Analyze the interrelationships among key stakeholders, professional organizations, and health care professionals within the home health care organization.

Use the outline as a guide:
II. Stakeholders, Professional Organization, and Health Care
Professional within the home health organization
A. Stakeholders
1. Person(s) being cared for
2. Person(s) directly involved in care
a) Friends/family,
b) Health and social professionals
c) Volunteer organizations
3. Individuals interested in care that observe care infrequently or
remotely; those that do not have direct input to regular care program
4. Outsiders potentially affected by home care system
B. Professional Organizations
1. National Association for Home Care and Hospice (NAHC)
2. Home Health Care Nurses Association (HHNA)
3. American Association of Healthcare Administrative Management
(AAHAM)
4.Other State/Local regulatory bodies
C. Different Health Care Professionals
1. Licensed personnel
2. Registered Nurse
3. Home Care Aide
4. Social Worker
D. Rehabilitation Service Professionals
1. Physical and Occupational therapist
2. Speech and Language Pathologists
3. Dieticians


Need 2-3 PP slides with detailed speaker notes. With atleast 700 word analysis.

Internship Report:

o 1 - Background of the organization/work unit. ??" Home health care marketing for home health and hospice

o 2 - Identification and synopsis of the problem.
Problem- doctors referring patients to home health when they dont particularly need it. Also home heath companies keeping patients on service when they dont need it. HIPAA violations pertaining to home health

o 3 ??" Research Method/Process


o 4 ??" Description of potential solutions
Having Medicare watch these companies more closely. Etc..

o 5 - Conclusion

Purpose: to explore a community / public health topic through current research relating to your practicum experience.

HOME HEALTH CARE NURSE AND DIABETIC PATIENT(S)!!

Directions:
#1) Select and explore a population-focused topic / problem / issue relevant to Public Community Health in your practicum experience. (My 8 hour practicum was Home Health Care / Caring for DIABETES).
#2) Based on Level's of Prevention Pyramid, identify and discuss primary, secondary, and tertiary levels of prevention.
#3) Develop a policy statement relevant to the selected topic / problem / issue.

Objectives:
#1) Apply critical thinking skills to the exploration and development of a paper that addresses a Public Health Community Health Topic / Problem / Issue.
#2) Analyze and Synthesize literature on the topic / problem / issue.

Directions Continued:
1) Write a 3-4 page paper, (must include a REFERENCE PAGE as page # 5).
2) Must be APA FORMAT
3) Three Peer Reviewed REFERENCES are to be listed; three (3) references MUST be from Nursing Journals. (MUST INCLUDE THESE JOURNALS WITH YOUR PAPER!!!)
4) Journal References should be within the last 5 years.

GRADING CRITERIA: (40 points total)

Introductory Section (4 points)

1 General Discussion of the topic (diabetic patient) / problem / issue (2 points)
2 Description of your interest in the selected topic / problem / issue (2 points)

Main Section (14 points)

1 Provide an in depth exploration of TWO (2) dimensions of the topic / problem / issue that you select. Dimensions explored may be , i.e. physiological, psychological, socio-cultural, developmental or spiritual ( 6 points).
2 Identify and discuss TWO (2) Public Health Nursing / Community Health Nursing INTERVENTIONS at the levels of Primary, Secondary, and Tertiary as they relate to the topic / problem /issue explored (6 points)
3 Discuss the impact of this topic / problem / issue on the Community (2 points)

Summary / Conclusion (5 points)

1 State Conclusion based on your analysis and synthesis of information is more research or inter-professional teamwork needed for interventions, etc? (3 points)
2 Based on your summary, make one (!) policy recommendation that you think would positively influence the status of your public health topic / problem / issue (2 points)

References(4 points)

1 At least three (3) current references (from within the past five years) from PEER REVIEWED NURSING JOURNALS (1 point)
2 References cited correctly in APA Format throughout the paper (3 points)

APA Style Format (9 points total)

I Title Page (4 points) Includes:
a) Running Head (1 point)
b) Upper half page includes:
I) Centered title in upper and lower case letters (no more than 12 words in length)
II) Author's Name: First Name, Middle Initial and Last Name (1 point)
III) Institutional Affiliation (1 point)

II Throughout Paper (3 points)
a) Doubled space plain text ( 1 point)
b) Times Roman 12 font (1 point)
c) All pages numbered (1 point)

III Reference Page (2 Points)
a) Word "Reference" (without quotes) centered at top of reference page (1 point)
b) Listed references are listed in alphabetical order ( 1 point)

IV General Paper Writing (4 points Total)
a) Logical organization (1 point)
b) No more than two (2) grammatical errors (1 point)
c) No more than two (2) misspelled words (1 point)
d) Length of paper NO MORE than 4 pages (plus a reference page) (1 point)

NOTE: I need the first page of each reference so it can be attached to my paper.

This paper should research marketing practices and principles used in home health care. The findings should explain important principles of marketing, how marketing can be implemented in home care, by whom, how marketing efforts are organized, the tools used, and how the results of marketing projects are assessed. ( SHOULD INCLUDE AT LEAST THREE CURRENT PUBLISHED SOURCES)

In addition: The paper should include an interview from an individual working in the home health care field. In particular, this person should state whether or not the theories of marketing are being put into action where this person is employed. What problems he or she faces, how they solve them and their perception of the value and future of marketing in the home health care field.

In addition, The paper should include how the marketing process is physically integrated into the agency's daily operations and how it can be seen in the community.

Canada

Write a 3-5 page essay, comparing the U.S. health care system with the health system of your choosing (PLEASE NOTE: The main body of the paper should be 3-5 pages minimum in length. This page count does not include the title/cover page, abstract, table of contents, or references). The written paper is to be prepared in accordance with the following guidelines and must contain all of the following components:
TITLE PAGE (Follow APA guidelines)
ABSTRACT- Limit the abstract to 150 words. Do not repeat the title at the beginning of the abstract and do not cite references in it. Avoid abbreviations. Include the purpose of the article, main findings, and principle conclusions. Although the abstract is at the beginning of the paper, it is often easier to write the paper and then go back and write your abstract.
TABLE OF CONTENTS
INTRODUCTION (overview of the topic - usually one to two paragraphs)
REVIEW OF LITERATURE ??" Write an overview of the background and development of the US health care system as well as the background and development of the health care system of the nation you choose. Be sure to review the 4 basic components of health services delivery: financing, insurance, delivery, and payment and how they function in each the US system vs. the other system (see pgs. 5-7 of the textbook for more information).
o Reference citations must be present within the body of the paper and should be included for all information obtained from an outside source. All reference citations should have a corresponding full reference listed on the reference page. In order to add depth to your paper, I fully anticipate students using supplemental references (journal articles, web sources, and books) in addition to the text book. Please note that Wikipedia is not considered a scholarly source for use in academic papers- Please avoid using it ?
DISCUSSION - analysis of the information presented in the review of literature. Compare and contrast the features of the US health care system and the system of the nation/country you choose. Discuss how the system components impact health professionals as well as patients (positively and/or negatively).
CONCLUSION - Based on information presented in discussion
RECOMMENDATIONS - student's personal thoughts or suggestions for change. Identify any system features that you would like to see incorporated into the US system.
REFERENCES: Students are responsible for the accuracy and completeness of references and must follow the APA guidelines for citations.
***Please note: Papers must include headings for each of the sections listed above. Headings should centered and capitalized.
Additional information:
Manuscript Preparation: Assignment should be prepared in Microsoft Office as a .doc or .docx file. The manuscript shall be typewritten double-spaced with 1" margins on all four sides. The pages are to be numbered consecutively, beginning with the first page of text. The page number should in the upper right hand corner of each page. The font for the type should 12 point Times Roman or Times New Roman.

Text Requirements: The cover page should contain the title and authors names. The abstract should be on a separate page. The Table of Contents should be on a separate page. The main text should begin on a separate page and be not less than 3-5 pages double-spaced pages. You may exceed 3-5 pages of text for the body of your paper. However, papers that are shorter in length will have points deducted.

Illustrations (optional): If tables, graphs, figures, etc., are included they should be appropriately identified.

Assignment Submission: Submit as an attached document under the Written Assignment tab. Click on View/Complete Assignment: Written Assignment #1. Scroll down to attach local file and upload your Word Document. Click submit.
* Please refrain from emailing assignments to the instructor.
***Some APA resources have been placed in the Course materials section for your convenience. Here you will find information on writing a title page, how to paraphrase, how to cite references within the paper etc.

The book:

Delivering Healthcare in America.

A Systems Approach

F O U R T H E D I T I O N
Leiyu Shi, DrPH, MBA, MPA Professor, Johns Hopkins School of Public Health Co- Director, Johns Hopkins Primary Care Policy Center for the Underserved Johns Hopkins University Baltimore, Maryland

Douglas A. Singh, PhD, MBA Associate Professor, School of Public and Environmental Affairs Indiana University South Bend South Bend, Indiana

Jones and Barlett Publishers
Sudbury ,Massachusetts.
Boston,London,Toronto,Singapore.

Context: Canada:Canada implemented its national health in-surance system referred to as Medicare under the Medical Care Act of 1966. Currently, Medicare is composed of 13 provincial and territorial health insurance plans sharing basic standards of coverage as defined by the Canada Health Act ( Health Canada 2006). The bulk of financing for Medicare comes from general provincial tax revenues; the federal government provides a constant amount that is independent of actu-al expenditures. The public pays for nearly 70 percent of total health care expenditures in Canada. The remaining 30 percent, paying for supplementary services such as drugs, dental care, and vision care, is financed pri-vately ( Canadian Institute for Health Infor-mation 2005). Provincial and territorial departments of health have the responsibili-ty to administer medical insurance plans, de-termine reimbursement for providers, anddeliver certain public health services. Prov-inces are required by law to provide reason-able access to all medically necessary services and to provide portability of bene-fits from province to province. The program provides comprehensive coverage, but ex-cludes dental care. Coverage for home health care and prescription drugs varies across the provinces. To cover these exclusions, many Canadians have supplemental coverage through private insurance provided by em-ployers. Patients are free to select their providers ( Akaho et al. 1998). Several prov-inces have established contracts with providers in the United States for certain specialized services. However, contrary to popular per-ceptions, few Canadians have to obtain health care services in the United States due to waiting times or unavailability of technol-ogy in their own country ( Katz et al. 2002). Nearly all the Canadian provinces ( On-tario being one exception) have resorted to regionalization by creating administrative districts within each province. The objective of regionalization is to decentralize authori-ty and responsibility to more efficiently ad-dress local needs and to promote citizen participation in health care decision- making ( Church and Barker 1998). The majority of Canadian hospitals are operated as private nonprofit entities run by community boards of trustees, voluntary organizations, or mu-nicipalities, and most physicians are in pri-vate practice ( Health Canada 2006). Most provinces use global budgets and allocate set reimbursement amounts for each hospital. Physicians are paid fee- for- service rates ne-gotiated between each provincial govern-ment and medical association ( MacPhee 1996; Naylor 1999). Over the years, federal financial support to the provinces was drastically reduced. Un-der the increasing burden of higher costs,certain provinces, such as Alberta and On-tario, have started small- scale experimenta-tion with privatization. However, in 2003, the Health Council of Canada, comprised of rep-resentatives of federal, provincial, and terri-torial governments, as well as health care experts, was established to assess Canadas health care system performance and establish goals for improvement. The Councils 2003 First Ministers Accord on Health Care Re-newal created a five- year, $ 16 billion Health Reform Fund targeted to improving primary health care, home care, and catastrophic drug coverage ( Health Council of Canada 2005).

The actually title is "Support Methods In Healthcare: How technology has changed medicine".

1.One topic in the paper could be talking about the Electronic Health Record(EHR). Good, bad, solution to problems, how the country will implement the EHR, how this effect doctors, nurses, insurance company, all medical staff, and how will patient care be effected.
2.Technology effect in home health care
3.Technology effect call centers.
4.Technology how it has effect healthcare system
5. How will the patients information be safe on Electronic Health Records.

Application: Understanding Expenditures and Sources of Funds for Health Services Organizations

Choose one of the following settings to be the focus of your Application Assignment: Hospital care, physician and clinical services, home health care, drugs, or nursing homes.

Review Exhibit 7.7 on page 183 of Understanding the U.S. Health Services System. What percentage of health services expenditures does this type of setting receive?


Next, look at Exhibit 7.9 on pages 184??"185. What sources of funds does this type of setting typically receive?


Then look at Exhibit 7.8 on page 183 and review the information on expenditure trends for this setting. Based on the information presented in the Learning Resources throughout this course, consider explanations for the trends in personal health services expenditures from 1960 to 2007.


Compare the data for this setting with the data for at least one other setting, and consider similarities and differences between them.
With this in mind, write a 1- to 2-page paper in which you:

Summarize your findings and analysis as indicated above


Explain potential implications for health care administrators in the setting you have chosen
Your written assignments must follow APA guidelines. Be sure to support your work with specific citations from this week's Learning Resources and additional scholarly sources as appropriate. Refer to the Pocket Guide to APA Style to ensure your in-text citations and reference list are correct.

This is a CLC assignment.
Choose a nursing problem from your current practice setting, and identify a possible solution to that problem. The nursing problem that we choose on which you have to write the power point on is: HOW WORK PLACE DEMANDS INFLUENCES PATIENT SAFETY"
Conduct a search of the literature related to this problem.
Analyze and critically appraise evidence-based literature to support the solution to the identified problem. A minimum of (5) articles must be identified. This may include guidelines from the National Guideline Clearinghouse, Joanna Briggs Institute, or a review from the Cochrane Database of Systematic Review.
Prepare a 10-minute (8-10 slides; no larger than 5 MB) PowerPoint presentation related to the problem, evidence appraisal, and practice implications.
Include the following components into the presentation:
1. Present the nursing practice problem with the PICO question.
2. Discuss your appraisal of the literature that addresses the problem.
3. Present the proposed practice changes from an integration of the findings.
While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

The PICO statement will provide a framework for your Capstone Project (The project students must complete during their final course in the RN-BSN program of study). Review the PICO article "Evidence-Based Practice, Step by Step: Asking the Clinical Question" (2010)
The first step of the EBP process is to develop a question from a practice problem. Start with the patient and identify the clinical problems or issues that arise from clinical care. (AT LEAST 10 PICO QUESTIONS AND ANSWERS ARE NEEDED.) THANKS
Review the PICO article "Evidence-Based Practice, Step by Step: Asking the Clinical Question" (2010) along with the PICO PowerPoint.
Following the PICO format, write a PICO statement in an area of interest to you, which is applicable to your proposed Capstone Project.



AJN, American Journal of Nursing
Issue: Volume 110(3), March 2010, pp 58-61
Copyright: ? 2010 Lippincott Williams & Wilkins, Inc.
Publication Type: [Feature Articles]
DOI: 10.1097/01.NAJ.0000368959.11129.79
ISSN: 0002-936X
Accession: 00000446-201003000-00028
Hide Cover
[Feature Articles]
? Previous Article ## Table of Contents ## Next Article ?
Evidence-Based Practice, Step by Step: Asking the Clinical Question: A Key Step in Evidence-Based Practice
Stillwell, Susan B. DNP, RN, CNE; Fineout-Overholt, Ellen PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M. PhD, RN
Author Information
Susan B. Stillwell is clinical associate professor and program coordinator of the Nurse Educator Evidence-Based Practice Mentorship Program at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advancement of Evidence-Based Practice, Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing, and Kathleen M. Williamson is associate director of the Center for the Advancement of Evidence-Based Practice.
Contact author: Susan B. Stillwell, [email protected].

Abstract
This is the third article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Ask the Authors" call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May's Evidence-Based Practice, Step by Step.


To fully implement evidence-based practice (EBP), nurses need to have both a spirit of inquiry and a culture that supports it. In our first article in this series ("Igniting a Spirit of Inquiry: An Essential Foundation for Evidence-Based Practice," November 2009), we defined a spirit of inquiry as "an ongoing curiosity about the best evidence to guide clinical decision making." A spirit of inquiry is the foundation of EBP, and once nurses possess it, it's easier to take the next step?to ask the clinical question.1 Formulating a clinical question in a systematic way makes it possible to find an answer more quickly and efficiently, leading to improved processes and patient outcomes.
In the last installment, we gave an overview of the multistep EBP process ("The Seven Steps of Evidence-Based Practice," January). This month we'll discuss step one, asking the clinical question. As a context for this discussion we'll use the same scenario we used in the previous articles (see Case Scenario for EBP: Rapid Response Teams).
In this scenario, a staff nurse, let's call her Rebecca R., noted that patients on her medical?surgical unit had a high acuity level that may have led to an increase in cardiac arrests and in the number of patients transferred to the ICU. Of the patients who had a cardiac arrest, four died. Rebecca shared with her nurse manager a recently published study on how the use of a rapid response team resulted in reduced in-hospital cardiac arrests and unplanned admissions to the critical care unit.2 She believed this could be a great idea for her hospital. Based on her nurse manager's suggestion to search for more evidence to support the use of a rapid response team, Rebecca's spirit of inquiry led her to take the next step in the EBP process: asking the clinical question. Let's follow Rebecca as she meets with Carlos A., one of the expert EBP mentors from the hospital's EBP and research council, whose role is to assist point of care providers in enhancing their EBP knowledge and skills.
Types of clinical questions. Carlos explains to Rebecca that finding evidence to improve patient outcomes and support a practice change depends upon how the question is formulated. Clinical practice that's informed by evidence is based on well-formulated clinical questions that guide us to search for the most current literature.
There are two types of clinical questions: background questions and foreground questions.3-5 Foreground questions are specific and relevant to the clinical issue. Foreground questions must be asked in order to determine which of two interventions is the most effective in improving patient outcomes. For example, "In adult patients undergoing surgery, how does guided imagery compared with music therapy affect analgesia use within the first 24 hours post-op?" is a specific, well-defined question that can only be answered by searching the current literature for studies comparing these two interventions.
Background questions are considerably broader and when answered, provide general knowledge. For example, a background question such as, "What therapies reduce postoperative pain?" can generally be answered by looking in a textbook. For more information on the two types of clinical questions, see Comparison of Background and Foreground Questions.4-6
Ask the question in PICOT format. Now that Rebecca has an understanding of foreground and background questions, Carlos guides her in formulating a foreground question using PICOT format. TABLE. Comparison of...PICOT is an acronym for the elements of the clinical question: patient population (P), intervention or issue of interest (I), comparison intervention or issue of interest (C), outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(s) (T). When Rebecca asks why the PICOT question is so important, Carlos explains that it's a consistent, systematic way to identify the components of a clinical issue. Using the PICOT format to structure the clinical question helps to clarify these components, which will guide the search for the evidence.6, 7 A well-built PICOT question increases the likelihood that the best evidence to inform practice will be found quickly and efficiently.5-8
To help Rebecca learn to formulate a PICOT question, Carlos uses the earlier example of a foreground question: "In adult patients undergoing surgery, how does guided imagery compared with music therapy affect analgesia use within the first 24 hours post-op?" In this example, "adult patients undergoing surgery" is the population (P), "guided imagery" is the intervention of interest (I), "music therapy" is the comparison intervention of interest (C), "pain" is the outcome of interest (O), and "the first 24 hours post-op" is the time it takes for the intervention to achieve the outcome (T). In this example, music therapy or guided imagery is expected to affect the amount of analgesia used by the patient within the first 24 hours after surgery. Note that a comparison may not be pertinent in some PICOT questions, such as in "meaning questions," which are designed to uncover the meaning of a particular experience.3, 6 Time is also not always required. But population, intervention or issue of interest, and outcome are essential to developing any PICOT question.
Carlos asks Rebecca to reflect on the clinical situation on her unit in order to determine the unit's current intervention for addressing acuity. Reflection is a strategy to help clinicians extract critical components from the clinical issue to use in formulating the clinical question.3 Rebecca and Carlos revisit aspects of the clinical issue to see which may become components of the PICOT question: the high acuity of patients on the unit, the number of cardiac arrests, the unplanned ICU admissions, and the research article on rapid response teams. Once the issue is clarified, the PICOT question can be written.
Because Rebecca's issue of interest is the rapid response team?an intervention?Carlos provides her with an "intervention or therapy" template to use in formulating the PICOT question. (For other types of templates, see Templates and Definitions for PICOT Questions.5, 6) Since the hospital doesn't have a rapid response team and doesn't have a plan for addressing acuity issues before a crisis occurs, the comparison, or (C) element, in the PICOT question is "no rapid response team." "Cardiac arrests" and "unplanned admissions to the ICU" are the outcomes in the question. Other potential outcomes of interest to the hospital could be "lengths of stay" or "deaths."
Rebecca proposes the following PICOT question: "In hospitalized adults (P), how does a rapid response team (I) compared with no rapid response team (C) affect the number of cardiac arrests (O) and unplanned admissions to the ICU (O) during a three-month period (T)?"
Now that Rebecca has formulated the clinical question, she's ready for the next step in the EBP process, searching for the evidence. Carlos congratulates Rebecca on developing a searchable, answerable question and arranges to meet with her again to mentor her in helping her find the answer to her clinical question. The fourth article in this series, to be published in the May issue of AJN, will focus on strategies for searching the literature to find the evidence to answer the clinical question.
Now that you've learned to formulate a successful clinical question, try this exercise: after reading the two clinical scenarios in Practice Creating a PICOT Question, select the type of clinical question that's most appropriate for each scenario, and choose a template to guide you. Then formulate one PICOT question for each scenario. Suggested PICOT questions will be provided in the next column.
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Case Scenario for EBP: Rapid Response Teams TABLE. Templates and...
You're a staff nurse on a busy medical?surgical unit. Over the past three months, you've noticed that the patients on your unit seem to have a higher acuity level than usual, with at least three cardiac arrests per month, and of those patients who arrested, four died. Today, you saw a report about a recently published study in Critical Care Medicine on the use of rapid response teams to decrease rates of in-hospital cardiac arrests and unplanned ICU admissions. The study found a significant decrease in both outcomes after implementation of a rapid response team led by physician assistants with specialized skills.2 You're so impressed with these findings that you bring the report to your nurse manager, believing that a rapid response team would be a great idea for your hospital. The nurse manager is excited that you have come to her with these findings and encourages you to search for more evidence to support this practice and for research on whether rapid response teams are valid and reliable.
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Practice Creating a PICOT Question
Scenario 1: You're a recent graduate with two years' experience in an acute care setting. You've taken a position as a home health care nurse and you have several adult patients with various medical conditions. However, you've recently been assigned to care for hospice patients. You don't have experience in this area, and you haven't experienced a loved one at the end of life who's received hospice care. You notice that some of the family members or caregivers of patients in hospice care are withdrawn. You're wondering what the family caregivers are going through, so that you might better understand the situation and provide quality care.
Scenario 2: You're a new graduate who's accepted a position on a gerontology unit. A number of the patients have dementia and are showing aggressive behavior. You recall a clinical experience you had as a first-year nursing student in a long-term care unit and remember seeing many of the patients in a specialty unit for dementia walking around holding baby dolls. You're wondering if giving baby dolls to your patients with dementia would be helpful.
What type of PICOT question would you create for each of these scenarios? Select the appropriate templates and formulate your questions.
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REFERENCES
1. Melnyk BM, et al. Igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs 2009;109(11):49?52. [Context Link]
2. Dacey MJ, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007;35(9):2076?82. [Context Link]
3. Fineout-Overholt E, Johnston L. Teaching EBP: asking searchable, answerable clinical questions. Worldviews Evid Based Nurs 2005;2(3):157?60. 360 Link esolver [Context Link]
4. Nollan R, et al. Asking compelling clinical questions. In: Melnyk BM, Fineout-Overholt E, editors. Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 25?38. 360 Link esolver [Context Link]

5. Straus SE. Evidence-based medicine: how to practice and teach EBM. 3rd ed. Edinburgh; New York: Elsevier/Churchill Livingstone; 2005. [Context Link]
6. Fineout-Overholt E, Stillwell SB. Asking compelling questions. In: Melnyk BM, Fineout-Overholt E, editors. Evidence-based practice in nursing and healthcare: a guide to best practice [forthcoming]. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins. [Context Link]
7. McKibbon KA, Marks S. Posing clinical questions: framing the question for scientific inquiry. AACN Clin Issues 2001;12(4):477?81. [Context Link]
8. Fineout-Overholt E, et al. Teaching EBP: getting to the gold: how to search for the best evidence. Worldviews Evid Based Nurs 2005;2(4):207?11. [Context Link]


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This is a research proposal paper that must be in APA style, must follow either the quantitative or qualitative research proposal guidelines as shown in "The practice of nursing research:conduct, critique,& utilization" by Nancy Burns and Susan Grove 3rd edition, pages 708 or 711.
The topic to be researched is the use of Advanced Practice RN's(APRN) in the home health care arena. This proposal will be used to give support to the need for establishing the use of APRN in the home care agency, because home care patients are being released quicker and sicker from hospitals, that the future trend in health care will see more and more patients recieving cares in their homes rather than hospitals, that home care nurses must be equipped to handle this type of client and advanced practice nurses will be a good fit...APRN's will SAVE $$$ by their expert skills in managing complex cases and being a resource for other home care staff members.
The articles I've found are as follows:

Mitty, E. (1998) Integrating advanced practice nurses in home care.Nurse Health Care Perspective nov-dec 19, (6) 264-70

Dahl, J (2002) APN spells success for a heart failure program
Nurse Manage feb 33, (2) 46-8.

Frantz, A (1999) Exploring expert cardiac home care nurse competence Home Healthcare nurse Nov-dec 17, (11) 706-17

Franz, A (2001) recovering from CAGB are you current
Home Healthcare nurse july 19 (7) 417-24

Portillo (1998) graduate program: advanced practice nurses in the home AACN Clionical Issues aug 9 (3) 355-61

Hemstrom, M (2000) the clinical specialist in community health Public Health Nurse sept-oct 17 (5) 386-91

Morgan, M (1999) a physician/advanced practice nurse home visiting program. N J Med sept 96 (9) 51-3

Paul, S (2000) Impact of a nurse-manged heart failure clinic
American Journal of Crit care march 9 (2) 140-6

thanks...

A critical incident usually represents an identified problem confronting you as a nurse and your role as a decision maker.The analysis of the incident requires the application of principles of menagement and sound judgement.Many times to formulate the ''right '' answer for a problem is not as important as how you come to the solution and the reasoning you use to arriveat a recommended course of action. For this assignment you are to formulate a two to three page paper utilising critical incident analysis to a situation or experience in the work place.Diagram your problem with several alternatives,pros and cons of each and choice.Then discuss the problem as follows:
1 .Clearly identify a problem that you have confronted in the workplace.Describe status of problem at one point in time.Identify all the factors /players who are involved with the problem and their rolein the workplace.Identify what,when, where,why,who.Make sure it is the problem you have addressed and not just a symptom of the problem you are identifying.

state the problem in one sentence

2. Specify any alternatives to the problem.Identify all logical alternatives with it's pros and cons.Consider if the problem was not addressed at this time,would it eventually go away?What risk is involved with implementing each alternetive? Describe fully how each alternative will affect the outcome.

Draw diagram

3. Make a choice.Which of your identified alternatives did you choose in approaching the problem based on the information you have gathered?Why did you choose this alternative? Specify the ethical principle that you applied in making this decision and explainwhy you used this principle.

4. Implement your choice. Describe fully what happened when you implemented your choice ,the results obtained ,the skills required in your decision of how to handle the problem.

5. Consider the feedback issue.Identify fully what you would do differently next time if you encounter this same or similar problem?

Personal Evaluation :What did you learn from this paper's step -by-step approach to problem solving?How can you utilize this type of analysis in yourrole as a nurse?Be complete.

Professional presentation of paper.Number and label each section you address,proper grammar,in folder,no abbreviations or''slag''e.g.,''nurse tech''.Do not identify people or placesby name-use initials.Answer all questions for each section.

At work I had a patient that was having two decubital wounds stage four on her sacral area and she was parallyzed from the waist down and she was having lace in her head and pubical area.She was discharged home with the home health care visits but she and her husband refuse eny type of visits by the nurse or going to a nursing home.She needed a IV antibiotiks but without nursing supervision at home she was not able to qure from the infection and she was not able to stay in the hospital any loger .So I think that we can use this problem and name it:deficient knowledge related to the disease process .-OR you can ude something different if it has more sence.

Risk Management Assessment Summary


Leaders in a health care organization have identified risk management as an opportunity for improvement for the upcoming year. The organization has hired you as a consultant to help assess the organization?s current status and define the future plan for addressing risks.


? Select an organization type in the health care industry as the basis for this assignment. The organization may be your employer or a health care organization of particular interest to you. Types of health care organizations include, but are not limited to, the following:


o Hospital, nursing facility, physician office, emergency medical services, managed care organization, home health care, community health department or provider, pharmacy, laboratory, drug manufacturer, medical device manufacturer, durable medical equipment supplier, and electronic medical records software suppliers

? Research the key concepts of risk management in health care and the factors that influence risk management for your chosen type of organization.
? Write a 1,050- to 1,400-word paper in which you complete the following:
o Describe the purpose of risk management in health care organizations in general and in your chosen organization in particular.

o Explain key steps this organization may take to identify and manage their risks.

o Identify three typical or actual risks in your chosen organization. Describe how each risk might negatively affect your organization and its stakeholders.

o Summarize the types of education, training, or policies that would help this type of organization mitigate these risks.


? Include at least four sources, two from the University Library and two from either the course textbooks or this week?s Electronic Reserve Readings. Prepare a reference list of all resources and websites used in your research.

Resource: Risk and Quality Management Assessment Summary Grading Criteria and Sample Executive Summary located in the Center for Writing Excellence

Risk and quality management provide different methods, tools, and techniques to health care organizations to ensure that they provide quality health care. Leaders in a health care organization have hired you as a consultant to help assess the organization?s current status and define a future plan for providing quality health care.

Select an organization type in the health care industry as the basis for this assignment. The organization may be your employer or a health care organization of particular interest to you. Types of health care organizations include, but are not limited to, the following:

a. Hospital
b. Nursing facility
c. Emergency medical services
d. Managed care organization
e. Home health care
f. Community health department or provider


Research the key concepts of risk and quality management in health care and the factors that influence risk and quality management for your chosen type of organization.

Research the relationship between risk management and quality management.

Write a 1,375 words put heading for each question answered in which you complete the following:

? Describe your chosen organization.
? Describe the purpose of risk and quality management in health care organizations in general and in your chosen organization.

? Describe the key concepts of risk and quality management in your chosen organization.

? Explain steps the organization may take to identify and manage their risks.

? Identify at least three typical or actual risks in the organization. Describe how the risks might negatively affect the quality.

? Identify at least three internal and external factors that influence quality outcomes in the organization. Describe how these factors might negatively affect quality outcomes for the organization.

? Outline at least three of the organization?s long-term goals and at least three short-term goals.

? Identify at least three fundamental risks and quality management policies that should be implemented and how they will influence health outcomes.

? Explain the relationship between risk management and quality management in the organization and how these two disciplines complement each other.

Include at least four peer reviewed sources, two from the University Library and two from either the course textbooks or this week?s Electronic Reserve Readings. You may use additional CREDIBLE sources; however, you MUST use the four sources previously stated. Prepare a reference list of all resources and websites used in your research. DO NOT USE WIKIPEDIA OR DICTIONARIES!!

Format with APA 6TH edition guidelines.

I hope everyone enjoyed the time off for the holidays. Now it is back to work for us. In regards to the team task this week, a possible topic from our weekly focus we can debate on in our paper is the use of labor unions in the change process. There is most likely sufficient information to argue for both sides. Let me know what you all think. See below:

The use of labor union in change process

Change process is difficult both on the employees and management; I believe that labor union can make the process a little bit easier for both parties. Change will bring some changes that the labor union can negotiate on behalf of the employers and no one will be afraid of being singled out by the management. The fact is that, when an organization have a labor union to work with, they can partner together to facilitate change easier. When the organization knows that change is required, it can disseminate this information to the leadership of the union and the union can then pass the information along to the employees. When everyone is on the same page, it improves the chances of the organization getting through the change. It will be a win-win situation.


Simpler Negotiations
As an employer, one of the advantages of dealing with a labor union is that it simplifies the negotiations process. When you deal with a labor union, you do not have to negotiate with multiple employees. You simply talk to the head of the labor union and the head of the union speaks for all of the workforce. By doing this, you can negotiate faster and more efficiently without having to worry about meeting with many different employees.
Employee Satisfaction
Another advantage of dealing with labor unions is that it can improve employee satisfaction. When employees deal with unions, they may be more satisfied because they have a voice to speak to the employer. They get higher wages on average and better benefits packages. When you meet the needs of the employees better, they will be more satisfied in their jobs and will be willing to work harder for you. This could lead to higher productivity and better quality production.
Less Turnover
Another advantage of labor unions for organizations is that they lead to less turnover. When you have a workforce that is comprised of labor union members, they will not leave their jobs as frequently. They have to pay dues to be a part of the union, and they typically do not want to lose their position in the organization. When you have lower levels of turnover, it saves your business money in the long run by not having to train as many new employees.
Easier to Make Changes
Businesses regularly have to undergo change if they want to stay at the forefront of their industry. When a business has a labor union to work with, they can partner together to facilitate change easier. When the employer knows that change is required, it can disseminate this information to the leadership of the union and the union can then pass the information along to the employees. When everyone is on the same page, it improves the chances of the company getting through the change.

Reference:
U.S. Bureau of Labor Statistics; The Effect of Unions on Employee Benefits -- Recent Results From the Employer Costs for Employee Compensation Data; John W. Budd; June 2005

Economic Policy Institute; How Unions Help All Workers; Lawrence Mishel, et al.; August 2003



Points well taken. Thanks for sharing. You have added to our discussion and learning. Are there some potential data analysis problems when using compound or complex questions? Are such questions harder to answer in a meaningful way? Would you want the consultant to be certified by a respected professional organization?

Complex questions are subjected to ambiguity and different interpretations by different people. Different employees can read different meanings to a single complex question. There are a number of ways that complex questions can be misinterpreted in the real world. A major error can be performing multiple comparisons. It may be helpful to consider some aspects of statistical thought which might lead many people to be distrustful of it. Complex questions live room for probabilistic perspective. This is in contrast to the way non-mathematicians often cast problems: logical, concrete, often dichotomous conceptualizations are the norm: right or wrong, large or small, this or that and this is a big problem when analyzing the data.
There are a lot of reasons I would want to engage a certified consultant in my organization project. First, these people will have the evidence of successful track records which will be found in client testimonials, references, and repeat business associations. They will adhere to the highest ethical standards, they have more experience in their field of expertise, they have life-long professional education and they also have a reference network for challenging client problems, so my organization can worry less about failure. USED




Additionally, many non-mathematicians hold quantitative data in a sort of awe. They have been lead to believe that numbers are, or at least should be, unquestionably correct. Consider the sort of math problems people are exposed to in secondary school, and even in introductory college math courses: there is a clearly defined method for finding the answer, and that answer is the only acceptable one. It comes, then, as a shock that different research studies can produce very different, often contradictory results. If the statistical methods used are really supposed to represent reality, how can it be that different studies produce different results? In order to resolve this paradox, many naive observers conclude that statistics must not really provide reliable (in the nontechnical sense) indicators of reality after all. And, the logic goes, if statistics aren't "right", they must be "wrong". It is easy to see how even intelligent, well-educated people can become cynical if they don't understand the subtleties of statistical reasoning and analysis.
? A history of results and excellent performance. Evidence of a successful track record is found in client testimonials, references, and repeat business, all of which are required to maintain their CMC? certification.
? Adherence to the highest ethical standards of the profession. Your CMC? has successfully completing both written and oral ethics examinations covering commitments to the client, to fiscal responsibility, to the public, and to the profession.
? Experience in the field. A minimum of three years of continuous consulting and successful results are required for certification.
? Life-long professional education. Your CMC? takes advantage of IMC USA's national conferences, local workshops, topical research, the Academy for Professional Development, newsletters, and other chapter-level offerings.
? A reference network for challenging client problems. They can utilize IMC USA's national database, local chapter reference sources, and the combined wisdom of the knowledge management created and maintained within IMC USA membership. USED




Thanks for sharing your response. I think that you made some valid points. Might employees be afraid of managers because of management's behavior? Might employees move into being silent because they have been punished for speaking up? Might employees be silent because it is not safe to speak-up? What do these dynamic have to do with organizational structure?


There is every probability that employees that had been intimidated by the management will be afraid to speak up and may imbibe the culture of silence. Line and staff organizational structure may the perfect structure where this can happen. This is because managers of line and staff have authority over their subordinates and can punish them as they so wish if they determine so. Besides, the decision-making process is slower in this type of organizational structure because of the layers and guidelines that are typical to it, so upper management hardly learn of lower level employees complaints.




I want to thank you for reading and responding to my post. As a potential change manager, what would you do if the allocation of resources were too few to make the plan successful? Might the rationale for the allocation be a starting point? Can management sometime plan a change hat it wants to fail?

Define goals and criterias: I will look at the profitability, risks and value to customers.
I will compare the criterias and choose the most important ones.
I will take a second look at the alternatives.
I will priortize projects against the organization objectives.
I will calculate priorities.
I will order projects by benefits and cost ratio.
I will cut project from the bottom until I meet the budget.
There is always a second best decision in any situation, instead of failing, I will switch to the second best project to save allocations and resources.





Develop Part I of a comprehensive plan to implement an organization change.
Choose an issue from your workplace and create a plan for a proposed change to resolve the issue. (I work in home health care setting).
Your change proposal must be something you might actually implement in your workplace. Iwant issue related to Long-term care.
Part I of your plan focuses on assessment of the change issue and planning for the proposed change.
Prepare a 1,050- to 1,400-word plan with the following:
? Examine the need in the organization for your proposed change.
? Examine organizational and individual barriers to your proposed change.
? Identify factors that might influence your proposed change.
? Summarize factors influencing organizational readiness for your proposed change.
? Identify the theoretical model that relates to your proposed change.
? Identify internal and external resources available to support your change initiative.
Use the University Library to conduct a search for current peer-reviewed literature that provides data to support your change application.
Format your plan consistent with APA guidelines.

choose an issue from your workplace and create a plan for a proposed change to resolve the issue.
workplace - long term home health care; issue - intake department is lacking in organizing referrals and relating appropriate material to the visiting nurse prior to home visit (most referrals are obtained from nursing rehab facilitites).

Part 1 of the plan focuses on assessment of the change issue and planning for the proposed change

prepare a 1000 word plan with the following:

A) examine the needin the organization ofr your proposed change
B) examine organizational and individual barriers to your proposed change
C) identify factors that might influence your proposed change
D) summarize factors influencing organizational readiness for your proposed change
E) identify the theoretical model that relates to your proposed change
F) indentify internal and external resources available to support your change initiative

use at least 3 current peer-reviewed sources that support your change application


PLEASE TAKE NOTE THIS ASSIGNMENT CONSIST OF 3 PARTS. WOULD LIKE TO REQUEST THE SAME WRITER FOR THE PARTS II AND PART III. THANKS

This paper is for the class Management of Continuum Care Services

Scenario: Your state is attempting to integrate services for people needing long-term care. Using an organization chart or list, research your state's Department of Health & Human Services and Department of Aging (exact department names may vary from state to state):


Identify and decribe all the programs run by these two departments that potentially are related to long-term care and thus should be involved in the integration effort.
Describe how the services of these departments are currently integrated with each other and with any other related state departments.
Choose one program offered by one of the departments and explain how it could be improved to better meet the needs of the continuum (for example: choose Medicare Home Health Care and describe how adding payment for custodial long-term care in the home might benefit clients, providers, etc.).


Customer is requesting that (freelancewriter) completes this order.

Using courses you have previously taken and/or are currently taking, compile a list of specific skills and knowledge you have learned. Using your list, determine how these skills and knowledge might enhance your personal portfolio. Why are these skills and knowledge important for employment in your field? Why might they be attractive to potential employers?
Classes taken-
Foundations in integrative studies- Understand the distinctions between multidisciplinary, transdisciplinary, and interdisciplinary. Encourages interdisciplinary thinking. Understand the criticisms lodged against interdisciplinary studies.
Nonverbal communication- seeing and understanding what nonverbal cues are and how to read them.
Personal finance- fully grasping what it means to save and invest. Spending money wisely as a college student. What to look for when buying stocks and investments. All these are variables that will be used in the near future
Communication in organization- key elements that are used and needed in everyday life, personally and professionally to keep on track and keep moving forward.
Career and professional development- where I want to be professionally in five years. What type of work force do I want to enter.
Field of Employment: home healthcare and marketing/liaison
Incorporate all this into the paper. All this must be in your own words. No citations or references

Topic: Compare the job descriptions for an LPN and RN in the home healthcare clinical setting. Identify a minimum of three differences between the job descriptions. Provide a rationale supported by the Nurse Practice Act for the differences. Analyze the topic referencing one article related to scope of practice from the nursing literature. The article must come from a nursing journal and be no older than 3 years old. Do not select an editorial or letter to editor.

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, they trat 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
2012 Laureate Education, Inc. 1
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 whether t 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 governance envirnment 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.
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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
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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

Using these two articles, please write a two page essay following the prompts below. Please furnish references as per the APA format. Thank you




As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty. In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care?
According to Rutherford (2008, para. 15), Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language. In this Discussion you consider the reasoning behind and the value of standardized codification.
To prepare:
Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.
Reflect on the importance of continuity in terminology and coding systems.
In the article, Standardized Nursing Language: What Does It Mean for Nursing Practice? the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, We document our care using standardized nursing languages but we don't fully understand why we do (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.
Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.
Post on or before Day 3 an explanation of why nurses need to document care using standardized nursing languages and whether this standardization can be limited to specialty areas or if it should be across all nursing practice. Support your response using specific examples from your own specialty or area of expertise and using at least one additional resource from the Walden Library.



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Standardized Nursing Language: What Does It Mean for Nursing Practice?

Standardized Nursing Language: What Does It Mean for Nursing Practice?
Marjorie A. Rutherford, RN, MA
Abstract
Use of a standardized nursing language for documentation of nursing care is vital both to the nursing profession and to the bedside/direct care nurse. The purpose of this article is to provide examples of the usefulness of standardized languages to direct care/bedside nurses. Currently, the American Nurses Association has approved thirteen standardized languages that support nursing practice, only ten of which are considered languages specific to nursing care. The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical setting, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
Citation: Rutherford, M., (Jan. 31, 2008) "Standardized Nursing Language: What Does It Mean for Nursing Practice? "OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1.
DOI: 10.3912/OJIN.Vol13No01PPT05
Key words: communication, North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), nursing judgments, patient care, quality care, standardized nursing language
Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses' recent implementation of the Nursing Intervention Classification (NIC) (McCloskeyDochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system. During the conversation, one
^md







...it is impossible for medicine, nursing, or any health carerelated discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process.
nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidencebased outcomes for nursing.
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3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
Most articles in the nursing literature that reference standardized nursing languages are related to research or are scholarly discussions addressing the fine points surrounding the development or evaluation of these languages. Although the value of a specific, standardized nursing language may be addressed, there often is limited, indepth discussion about the application to nursing practice.
Practicing nurses need to know why it is important to document care using standardized nursing languages, especially as more and more organizations are moving to electronic documentation (ED) and the use of electronic health records. In fact, it is impossible for medicine, nursing, or any health carerelated discipline to implement the use of ED without having a standardized language or vocabulary to describe key components of the care process. It is important to understand the many ways in which utilization of nursing languages will provide benefits to nursing practice and patient outcomes.
Norma Lang has stated, "If we cannot name it, we cannot control it, practice it, teach it, finance it, or put it into public policy" (Clark & Lang, 1992, p. 109). Although nursing care has historically been associated with medical diagnoses, nurses need an explicit language to better establish their?standards and influence the regulations that guide their practice.
...today nursing needs a unique language to express what it does so that nurses can be compensated for the care provided.
A standardized nursing language should be defined so that nursing care can be communicated accurately among nurses and other health care providers. Once standardized, a term can be measured and coded. Measurement of the nursing care through a standardized vocabulary by way of an ED will lead to the development of large databases. From these databases, evidencebased standards can be developed to validate the contribution of nurses to patient outcomes.
The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical arena, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing nterventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
Standardized Language Defined
Keenan (1999) observed that throughout history nurses have documented nursing care using individual and unitspecific methods; consequently, there is a wide range of terminology to describe the same care. Although there are other more complex explanations, Keenan supplies a straightforward definition of standardized nursing language as a "common language, readily understood by all nurses, to describe care" (Keenan, p. 12). The Association of Perioperative Registered Nurses (AORN) (n.d.) adds a dimension by explaining that a standardized language "provides nurses with a common means of communication." Both convey the idea that nurses need to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care. In this way, nurses from different units, hospitals, geographic areas, or countries will be able to use commonly understood terminology to identify the specific problem or intervention implied and the outcome observed. Standardizing the language of care (developing a taxonomy) with commonly accepted definitions of terms allows a discipline to use an electronic documentation system.
Consider, for example, documentation related to vaginal bleeding for a postpartum, obstetrical patient. Most nurses document the amount as small, moderate, or large. But exactly how much is small, moderate, or large? Is small considered an area the size of a fiftycent piece on the pad? Or is it an area the size of a grapefruit? Patients benefit when nurses are precise in the definition and communication of their assessments which dictate the type and amount of nursing care necessary to effectively treat the patient.
The Duke University School of Nursing website < www.nursing.duke.edu> has a list of guidelines for the nurse to use for evaluation of a standardized nursing language. The language should facilitate communication among nurses, be complete and concise, facilitate comparisons across settings and locales, support the visibility of







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nursing, and evaluate the effectiveness of nursing care through the measurement of nursing outcomes. In addition to these guidelines the language should describe nursing outcomes by use of a computercompatible coding system so a comprehensive analysis of the data can be accomplished.
Current Standardized Nursing Languages and Their Applications
The Committee for Nursing Practice Information Infrastructure (CNPII of the American Nurses Association (ANA) has recognized thirteen standardized languages, one of which has been retired. Two are minimum data sets, seven are nursing specific, and two are interdisciplinary. The ANA (2006b) Recognized Terminologies and Data Element Sets outlines the components of each of these languages.
The submission of a language for recognition by CNPPII is a voluntary process for the developers. This terminology is evaluated by the committee to determine if it meets a set of criteria. The criteria, which are updated periodically, state that the data set, classification, or nomenclature must provide a rationale for its development and support the nursing process by providing clinically useful terminology. The concepts must be clear and ambiguous, and there must be documentation of utility in practice, as well as validity, and reliability. Additionally, there must be a named group who will be responsible for maintaining and revising the system (Thede & Sewell, 2010, p. 293).
Another ANA committee, the Nursing Information and Data Set Evaluation Center (NIDSEC), evaluates implementation of a terminology by a vendor. This approval is similar to obtaining the good seal of approval from Good Housekeeping or the United Laboratories (UL) seal on products. The approval signifies that the documentation in the standardized language supports the documentation of nursing practice and conforms to standards pertaining to computerized information systems. The language is evaluated against standards that follow the Joint Commission's model for evaluation. The language must support documentation on a nursing information system (NIS) or computerized patient record system (CPR). The criteria used by the ANA to evaluate how the standardized language(s) are implemented, include how the terms can be connected, how easily the records can be stored and retrieved, and how well the security and confidentiality of the records are maintained. The recognition is valid for three years. A new application must be submitted at the end of the three years for further recognition. Some, but not all of the standardized languages are copyrighted. (The previous paragraphs were updated 2/23/09. See previous content.)
Vendors may also have their software packages evaluated by NIDSEC. The evaluation is a type of quality control on the vendor. An application packet must be purchased, priced at $100, then the fee for the evaluation is $20,000 (American Nurses Association, 2004). The only product currently recognized is Cerner Corporation CareNet Solutions (American Nurses Association, 2004). The recognition signifies that the software in the Cerner system has met the standards set by NIDSEC. The direct care/bedside nurse must understand the importance of the inclusion of standardized nursing languages in the software sold by vendors and demand the use of a standardized nursing language in these systems.
Benefits of Standardized Languages
The use of standardized nursing languages has many advantages for the direct care/bedside nurse. These include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. These advantages for the bedside/direct care nurse are discussed below.
Better Communication among Nurses and Other Health Care Providers
Improved communication with other nurses, health care professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language. Physicians realized the value of a standardized language in 1893 (The International Statistical Classification of Diseases and Related Health Problems, 2003) with the beginning of the standardization of medical diagnosis that has become the International Classification of Diseases (ICD10) (Clark & Phil, 1999). A more recent language, the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), provides a common language for mental disorders. When an obstetrician lists "failure to progress" on a patient's chart or a psychiatrist names the diagnosis "paranoid schizophrenia, chronic," other physicians, health care practitioners, and thirdparty payers understand the patient's diagnosis.












Improved communication with other nurses, health care professionals, and administrators of the
ICD10 and DSMIV are coded by a system of numbers for input into computers. The IDC10 is a coding system used mainly for billing purposes by organizations and practitioners while the DSMIV is a categorization system for psychiatric diagnoses. The DSMIV categories have an ICD10 counterpart code that is used for billing purposes.
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institutions in whih nurses work is a key benefit of using a standardized nursing language.
Nurses lacked a standardized language to communicate their practice until the North American Nursing Diagnosis (NANDA), was introduced in 1973. Since then several more languages have been developed. The Nursing Minimum Data Set (NMDS) was developed in 1988 (Prophet & Delaney, 1998) followed by the Nursing Management Minimum Data Set (NMMDS) in 1989 (Huber, Schumacher, & Delaney, 1997). The Clinical Care Classification (CCC) was developed in 1991 for use in hospitals, ambulatory care clinics, and other settings (Saba, 2003). The standardized language developed for home, public health, and school health is the Omaha System (The Omaha System, 2004). The Nursing Intervention Classification (NIC) was published for the first time in 1992; it is currently in its fourth edition (McCloskeyDochterman & Bulachek, 2004). The most current edition of the Nursing Outcomes Classification system (NOC), as of this writing, is the third edition published in 2004 (Moorhead, Johnson, & Maas, 2004). Both are used across a number of settings.
Use of standardized nursing languages promises to enhance communication of nursing care nationally and internationally. This is important because it will alert nurses to helpful interventions that may not be in current use in their areas. Two presentations at the NANDA, NIC, NOC 2004 Conference illustrated the use of a standardized nursing language in other countries (Baena de Morales Lopes, Jose dos Reis, & Higa, 2004; Lee, 2004). Lee (2004) used 360 nurse experts in quality assurance to identify five patient outcomes from the NOC (Johnson, Maas, & Moorhead, 2000) criteria to evaluate the quality of nursing care in Korean hospitals. The five NOC outcomes selected by the nurse experts as standards to evaluate the quality of care were vital signs status; knowledge: infection control; pain control behavior; safety behavior: fall prevention; and infection status.
Baena de Morales Lopes et al. (2004) identified the major nursing diagnoses and interventions in a protocol used for victims of sexual violence in Sao Paulo, Brazil. The major nursing diagnoses identified were: rape trauma syndrome, acute pain, fear/anxiety, risk for infection, impaired skin integrity, and altered comfort. Through the use of these nursing diagnoses, specific interventions were identified, such as administration of appropriate medications with explanations of expected side effects, emotional support, helping the client to a shower and clean clothes, and referrals to needed agencies. The authors used these diagnoses in providing care for 748 clients and concluded that use of the nursing diagnoses contributed to the establishment of bonds with their clients. These are just two examples illustrating how a standardized language has been used across nursing specialties and around the world.












Increased Visibility of Nursing Interventions
Nurses need to express exactly what it is that they do for patients. Pearson (2003) has stated, "Nursing has a long tradition of overreliance on handing down both information and knowledge by wordofmouth" (p. 271). Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Pearson states that at the present time the preponderance of care documentation focuses on protection from litigation rather than patient care provided. He anticipates that use of computerized nursing documentation systems, located close to the patient, will lead to more patientcentered and consistent documentation. Increased sensitivity to the nursing care activities provided by these computerized documentation systems will help highlight the contribution of nurses to patient outcomes, making nursing more visible.
Nurses need to express exactly what it is that they do for patients.



Nursing practice, in addition to the interventions, treatments, and procedures, includes the use of observation skills and experience to make nursing judgments about patient care.


Because nurses use informal notes to verbally report to one another,
Interventions that should be undertaken to in support nursing judgments and that demonstrate the depth of nursing judgment are built into the standardized nursing languages. For example, one activity listed under labor induction in the NIC language is that of reevaluating cervical status and verifying presentation before initiating further induction
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rather than patient records and care plans, their work remains invisible.
measures (McCloskeyDochterman & Bulechek, 2004). This activity guides the nurse to assess the dilatation and effacement of the cervix and presentation of the fetus, before making a judgment about continuing the induction procedure.

LaDuke (2000) provides an additional example of using the NIC to make nursing interventions visible. For example, LaDuke noted that the intervention of emotional support, described by McCloskeyDochterman & Bulechek (2004) requires "interpersonal skills, critical thinking and time" (LaDuke, p. 43). NIC identifies emotional support as a specific intervention, provides a distinct definition for it, and lists specific activities to provide emotional support. Identification of emotional support as a specific intervention gives nurses a standardized nursing language to describe the specific activities necessary for the intervention of emotional support.
Improved Patient Care
The use of a standardized nursing language can improve patient care. Cavendish (2001) surveyed sixtyfour members of the National Association of School Nurses to obtain their perceptions of the most frequent complaints for abdominal pain. They used the NIC and NOC to determine the interventions and outcomes of children after acute abdomen had been ruled out. Nurses identified the chief complaints of the children, the most frequent etiology, the most frequent pain management activities from the NIC, and the change in NOC outcomes after intervention.
The three chief complaints were nausea, headache, and vomiting; the character of the pain was described as crampy/mild or moderate; and the three most identified etiologies were psychosocial problems, viral syndromes, and relationship to menses. The psychosocial problems included test anxiety, separation anxiety, and interpersonal problems. Nutrition accounted for a large number of abdominal complaints, such as skipping meals, eating junk food, and food intolerances. Cultural backgrounds of the children, such as the practice of fasting during Ramadan, were identified as causes for abdominal complaints.
The three top pain management activities from NIC were: observe for nonverbal cues of discomfort, perform comprehensive assessment of pain (location, characteristics, duration, frequency, quality, severity, precipitating factors), and reduce or eliminate factors that precipitate/increase pain experience (e.g., fear, fatigue, and lack of knowledge) (Cavendish, 2001). Cavendish described a decrease in symptoms, based on the Nursing Outcomes Classification Symptom Severity Indicators, following the intervention. Symptom intensity decreased 6.25%, symptom persistence decreased 4.69%, symptom frequency decreased 6.25%, and associated discomfort decreased 41.06% (p. 272). Similar studies are needed to provide evidence that specific nursing interventions improve patient outcomes.





Enhanced Data Collection to Evaluate Nursing Care Outcomes
The use of a standardized language to record nursing care can provide the consistency necessary to compare the quality of outcomes for various nursing interventions across settings. As stated earlier, more organizations are moving to electronic documentation (ED) and electronic health records. When the nursing care data stored in these coputer systems are in a standardized nursing language, large local, state, and national data repositories can be constructed that will facilitate benchmarking with other hospitals and settings that provide nursing care. The National Quality Forum (NQF) (NQF, 2006), is in the process of developing national standards for the measurement and reporting of health care performance data. The Nursing Care Measures Project is one of the 24 projects on which the NQF is developing consensusbased, national standards to use as mechanisms for quality improvement and measurement initiatives to improve American health care. The NQF has stated, "Given the importance of nursing care, the absence of standardized nursing care performance measures is a major void in healthcare quality assurance and work system performance"(NQF, May 2003, p. 1).
The use of a standardized language to record nursing care can provide the consistency necessary to compare the quality of outcomes for various nursing interventions across settings.




Patient outcomes are also related to the uniqueness of the individual, the care given by other health care professionals, and the environment in which the care is provided. The American Nurses Association's National Center for Nursing Quality (NCNQ) maintains a database called the National Database of Nursing Quality
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IndicatorsTM (NDNQI) (American Nurses Association, 2006a). This database collects nursesensitive and unit specific indicators from health care organizations, compares this data with organizations of similar size having similar units, and sends the comparison findings back to the participating organization. This activity facilitates longitudinal benchmarking as the database has been ongoing since the early 1990's (National Database, 2004).
The alreadymentioned NOC system outcomes are nursesensitive outcomes, which means the they are sensitive to those interventions performed primarily by nurses (Moorehead et al., 2004). Because the NOC system measures nursing outcomes on a numerical rating scale, it, too, facilitates the benchmarking of nursing practices across facilities, regions, and countries. The current edition of NOC (2004), which assesses the impact of nursing care on the individual, the family, and the community, contains 330 outcomes classified in seven domains and 29 classes.
A NOC outcome common to nurses who work with elderly patients who have a swallowing impairment is aspiration prevention (Moorehead et al., 2004). Patient behaviors indicating this outcome include identifying risk factors, avoiding risk factors, positioning self upright for eating/drinking, and choosing liquids and foods of proper consistency. Rating each indictor on a scale from one (never demonstrated) to five (consistently demonstrated) helps track risk for aspiration in individuals at various stages of illness during the hospitalization. It also gives an indication of a person's compliance in following the prevention measures and the nurse's success in patient education.
A NOC outcome that labor nurses frequently use is pain level (Moorehead et al., 2004), related to the severity and intensity of pain a woman experiences with contractions. The pain level can be assessed before and after the use of coping techniques such as breathing exercises and repositioning. Indicators for this specific pain outcome include: reported pain, moaning and crying, facial expressions of pain, restlessness, narrowed focus, respiratory rate, pulse rate, blood pressure, and perspiration (p. 421) and are rated on a scale from severe (1) to none (5). The difference between the numerical ratings for each indicator before and after use of the coping techniques estimates the success of the intervention in achieving the outcome of reducing the pain level for laboring mothers.
Greater Adherence to Standards of Care
Related to the quality of nursing care is the level of adherence to the standards of care for a given patient population. The NIC and NOC standardized nursing language systems are based on both the input of expert nurses and the standards of care from various professional organizations. For example, the NIC intervention of electronic fetal monitoring: intrapartum (McCloskeyDochterman & Bulechek, 2004) is supported by publications of expert authors and researchers in the field of fetal monitoring and by standards of care from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The first activity listed under electronic fetal monitoring: intrapartum is to verify maternal and fetal heart rates before initiation of electronic fetal monitoring (p. 328), which is understood to be one of the gold standards for electronic fetal monitoring. There are several reasons why both heart rates need to be identified. The nurse must be sure that it is the fetal heart rate being monitored and not the heart rate of the mother. Moreover, it is important to ascertain the exact position of the fetus before positioning the fetal monitor's transducer. This illustration exemplifies how important standards are reinforced by the NIC activities.
Facilitated Assessment of Nursing Competency
Standardized language can also be used to assess nursing competency. Health care facilities are required to demonstrate the competence of staff for the Joint Commission. The nursing interventions delineated in standardized nursing languages can be used as a standard by which to assess nurse competency in the performance of these interventions. A Midwestern hospital is already doing this (Nolan, 2004). Using an example from the NIC system, specifically intrapartal care (McCloskeyDochterman & Bulechek, 2004), a nurse's competency can be established by a preceptor's watching to see whether the nurse is performing the recommended activities, such as a vaginal examination or the assessment of the fetus presentation. The preceptor can also evaluate the nurse's teaching skills regarding what the patient should expect during labor, using the activities listed under the teaching intervention.
Implications of Standardized Language for Nursing Education, Research, and Administration
In addition to enhancing the care provided by direct care nurses, standardized language has implications for nursing education, research, and administration. Nurse educators can use the knowledge inherent in standardized nursing languages to educate future nurses. Such a system can be used to describe the unique roles of the nurse. Nurse educators can teach students to use systems such as the CCC and Omaha System when in the community health fields, or the use of the NANDA, NIC, NOC terminology when in the acute care setting. References to the primary resources upon which each intervention is based are listed at the end of each individual intervention to provide information supporting each intervention. By referring to the references








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associated with these nursing standards, nurse educators can role model the use of standardized language to help students recognize the body of knowledge upon which the standards are built. Tying the standardized language to education and practice will enhance its implementation and expand practicing nurses' knowledge of interventions, outcomes, and languages. Armed with an appreciation of the value of standardized language, students can champion further development and use of the standardized nursing languages once they enter professional practice.
The use of standardized languages can provide a launching point for conducting research on standardized languages. The research conducted by the two teams of educators at the Uniersity of Iowa on the NIC and NOC are excellent examples of the research that can be done on the standardized nursing languages using computerized databases designed for research (McCloskeyDochterman & Bulechek, 2004; Moorehead et al., 2004).





Nursing research performed with...larger sample sizes...using databases may reveal more powerful patterns with stronger implications for practice than can past research that depended on small samples.
Although nursing researchers have traditionally used historic data (data describing completed activities), computerized documentation based on a standardized language can enable researchers and quality improvement staff to use "realtime" data. This data is more readily accessible and retrievable as compared to the traditional, time consuming task of sifting through stacks of charts for the needed information.
When the bedside nurse documents via a nursing information system having a standardized language, the data are stored by the hospital, usually in a data warehouse. When the aggregate data are accessed by administrators and researchers, trends in patient care can be uncovered (Zytkowski, 2003), best practices of nursing care unlocked, efficiencies in nursing care discovered, and a relevant knowledge base for nursing can be built. Nursing research performed with these larger sample sizes achieved by using databases may reveal more powerful patterns with stronger implications for practice than can past research that depended on small samples.
Kennedy (2003) states that one byproduct of accurate documentation of patient care is an estimation of acuity level. Patient care data entered into a computer and stored in a database can be used to help develop and adjust nursing schedules based on the projected patient census and acuity. Utilizing a standardized nursing language to document care can more precisely reflect the care given, assess acuity levels, and predict appropriate staffing. Use of a standardized nursing documentation system can provide data to support reimbursement to a health care agency for the care provided by professional nurses.


Summary
Use of a standardized language is not something that is done just because it will be useful to others. Use of a standardized language has far reaching ramifications that will help in the delivery of nursing care and demonstrate the value of nursing to others. The benefits of a standardized nursing language include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency.
The ultimate goal should be the development of one standardized nursing language for all nurses.


The ultimate goal should be the development of one standardized nursing language for all nurses. Although that goal has not yet been attained, examples of work toward it can be demonstrated. The International Council of Nurses (ICN) has developed the International Classification for Nursing Practice (ICNP) (ICN, 2006) in an attempt to establish a common language for nursing practice. The ICNP is a combinatorial terminology that crossmaps local terms, vocabularies, and classifications.

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The Nursing Intervention Classification (NIC) and Nursing Outcome Classification (NOC) were developed as companion languages. These have linkages to other nursing languages, such as NANDA nursing diagnoses, the Omaha System, and Oasis for home health care, among others. Both are included in Systematized Nomenclature of Medicine's (SNOMED) multidisciplinary record system. NIC has been translated into nine foreign languages and NOC into seven foreign languages.
By using one standardized nursing language, nurses from all over the world will be able to communicate with one another, with the goal of improving care for patients globally. Nurses will be able to convey the important work they do, making nursing more visible.
Correction Notice: The paragraphs below appeared in this article on the original publication date of January 31, 2008. The information in these paragraphs has been revised in the above article as of February 23, 2009 to clarify the difference between CNPII and NIDSEC. (See current content.)
Current Standardized Nursing Languages and Their Applications
The Nursing Information and Data Set Evaluation Center (NIDSEC) of the American Nurses Association (ANA) (2004) recognizes thirteen standardized languages that support nursing practice, ten of which document nursing care. The ANA (2006b) Recognized Terminologies and Data Element Sets outlines the components of each of these languages.
The submission of a language for approval by the NIDSEC is a voluntary process for the developers. This approval is similar to obtaining the good seal of approval from Good Housekeeping or the United Laboratories (UL) seal on products. The approval signifies that the documentation in the standardized language supports the documentation of nursing practice and conforms to standards pertaining to computerized information systems. The language is evaluated against standards that follow the Joint Commission's model for evaluation. The language must support documentation on a nursing information system (NIS) or computerized patient record system (CPR). The criteria used by the ANA to evaluate the standardized languages include the terminology used, how the terms can be connected, how easily the records can be stored and retrieved, and how well the security and confidentiality of the records are maintained. The recognition is valid for three years. A new application must be submitted at the end of the three years for further recognition. Some, but not all of the standardized languages are copyrighted.
Author
Marjorie A. Rutherford, RN, MA
Email: [email protected]
Marjorie A. Rutherford is currently a doctoral student at the University of South Florida. Her area of study is nursing informatics with a focus on the Nursing Intervention Classification (NIC) system and the Nursing Outcome Classification (NOC) system. She has over 32 years of obstetrical experience, primarily in labor and delivery, and has five years of mental health experience. She has taught nursing as a clinical instructor at Polk Community College and as an adjunct instructor at the University of South Florida. She is currently employed on the nursing faculty of Keiser College in Lakeland, FL.
References
American Nurses Association (2006a). NCNQ, Home of the NDNQI. Retrieved January 15, 2006, from www.nursingworld.org/quality/
Amercian Nurses Association. (2006b) Recogized terminologies and data element sets.
American Nurses Association (2004). NIDSEC. Retrieved September 14, 2004. Association of Perioperative Registered Nurses (n.d.). Perioperative nursing data set. Retrieved September 30, 2004, from www.aorn.org/research/ Baena de Morales Lopes, M., Jose dos Reis, M., & Higa, R. (2004). Nursing diagnosis: An aid when assisting the female victim of sexual violence. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. Cavendish, R. (2001). The use of standardized language to describe abdominal pain. The Journal of School Nursing, 17(5), 266273. Clark, J., & Lang, N. (1992). Nursing's next advance: An internal classification for nursing practice. International Nursing Review, 39(4), 109111, 128. Clark, J. & Phil, M.. (1999). A language for nursing. Nursing Standard, 13(31), 4247. Duke University School of Nursing. (n.d.). How to choose a nursing language. Retrieved December 28, 2006, from www.duke.edu/~goodw010/vocab/howtochoose.html Huber, D., Schumacher, L., & Delaney, C. (1997). Nursing







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management data set. JONA, 27(4), 4248. International Council of Nurses. (2006). International classification of nursing practice (ICNP). Retrieved January 15, 2006, from www.icn.ch/icnp_def.htm Johnson, M., Maas, M., & Moorhead, S. (2000). Nursing outcomes classification (NOC) (2nd ed.). St. Louis: Mosby. Keenan, G. (1999). Use of standardized nursing language will make nursing visible. Michigan Nurse, 72(2), 1213. Kennedy, R. (2003). The nursing shortage and the role of technology. Nursing Outlook, 51(3), S3334. LaDuke, S. (2000). NIC puts nursing into words. Nursing Management, 31(2). Lee, B. (2004). Availability of NOC for the evaluation of quality of nursing care in Korea. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. McCloskey Dochterman, J., & Bulechek, G. (2004). Nursing interventions classification (NIC) (4th ed.). St. Louis, MO: Mosby. Moorehead, S., Johnson, M., & Maas, M. (2004). Nursing outcomes classification (NOC) (3rd ed.). St. Louis, MO.: Mosby. National Database of Nursing Quality Indicators. (2004). Transforming data into quality care Washington, DC: American Nurses Association. Nolan, P. (2004). NIC and the performance continuum. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. Nursing Quality Forum. (20002004). Welcome to the national quality forum, project summaries. Retrieved January 15, 2006, from www.qualityforum.org/ Nursing Quality Forum. (May 2003). Core measures for nursing care performance. Retrieved January 15, 2006, from www.qualityforum.org/ Pearson, A. (2003). The role of documentation in making nursing work visible. International Journal of Nursing Practice, 9(5), 271. Prophet, C. & Delaney, C. (1998). Nursing outcomes classification: Implications for nursing information systems and the computerbased patient record. Journal of Nursing Care Quality, 12(5), 2129. Saba, V. (2003). Clinical care classification (CCC) System. Retrieved December 1, 2004 from www.sabacare.com The international statistical classification of diseases and related health problems (10th Ed.). (2003). Retrieved September 30, 2004 from www.who.int/classifications/icd/en/ The Omaha system: Omaha system overview. (2004). Retrieved from www.omahasystem.org/systemo.htm
Thede, L. Q., & Sewell, J. P. (2010). Informatics and Nursing: Opportunities and Challenges (3rd ed.). Philadelphia: Lippincott, Williams & Wilkins.
Zytkowski, M. E. (2003). Nursing informatics: The key to unlocking contemporary nursing practice. AACN Clinical Issues, 14(3), 271281.







2008 OJIN: The Online Journal of Issues in Nursing Article published January 31, 2008

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Preparing Nurses to Use Standardized Nursing Language in the Electronic Health Record
Maria MLLER-STAUB
Pflege PBS, Selzach, Solothurn, Switzerland
Abstract. Research demonstrated nurses education needs to be able to document nursing diagnoses, inter- ventions and patient outcomes in the EHR. The aim of this study is to investigate the effect of Guided Clini- cal Reasoning, a learning method to foster nurses abilities in using standardized language. In a cluster randomized experimental study, nurses from 3 wards received Guided Clinical Reasoning (GCR), a learning method to foster nurses in stating nursing diagnoses, related interventions and outcomes. Three wards, re- ceiving Classic Case Discussions, functioned as control group. The learning effect was measured by assess- ing the quality of 225 nursing documentations by applying 18 Likert-type items with a 0-4 scale of the meas- urement instrument Quality of Nursing Diagnoses, Interventions and Outcomes (Q-DIO). T-tests were applied to analyze pre-post intervention scores. GCR led to significantly higher quality of nursing diagnosis documentation; to etiology-specific nursing interventions and to enhanced nursing-sensitive patient out- comes. Before GCR, the pre-intervention mean in quality of nursing documentation was = 2.69 (post- intervention = 3.70; p < .0001). Similar results were found for nursing interventions and outcomes. In the control group, the quality remained unchanged. GCR supported nurses abilities to state accurate nursing diagnoses, to select effective nursing interventions and to reach enhanced patient outcomes. Nursing diagno- ses (NANDA-I) with related interventions and patient outcomes provide a knowledgebase for nurses to use standardized language in the EHR.
Keywords: Electronic Health Record; Guided Clinical Reasoning; NANDA nursing diagnoses; nursing interventions; outcomes.
1. Introduction
Escalating costs and legal cases require health care disciplines to develop measures so that the quality of discipline-based services can be compared across settings and locali- ties [1]. Also nurses are mandated to describe, document and evaluate their contribution to health care [2]. The naming of nursing phenomena and representing these phenom- ena in a standardized manner is a challenge for the nursing profession. To describe and ensure cost effective, high quality, appropriate outcomes of nursing care delivered across settings and sites, standardized terms and definitions are required. Classifica- tions provide such standardized language [3-6]. Without classifications, nursing has had difficulties in communicating clinical problems ??" nursing phenomena ??" in a clear, precise, or consistent manner [7].
In many countries, nursing documentation is part of the patient health care record and health laws require the documentation of medical and nursing treatments. Patients health problems, which nurses take care of, the nursing interventions performed and the evaluation of the care given must be documented. Therefore, the nursing portion of the record is a means not only to document and compare, but also to ensure and improve nursing care quality [2]. Classifications representing standardized nursing language need to be implemented in practice. Nurs managers perceive the selection of a classi- fication system as difficult, because only few findings were available about the criteria classifications should fulfil.
338 M. Mller-Staub / Preparing Nurses to Use Standardized Nursing Language in EHR
Even though classifications were developed, many nurses have not been trained to use standardized language [8-11]. Deficiencies in accurately stating and documenting nurs- ing diagnoses, and to relate them with nursing interventions and outcomes were re- ported [12]. Accurate diagnoses are a prerequisite for choosing diagnostic-specific interventions, intending to affect favorable nursing-sensitive patient outcomes. Coher- ence among diagnoses, interventions, and outcome classifications, displayed in evi- dence-based linkages, is crucial. Clinical information systems rely on classifications, and data aggregation and evaluation is facilitated when clinical information systems incorporate standardized nursing language. Further investigation of implementing and evaluating nursing classifications was urgently recommended [13].
Objectives
The aim of this study was to evaluate the effect of consecutive Guided Clinical Reason- ing and Classic Case Discussions in assisting nurses to accurately state nursing diagno- ses and to link them with interventions and outcomes, in order to be prepared for using standardized nursing language in the Electronic Health Record (EHR).
Material and Methods
The effect of consecutive Guided Clinical Reasoning and Classic Case Discussions in assisting nurses to more accurately state nursing diagnoses and to link them with inter- ventions and outcomes was evaluated in a clinical study. In a cluster randomized, con- trolled experimental design, nurses from 3 wards of a Swiss hospital participated in Guided Clinical Reasoning to enhance diagnostic expertise. Three wards functioned as control group. The control group received Classic Case Discussions to support utiliza- tion of NANDA-I nursing diagnoses. The quality of totally 444 documented nursing diagnoses, corresponding interventions and outcomes was evaluated. An independent sample of 222 at pre- and 222 at post intervention was chosen because this study fo- cuses on nurses performance in accurately stating nursing diagnoses, choosing and performing effective nursing interventions and on achievement of nursing sensitive patient outcomes. Nursing documentations were assessed at baseline and three to seven months after the study intervention. The time span for sampling was the same for the intervention and for the control group. None of the wards was aware of group alloca- tion and nursing documentations were drawn from the archives to guarantee blinding. The study intervention consisted of monthly Guided Clinical Reasoning of 1.5 hours for the period of five months (in the year 2005). Guided Clinical Reasoning employs real cases of hospitalised patients to facilitate critical thinking and reflection. It is an interactive method, using iterative hypothesis testing by asking questions to obtain diagnostic data, by asking for signs and symptoms seen in the patient, and by asking about possible etiologies and linking them with effective nursing interventions. Accu- rate nursing diagnoses and effective nursing interventions were stated for the patient cases and controlled by use of the NNN-Classification outlined in a textbook. The effect of the study intervention was analyzed by assessing the quality of documented nursing diagnoses, interventions and outcomes, applying 18 items of the Q-DIO, and tested by T-tests and mixed effects model analyses.
Results
A statistically significant improvement in stating accurate nursing diagnoses, including improvements in assigning signs/symptoms, and correct etiologies coherent to the di-
M. Mller-Staub / Preparing Nurses to Use Standardized Nursing Language in EHR 339
agnoses, was found. Before Guided Clinical Reasoning (GCR), the mean score of the intervention group was 2.69 (SD = 0.90) compared with 3.70 (SD = 0.54, p < 0.0001) at post intervention. In the control group the baseline mean score in nursing diagnoses was 3.13 (SD = 0.89) compared with 2.97 (SD = 0.80, p = 0.17) in the second meas- urement.
We also found a statistically significant increase in naming concrete nursing interven- tions, showing what intervention will be done, how, how often, and by whom. The interventions were formulated coherently and related to the etiologies of the nursing diagnoses; and they included documentation of the etiology-specific interventions per- formed. Before Guided Clinical Reasoning the mean score of the intervention group was = 2.33 (SD = 0.93) compared with 3.88 (SD = 0.35, p < 0.0001) at post interven- tion. In the control group, the baseline mean score was = 2.70 (SD = 0.88) compared to 2.46 (SD = 0.95, p = 0.05), in the second measurement.
Nursing outcomes also showed statistically significant improvements in the interven- tion group. The outcomes were observably and measurably formulated. The outcomes were better than at pre-intervention and than in the control group, and contained de- scriptions of attained improvements in patients. Before Guided Clinical Reasoning, the mean score of the intervention group was = 1.53 (SD = 1.08) compared with 3.77 (SD = 0.53, p <0 .0001) at post intervention. In the control group, the baseline mean was = 2.02 (SD = 1.27) compared to 1.94 (SD = 1.06, p = 0.62) in the second measurement.
Discussion
The focus of todays healthcare is on high quality patient outcomes. Being able to state accurate nursing diagnoses, and to choose effective nursing interventions and outcomes is a prerequisite for nurses to promote high quality nursing care and for documenting it in the EHR. In our study higher quality nursing diagnosis documentation and etiology- specific nursing interventions were related with significant improvements in patient outcomes documentation. The literature supports our results of the control group: Of- ten, nurses were not competent diagnosticians, lacking critical thinking skills and not being able to evaluate and document care [9, 14]. Deficiencies regarding nursing diag- nostic content were previously reported [15, 16]. In our study GCR was more effective than Classical Case Discussions in assisting nurses to accurately state nursing diagno- ses and to link them with interventions and outcomes. This study provides evidence that carefully implementing classifications into clinical practice can lead to enhanced, accurately stated nursing diagnoses, coherent nursing interventions and outcomes.
Conclusions
Accurately stating diagnoses, linked with coherent interventions is important to reach favorable patient outcomes. We conclude that merely stating diagnostic titles is insuffi- cient to capture patients needs. Only etiology specific diagnoses are the basis to choose effective nursing interventions, leading to better outcomes. Our findings sup- port the use of NANDA-I, NIC and NOC (NNN) because a) only the NANDA-I diag- noses contain allocated signs/symptoms and etiologies and b) only these three classifi- cations contain determined and tested linkages between diagnoses, interventions and outcomes. These classifications are monodisciplinary in nature. Their advantage is that they describe nursing in conceptually driven ways. A disadvantage of monodisciplinar- ity can be seen in the specialty of nursing language. While many terms in the NNN are
340 M. Mller-Staub / Preparing Nurses to Use Standardized Nursing Language in EHR
interdisciplinary (e.g. pain, incontinence), others are nursing specific (self-care assis- tance, constipation management). For multidisciplinary collaboration, this implies that other professionals need to learn understanding nursing language in a similar way as nurses understand medical language.
To prepare nurses for using standardized nursing language into the EHR, they must have clinically applicable knowledge about nursing classifications. Based on the results of this study, we suggest rethinking the methods to implement nursing diagnoses, in- terventions and outomes and to apply and further evaluate GCR.
Implications from this study can be drawn for the electronic health record. Based on the results of this thesis we suggest the use of NNN for electronic nursing documentation. To attain favourable patient outcomes, nursing diagnoses must be linked with interven- tions, specific to an identified etiology, and nursing-sensitive patient outcomes must be identified. High quality software programs contain such evidence-based and automated linkages between diagnoses, interventions and outcomes. The software should also provide links between the nursing assessments; the nursing diagnoses and related nurs- ing progress notes. The Q-DIO is useful as an audit tool and is recommended for de- velopment as an integrated feature in the electronic health record. We conclude that implementation of NANDA-I diagnoses, related interventions and nursing-sensitive patient outcomes led to higher quality of nursing documentation. Standardized nursing language reflects and communicates nursings work. When used for documentation purposes, standardized nursing language permits data aggregation for subsequent evaluation of nursing-sensitive patient outcomes, essential in the measurement of the quality and cost effectiveness of nursing care.
References
. [1] Institute of Medicine. Keeping Patients Safe. Washington, DC: National Academy Press; 2004.
. [2] KVG. Schweizerisches Krankenversicherungsgesetz. Bern: Bundesamt fr Gesundheit; 1995.
. [3] Center for Nursing Classification and Clinical Effectiveness. Nursing Outcomes Classification ?(NOC). Iowa City: The University of Iowa College of Nursing; 2004 [updated 2004; cited 2005 ?September 6]; http://www.nursing.uiowa.edu/centers/cncce/noc/nocoverview.htm].
. [4] Dochterman J, Bulechek GM, editors. Nursing Interventions Classification NIC. St. Louis: ?Mosby; 2004.
. [5] ICN. Leading nursing diagnosis organization to collaborate with the International Classification of ?Nursing Practice. Chicago: International Council of Nurses; 2004 03/27/04.
. [6] Johnson M, Bulechek G, Butcher H, McCloskey Dochtermann J, Maas M, Moorhead S, et al. NANDA, NOC and NIC linkages: Nursing diagnoses, outcomes, & interventions. 2 ed. St. Louis: ?Mosby; 2006.
. [7] Ehrenberg A, Ehnfors M, Smedby B. Auditing nursing content in patient records. Scandinavian ?Journal of Caring Sciences. 2001;15:133-41.
. [8] Bartholomeyczik S. Qualittsdimensionen in der Pflegedokumentation - eine standardisierte ?Analyse von Dokumenten in Altenpflegeheimen. Pflege: Die wissenschaftliche Zeitschrift fr ?Pflegeberufe. 2004;17:187-95.
. [9] Lunney M. Helping nurses use NANDA, NOC, and NIC. Jona. 2006;36(3):118-25.
. [10] Mller-Staub M. Evaluation of the implementation of nursing diagnostics: A study on the use of ?nursing diagnoses, interventions and outcomes in nursing documentation. Wageningen: Ponsen & ?Looijen; 2007.
. [11] Mller-Staub M. Evaluation of the implementation of nursing diagnostics. Nijmegen: Radboud ?University; 2007.
. [12] Mller-Staub M, Lavin MA, Needham I, van Achterberg T. Nursing diagnoses, interventions and ?outcomes - Application and impact on nursing practice: A systematic literature review. Journal of ?Advanced Nursing. 2006;56(5):514-31.
. [13] Currell R, Urquhart C. Nursing record systems: Effects on nursing practice and health care out-
comes. Cochrane Review. 2003;3(CD002099).
M. Mller-Staub / Preparing Nurses to Use Standardized Nursing Language in EHR 341
. [14] Smith-Higuchi KA, Dulberg C, Duff V. Factors associated with nursing diagnosis utilization in Canada. Nursing Diagnosis. 1999;10(4):137-47.
. [15] Lunney M. Critical thinking & nursing diagnoses: Case studies & analyses. Philadelphia: NANDA International; 2001.
. [16] Lunney M. Critical thinking and accuracy of nurses' diagnoses. International Journal of Nursing Terminologies and Classifications. 2003;14(3):96-107.
Email address for correspondence [email protected]

Request for T.Lavinder!

THIS IS THE INSTRUCTIONS FOR THE RESEARCH CRITIQUE
NURS 225: RESEARCH
GUIDELINES FOR RESEARCH CRITIQUE

Directions for formatting the critique:

Number all pages; title page will be page number 1 [see APA manual for format of title page, use of running head with page number, and proper citation of a journal article and book; use 12 pt. font, no bold print with APA]. Do not include an abstract with this assignment.

For the body of this assignment you will not use a strict APA format. The form for the critique begins on page 2. Save this document as a Word file onto your desktop there is no need to re-type the form. Just type in your responses to each of the italicized bulleted questions/objectives. Your responses should be typed in regular font. Double-space your narrative response.

Use main headings [i.e., Introduction; Problem/Purpose, etc.], then respond to each of the bulleted questions/objectives. Type your responses in regular font.

Be sure to clearly explain answers, validate yes and no answers with at least a comment or two. Some of your narrative responses will be more detailed. Use proper grammar and proper sentence structure.

The critique, including title and reference pages, should be about 810 pages. Do not be overly concerned about the length of the paper; just be sure to clearly respond to each of the questions/objectives.

NOTE: Refer to the points on critiquing research studies that are detailed throughout the textbook. Although its not based on the guidelines above, you may find the example of an article critique helpful (see Module/Week 5 Additional Materials.

Points assigned to each component of critique are cited in parentheses [Total points possible: 225].

The form for the critique begins on page 2. Save this document as a word file onto your desktop then you may format as needed and type in your responses. Do not retype the form/information.















RESEARCH CRITQUE


Introduction (5)
Does title fit well with the content of the article?
Are the independent/dependent or variables of interest clearly defined?
Discuss the content of the abstract, is it a good overview of the content, is it consistent with content?

Problem/Purpose (10)
State the problem.
Do the authors identify the significance of the problem?
Do they provide adequate background information to support the problem?
Do the authors explain the purpose or aim of the study?

Literature Review (10)
Are relevant previous described?
Are the references current? (number of sources in the last 10 years and in the last 5 years)
Do the authors summarize their review of the literature to reveal what is known/not known and the need for further study?

Framework/Theoretical Perspective (10)
Is the study based on a specific theory or theoretical framework?
If the study is based on a specific theory, do the authors tie the framework/theory to their study concepts/variable of interest? If so, how is this accomplished?

List the Research Question(s) OR Hypotheses (10)
Research hypothesis or hypotheses
Research question(s)

Identify and Define Variables (10)
Independent variables [intervention/treatment], identify and define variable(s), - what is the treatment or intervention and how is it implemented?
Dependent variables [outcome of the treatment effect] define the dependent variable and describe how it is measured.
If the study does not have and independent and dependent variable, identify and define and the study variables of interest.

Demographics of Sample (5)
Were demographics of the sample included? If yes, provide a few examples of demographics, i.e. 50% male, 50% female, etc.







Research Design (15)
Identify the research design and define the design, i.e. nonexperimental, descriptive survey, correlational, etc.
Is the design used in the study the most appropriate design to obtain the needed data?
If an experimental study, identify the treatment or intervention
Were subjects assigned to groups? If so, how was this done?
Did the researchers conduct a pilot study? If so, what did they have to say about it did they make changes based on the pilot study?

Sample/Setting (15)
Sampling criteria this is usually referred to as inclusion criteria meaning what characteristics did participants need in order to be included in the study? i.e. female, 40-50 years of age, pregnant with 1st child, etc.
Sampling method, how did researchers obtain participants, what kind of approach was used nonprobability [nonrandom] or probability [random]?
Was informed consent obtained? Institutional Review Board mentioned?
Identify the setting of the study did the setting fit well with the studys objectives?

Measurement, Methods & Instruments (15)
Who developed the instruments used? The author, someone else?
Identify the type of measurement used in the study [Likert scale, physiological measure, etc.] and the level of measurement used [remember basic stats nominal, ordinal, interval, or ratio]
Discuss instrument development if applicable [some studies will use established instruments developed by other researchers/scientists if so note this]
Did the authors discuss the reliability and validity of the instruments used?

Data Collection (10)
How were data collected?
Timing of data collection [one time [cross-sectional] collection, longitudinal?]
Where were the data collected?

Data Analysis (10)
Are data analysis procedures clearly described? Explain
Are data analysis procedures appropriate for the type of data collected? Explain.

Statistical Analyses (15)
What statistical measures were used to test or report reliability and validity of the measurement methods [usually refers to the instruments used] in the study?
What statistical measures were used to analyze the data collected [the data that answered the research hypotheses or research questions]?
Was the level of significance or alpha identified? If so indicate what it was [.05; .01; or .001. remember .05 means that the researchers are 95% confident that there was cause and effect or correlation b/w variables, .01 means that they were 99% confident, and .001 means that the researchers were 99.9% confident that their intervention was effective and directly related to the outcome of effect.


Limitations (10)
What limitations were identified?
Can you identify any other limitations?

Implication of Findings (10)
What implications for nursing were described?
Can you think of any implications that were not described?
What were the suggestions for further study?

Generalization of Findings (5)
Did the author(s) generalize the findings [did they apply the findings of their study beyond the sample studied and make application to the population in general? Remember that a random [probability] sample is considered to be generalizable whereas a nonrandom [nonprobability] sample is not.

Format (5)
Did you discover any spelling, punctuation, or grammatical errors? What about sentence structure, organization, clarity?


Overall Evaluation (20)
Were the steps of the research process logically linked together [did the authors research questions or hypotheses make sense based on the review of literature, did the methods employed, i.e., quantitative/qualitative fit well with the intent of the study, etc.?
What are your impressions about the overall quality of the study?
Your impressions regarding applicability of the study nursing practice and how it contributes to nursing knowledge
Include any other points of critique or commentary as desired.



NOTE: Do not critique the article based on the information posted below; Quality of Work applies to the quality of your work on this critique assignment.

Quality of Work (20)
Thoroughness
Proper grammar and sentence structure
Clear communication of ideas
Depth of information
Organization, APA formatted citatio of reviewed article

THIS IS THE RESEARCH TO BE CRITIQUE

Health Policy & Systems
Factors Associated With Work Satisfaction of
Registered Nurses
Christine Kovner, Carol Brewer, Yow-Wu Wu, Ying Cheng, Miho Suzuki
Purpose: To examine the factors that influence the work satisfaction of a national sample of
registered nurses in metropolitan statistical areas (MSAs).
Design: A cross-sectional mailed survey design was used. The sample consisted of RNs randomly
selected from 40 MSAs in 29 states; 1,907 RNs responded (48%). The sample of
1,538 RNs working in nursing was used for analysis.
Methods: The questionnaire included measures of work attitudes and demographic characteristics.
The data were analyzed using ordinary least-squares regression.
Findings: More than 40% of the variance in satisfaction was explained by the various work
attitudes: supervisor support, work-group cohesion, variety of work, autonomy, organizational
constraint, promotional opportunities, work and family conflict, and distributive
justice. RNs who were White, self-perceived as healthy, and working in nursing education
were more satisfied. RNs that were more career oriented were more satisfied. Of the
benefits options, only paid time off was related to satisfaction.
Conclusions: Work-related factors were significantly related to RNs work satisfaction.
JOURNAL OF NURSING SCHOLARSHIP, 2006; 38:1, 71-79. C2006 SIGMA THETA TAU INTERNATIONAL.
[Key words: work satisfaction, nurses, work attitudes]
* * *
Nursing shortages have been widely reported in the
literature both regionally (Cushman, Ellenbecker,
Wilson, McNally, & Williams, 2001) and within
healthcare organizations (Buerhaus, Staiger, & Auerbach,
2003; Grumbach, Ash, Seago, Spetz, & Coffman, 2001).
Work satisfaction is an important issue for registered nurses
(RNs) and managers in part because of its reported relationship
with RN turnover (Davidson, Folcarelli, Crawford,
Duprat, & Clifford, 1997; Francis-Felsen et al., 1996;
Gurney, Mueller, & Price, 1997; Ingersoll, Olsan, Drew-
Cates, DeVinney, & Davies, 2002; Lake, 1998; Larrabee
et al., 2003; Prevosto, 2001; Shader, Broome, Broome,West,
& Nash, 2001, which can lead to organizational shortages
and absenteeism (Siu, 2002; Song, Daly, Rudy, Douglas, &
Dyer, 1997). Results from studies about determinants of RN
work satisfaction should be of interest to both administrators
and policy makers.
Background
A substantial body of literature exists about factors associated
with RN satisfaction with work (Stamps, 1997).
Various measures of satisfaction have been used, but many
are not based on a theoretical framework. Price (2004) and
Gurney et al. (1997) proposed an integrated theoretical
model of work satisfaction and voluntary turnover (intent
to leave) that combines economic, psychological, and sociological
theories with empirical findings about the determinants
of turnover. They theorized that a variety of
work-setting characteristics and attitudes toward work are
associated with satisfaction, resulting in intent to leave jobs.
Some empirical evidence for the model (Agho, Mueller, &
Price, 1993; Davidson, Folcarelli, Crawford, Duprat, &
Clifford, 1997; Gaerter, 1999; Gurney et al., 1997) has been
presented. A modification of Gurney et al.s model is shown
in the Figure.
Demographic characteristics have been associated with
RN work satisfaction (Blegen & Mueller, 1987; Ingersoll
Christine Kovner, RN, PhD, Upsilon, Professor, College of Nursing, New
York University, New York City; Carol Brewer, RN, PhD, Associate Professor,
School of Nursing; Yow-Wu Wu, PhD, Associate Professor, School
of Nursing; Ying Cheng, MA, Doctoral Candidate; all at University at Buffalo,
Buffalo, NY; Miho Suzuki, RN, MSN, Upsilon, Doctoral Candidate,
College of Nursing, New York University, New York City. This manuscript
was supported by the Agency for Healthcare Research and Quality, Grant
R01HS01132002. The authors of this article are responsible for its contents.
No statement in this article should be construed as an official position
of the Agency for Healthcare Research and Quality. Correspondence to Dr.
Kovner, College of Nursing, New York University, 246 Greene Street, Room
618E, New York, NY 10003. E-mail: [email protected]
Accepted for publication August 7, 2005.
Journal of Nursing Scholarship First Quarter 2006 71
RN Work Satisfaction
Job satisfaction
RN characteristics
Demographic
Health
Work setting
Social support and
integration to:
Work-to-family conflict
Family-to-work conflict
Job stress
Organizational constraints
Role overload
Promotional opportunities
Professional values
Autonomy
Routinization
Disposition and orientation
Work motivation
Career orientation
Direct patient care
Job hazards (injuries)
Pay (income, benefits)
Distributive justice
Movement constraints
MSA characteristics
Figure. Factors contributing to nurses job satisfaction. Based on Gurney, Mueller, & Price (1997). Adapted with permission.
et al., 2002; Langemo, Anderson, & Volden, 2002; Lum,
Kervin, Clark, Reid, & Sirola, 1998; Weisman, Alexander,
& Chase, 1980), and studies have indicated both a positive
relationship between autonomy and satisfaction (Acorn,
Ratner,&Crawford, 1997; Kramer&Schmalenberg, 2003)
as well as contradictory findings (Davidson et al., 1997;
Gurney et al., 1997; McNeese-Smith & Crook, 2003). The
relationship between variety and work satisfaction is equivocal
(Gurney et al., 1997; McNeese-Smith&Crook, 2003).
Findings are contradictory about the relationship between
distributive justice and work satisfaction (Gurney et al.,
1997; Taunton, Boyle, Woods, Hansen, & Bott, 1997),
workload, organizational constraint, and work satisfaction
(Adams&Bond, 2000; Davidson et al., 1997; Gurney et al.,
1997; Hoffman & Scott, 2003; Shaver & Lacey, 2003),
supervisor and mentor support, and satisfaction (Decker,
1997; Gurney et al., 1997; Larrabee et al., 2003; McNeese-
Smith & Crook, 2003).
Work-group cohesion, also termed integration, relationship
with coworkers, and peer support (Adams & Bond,
2000; Decker, 1997; Gurney et al., 1997; Larrabee et al.,
2003; Shader et al., 2001) and promotional opportunity
satisfaction (Gurney et al., 1997; Mills & Blaesing, 2000;
Taunton et al., 1997) have been related to work satisfaction.
Work-to-family conflict and family-to-work conflict are
related concepts that have been negatively related to work
outcomes, family outcomes, and employee physical and
mental health (Frone, 2003), but they were not included
in Price et al.s model. Family-to-work conflict (family conflicts
with work) has been positively related to job dissatisfaction,
work-related absenteeism, tardiness, and poor
job performance in various occupations (Bernas & Major,
2000; Frone, Russell, & Cooper, 1992; Frone, Yardley, &
Markel, 1997) and also among nurses (Decker, 1997). In
contrast, work-to-family conflict (work conflicts with family)
has been associated with intentions to quit ones job
and turnover (Greenhaus, Parasuraman, & Collins, 2001;
Kirchmeyer & Cohen, 1999).
Although not included in Price et al.s model, some
evidence exists that metropolitan statistical area (MSA)
characteristics affect nurses work participation behavior
(Buerhaus, 1993; Buerhaus & Staiger, 1996, 1997), but not
clear is whether these factors have any effect directly on
work satisfaction. For example, in areas with many inpatient
days, competition for RNs might be high. This competition
72 First Quarter 2006 Journal of Nursing Scholarship
RN Work Satisfaction
might force employers to improve working conditions,
which would improve RN work satisfaction. Similarly,
in areas with competition among healthcare providers, they
might compete in relation to quality or cost. If they compete
on quality, they might be satisfactory places to work. However,
if they compete on cost, they might be unsatisfactory
places to work. The purpose of the study reported here was
to empirically test the revised model shown in the Figure in
a national sample of woring RNs to determine the factors
associated with RNs work satisfaction.
Methods
The target population for this study was all registered
nurses (RNs) in metropolitan statistical areas (areas around
and including metropolitan areas) in the United States.
About 78% of RNs live in MSAs (Spratley, Johnson,
Sochalski, Fritz, & Spencer, 2001). The sampling design included
a two-stage sample of RNs in MSAs. First, MSAs
were selected; then RNs were randomly selected from all
RNs in each MSA. Because of financial constraints for this
study, only 40 MSAs were randomly selected from the original
51 MSAs used by the Center for Studying Health System
Change in the Community Tracking Study (CTS) in 2000
(Metcalf, Kemper, Kohn, & Pickreign, 1996). The original
sampling strategy for the CTS was designed to result in a
nationally representative sample of RNs. RNs were sampled
from 29 states and the District of Columbia (AL, AR,
AZ, CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, DC,
MI, MO, NC, NJ, NV, NY, OH, OK, PA, SC, TN, TX, VA,
WV, and WA). The board of nursing in each area was contacted
to get an updated list of names and addresses for all
RNs. From these lists, 4,000 RNs were randomly selected
from the 40 MSAs with equal probabilities of selection. An
advantage of this method is that the statistical analyses do
not require the use of sampling weights.
After the sample of 4,000 RNs was selected, each nurse
was sent a mailed questionnaire based on a seven-stage procedure
reported by Dillman (2000), including: (a) an alert
letter, (b) the first survey, (c) a postcard reminder, (d) a second
survey, (e) a third survey, (f) a follow-up phone call,
and (g) a fourth survey. Each selected RN received the first
survey with a $1.00 incentive and was eligible for one of
10 prizes of $100 in a drawing. These procedures resulted
in completed questionnaires being obtained from 1,906 of
the 4,000 sampled RNs. The overall response rate was 48%
and ranged across the 40 MSAs from 30% to 51%. Fortyfive
respondents were eliminated from the analytic sample
because they had moved to an area for which we could not
obtain MSA data, and 324 were eliminated because they
were not employed in nursing. Thus, the final sample was
1,538 nurses who were working in nursing.
Four types of variables were derived from the model: (a)
RNdemographic characteristics and health (age, sex, ethnicity,
race, marital status, highest degree in nursing, living with
children, years of experience in nursing, advanced certification,
partners income, overall health status, current enrollment
in an educational program, and religious beliefs), (b)
MSA characteristics (medical, surgical, and other specialists
per 1,000 population, primary care practitioners per 1,000
population, index of competition, percentage of HMO hospital
services paid through fee schedules, inpatient days, and
RN-to-population ratios, unemployment rate in 2002, and
MSA, and (c) RN perceptions of the labor market that represented
movement constraints (local job opportunity and
outside job opportunity). The fourth group was work setting,
which included work attitudes (autonomy, variety, distributive
justice, work group cohesion, supervisory support,
mentor support, work-family conflict, family-work conflict,
promotional opportunity, organizational constraints, quantitative
workload, work motivation, career orientation,
partners career orientation, and satisfaction) and characteristics
of the work (annual income, holding more than one
position for pay, work setting, position, work shift, transfer
of work unit, change in supervisor, needle sticks, strains and
back injury, paid time off benefit, medical insurance benefit,
retirement benefit, tuition reimbursement, importance of
benefits, and number of benefits). The full list of variables
is shown in Table 1.
Work attitudes were measured with scales used in previous
research (Carlson & Frone, 2003; Gurney, 1990; Quinn &
Staines, 1979; Spector & Jex, 1998). Satisfaction was measured
with the five-item Quinn and Stainess facet-free job
satisfaction scale (Quinn&Staines, 1979), but with slightly
altered response items.We expanded the number of options
in several cases, such as from the original three-response options
(strongly recommend, have doubts about recommending,
and advise the friend against) to four-response options
(strongly recommend, somewhat recommend, somewhat advise
against, and strongly advise against). The Cronbach
alpha coefficient was .86. Quinn and Staines reported that
these indicators of job satisfaction were correlated with less
role ambiguity (?.22), depressed mood at work (?.43), and
more facet-specific job satisfaction (.55), indicating evidence
of the validity of the scale (Cook, Hepworth, Wall, & Warr,
1981). All scales were Likert-type, varying in the number
of items from 3 (for work-family conflict) to 10 (for organizational
constraints). Table 1 shows the definition, mean,
standard deviation, actual range, Cronbach alphas, and the
number of items for all scales used in the analysis. Reliability
coefficients for the scales ranged from a low of .70 for variety
to .95 for supervisory support and distributive justice.
The one-factor structure of each scale using confirmatory
factor analysis was supported in all cases except organizational
constraint. After removing one item from that scale,
a one-factor solution was supported.
Partners annual income was logged to normalize the distribution.
As for group two characteristics, all variables related
toMSAexcept unemployment rate were obtained from
InterStudy (2001). Unemployment rate was obtained from
the Bureau of Labor Statistics. Primary care practitioners are
physicians who provide primary care such as family practice
physicians. Index of competition is how competitive the
HMO marketplace is.
Journal of Nursing Scholarship First Quarter 2006 73
RN Work Satisfaction
Table 1. Definition, Reliability, Number of Items, Mean, Standard Deviation, and Actual Range of Work Attitude Scales (N=1,538)
Definition Alpha Number of items Mean (SD) Actual range
Local job opportunity Likelihood of obtaining jobs in local area as good, worse, or better
than current jobb
.88 2 2.95 (1.21) 1.005.00
Outside job opportunity Likelihood of obtaining jobs outside local area as good, worse, or
better than current jobb
.90 2 3.09 (1.15) 1.005.00
Supervisory support Degree to which supervisor supports and encourages employeeb .95 5 3.59 (1.03) 1.005.00
Mentor support Degree of adequacy of access to an appropriate experienced
professional to sponsorship, protectorship and professional
benefactorshipb
.91 6 3.00 (0.88) 1.005.00
Work group cohesion Degree to which employees have friends in the immediate work
environmentb
.90 4 3.81 (0.83) 1.005.00
Variety Degree to which job performance is repetitiveb .77 4 3.03 (0.71) 1.005.00
Quantitative workload Amount of performance required in a jobc .89 5 4.13 (1.16) 1.006.00
Autonomy Degree to which employees control their job performanceb .79 4 4.09 (0.73) 1.505.00
Organizational constraint Degree to which situations or things interfere with employees job
performancec
.89 10 2.41 (0.92) 1.006.00
Promotional opportunities Degree to which career structures within an organization are
available to its employeesb
.90 5 2.87 (0.92) 1.005.00
Work-to-family conflict Degree to which an employees job interferes with family lifed .94 3 3.13 (1.40) 1.006.00
Family-to-work conflict Degree to which an employees family life interferes with jobd .89 3 1.73 (0.90) 1.006.00
Work motivation Degree to which work is central to an employees lifeb .83 4 2.08 (0.74) 1.005.00
Distributive justice Degree to which the an employees rewards are related to
performance inputs into the organization b
.95 4 2.60 (0.98) 1.005.00
Job satisfactiona Employees general affective reaction to the job without reference to
any specific job facete
.86 5 ?.012 (0.80) ?2.141.03
Note. aThe standardized score was used for job satisfaction because the numbr of items varied for each question. bGurney, Mueller, & Price (1997), c Spector & Jex (1998),
d Frone, Yardley, & Markel (1997), e Quinn & Stains (1979)
Findings
As shown inTable 2, working RNs were primarily women,
White, married, and only 14.2% had children under 6 years
old living with them. 19.1% had more than one position
for pay, 61% worked in hospitals, and a similar percentage
were in direct care positions. In addition to pay, the RNs had
a variety of noncompensation benefits: 85.2% had medical
insurance, 82.6% had retirement benefits, and 83.5% said
these benefits were somewhat to very important to them for
staying in the current position. At the same time 10.9% had
transferred to another work unit and 34.5% had a change in
the immediate supervisor in the last year. Table 3 shows that
the RNs had a mean age of 46.4, 18.8 years of experience,
and $49,940 annual income.
We used ordinary least squares (OLS) regression to estimate
the model, because the dependent variable was continuous
and we were testing a linear relationship. As shown in
Table 4, the model explains 54% of the variance in work
satisfaction, with most of the variation explained by the
work setting variables. Only the significant findings are included
in the table. No other variables were significantly
related to job satisfaction. Table 4 also shows the relationships
between the predictor variables and satisfaction.
Non-Hispanic Black RNs were less satisfied than were non-
Hispanic White RNs. RNs who were in poor or fair health
were less satisfied than were those with very good health,
but injuries did not influence satisfaction. Of the MSA characteristics,
only unemployment rate was significantly related
to satisfaction. Local job opportunity was related to satisfaction,
but nonlocal job opportunity was not. Of work setting
variables, the only benefit option related to satisfaction
was not having paid time off (e.g., vacation). RNs working
in nurse education were more satisfied than were those in
hospitals. Less career-oriented RNs were less satisfied than
were those who were more career oriented. RNs working as
managers or instructors were less satisfied than were RNs
providing direct care.
More than 40% of the variance in work satisfaction was
explained by the various attitude scales. High autonomy,
high distributive justice, high group cohesion, high promotional
opportunities, high supervisor support, high variety of
work, low work-to-family conflict, and low organizational
constraint, significantly contributed to satisfaction.
Discussion
Our sample is similar to the sample of working RNs from
the National Sample Survey of Registered Nurses (NSSRN;
74 First Quarter 2006 Journal of Nursing Scholarship
RN Work Satisfaction
Table 2. Demographic and Work-Related Characteristics of the Sample (N=1,538)
n (%)
Sex Female 1461 (95.0)
Male 77 (5.0)
Ethnicity Hispanic or Latino 38 (2.5)
Not Hispanic or Latino 1465 (97.5)
Race White 1306 (84.9)
Black 101 (6.6)
Asian 74 (4.8)
Other 57 (3.7)
Marital status Now married 1067 (69.5)
Unmarried 469 (30.5)
Live with children under age 6 Yes 219 (14.2)
No 1319 (85.8)
Live with children between age 6-11 Yes 269 (17.5)
No 1269 (82.5)
Live with children between age 12-17 Yes 415 (27.0)
No 1123 (73.0)
Live with children age over 18 Yes 480 (31.2)
No 1058 (68.8)
Overall health Poor or fair 137 (8.9)
Good 482 (31.5)
Very good 556 (36.3)
Excellent 356 (23.3)
Highest nursing degree Diploma 259 (17.1)
Associate 566 (37.3)
Baccalaureate 525 (34.6)
Masters/doctorate 167 (11.0)
Formal educational program Currently enrolled 129 (8.4)
Not currently enrolled 1409 (91.6)
Advanced certificate Yes 413 (26.9)
(National specialty or NP certification) No 1125 (73.1)
Nursing education in the US Yes 1448 (94.1)
No 90 (5.9)
Importance of religious beliefs Not at all/not very important 232 (15.3)
Moderately/very/extremely important 1283 (84.7)
MSA size Small (population <250,000) 181 (11.8)
Medium 402 (26.1)
Large (>1 million) 955 (62.1)
Position for pay More than one 293 (19.1)
Only one 1238 (80.9)
Work setting Hospital 938 (61.0)
Nursing home 86 (5.6)
Nursing education program 44 (2.9)
Home health care 126 (8.2)
Ambulatory care 218 (14.2)
Other 126 (8.2)
Position Manager 282 (18.9)
Consultant 26 (1.7)
Instructor 70 (4.7)
continued.
Journal of Nursing Scholarship First Quarter 2006 75
RN Work Satisfaction
Table 2. (continued)
n (%)
Direct care 943 (63.3)
Advanced practice nurse 100 (6.7)
Other 69 (4.6)
Work shift Day 890 (59.9)
Night 302 (20.3)
Other 295 (19.8)
Transfer of work unit Yes 167 (10.9)
No 1366 (89.1)
Change in supervisor Yes 529 (34.5)
No 1003 (65.5)
RNs career orientation Less than others 184 (12.0)
The same as others 755 (49.2)
More than others 594 (38.7)
Partners career orientation Less than others 132 (8.7)
The same as others 534 (35.4)
More than others 435 (28.8)
No partner 409 (27.1)
Needle sticks Never 1153 (75.0)
One time 284 (18.5)
More than one time 101 (6.6)
Strains/back injury Never 839 (54.6)
One time 311 (20.2)
More than one time 388 (25.2)
Paid time off benefit Have it and used it 552 (35.9)
Have it but not used it 778 (50.6)
Do not have it 208 (13.5)
Medical insurance benefit Have it and used it 277 (18.0)
Have it but not used it 1033 (67.2)
Do not have it 228 (14.8)
Retirement benefit Have it and used it 122 (7.9)
Have it but not used it 1149 (74.7)
Do not have it 267 (17.4)
Tuition reimbursement Have it and used it 129 (8.4)
Have it but not used it 922 (59.9)
Do not have it 487 (31.7)
Importance of benefits to stay in the position Not at all/Not very important 254 (16.5)
Somewhat/Very important 1284 (83.5)
aSample sizes smaller than 1,538 indicate missing data.
Spratley et al., 2001) with the samples respectively, male (5%
vs. 6%), White (85.0% vs. 85.3%), and married (69.5%
vs. 70.4%) RNs. Although the mean age of the workingin-
nursing RN sample from the NSSRN was not available,
our sample (M=46.4) is similar to the mean age of the total
sample of the NSSRN that was 45.2 (Spratley et al.,
2001).
One of the issues in a study such as the one described
here is how meaningful the potential changes in satisfaction
are. Although the relationships might be significant,
the cost or effort to make a change (such as increasing variety
and autonomy) might not be related to a meaningful
change in satisfaction. In this study satisfaction scores were
standardized so the mean is approximately zero. A score of 1
is one standard deviation above the mean. What proportion
of a standard deviation would be meaningful? If a one unit
change in supervisory support is related to a.081 change in
satisfaction, that is unlikely to be meaningful. On the other
hand a one-unit change in career orientation that results in
a .183 change might be meaningful.
Working as an RN is often physically and emotionally
demanding. RNs with poor or fair health might find this
76 First Quarter 2006 Journal of Nursing Scholarship
RN Work Satisfaction
Table 3. Means and Standard Deviations of Continuous
Demographic Variables and Metropolitan Statistical Area
Characteristics (N=1,538)
M SD
Age 46.4 (10.5)
Years of experience in nursing 18.8 (11.1)
RNs annual income $49,940 (19,903)
Log of partners annual income 7.98 (4.83)
Number of benefits 6.29 (2.61)
Medical, surgical, and other specialists 1.81 (0.65)
per 1000 population
Primary care practitioners per 1000 population 0.23 (0.08)
Index of competition 0.68 (0.21)
Percentage of HMO hospital services paid through 13.8 (11.0)
fee schedules
Unemployment rate in 2002 5.51 (0.97)
Inpatient days per 1000 population 0.98 (0.33)
RN size divided by corresponding MSA population 0.99 (0.25)
Note. Sample sizes for each variable may be smaller than 1,538 because of
missing values.
burden difficult, so that they are less satisfied than are RNs
with very good health. Why the non-Hispanic Black RNs
in our sample were less satisfied than were their White coworkers
is not clear, and Bush (1988) found race ws not
related to satisfaction.
Regarding compensation, contrary to findings from some
other studies (Gurney et al., 1997; Ingersoll et al., 2002),
wages were not associated with satisfaction. However, dis-
Table 4. Ordinary Least Squares Regression Analysis of Significant Determinants of Job Satisfaction (N = 1,342)
Significant category for Unstandardized
Construct Variable (Reference Category) categorical variables coefficient R2 R2 change
Constant ?.971??
Demographic and Health Race/Ethnicity (Non-Hispanic White) Non-Hispanic Black ?.204?? .090 .090???
Overall health status (Very good) Poor or Fair ?.151?
MSA market Unemployment rate 2002 ?.040? .099 .009
Movement constraints Local job opportunity ?.042? .135 .035???
Work setting Supervisory support .081??? .541 .407???
Work-group cohesion .083??
Work setting (Hospital) Nursing education program .355?
Position (Direct care) Manager ?.113?
Instructor ?.283?
Variety .106???
Autonomy .106???
Organizational constraint ?.154???
Promotional opportunity .091???
Work family conflict ?.077???
Career orientation Less than others ?.219???
(Same as others) More than others .183???
Paid time off benefit Not have it .227??
(Have it but not used it)
Distributive justice .087???
?p <.05, ??p <.01, ???p <.001.
tributive justice, which pertains to the fairness of pay, was
related to satisfaction. Interestingly, the only benefit associated
with satisfaction was paid time off. Possibly these other
benefits could directly affect turnover while not having an
effect on satisfaction.
Working shifts other than the day shift and shift length
were not related to satisfaction, consistent with findings
from other studies (Hoffman & Scott, 2003). The RNs
quantitative workload was not related to satisfaction. RNs
who perceived that they had high workloads were no more
or less satisfied than were those who perceived that they had
low workloads. This finding is contrary to some findings
(Davidson et al., 1997; Gaerter, 1999; Hoffman & Scott,
2003; Sheward & Hagen, 2005), and others have found
no relationship between workload and satisfaction (Gurney
et al., 1997; Shaver & Lacey, 2003). These contradictory
findings might be related to the samples or to instrument
used to measure satisfaction. None of these studies included
the measure of satisfaction used in our study. The study reported
here had a nationally representative sample, which
none of the above studies had. The difference might be related
to the perceived fairness (distributive justice) of the
workload rather than the actual workload. If everyone is
working hard, that might not affect satisfaction. However,
if some people have higher workloads or fewer days off,
the lack of justice could lead to dissatisfaction. Although
much has been written about the need for RNs to have support
from mentors (Prevosto, 2001), this variable was not
related to satisfaction in our sample. Supervisory support,
however, was related to RN work satisfaction, as was work
group cohesion, and both of these conditions might indicate
Journal of Nursing Scholarship First Quarter 2006 77
RN Work Satisfaction
support aspects of mentoring. These work setting factors
can be influenced by employers.
Conflicts between work and family have been reported to
be related to work satisfaction. We defined two concepts:
work-to-family conflict (work interferes with family) and
family-to-work conflict (family interferes with work). When
work interfered with family, the RN work satisfaction was
lower; however, when family interfered with work no relationship
to work satisfaction was found. Work-to-family
conflict was related to satisfaction in nonnursing samples
as well. Organizational and personal initiatives to reduce
work-to-family conflict would be particularly appropriate
targets to address (Frone, 2003).
Conclusions
The study reported here included a national random sample
of RNs in a variety of nursing positions and healthcare
organizations, unlike many other studies of work satisfaction
that were focused on only staff nurses in hospitals
(Adams & Bond, 2000). However, only the educational
work setting influenced satisfaction. Thus, differences in our
sample from studies focused on RNs in hospitals might account
for some differences in findings. On the other hand,
our model explained 54% of the variance inRNsatisfaction.
Thus, the model we tested, which included many variables
not analyzed in other studies, might account for some differences
from previously published studies.
Of particular interest to managers is what factors are mutable
by management or governmental policy in such a way
that they increase satisfaction. Considering the need to recruit
and retain minority nurses, managers should be particularly
sensitive to the concerns of non-Hispanic Black nurses
to determine how to increase their satisfaction. Organizational
characteristics such as paid time off, autonomy, variety,
distributive justice, supervisory support, promotional
opportunity, and organizational constraints are factors over
which organizations have a great deal of control. Interestingly
and contrary to economic literature, the amount of
wage was not significant but the fairness of the wage was
important, and this perception can be modified by employers.
Having paid time off as a benefit is a way employers
could reduce work-to-family conflict; e.g., flexibility in work
schedules might be an important factor in work satisfaction.
Work-to-family conflict and group cohesion might be improved
if organizations provide work environments that are
family friendly, with supervisors trained to foster activities
in work units that increase group cohesion. Improving those
organizational characteristics should lead to increased RN
satisfaction with work.
Future research should include studies with large enough
sample sizes to assess whether factors associated with satisfaction
vary by subgroup such as new graduates in the 1st
year of practice. Some measures that have been reported to
be related to satisfaction, such as communication with physicians
were not included in this study and should be included
in future research. This study was focused on individuals,
not organizations, and it included little information about
the organizations in which the RNs worked. We did not assess
organizational size or other characteristics, nor did we
include data about the dynamics of the work setting, such
as how care was organized.
Understanding satisfaction is important because it has
been linked inversely to turnover. Findings from this and
other studies indicate that organizations can do much to
increase RN satisfaction with work.
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Journal of Nursing Scholarship First Quarter 2006 79

Case Study #1: McLanahan University

McLanahan University is an accredited university of approximately 28,000 full-time and 12,000 part-time students, offering baccalaureate, masters, and doctoral programs. It is located in a multicultural city of 1,200,000 inhabitants. There are five acute care hospitals, one of which is a 375-bed magnet hospital. Other health care facilities in the city include three chronic and long-term care agencies, numerous nursing homes, eight home health care agencies, a public health unit, physicians? and nurse practitioners? offices, and walk-in clinics.

Dr. Seranous Koupouyro is the director of The McLanahan School of Nursing, which comprises 10 masters-prepared and 11 doctorally-prepared full-time nursing faculty. Faculty have been meeting for four months to redesign the BSN curriculum. Part-time faculty have been regularly invited to join the curriculum work, but their involvement has been slight. The goal is to implement the revised curriculum in 18 months for a class of 125 students.

The Total Faculty group endorsed the existing humanistic-caring, feminist philosophical approaches. Core curriculum concepts, key professional abilities, and principal teaching-learning approaches were identified and the curriculum nucleus endorsed.

The curriculum committee has developed the outcome statements, and after these were approved, they formulated the level competencies. The outcome statements address the provision of evidence-based nursing care in accordance with regulatory standards, effective communication and management, ethical and cultural competence, and advocacy to enhance social justice. The faculty are now ready to consider the curriculum design.
1.How should the curriculum committee proceed with the work yet to be done?
2.What should the curriculum committee consider next?
3.What resources would assist the committee in its curriculum design process?
4.What should be included in the curriculum design?
5.How will the curriculum nucleus influence the curriculum design?
6.How could nursing and non-nursing courses be determined?
7.What policies should be taken into account for the curriculum design?

Case Study #2: Philmore College

Situated in a small, non-industrial town, Philmore College was originally a ?hilltop? college established in 1818 as a school for boys and later, for boys and girls. The school has evolved into a 4-year, privately endowed, non-sectarian, post-secondary institution. Since the 1960?s, programs leading to baccalaureate degrees in psychosocial and physical sciences have been offered. A decision has been made to offer a 12-month accelerated BSN program in response to the nursing shortage and the demand by applicants with prior degrees. This program will be additional to the upper division BSN degree that is currently offered.

The 9 master?s-prepared and 4 PhD full-time nursing faculty have combined nursing practice and teaching experience ranging from 4?18 years. The director, Dr. Agnes Philmore, a direct descendant of the founder, joined Philmore College in 1996. All nursing faculty, including the director, engage in classroom and clinical teaching. The practice experiences for the upper division BSN students are offered in one local 200-bed community hospital, a 224-bed tertiary care hospital in a neighboring city, and a 76-bed long-term and residential care facility. Students also have community nursing experience, which is coordinated and supervised by a primary care nurse practitioner with an adjunct faculty appointment. Approximately 85 students graduate annually and have been consistently successful in the licensure examinations and in obtaining employment.

The director, faculty, several students, and a local nurse practitioner, who comprise the curriculum committee, have been meeting to design the 12-month program. The curriculum nucleus has been determined and the curriculum outcomes written. The principal teaching-learning approaches are focused on active and constructed learning. Courses for the discipline-specific, accelerated 182-month program have been identified. The committee is ready to begin course design.
1.What parameters must the curriculum committee consider when designing the courses?
2.In what way will a commitment to active learning influence course design?
3.Which components should be included in the courses?
4.What classroom and clinical experiences could be incorporated into the courses?
5.What would sample clinical and classroom courses look like for this accelerated baccalaureate-nursing program?

APA format/4-6 pages/at least 4 current published sources. I need the FIRST page of each reference to submit with my paper. I need a Reference Page done in APA format.
Topic: Quality Assessment & Performance Improvement in Home Health Care Delivery. Must explain the following: The important elements of QA/PI, how they are implemented, by whom, how they are organized, the tools used, and how the results are used. In addition, the research should include an interview with someone who is or has worked in Quality Assessment/Performance Improvement in the home health care field. Determine the effectiveness of the QA/PI policies where the person is employed. The following questions should be included: What problem he or she faces, how they solve them, and their perception of the value and future of QA/PI. Also, details of how the QA/PI process is physically integrated into the facilities daily operations.

Thank you!

Term paper: You are to use your imagination...ie. write a story (like writing an episode of ER or a movie script)regarding pharmacy. For example...you can write a story about a baby who is in the neonatal care unit and the new doctor wrote an RX for a medication that might be an overdose. Get the idea? It doesn't have to be a hospital setting..it can be retail, or anything that is in the health care field. I had a student last semester who wrote a story about her mom who is a home health care worker for a senior citizen. When her patient was having muscle cramps and seemed to be "out of it", she checked her meds and found out that she was getting the same medication from different pharmacies, one was brand name, the other generic. She was overdosing. So, use your own experience, or someone you know or make one up. Make sure you follow the criteria... It has to have a beginning, middle and an end (like a real TV script.) Most of all...have fun with it...use your imagination. Good Luck.

Family Assessment Rubric - will be sent
Sample Paper for family assessment will be sent

Family Assessment

Family Centered Nursing - health care that focuses on the health of the family as a unit, as well as the maintenance and improvement in the health and growth of each person in the unit. The recipient of care is the family itself (Harkreader, 2000).

Three beliefs that underlie the family-centered approach to the nursing process:
1. All individuals must be viewed within their family context
2. Families have an impact on individuals
3. Individuals have an impact on families

What is a Family?
? Two or more people who are emotionally involved with each other and live closely together (may be unrelated either biologically or legally) (Friedman, 1992).
? A family is whom the family says it is ? a set of relationships that the client defines as family, may be biological or legal or social ties.
? A family involves commitment over time.
Family Forms
Social trends affect families
There is a decline in traditional families
Divorce rate is over 50%
1. Nuclear family
2. Extended family (multigenerational)
3. Single parent family
4. Adoptive family
5. Foster family
6. Blended family
7. Alternate patterns of relationships
? Communal
? Homosexual

Family Theories ? used to explain the dynamics of family relations; gives a conceptual approach to family assessment.
1. Family developmental theory-stages of the family throughout its generational life cycle, divided into 8 stages (Duvall)
? Married couple without children
? Early childbearing family
? Family with preschool children
? Family with school age children
? Family with teenagers
? Family launching young adults
? Family in middle years (empty next to retirement)
? Family in retirement and old age
2. General systems theory
? Family is viewed as a social system existing and interacting with larger systems of the community
? The family is goal directed
? Can be open or closed
? An open family is healthy because there are interactions within the family and the external environment. As the needs of its members change, the family can adjust to maintain harmony and balance. When the open family system loses its balance, outside help can assist in its stabilization
? A closed family excludes others, functions in isolation, and is a pathological model (abusive family, family has secrets)
These models can be used in assessment by looking at what developmental stage the family is in and whether the family is an open or closed system and what type of support or input is available to the family.

Family Tasks ? described by Duvall and Miller as tasks that the family must accomplish in order to contribute to the mental health or mental illness of family members.
? Physical maintenance and safety (food, clothing, shelter, health care)
? Allocation of resources: meeting family needs and costs, provision for education
? Division of labor
? Socialization of family members: transmits beliefs, values, attitudes and coping mechanisms
? Reproduction and release of family members
? Maintenance of order, authority and decision making
? Placement of members into the larger society
? Maintenance of motivation and morale; meeting personal and family crises, refining a philosophy of life and family loyalty through rituals, nurturing and support of members

Parenting Styles ? 3 types
? Authoritarian ? obedience is expected
? Authoritative ? ultimate authority, yet some negotiation and compromise allowed
? Permissive ? little or no control over child?s behavior, rules are inconsistent and unclear
Assessment
Structure ? how the family is organized
Roles ? who does what
Power ? how are decisions made
Communication ? processes
Functions ? how does the family accomplish its tasks and goals
Resources ? ability to meet financial needs, support
Diagnosis
Compromised family coping
Disabled family coping
Ineffective family therapeutic regimen
Interrupted family processes
Readiness for enhanced family coping

Planning
? Needs to be negotiated, collaborative, and realistic
? Goal is to assist family to optimal functioning
? Considers developmental stage
? Incorporates family goals

Interventions (examples)
? Acknowledge feelings
? Explore coping skills
? Limiting the source of the problem
? Explore solutions
? Give options
? Role model
? Identify destructive behaviors
? Collaborate with other disciplines
? Support communication between family members
? Assist in problem solving
? Support conflict resolution
? Assist in the use of internal and external resources
? Provide health care information
? Provide health promotion information
? Assist family to identify strengths
? Encourage journaling to record activities
? Support role of caregiver
? Assist with role changes
? Assist with respite care
? Assist family to obtain services such as housecleaning, legal and financial services, home health care, hospice, food services

Evaluation

Annotated bibliography of the following subject: How is the obesity epidemic affecting the elderly population and what is being done to prepare for what?s to come.

Choose a topic related to this course (see course description and objectives) where you have an interest. These topics must be submitted by Monday, 8 a.m., of the second week of the course and approved by the professor. Your annotated bibliography topic will become the topic of the focus paper due week 8. Extensive library skills are required to successfully complete this assignment.

A description/example of how an annotated bibliography is written is included within the course shell under RESOURCES.
The categories for grading of this project are as follows:
? Uses an array of books, articles and documents
? Gives a succinct, concise analysis of each of the above.
? Uses a brief, descriptive and evaluative statement of 2 to 3 sentences which capture the precise essence of what the writer is expressing. This must be expressed in your own words. Cutting and pasting information from other sources is unacceptable.
? Incorporates an extensive library search.
? APA format utilized throughout the document

The resources for the annotated bibliography needs to come from databases on Drexel University Health Sciences Library.
Go to http://www.library.drexel.edu/healthsciences. To logon, username = tah74 password shejaj1
Then click on Databases, drop down to Health Sciences.

I have completed 15 resources which I will list so you do not duplicate them. From the directions, I think 3 paragraphs are required on each resource. paragraph #1 = describe in your own words what the author is trying to say. paragraph #2 = What is your opinion of the article. paragraph #3 = how does this article pertain to your research?

Again, the topic is: How is the obesity epidemic affecting the elderly population, how is it affecting the health care staff, and what is being done to prepare for what?s to come.

The resources already used are as follows:


Hignett, S., & Griffiths, P.. (2009). Risk factors for moving and handling bariatric patients. Nursing Standard, 24(11), 40-8. Retrieved January 28, 2010, from ProQuest Nursing & Allied Health Source.

Holland, D., Krulish, Y., Reich, H., Roche, J., (2001). How to creatively meet care needs of the morbidly obese. Nursing Management, 32(6). Retrieved January 12, 2010 from OvidSP.

Rotkoff, N., (1999) Care of the morbidly obese patient in a long-term care facility. Geriatric Nursing, 24(6). Retrieved January 10, 2010 from Science Direct.


Bradway, C., DiResta, J., Fleshner, I., Polomano, R., (2008). Obesity in Nursing Homes: A Critical Review. Journal of the American Geriatrics Society. 56(8), 1528-1535.
120847939


Lapane, K., Resnik, L., (2005). Obesity in Nursing Homes: An Escalating Problem. Journal of the American Geriatrics Society. 53(8). Retrieved from Wiley InterScienceon January 14, 2010.


Baker, G., Drake, D., Pokorny M., Rose, M., Scott, E. et al. (2009). Challenges in caring for morbidly obese patients. Home Healthcare Nurse. 27(1). Retrieved from OvidSP on January 20, 2010.


Drake, D., Dutton, K., Engelke, M., McAuliffe, M., Rose, M., (2005). Challenges that nurses face in caring for morbidly obese patients in the acute care setting. Surgery for Obesity and Related Diseases. 1(5). Retrieved from Science Direct.

Beck, B., Dulon, M., Kromark, K., Nienhaus, A., (2009). Back disorders and lumbar load in nursing staff in geriatric care: a comparison of home-based care and nursing homes. Journal of Occupational Medicine and Toxicology. 4. Retrieved on January 16, 2010 from PubMed Central.

Baal, P., Boshuizen, H., Brouwer, W., Engelfriet, P., Feenstra, T., (2008). Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Medicine. 5(2). Retrieved on January 20, 2010 from PubMed Central.

Campbell, C., Ellis, J., Grabowski, D., (2005). Obesity and Mortality in Elderly Nursing Home Residents. Journal of Gerontology: Medical Sciences. 60A(9). Retrieved on January 20, 2010 from ProQuest.


Brzezinski, S., (2008). Morbid Obesity: Issues and Challenges in Home Health. Home Healthcare Nurse. 26(5). Retrieved on January 20, 2010 from OvidSP.


Allo, A., Bonnema, S., Salihu, H., (2009). Obesity: What is an elderly population growing into? Maturitas. 63(1). Retrieved from PubMed

Bissoli, L., Bosello, O., Fantin, F., Francesco, V., Harris, T., et al, (2005). Health consequences of obesity in the elderly: a review of four unresolved questions. International Journal of Obesity. 29, pgs 1011-1029. Retrieved on January 20, 2010 from PubMed.


Taylor, J., (2002). The Vanderbilt Fall Prevention Program for long-term care: eight years of field experience with nursing home staff. Journal of the American Medical Directors Association. 3(3). Retrieved January 20, 2010 from OvidSP.

Hale, J., Lemon, S., Magner, R., Zapka, J., (2009). Lifestyle behaviors and weight among hospital-based nurses. Journal of Nursing Management. 17(7). Retrieved on January 16, 2010 from PubMed Central.



There are faxes for this order.