational roles and more than 30 years of professional organizational experience, serving in a variety of positions at local, state, and national levels. In 2006, Ms. LaSala was appointed to a four-year term on the Ethics Advisory Board for the American Nurses Association Center for Ethics and Human Rights. She has a vested interest in the specialty of ethics and is currently the coach for the MGH Patient Care Services Ethics in Clinical Practice Committee (EICP), a member of the EICP Advance Care Planning Task Force, the MGH Ethics Task Force, the American Society of Bioethics and Humanities (ASBH), and the ASBH Nurse Affinity Group. Ms. LaSala has authored and co-authored journal manuscripts, textbooks, and newsletters and has presented on a variety of clinical and educational topics.
Dr. Bjarnason serves as the Associate Administrator & Chief Nursing Officer for the Ben Taub General Hospital and the Quentin Mease Community Hospital in Houston, Texas. Dr. Bjarnason is active in a number of professional nursing organizations, including the American Nurses Association (ANA), where she serves as an appointed member of the ANA Board of Ethics and Human Rights; the Texas Nurses Association District 9; Sigma Theta Tau - Alpha Delta Chapter; the Southern Nursing Research Society; and the American Organization of Nurse Executives. She has authored/co-authored several peer-reviewed articles for professional journals. In addition to healthcare regulation and accreditation, Dr. Bjarnason's interests include patient self-determination, end-of-life care, advocacy, professionalism, and practice. She was awarded a doctorate in nursing from the University of Texas Medical Branch Graduate School of Biomedical Science (Galveston) in 2007 and has been a certified nurse executive since 1999.
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Copyright of Online Journal of Issues in Nursing is the property of American Nurses Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Source: Online Journal of Issues in Nursing, 2010; 15(3)
Item Number: 2010890002

You are to write a 6-page paper. For Outside Sources, Use Internet Only!

PERSONAL DEVELOPMENT PLAN (PDP)
The Personal Development Plan has three major parts: an Analysis Part, a Planning/Goal Setting Part, and a Timetable. You will engage in a self-analysis of your leadership experiences and styles as well as your experience with others in positions of leadership. The purpose of this exercise is to clarify where you are individually in terms of your desire and motivation to be a leader (Participative Leadership), what type of leader you would like to work for (or not work for), what types of leadership situations would complement you and your style, what strengths you (could) bring to leadership situations, and what challenges you(could) face in leadership situations.

The write-up for this first part should, in detail, describe your most critical leadership challenges and explain why you have them (using examples/behaviors), including what specific problems/successes they are now causing, or have caused, you and others in the past(Remember you are a Participative Leader).

The second part asks you to look at your analyses and propose a plan for developing your leadership strengths by putting yourself in contexts in which you might use those strengths to overcome the challenges you identified. The plan should also look at reducing or eliminating those characteristics that challenge you in leadership situations, again by putting yourself in roles and places that force you to use your skills or by learning to cope in different ways with those challenges. There is no set format for this plan, but you should bring as much detail as possible to it so that you can implement it with relative confidence.

The third part asks you to lay out a timetable for the specific behaviors you will change or development actions you will take.

A good way to structure your Personal Development Plan is as follows:

Describe the competency or skill or principle you would like to develop or improve upon. Include both the conceptual description of the skill or competency (e.g., Conflict Resolution Techniques are methods for dealing with conflict. There are several strategies, such as avoidance, cooperation, and collaboration.) and the practical/applied description for you (e.g., In most conflict situations I tend to use the avoidance technique and would like to begin to develop my ability to collaborate.....). In this section you will also want to include things you are particularly good at or strengths that you demonstrate. Both the challenges and the strengths can be demonstrated in either (or both) your work or non-work lives. Remember: Sometimes it is merely that you are using a strength at an inappropriate place or time that is causing you the challenge!

Next, you need to do an analysis of situations that use the competency or skill and determine (a) what is causing you to use the skill poorly or preventing you from using the skill appropriately, (b) what you do when faced with a situation/ environment calling for the application of the skill, and (c) what the result of your behavior is. This is called a "functional analysis" or an "A-B-C" analysis (Antecedent, Behavior, and Consequence). One way to figure this out is to use a journal to record your "Antecedents, Behaviors, and Consequences."

Once you know what is causing or preventing the use of the competency or behavior, then you can formulate a plan to develop or stop it. This is the crux of this project, so, pay particular attention here. It is not enough to say something like, "I will try harder to be more patient and understanding." You cannot change behavior and habits by the mere force of will. You need an action plan of what you will do and a timetable for accomplishing and measuring it. Chart I is an abbreviated example to show you what constitutes a skill, a cause, a strategy, a measurement, and a time table. (Yours should be in chart form, with a narrative form that provides more detail and explanation.)

There are a number of developmental strategies, such as reading more about the subject or skill, additional training, getting counseling, getting a mentor/coach, engaging in planned behavioral changes, etc. You need to have at least one (and more is better!) for each of the competencies you choose.

There are a number of ways to measure your progress and outcomes: behavioral observations (e.g., doing things differently), feedback from others (e.g., from coworkers, mentor, friends, family), outcome assessments (e.g., taking less work home, spending less time on Problem X), and self-evaluation (e.g., reflections on feelings, thoughts, stress levels). In essence, if you can observe or report changes and/or you can measure them. You'll need to decide how you will know when a change has really been made.



There are faxes for this order.

Introduction
In this assignment you will be asked to submit a recommendation to local government
(of a town called Little Whinging, a remote village in Queensland, Australia). This governing body has recognized the importance of dealing with their aging population. In fact, like much of the rest of the world, the Little Whinging population is growing old. Infant mortality is down, as is the average number of children being born per year. In addition, life expectancy is increasing. This means that Little Whinging estimates that around 1/5 people living in Little Whinging will be over 65 by the year 2030. By the year 2050 Little Whinging data crunchers warn that this number may rise to 25% of the population (1/4). As such, they are focusing heavily on preparing for the future. They love their village, and they care about their population, its sustainability, and the health of young and old residents. The important thing to know about Little Whinging, however, is that they are really interested in making evidence-based decisions for how to proceed in their village. The Mayor is scientifically literate, as are most of the members on the committee that will be making decisions about where to focus the bulk of their efforts (and budget). They want to make sure that they are not just operating on instinct. Rather, they want to know how they should move forward on the basis of what the existing empirical evidence suggests is effective. They do have some limitations, however. They are politicians after all. This means that while they want to do the absolute best that they can, they also have financial restrictions. Accordingly they are looking for evidence-based suggestions that are feasible financially (or at the very least, justifiable financially). Being sensible, they know that psychologists are best placed to answer their question: How should they move forward? They have therefore put out a public call for submissions. They want psychologists to make a series of recommendations about what they should do. They are going to evaluate all reports, and take the recommendations of the one that makes the most sensible, and practical recommendation (on the basis of the literature). Your task is to write that submission. The government of Little Whinging has strategic plans for moving forward. It wants to enact policies or strategies that work on retaining older adults in the workforce. Your task is to write a proposal to be submitted to the Little Whinging Committee for Aging.

Essay Question : Keeping Older Adults in the Workforce

From the Little Whinging Brief: Mayor McGonagall calls for an evidence based report on how Little Whinging should move forward in its goal of keeping older adults in the workforce. Specifically, she asks that the report focus on making:
*Two recommendations for how to keep older adults healthy, and in the workforce, or to promote workforce acceptance of older employees. She asks that those preparing the submissions choose carefully ? she wants to know what two factors specifically Little Whinging should concentrate on in order to keep older adults in the workforce. This will mean carefully evaluating factors that keep older adults healthy and active at work, or older adults in the workforce in general, and weighing the relative importance of them. Remember too that these should be malleable factors. Changing the personalities of older adults in the workforce is likely unfeasible. Other things, however, are well suited to intervention.
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In making recommendations she asks that they are rigorously supported by literature, and that the choice of each factor is justified briefly with regard to competing suggestions (e.g., why did you choose this factor, why is it so important?). In addition, she asks that you acknowledge any barriers that might exist in actually implementing the two chosen strategies to keep older adults in the workforce. Finally, she asks that financial feasibility be taken into account. This might involve weighing the cost of losing older employees, and having more older government dependents, vs. implementing the strategies. Financial benefits that might emerge downstream as a consequence of keeping older adults in the workforce could also be highlighted. In addition, it is possible that factors such as adult happiness or health in the workforce could be argued as offsetting costs.
* One recommendation for something that should not be done if the goal is to promote keep older adults in the workforce. This could be a firm recommendation for a strategy not to use, or alternatively, a recommendation about something that needs to be reduced through intervention (e.g., attitudes of business owners or human resources managers). As above, justifications must be made as to why this factor was chosen, as well as an acknowledgement of any barriers, and an assessment of feasibility (either of implementing a program to reduce some factor).The report should be prefaced with a brief introduction highlighting that the population is aging (this can be globally, as it is unlikely you will have specific statistics about Little Whinging ? they do not use the internet much). The goal should also be outlined, with relevant definitions (e.g., what is healthy aging? What do we mean by independent? Do we have problems keeping older adults in the workforce?). A conclusion should sum up the main points of the report, and end with a pithy reiteration of recommendations.
General Guidelines for the Assignment
1. This is a *little* bit like a report:
A. You can include subheadings (e.g., Recommendation #1: Promoting Health in Older Adults)
B. You can mention Little Whinging and Mayor McGonagall (e.g., ?Little Whinging is building a retirement village, and has called for submissions including recommendations for how best to build a retirement village that promotes both health and happiness in its residents. In this report I make three recommendations on the basis of empirical evidence that will assist Little Whinging in meeting their goal.?
C. You can discuss real-world examples of where certain practices have worked, or refer to government policies (in Australia or overseas) that concern aging or aged care. Having said this, it is vital that all such examples are referenced (see below ? APA 6). In addition, pick your source carefully. Facebook or reddit, for example, is probably not the best place to reference for information. Likewise Wikipedia. You can reference websites, however - again, look for government reports, official websites of programs that have been running etc. It is likely (and recommended) that the bulk of your references will be to empirical studies, reviews, meta-analyses etc.
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D. We are asking you to discuss feasibility. This may come as a challenge, as it is not something we typically do. This should only be a few sentences for each recommendation (well cited, of course). Note, we are not asking you to do a formal cost-benefit analysis. Rather, you should imagine that you are trying to make the argument for your recommendation, and want to reassure the government official ? this is feasible, or even if it is expensive, it is worth it. Feasibility *could* cover:
i. Talking about any estimated saving for the government (e.g., you could find some evidence that depression in older adults is generally costly (would be fine to use a US statistic here) and argue that while the implemented program may involve costs, it will likely save money down the road).
ii. An acknowledgement that the program or intervention will be costly, but a justification based on moral grounds (e.g., while the program will be costly, the government?s goal is to happiness and health in older adults, thus the cost is reasonable).
iii. A reference to an example of where a similar strategy has been implemented successfully (e.g., in Japan, fitness programs for the elderly have been running for years, and appear to be paying off).

References that may be of assistance

Aged Care Act. (1997). Retrieved from
http://www.comlaw.gov.au/Details/C2013C00389

Baltes, P. B. (1991). The many faces of human ageing: toward a psychological culture of
old age. Psychological Medicine, 21(04), 837?854.

Baltes, P. B., Baltes, M., Freund, A., & Lang, F. (1999). The measurement of selection,
optimization, and compensation (SOC) by self report: Technical report 1999.
Max-Planck-Institut f?r Bildungsforschung.

Baltes Paul, B., & Baltes, M. M. (1990). Successful aging: Perspectives from behavioral
sciences.

Breyer, F., & Felder, S. (2006). Life expectancy and health care expenditures: a new
calculation for Germany using the costs of dying. Health Policy, 75(2), 178?186.

Browning, C. J., & Thomas, S. A. (2005). Behavioral change: An evidence-based
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?


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Writter:pheelyks
Lecture and Theory:
In the description section of the paper, articulate a critical appraisal of the evidence (i.e., a description of whether the evidence is valid and applicable to the individual patient situation at hand) and create an annotated bibliography. In essence, this section is a synthesis of the evidence found. Synthesizing the evidence gives students a sense of how the studies in the literature relate to each other.

It is often helpful to use a summary table, such as the one shown below, to outline what is learned from the literature. This kind of table allows a clinician to review each study's relevance, methodology, quality, and findings, which can then be compared to their own experience and knowledge and from which conclusions can be drawn.

There is an expectation that clinicians adopt research evidence into the decision-making efforts to change their practice. However, clinicians know it is not that simple. Clinicians have not been necessarily known to read the latest research, make a decision, and then change practice. Why?

One, clinicians do not practice in silos; their decisions are influenced by local, state, and national policy, by administrators, and by other healthcare professionals.

Two, clinicians have different ways of knowing. Clinicians face a real challenge when trying to incorporate their experiences with the best evidence. Carper (1978) identified four fundamental patterns of knowing in nursing:

1) Empiric

2) Ethical

3) Personal

4) Aesthetic patterns





Three, as Melnyk and Fineout-Overholt (2004) note, "In any clinical setting, there are numerous information resources to answer a variety of questions about patient care or about clinical procedures and protocols" (p. 205). Although there is an expectation that clinicians keep up with the latest research and adopt the latest practices, depending on the resources clinicians have, they may not be able to get critical, succinct, appraisal of literature at the point-of-care delivery in a timely manner (Pipe, Wellik, Buchda, Hansen, & Martyn, 2005).



Critically Appraising the Evidence


The process of formulating a clinical question, placing it into a PICO format, and collecting the best and most relevant evidence to answer the question should help students consider possible strategies and solutions to develop an implementation plan. The annotated bibliography assists in reviewing the relevance, accuracy, and quality of the sources cited. What follows is to critically appraise the evidence for validity, relevance, and applicability. Key questions to ask in the evidence appraisal are (Melnyk and Fineout-Overholt, 2004, p. 13):

What were the results of the study?

Are the results valid?

Will the results help me in caring for my patients?





Validity describes assertions, conclusions, or intellectual processes that are persuasive because they are well founded on good research design and control. What is valid is based on the best available approximation to the truth for a given proposition, inference, or conclusion.

Clinicians encounter clinical questions on a daily basis. Patients, staff, and peers seem forever to be reading, seeing, and hearing new information on the news, on the Internet, in journals, newspapers, and in a variety of other ways. Asking questions should lead to change of practice or to affirm that what is already being done is being done well. As a matter of fact, clinical questions should lead clinicians to clinical inquiry, and clinical inquiry should lead the practitioner to research.



Synthesizing the Literature


What was the goal? Was it to provide supporting evidence for an idea, or was it to answer a clinical question? Was it to develop a new project/policy, or to help make a clinical decision? The emphasis of the synthesis should be on the original goal.

Compare and contrast the literature found. Note the consistencies and differences across the studies. Draw conclusions, and then propose one or two strategies for solving the problem. Defend the rationale for choosing the strategies, and describe the expected outcomes of the strategies. There are various models to help build strategies, but foremost in the mind should be the purpose of the project. According to Melnyk and Fineout-Overholt (2004, p. 186).



Article Summary


The article summary, conducted in this course as an annotation, is a brief descriptive and evaluative paragraph. The purpose of the annotation is to inform the reader of the relevance, accuracy, and quality of the sources cited. A literature review is not a summary, but a conceptual organized synthesis of the results of the search. It is an organized presentation that defends the problem, proposed solution and strategies. The synthesis of the literature review explains what is known or not known in the literature (the gap). A good literature review presents both pros and cons of an issue. According to LoBiondo-Wood & Haber (1998) characteristics of a relevant review of literature reflects critical thinking and includes:

Purposes of a literature review were met.

Summary is succinct and adequately represents the reviewed source.

Critiquing (objective critical evaluation) reflects analysis and synthesis of material.

Application of accepted critiquing criteria to analyses for strengths, weaknesses, or limitations and conflicts or gaps in information as it relates directly and indirectly to the area of interest.

Review consists of mainly primary sources [versus secondary sources]

Sufficient numbers of sources are used, especially data based sources

Summarizes material rather than continually quoting content

Critiques of studies are presented in a logical flow ending with a conclusion or synthesis of the reviewed material that reflects why the study, project.



Nursing Theory


According to Polit and Beck (2006), a theory, "simply statedis a systematic, abstract explanation of some aspect of reality" (p. 33). Nursing theory is the term given to the body of knowledge used to support nursing practice. The aim of nursing theory is to describe, explain, predict, or prescribe nursing practice. Theories are called descriptive theories, describing characteristics found in a phenomenon; explanatory theories, describing relationships among the dimensions of the phenomena; predictive theories, predicting relationships between the characteristics of the phenomena; and prescriptive theories, which address nursing therapeutics and the consequences of interventions.

Researchers may begin with a theory, conceptual model, or framework with which to frame the research findings. In other words, if the theory were true, would the finding make sense? Would it describe what is being done or explain the phenomena under study? Would it help predict a possible outcome or allow us to prescribe a particular treatment?

Nursing theory, like many other theories, is guided by the use of common language, identification of concepts, and definition of relationships and structured ideas. It attempts to guide how the profession of nursing conducts research (or inquiry), communicates practice, and provides a mechanism for predicting outcome of nursing practice. Theories can be tested by the researcher (Polit and Beck, 2006).

Some nursing theories include: Leininger's Theory of Culture Care Diversity and Universality, Newman's Theory of Health as Expanding Consciousness, Parse's Theory of Human Becoming, Orlando's Theory of the Deliberative Nursing Process, Peplau's Theory of Interpersonal Relations, Azjen's Theory of Planned Behavior, Bandura's Social Cognitive Theory, and Watson's Theory of Human Caring.

Conceptual models are more loosely structured than theories and broadly present an understanding of the phenomenon of interest. They offer broad explanations of the nursing process but are not directly testable by the researcher (Polit and Beck, 2006). Some conceptual models include: Johnson's Behavioral System Model, King's General Systems Framework, Levine's Conservation Model, Neuman's Systems Model, Orem's Self-Care Framework, Rogers' Science of Unitary HumanBeings, Beckers' Health Belief Model, and Roy's Adaptation Model.

According to Polit and Beck (2006, p. 195), "Not every study has a conceptual model or theory but every research should have a framework." Frameworks are often derived from various disciplines and offer an orienting world view. A framework is a set of assumptions, concepts, values, and practices that constitute a way of viewing reality. A theoretical framework is based on a theory, and a conceptual framework is based on a conceptual model. Some frameworks include: a biomedical framework, ethical frameworks, community health frameworks, cultural frameworks, etc.



Change Theory


"Social change is important to study because a full understanding of many topics, such as the success or failure of different political systems, globalization, democratization, development and economic growth, are all rooted in this basic idea of social change" (Shackman, Liu, and Wang, 2004). Change theory is often used in managing organizational change with large groups. They often were based in social and organizational psychology and often focus on application of systems theory (Senge, 1994). Often the focus is from clinical/social psychology that addresses attitude changes. Theories of change link outcomes and activities to explain how and why the desired change is expected to come about. Change theory usually has a rigorous plan for success, an evaluation of outcomes at various stages, and an explanation as to why the steps or the initiative worked or did not work.

There are several change theories: Environmental Change Theory, social change theory. Kurt Lewin's change theory, behavioral change theory, systems and organizational change theories, to name a few. When creating an implementation plan, it is important to consider some type of change theory.




CONCLUSION:

Melnyk and Fineout-Overholt's (2004) systematic review on the effectiveness of strategies to change practice (p. 214) includes the following:

Passive dissemination of research is ineffective

A range of interventions has been shown to be effective in changing the behavior of healthcare professionals

Multifaceted interventions are more likely to be effective than a single intervention

Individual practitioners' beliefs, attitudes, and knowledge influence their behavior, but other factors, including organizational, economic, and community environments, also are important

A diagnostic analysis should be conducted to identify barriers and supportive factors likely to influence the proposed change in practice

Successful strategies to change practice need to be adequately resourced and require people with appropriate knowledge and skills


Review of the Literature

(1) Write a 1500-2000 word paper in which you:

(2) Analyze and appraise each article to support your problem, purpose, and solution.

(3) Group the analysis based on content of the article and the support for your project.

(4) This section should build and support your case in the readers mind of why your problem, purpose, and proposed solution are valid.

(5) Remember, you are building an argument to prove your case to do this project, this is not simply an article review!

ii) Incorporating a theory

(1) In addition to the Review of the Literature and Theory, write a 250-500 word paper in which you:

(2) Find a theory that will assist you in your implementation or support your solution to your problem.

(3) Describe this theory in simple terms

(4) Describe why this theory supports your project

(5) Describe how you will incorporate this theory

i) Use APA format including a title page, introduction, and conclusion. An abstract is not required. Cite in-text and in the References section.

Marketing Major Learning Objective: Demonstrate effective written and oral communication skills consistent with the professional marketing environment (COMM)

Course Objective 6: Create customer experiences that result in behavioral changes.

Most companies today that are serious about their customer relationships will have some sort of service promise. This would include guarantees, warranties, or other policies and procedures purporting to offer total customer satisfaction as part of its overall customer relationship management approach.

Please select a company of your choice(BALLYS TOTAL FITNESS AND HEALTH CLUB), preferably one with whom you have done business and had the opportunity to test the companys service promise, and post your choice in the Case Study Assignment conference area for approval by the end of Week 4. A copy or link to the companys guarantee/warranty or other text explaining their policies must be included in your company selection.

Retrieve and read the following article available in your Reserved Readings or through the UMUC virtual library retrieved through Business Source Premier:

Hart,a Christopher W.L. (1988). The Power of Unconditional Service Guarantees. Harvard Business Review, 66(4), 54-62.

The customer relationship concepts discussed in this article, your text, and any additional research you may conduct on the value of service promises and competitive service promises will provide the framework for your case study.

Prepare your case study by addressing each of the following questions:

Does the guarantee promise unconditional customer satisfaction as defined by Hart?
Is the guarantee easy to understand and communicate?
Is the guarantee meaningful in that it guarantees those aspects of service that are most important to the customer, including the customer's time and risk, and meaningful relative to the price of the product or service?
Is the guarantee easy for the customer to invoke?
How difficult is it for the customer to collect on the guarantee?
Compare and contrast the service guarantee with at least two other direct competitors.
What recommendations for improving your companys guarantee based on the principles and practices discussed in the text and in the Hart article would you suggest?
Submission requirements are as follows:

Paper should be at least seven pages, but no more than ten pages, of double-spaced text.
These page requirements should not include title page, exhibits, copy of guarantee or other supplemental text.
Writing must reflect college-level analysis, composition, and style such as MLA or APA.
Name and page number should appear on each page.
(For online courses) Save your work in a .doc or .rtf file only.
Submit your .doc or .rtf file in your assignment folder as an attachment (or to your faculty member) by the end of Week 9 as published in the course schedule
Please note the following grading rubric will be used by your faculty member when assessing your case study. This case study is as much a paper on customer service as it is on your ability to think and write at an acceptable college level.




Grading Rubric

CRM content - selection
5-4
3-2
1-0
5-0

Company selection is appropriate for the assignment and copy of the service promise is attached as an exhibit.
Company selection is highly appropriate and service promise attached
Company selection is appropriate or service promise attached
Company selection inappropriate and no service promise attached


CRM content - Harts six criteria
5-4
3-2
1-0
(5-0) *5=25-0

Q1. Discussion on the guarantee promise unconditional customer satisfaction as defined by Harts six criteria
Fully discusses and critiques the companys guarantee promise unconditional customer satisfaction as defined by Harts six criteria
Adequately discusses and critiques the companys guarantee promise unconditional customer satisfaction as defined by Harts six criteria.
There is a serious problem with the discussion.


Q2. Is the guarantee easy to understand and communicate?
Fully explains and critiques the companys service promise communications
Adequately explains and critiques the companys service promise communications
Minimal explanation or critiques of the companys service promise communications


Q3. Defends a position as to the meaningfulness of the service promise
All aspects of the service promise are comprehensively considered with supporting arguments.
All aspects of the service promise are considered with adequate arguments
Minimal aspects of the service promise are considered


Q4. Explanation of processes or procedures for invoking the service promise
Fully explains the companys processes or procedures for invoking the service promise
Adequately explains the companys processes or procedures for invoking the service promise
Minimal explanation of the companys processes or procedures for invoking the service promise


Q5. Explains how easy or difficult it is for the customer to collect on the guarantee.


Fully discusses the ease or difficulty of invoking the service promise
Adequately discusses the ease or difficulty of invoking the service promise
Minimal discussion of the ease or difficulty of invoking the service promise


CRM content ??" Competitive Comparison
15-11
10-6
5-0
15-0

Q6) Compare and contrast the service guarantee with at least two other direct competitors.
Two direct competitors are compared and contrasted with the subject company on all relevant dimensions.
Two direct competitors are compared and contrasted with the subject company on some of the dimensions.
Major problem either:

> Not compared with 2 competitors

> Minimal comparison on relevant dimensions


CRM content ??" Recommendations
5-4
3-2
1-0
5-0

Q7) Recommendations of substance for improving service promise made that are supported by Harts six criteria for a meaningful unconditional guarantee. Alternatively, lack of recommendations for the subject company is adequately defended.
Comprehensive, relevant, and literature supported recommendations are made.
Some relevant, and literature supported recommendations are made.
Minimal recommendations are made.


CRM content ??" Overall
5-4
3-2
1-0
5-0

Overall, paper provides evidence that student understands the importance of a service promise in the application of customer relationship principles.
The writer clearly understands the importance of a service promise in the application of customer relationship principles.
The writer shows a basic understanding of the importance of a service promise in the application of customer relationship principles.
The writer shows minimal understanding of the importance of a service promise in the application of customer relationship principles.


CRM Content - Total



55 - 0

COMM -Purpose and Audience
5-4
3-2
1-0
5-0

Overall, the case analysis provides evidence that student understands the importance of a service promise in the application of customer relationship principles.


- the writer successfully demonstrates the importance of service promise through the application of CRM principles

-The writer addresses the assignment in a creative/ innovative way.

-The writer goes beyond the requirements in some way.
-The writer fulfills all aspects of the assignment.



-The writer generally meets the expectations of the reader in terms of content, organization, language.




- The writer does not fulfill the assignment.








3-2
1-0
(5-0) *4=20-0



- The writer does a sufficient job of developing and following the main idea (thesis).


- Does not clear state a thesis or explain structure in the introduction


COMM -Organization and Structure
5-4
- The paper generall uses topic sentences to introduce ideas at the paragraph level.

- There may be some slight weakness in organization at either the macro or micro level; however, the reader can still follow the argument easily, and paragraphs are unified around central ideas.


- The paper exhibits serious problems with organizational structure that may include:

> few topic sentences

> paragraphs not centered

on one controlling idea.

>The order of evidence

appears random

>difficult to follow the

argument.


Introduction clearly states thesis and explains structure of the paper
- The writer develops a clear, strong thesis and presents clear topic sentences.


- The central theme of the argument generally understandable.

- There may be some slight problem with organizational flow or consistency in the argument
- The paper exhibits serious problems with organizational structure that may include:

>The order of evidence

appears random

>difficult to follow the

argument.


Conclusion of paper brings closure to the main thesis
- The conclusion clearly integrates the main thesis with the key findings in the paper
- The conclusion partially integrates the main thesis with the key findings in the paper
- No conclusion or conclusion has serious problems


COMM - Evidence/Arguments


5-4
3-2
1-0
(5-0) *3=15-0



Evidence is logical, contextualized and supported with relevant evidence from reliable academic sources
- The evidence presented is logical, contextualized, and appropriately researched and supported, and synthesized with the writers own argument.


-The paper contains a controlling idea; it is clear to the reader what the main idea is and what the basic arguments are.

- There is indication of research that forms the basis of the evidence presented.

- There is a relatively successful attempt to synthesize research within the argument.


The paper exhibits several problems that may include:

>The paper contains irrelevant support, and there is insufficient analysis and/or depth of analysis.

>The paper does not contain research and/or does not adequately cite that research.


The analysis is sophisticated and considers other perspectives.


The analysis is sophisticated and considers other perspectives.


- There is clear evidence of analysis and an attempt to consider alternate perspectives


The paper exhibits several problems that may include:

> limited to no research

> Alternatives not

considered


Attachments such as exhibits, graphs, bibliography, etc. are relevant to the discussion.
The attachments are scholarly and very relevant to the discussion.
The attachments are relevant to the discussion
The attachments exhibit some problems either:

> are not relevant to the discussion

> do not some from

appropriate sources


Communications -Readability, Style, Mechanics
5-4
3-2
1-0
(5-0) *2=10-0

Paper written in MLA or APA style
MLA or APA style full met throughout the paper
MLA or APA style generally met but there are a few errors
MLA or APA style not met.


Paper is has been proof read and edited and is free of overt grammatical and typographical errors. Paper adheres to submission requirements.
-The tone and style are appropriate for the audience.

- There are no noticeable proofreading or grammatical errors.

- Sentence structure and diction are effective and diverse

- Submission requirements met
- For the most part, tone and style are appropriate for the audience.

- (NEED A WORKS CITED PAGE)

Consider the following scenario:
You are a new warden at a large prison somewhere in the U.S. The prison that you have been assigned to have been plagued with numerous physical altercations, and has had 3 small riots on 2 separate cellblocks, another in the chow hall. Further, gang related violence has occurred in this prison & as is usually the case in prisons, gang loyalties fall along racial lines.
Your prison staff has had numerous problems based on racial identity. During turnout prior to shift change, you can see that the staff arrange themselves according to racial groups. When the prison tried to arrange a diversity training last month, an all time high was reached in employee absenteeism and there were more employee arguments and disagreements. The training seemed to poliarize the staff even further.
It has become a source of concern for you because you now have reason to believe that some staff may essentially turn a "blind eye" to inmate activities if the staff member and the inmate are of the same race/ethnicity. This naturally compromises the security of the institution and places everyon'e safety in jeapordy.
Upon attempting to improve employee racial relations in your prison, you note that there appears to be two rough "group views" within your prison staff. One group is hard lined and conservative, this group takes a punitive approach toward the inmate population. The other group is soft and liberal and takes a less restrictive approach with the inmate population. These groups seem to be at great odds with one another and the irony is that there are members of each racial/ethnic background and both genders who subscribe to both views.
1) As a warden addressing this problem within your staff subculture, determine if you would take a traditional view, a human relations view, or interactionist view of conflict and explain why.

2) Provide a discussion of the 5 stages of the conflict process as it might relate to thse 2 groups within the institution. Provide a hypothetical example that might exist at each stage in the conflict process.

3) How might you, as a warden, attempt tp resolve some of this conflict? Examine conflict resolution techniques (i.e. problem solving: face to face meeting; superordinate goals: create shared goals that cannot be attained without cooperation of each of conflicting parties; expansion of resource: when conflict is due to a scarcity in resources, expand the resource; Avoidance: Suppression of the conflict; Smoothing: Playing down differences while emphasizing common interests; compromise: each party gives up something of value; authoritative command: management uses formal authority to resolve conflict & then communicates its desires to parties involved; altering the human variable: use behavioral change techniques such as human relations to alter attitudes; altering the structural variable: chage the formal organizational structure and the interaction patterns of conflicting parties) & pick 3 that might be useful to resolving conflict in this scenario, be sure to explain why you believe those techniques are your preferred choice in this scenario.

These assignments are NOT simply a summary of the course material. Focus more on your reactions to what youve learned, heard and read. Your written response is based on the development of your insights into/on a specific topic. It is not a log of activities but rather a short essay of your well-reasoned reflections and thoughts supported by the concepts and ideas from the video lectures, class and the textbook. In the process of completing these assignments, you are making sense of what you are learning and exploring its relevance. Common questions that arise from these reflections include:
What happened?
Why did it happen?
What can be learned from this for future actions?
The specific assignments are structured to create an arc where you increasingly engage with the course material in the context of your larger world. You will begin by reflecting on past experiences, and then plan for future ones. You will relate what you are learning to paths taken by leaders who have demonstrated success. You will observe the operation of the principles we discuss out in the wild. And, finally, you will actively apply a concept covered at some point in the term by making a behavioral change and exploring what results.

Personal and subjective comments are appropriate in these assignments, including the use of personal pronouns. These are not the types of assignments where there is a single right or wrong answer. You will be evaluated on the use and application of the course material and the thoughtfulness of your response. The due dates noted below correspond to the same Lecture HW numbers and due dates in the syllabus.

Question:1. Reflect on an experience (eg. group/team work, job experience, college choice, etc.) where you felt like you just didnt fit in. Using the material from the video lecture and class, explain what caused this feeling. What could have been done differently to make the situation better? Using the benefit of hindsight, what advice would you give your former self if you were starting over? If the situation is still ongoing, are there practical steps you can take to improve the situation? Potential course concepts that apply include: personality, values, attitudes, motivation and fit.
There are faxes for this order.

Dear Essay Town,
Following is my request: analyze/review the article from the economist (copied below) in 3 pages. Emphasize the fact that the portion of GDP spent on healthcare is not a problem if society adequately benefits from it and everyone has access to it, then discuss ways in which the healthcare system is inefficient and wasteful in America, using the following article (and other articles you may have):

http://www.newamerica.net/index.cfm?pg=article&DocID=1145

and this summary information about this harvard business review article: Harv Bus Rev. 2004 Jun;82(6):64-76, 136.
Redefining competition in health care.
Porter ME, Teisberg EO.
Harvard University, Harvard Business School, Boston, USA. [email protected]
The U.S. health care system is in bad shape. Medical services are restricted or rationed, many patients receive poor care, and high rates of preventable medical error persist. There are wide and inexplicable differences in costs and quality among providers and across geographic areas. In well-functioning competitive markets--think computers, mobile communications, and banking--these outcomes would be inconceivable. In health care, these results are intolerable, with life and quality of life at stake. Competition in health care needs to change, say the authors. It currently operates at the wrong level. Payers, health plans, providers, physicians, and others in the system wrangle over the wrong things, in the wrong locations, and at the wrong times. System participants divide value instead of creating it. (And in some instances, they destroy it.) They shift costs onto one another, restrict access to care, stifle innovation, and hoard information--all without truly benefiting patients. This form of zero-sum competition must end, the authors argue, and must be replaced by competition at the level of preventing, diagnosing, and treating individual conditions and diseases. Among the authors' well-researched recommendations for reform: Standardized information about individual diseases and treatments should be collected and disseminated widely so patients can make informed choices about their care. Payers, providers, and health plans should establish transparent billing and pricing mechanisms to reduce cost shifting, confusion, pricing discrimination, and other inefficiencies in the system. And health care providers should be experts in certain conditions and treatments rather than try to be all things to all people. U.S. employers can also play a big role in reform by changing how they manage their health benefits.


SURVEY: HEALTH-CARE FINANCE

Money well spent?

Jul 15th 2004
From The Economist print edition
It depends on how you do the sums

DESPITE the prodigious growth in health-care spending over the past 40 years, there have long been nagging doubts over whether it provided value for money. Medical advances such as vaccines and antibiotics against infectious diseases have clearly done much to improve people's health, but these things are relatively cheap. What has all the rest of the spending achieved?

A commonly used gauge of health status is life expectancy. This measure casts doubt on the effectiveness of heavy spending on health care in recent decades on two grounds. First, the biggest increase in life expectancy pre-dated the introduction of national health-care systems. In England and Wales, for example, life expectancy at birth rose by 20 years in the first half of the 20th century, but by only ten years in the second half. The most important reason for the early gain was the conquest of the infectious diseases that were taking such a heavy toll a century ago. But the biggest improvement occurred before the introduction of mass immunisation programmes and antibiotics. It is thought that medical care accounts for only about a fifth of the 20th-century gains in life expectancy in Britain and America. The rest came from improvements in nutrition, sanitation, hygiene and housing.

The second reason to doubt the value of health-care spending emerges from international comparisons. America spends easily the highest proportion of its GDP on medical care, but its people's life expectancy at birth is lower than in many countries with more modest health budgets (see chart 6).

Such comparisons are often used to criticise the American health-care system or to defend stingy medical budgets in other countries. Yet what they really show is that health is a complex matter, with medical care just one contributory factor. Health can be seen as a capital good in which individuals invest not just through spending on medical care but through their own behaviour, for example by cutting out smoking, over-eating and binge-drinking. Living conditions and environmental factors can also affect health.

An influential exponent of this view is Stanford University's Victor Fuchs. In his classic text, ?Who Shall Live??, first published in 1974, he wrote that differences in health levels between America and other developed countries ?are not primarily related to differences in the quantity or quality of medical care. Rather, they are attributable to genetic and environmental factors and to personal behaviour.? He suggested that ?higher income often seems to do as much harm as good to health, so that differences in diet, smoking, exercise, automobile driving and other manifestations of ?lifestyle? have emerged as the major determinants of health.?

Until recently, most health economists were sceptical about the contribution of medical care to general health, says Ted Frech of the University of California, Santa Barbara. A former sceptic himself, he now argues that even allowing for the effect of lifestyles, medical care does make a difference. He is convinced about the value of drugs, especially the cholesterol-lowering statins used to counter cardiovascular disease. His analysis of 18 advanced countries suggests that pill-popping does work: ?Countries that consumed more pharmaceuticals saw their populations live longer and suffer less ill health than those that consumed less.?

William Schwartz of the University of Southern California School of Medicine stresses that medical care delivers more than longer lives. It pays an extra dividend by improving the quality of people's lives, for example through greater mobility, enhanced vision and pain relief. He argues that the cost of such treatments accounts for a considerable part of the spending gap between America and other countries.

At the same time, the quality of treatments has improved by leaps and bounds. New forms of surgery are less invasive and allow swifter recovery. New drug therapies mean that patients receiving heart transplants now spend only ten days at Stanford Hospital, whereas 20 years ago they often stayed two months or longer, says Ms Marsh. Jack Triplett, an economist at the Brookings Institution, cites cataract surgery as an example: ?At one time you had to spend ten days immobilised in intensive care. Now it's done as an outpatient appointment, so not only has quality improved but it takes far less time.?

In a recent book, ?Your Money or Your Life?, David Cutler, an economist at Harvard University, offers some interesting sums on the value of health care. For example, an American aged 45 today will live four-and-a-half years longer than he would have done in 1950 because of a decline in cardiovascular disease. Mr Cutler attributes two-thirds of this increase in life expectancy to better medical care and the remaining third to behavioural changes, such as giving up smoking. Survival rates for low-birth-weight infants have also improved greatly because of medical treatment. These are the two areas where health care has made the biggest difference to mortality in the past 50 years.

What's life worth to you?
People put a high value on living longer: Mr Cutler estimates that an extra year of life is worth $100,000 to an individual. On that basis, he reaches a startling conclusion: that in America ?the benefits of medical advances for these two conditions alone are equal to the entire increase in medical costs in the past half-century.? This finding appears to overturn the conventional wisdom that the value of medical spending is questionable, and to vindicate the vast sums poured into health care.

One difficulty with this kind of analysis is that it does not compare like with like. Costs are real: they have to be met out of workers' incomes, whether through insurance premiums, cash payments or taxes and social-security contributions. In contrast, the valuation of benefits is notional. True, it is derived from solid evidence, such as the amount of money people are prepared to pay for safety features, eg, car airbags, that could save lives in a crash. But this prompts the question: why do so many people take so little care of themselves even though it may cost little or nothing, whereas once they have become ill medical intervention costs such a lot?

Yet this new research underlines an important point: whatever the doubts about the contribution of medicine for much of the past century, it is now doing much more to push up life expectancy. Ahead lies the prospect of even greater gains as advances in the life sciences are translated into innovative therapies. Potential treatments include targeted techniques to combat cancer and tissue engineering to replace failing organs. John Potts, former research director of Massachusetts General Hospital, says that further big increases in life expectancy are ?within the capacity of the scientific knowledge base and medical delivery system if you didn't have to worry about costs?.

But costs should be less of a worry if the gains in health are so highly valued. Mr Cutler has no difficulty in principle with projections in which health spending as a share of the economy continues to grow to, say, 30%. Such a figure may seem outlandish, but the current share of 15% would itself have seemed absurd in 1960, when America's total health expenditure amounted to only 5% of GDP.

There are two major objections to the idea that health care should absorb an ever rising share of national income. If this arose from private choices subject to the constraints of household budgets, all well and good. But as Peter Zweifel, a health economist at Zurich University, points out, this is a market in which governments intervene on a massive scale. Governments, for their part, have to worry about raising taxes, which may slow economic growth.

Secondly, the overriding objective for policymakers, as Mr Fuchs insists, is to ensure that additional money put into health generates commensurate additional gains. Mr Goldman of RAND puts it this way: ?The question is whether medical technologies are effective at the margin. For example, there will be a class of people for whom statins are clearly valuable, but should we put them in the water?? Mr Cutler himself is a fierce critic of many wasteful features of American health care.

These worries are given added weight by a recent accumulation of findings about inefficiency and waste in medical care. Clearly, these problems need to be tackled first before writing a blank cheque for health budgets.