Nursing practicum learning agreement
Practicum goals:To analyze, develop, implement, and evaluate an evidence-based seizure disorder nursing assessment skills educational program for nursing staff at the Los Angeles Sheriff's Department Medical Services Bureau (LASDMSB).

Objective and Evidence of Accomplishment #(All Journal Entries Must Relate to a Practicum Objective or Evidence of Accomplishment)Reflective Learning.

1. Submit at least three or four pages of annotated bibliography.
2. Summary of evidence based on nursing seizure disorder assessment skills.
3. Summary of learning needs assessment developed.
4. The outline of education program for the nursing staff
5. Objectives.
6. Content outline.
7. Written copy of two different scenarios.

Introduction:

As the chief nursing officer, it is your job to oversee the recruitment, hiring, and retention of nurses for the acute care units of a healthcare organization. The organization has had difficulty retaining new graduates beyond the second year. Your task is to develop a plan for recruiting and retaining nursing staff, an interview guide for determining the most qualified nurses for a given job, and a plan to mentor the newly hired nurses.


Task:

A. Design a strategy (suggested length of 1 page) for recruiting nurses for the acute care units.


B. Write an original job description (suggested length of 1 page) to advertise a position for staff nurses to work 12-hour shifts in the acute care units.

C. Develop a short guide of 10 open-ended questions for interviewing candidates to work as staff nurses in the acute care units.

D. Design a strategy (suggested length of 1 page) for retaining staff nurses for the acute care units.

E. Design a mentoring program (suggested length of 3 pages) for the newly hired nurses.

Note: Assume that these nurses will all be new graduates.

F. Write a brief orientation guide (suggested length of 3 pages) for the newly hired nurses.

G. When you use sources, include all in-text citations and references in APA format.


Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly.

The paper should focus on patient outcomes related to the nursing staff (ie, nurse-to-patient ratio). The paper is APA format (no footnotes required). There should be a title page, introduction page, three main topics, conclusion, and the reference page. The title I came up with is How patient outcomes are affected by Nurse (RN) Staffing, but if you can come up with a better title I would appreciate it very much. There are five articles that I must use (approved by instructor), for this paper: (1) Nurse staffing, burnout, and health care-associated infection (American Journal of Infection control - Jeannie P. Cimiotti, et al), (2) Nurse Staffing and Inpatient Hospital Mortality-Jack Needleman, et al), (3) Nurse Staffing Effects on Patient Outcomes-Safety-Net and Non-safety Net Hospitals (Mary A. Blegen, et al), (4) The Effect of Hospital Nurse Staffing on Patient Health Outcomes: Evidence From California's Minimum Staffing Regulation (Andrew Cook, et al, Working Paper 16077 http://www.nber.org/papers/w16077), and (5) Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction- Linda H. Aiken, et al). The instructor wants the introduction page to be a "get my attention" page. I was thinking the first section should focus on negative aspects on care and patient outcomes due to insufficient nurse staffing, second section focus on positive aspects of care/outcomes with sufficient nurse staffing, third section to focus or make comparisons to California's Law on nurse to patient ratio, and the conclusion page. You may use other references that would support this topic. Thank you very much and please let me know if you should need any other information. The paper should be at least 15 pages not including the title page and reference pages.

Subject: Facilitate or improving communication between nursing staff on my unit (healthy relationship and mutual respect, decrease horizontal violence and gossip.)

CONTENT Total%_________% Earned
Develop a plan that you feel will make a difference at your worksite. 5
Describe the reason for designing your plan. 5
Identify one (1) caring based nursing theory as a guide. Utilize a change theory. 5
Discuss your implementation of this plan at your worksite. Specifically discuss the steps you took (strategies) to accomplish this plan (outline). 5
Evaluate the outcomes of your plan. 5
PRESENTATION STYLE
Format is APA, 4-5pages, at least two peer reviewed references cited in the paper (in addition to references for change and caring theory) , grammar, spelling, and clarity. 5


Customer is requesting that (Writergrrl101) completes this order.

Evidence and Expert Interview Paper

DIRECTIONS
1. Study the feedback that your instructor provided on Milestone #1 regarding your SMART goals.
2. Evidence: Peer-Reviewed Articles: You must have at least 2 peer-reviewed journals that support your SMART goals and your plan. You are expected to find ONE article for EACH SMART goal. As you search, enter key words that reflect the topic you have chosen for each SMART goal. You must select a different article for each goal.
3. Evidence: Internet Sites: Perform a search of the Internet to locate a credible website that pertains to EACH of your two SMART goals. The website should offer a tool or best practice, not just another article. You must identify at least one website for each goal; however, you may use the same website for both goals.
4. Expert Interview: Identify an expert, or experts, who can offer information or ideas on how you can attain each of your SMART goals and conduct an interview. If the expert can offer guidance on both of your SMART goals, you may interview the expert for both of them. If you cannot find an expert for both goals, you may choose a different expert for each one. The expert should help you acquire knowledge and provide guidance on how to achieve your goals. This person may or may not be a nurse, depending on the nature of your goals. You must report on the interview with the expert for each goal.
5. Organize and describe the relevance of your findings from each of your sources, indicating what information and insights you have gleaned.

6. Write a scholarly paper of your search and findings using APA format based on the 6th edition of the Publication manual of the APA (2010). You may find an APA template and an APA formatted sample paper in Doc Sharing.
Components of your paper should include the following: (Please follow the Milestone 2 Outline located in Doc Sharing)

a. Title page: Include your name, course, date, and instructor.
b. Introduction: Introduce the two SMART goals, and briefly describe why you chose these two goals for yourself.
c. Peer-Reviewed Articles: Identify a peer-reviewed article for each SMART goal. Analyze the article and its importance to each SMART goal. Provide a brief evaluation of each article, describing how the article applies to the specific SMART goal.
d. Credible Websites: Analyze one or more credible websites associated with each SMART goal. Provide a brief evaluation of website(s) describing how it applies to the specific SMART goal(s).
e. Informational Expert: Identify and recruit an informational expert to discuss your goals, offer information and/or ideas on how you can attain each of your SMART goals. Conduct an interview with each informational expert for each of the two SMART goals. The expert should facilitate the acquisition of knowledge and provide guidance as needed. This person may or may not be a nurse, depending on the nature of the goal. You may choose the same expert for more than one goal. Identify the expert?s qualifications (i.e. Nurse Manager, Vice President?). Provide an evaluation of the interview with the expert for each goal, and list any additional recommendations the expert provided to you pertaining to your goals.
f. Summary: Provide a summary of the findings gained through the peer-reviewed articles and websites. Additionally, summarize the insights gleaned from your informational expert.
In addition, this assignment should conform to the following requirements:
a. Written communication: Writing is free of errors that detract from the overall message.
b. APA formatting: Resources and citations are formatted according to APA (6th edition) style and formatting.
c. Number of resources: Minimum of three resources.

Here is Milestone 1..... (See Number 1 in directions)


SMART Goal 1: Leadership Development
S: specific
Who is involved in the goal, what is the goal, where will it take place? As a nurse administrator of a home health agency, my goal is to increase the communication between field staff and case managers regarding patient care to increase goals met.
M: measurable
(How are you going to achieve the goal? Currently, around 30% of patients are meeting their goals outlined in their plan of care. Additionally, only 40% of staff members currently attend weekly case conference to discuss patient care, and only call in reports to case managers when they feels it is needed, I want to increase communication among staff in order to increase patient meeting their nursing goals to 80% by July 2014.
A: attainable
What resources/expert available to assist you with attaining your goal? I can consult with staff individually and access resources, which is available to staff to improve communication and discuss roadblocks staff are encountering in communicating patient care. I will be seeking assistance from Fields Jackson from Kinnser software to discuss upgrading the current software used by the clinicians, and Arlene Maxim from A.D. Maxim Consulting to discuss professional training for all staff members.
R: realistic
Is this goal something that is realistically obtainable in a professional practice? It is an expectation of my job to evaluate staff members are able to effectively communicate with case managers and other nurses and meeting nursing goals set for the patient.
T: time bound
What specific dates or weeks will you accomplish each task of your project goal? By April 2014, I will meet with staff members to discuss ideas to improve communication between the field staff and case managers. By May 2014, I will create a process for increasing communication between staff members. And by July 2014, I will measure the improvements in the amount of communication among staff members by assessing the percentage of goals met in recertification and discharge summaries.
Smart Goal
Written in a complete sentence My completed goal statement: To implement a process of increasing communication between field staff and case managers to increase patient meeting nursing goals to 80% by July 2014.
Plan of Action
Attributes needed to achieve the goal; timeline of when you plan on doing what; explain how, when, and where you are going to meet or talk with your expert; and identify specific resources you plan on using to help you achieve your goals. Ineffective communication among healthcare providers can contribute to medical errors, patient harm, and financial harm to the facility (The Victorian Quality Control Safety and Quality in Health, 2010). Ensuring the management team is strong, cohesive, and working towards the same goal is imperative when drawing a team together. On March 17, 2014 I will hold a meeting in the conference room with the management team which includes case managers, business operations manager, and clinical service director to discuss current communication issues, how it is affecting patient outcomes, and teambuilding strategies to correct the problem. On March 17, 2014 at 3:30 I will meet with the scheduler in my office to discuss clearing all clinicians schedules as much as possible where they can attend case conference every Thursday morning from 9:00 to 10:00. March 18 through March 21, 2014, I will meet with field staff individually in the conference room to discuss roadblocks they are encountering with communicating patient needs and care to case manager and other members of management. March 24, 2014 hold a meeting in the conference room with case managers, business operations managers, and clinical service director to discuss findings from field staff interviews. March 26, 2014 I have a lunch meeting at Katz 21 with Fields Jackson from Kinnser software to discuss upgrading clinical software. Kinnser allows real-time access to all notes, schedules and communications including past visit episodes; with the feature of immediate submission of documents, including clinical notes, wound pictures, and communications case managers are able to instantly review and give feedback to field staff members (Kinnser, 2014). March 28, 2014, I have a telephone conference with Arlene Maxim from A.D. Maxim Consulting. The consulting firm offers in-services and in-agency training which analyzes key metrics to assure excellence in clinical outcomes, rapid program development and improved financial performances, programs include clinical management, working with administrative and office staff, and care plans & case management (A.D. Maxim Consulting, 2014). April 1-15, 2014 I will analyze data collected and formulate a proposal to governing board for plan of correction. The proposal will include implementing the new software and bringing in the consultant team to provide additional training to all staff. On April 18, 2014 I will have a meeting with governing board at 3:00 to discuss proposal and submit to board for approval. May 1, 2014 the new plan will be implemented for all staff to begin using new computer software and going through on-going training. The administrator, case managers, and clinical service director will meet every Tuesday, review clinical outcome data, and will make recommendations and implement changes as needed to ensure success by July 2014.

SMART Goal 2: Organizational Planning
S: specific
Who is involved in the goal, what is the goal, where will it take place? As a nurse administrator of a home health agency, it is my goal to incorporate a time management-mentoring project for all nurses to balance a healthy work-life balance by March 1, 2015.
M: measurable
How are you going to achieve the goal? Currently, only about 25% of the nurses are seeing all of their patients during the agency working hours of operation Monday thru Friday 8:00 a.m. to 5:00 p.m. Additionally, only 10% of the nursing staff are turning in all required nursing documentation per the agency policy of three times per week. I want to increase time management awareness and techniques among the nursing staff in order for 75% of the nurses to finish all work during working hours and spend quality time with their families by March 2015.
A: attainable
What resources/expert available to assist you with attaining your goal? I can consult with the staff individually to assess difficulties they are encountering with time management and access resources that is available to the nursing staff to improve their time management skills.
R: realistic
Is this goal something that is realistically obtainable in a professional practice? It is an expectation of my job to assist the nursing staff in being successful in their job duties of turning in all required nursing documentation 3 times per week and to see all assigned patients during the agency working hours.
T: time bound
What specific dates or weeks will you accomplish each task of your project goal? By May 1, 2014, I will meet with the nursing staff to discuss ideas to improve time management skills. By June 2, 2014, I will create a process for improving time management. And by September 1, 2014, I will measure the improvement of time management by reviewing time sheets and the percentage of required nursing documentation is being turned in a required. I will again meet with the nurses on October 1, 2014 individually to discuss any other areas of improvement needed to reach the goal of each nurse having a healthy work-life balance by March 1, 2015.
Smart Goal
Written in a complete sentence To implement a process of increasing time management skills in 75% of the nursing staff where they finish all work during working hours, turn in required nursing documentation three times per week, and spend quality time with their families by March 1, 2015.
Plan of Action
Attributes needed to achieve the goal; timeline of when you plan on doing what; explain how, when, and where you are going to meet or talk with your expert; and identify specific resources you plan on using to help you achieve your goals. Employees face the challenge of balancing work and life throughout the work week; it is up to the employer to aide in creating a flexible, supportive environment that allows employees to maximize organizational performance while maintaining their health and wellness (United States Office of Personnel Management, n.d). On April 15, 2014 I will meet with the nursing staff individually in the conference room to discuss the problems they are encountering on turning in nursing documentation three times per week and the challenges they are facing on seeing their patients between normal business hours of 8 to 5 Monday thru Friday. On April 21, 2014 I will meet with business operation manager, clinical service director, and case manager to discuss findings and discuss challenges that they are encountering. April 28, 2014 telephone conference with Selman Holman & Associates to discuss in-service for staff on being efficient and assistance on problem solving in the field. On May 1, 2014 I will meet with the nursing staff in the conference room to discuss ideas for time management skills and summary of current findings and receive the nurses feedback. By June 2, 2014 I will have the plan created and will present to the staff in the conference room on June 5, 2014 after case conference. Starting September 1, 2014 I will analyze all time sheets from June to present to see the percentage of nurses which are still working after hours to complete scheduled visits and continuing to have difficulties turning in required nursing documentation three times per week. I will meet with the staff on October 1, 2014 in the conference room to discuss findings, and inquire about other or new areas of concern they are facing enabling them from completing their work in a timely manner. I will then meet with the management team on October 2, 2014 to discuss necessary changes need for the goal to become successful. The new changes will be implemented by October 20, 2014. I will continue to monitor time sheets and speak with nursing staff monthly during case conferences to ensure the goal that 75% of the nursing staff will see all visits between regular working hours and turn in the required documentation by March 1, 2015. The time cards will then be examined quarterly to ensure that the agency continues to meet or exceed the goal.










Reference
A.D. Maxim Consulting, (2014). Training. Retrieved from https://www.admaximconsulting.com/consulting
Kinnser, (2014). Clinicians. Retrieved from http://www.kinnser.com/roles/clinicians/
The Victorian Quality Council Safety and Quality in Healthcare, (2010). Promoting Effective Communication Among Healthcare Professionals to Improve Patient Safety and Quality of Care. Retrieved from http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pdf
United States Office of Personnel Management, (n.d). Work-Life. Retrieved from http://www.opm.gov/policy-data-oversight/worklife/

4?5-page Impact Report to senior leadership that identifies the challenge, analyzes how it affects the organization from a nursing perspective, and details the new position.

Construct the report with the following headings:
The Nursing Challenge:

Identify the nursing challenge and its impact from a nursing perspective. Choose from:
Patient/staff safety, confidentiality, management/staff conflict, poor patient satisfaction survey scores, or nursing staff shortages.

The System/Organization:

Explain how the nursing challenge creates a gap or conflict between the organization's statements and practice.
Identify the organization type, that is, specialty hospital, teaching hospital, major health care system, et cetera, and summarize the organizational structure, its mission, vision, and philosophy statements.
Use systems theory and systems thinking to explain the gap or conflict.

SWOT Analysis:
Use the SWOT Analysis Template and include the SWOT analysis table in your paper.
Identify organizational factors that impact the situation using a SWOT analysis.
SWOT Analysis
Strengths Weaknesses
Opportunities Threats


What factors within the system may facilitate a solution for this problem?


Assess how the new nurse leader position will have power and influence and impact patient outcomes.
How will this position affect change within the organization?
Identify key leadership skills, knowledge, or abilities required for the position.
Written communication: Written communication should be free of errors that detract from the overall message.
APA formatting: Resources and in-text citations should be formatted according to current APA style and formatting.
4?5 pages in content length. Include a separate title page and a separate reference page.
Font and font size: Times New Roman, 12 point, double-spaced.
Number of resources: Use a minimum of three peer-reviewed resources.

Write a paper (1,500-2,000 words) in which you analyze and appraise each of the (15) articles identified below. Pay particular attention to evidence that supports the problem, issue, or deficit, and your proposed solution.

"Sample Format for Review of Literature

Organize your analysis of each article using the following sample format:

Cioffi, J., Purcal, N., & Arundell, F. (2005). ?A pilot study to investigate the effect
of a simulation strategy on the clinical decision making of midwifery students.?
Journal of Nursing Education, 44(3), 131-134.

(Summarize each section in 1-2 paragraphs.)

1) Summary of Article:


2) Research Elements: Design, Methods, Population, Strengths, Limitations:


3) Outcome(s): Research Results:


4) Significance to Nursing and Patient Care . An abstract is not required.

1.
Academic Journal
Observation results of handwashing by health-care workers in a neonatal intensive care unit.Full Text Available
(includes abstract); Caglar S; Yildiz S; Savaser S; International Journal of Nursing Practice, 2010 Apr; 16 (2): 132-7 (journal article - research, tables/charts) ISSN: 1322-7114 PMID: 20487058
Subjects: Handwashing; Nurses; Physicians; Adult: 19-44 years; Female; Male
Database: CINAHL Plus with Full Text


Add to folder Cited References: (24)
PDF Full Text (124.4KB)
2.
Academic Journal
School Nurse Inspections Improve Handwashing Supplies.Full Text Available
(includes abstract); Ramos, Mary M.; Schrader, Ronald; Trujillo, Rebecca; Blea, Mary; Greenberg, Cynthia; Journal of School Health, 2011 Jun; 81 (6): 355-8 (journal article - research, tables/charts) ISSN: 0022-4391 PMID: 21592131
Subjects: School Health Nursing; Handwashing; Materials Management; Nursing Role; Communicable Diseases; Toilet Facilities; Child: 6-12 years; Adolescent: 13-18 years; Male; Female
Database: CINAHL Plus with Full Text
Add to folder Cited References: (11)
HTML Full TextPDF Full Text (501.4KB)
3.
Academic Journal
Hand hygiene among nurses in Turkey: opinions and practices.Full Text Available
(includes abstract); Akyol AD; Journal of Clinical Nursing, 2007 Mar; 16 (3): 431-7 (journal article - research, tables/charts) ISSN: 0962-1067 PMID: 17335518
Subjects: Cross Infection; Handwashing; Nurse Attitudes; Nursing Staff, Hospital; Professional Compliance; Adult: 19-44 years
Database: CINAHL Plus with Full Text
Add to folder Cited References: (38) Times Cited in this Database: (3)
PDF Full Text (474.1KB)
4.
Academic Journal
Hand hygiene practices in adult versus pediatric intensive care units at a university hospital before and after intervention.Full Text Available
(includes abstract); Hussein R; Khakoo R; Hobbs G; Scandinavian Journal of Infectious Diseases, 2007 Jun-Jul; 39 (6-7): 566-70 (journal article) ISSN: 0036-5548 PMID: 17577819
Subjects: Handwashing; Health Personnel; Intensive Care Units; Intensive Care Units, Pediatric; Female; Male
Database: CINAHL Plus with Full Text
Add to folder Times Cited in this Database: (1)
PDF Full Text

5.
Academic Journal
Preventing the spread of acute respiratory viral infections.Full Text Available
(includes abstract); Gould D; Drey N; Nursing Standard, 2009 Oct 7-13; 24 (5): 44-9 (journal article) ISSN: 0029-6570 PMID: 19899337
Subjects: Respiratory Tract Infections; Respiratory Tract Infections; Virus Diseases; Virus Diseases
Database: CINAHL Plus with Full Text
Add to folder Cited References: (29) Times Cited in this Database: (1)
PDF Full Text (156.8KB)
6.
Academic Journal
Behavior-change interventions to improve hand-hygiene practice: a review of alternatives to education.Full Text Available
(includes abstract); Wilson, Sarah; Jacob, Casey J.; Powell, Douglas; Critical Public Health, 2011 Mar; 21 (1): 119-27 (journal article - review) ISSN: 0958-1596
Subjects: Handwashing; Hygiene; Health Behavior; Professional Compliance; Cross Infection
Database: CINAHL Plus with Full Text
Add to folder Times Cited in this Database: (1)
PDF Full Text



Add to folder Cited References: (41)
PDF Full Text (133.8KB)

7.
Academic Journal
Using an aseptic technique to reduce the risk of infection... art & science clinical skills: 10.Full Text Available
(includes abstract); Hart S; Nursing Standard, 2007 Aug 1-7; 21 (47): 43-8 (journal article - tables/charts) ISSN: 0029-6570 PMID: 17824454
Subjects: Asepsis; Handwashing; Infection Control
Database: CINAHL Plus with Full Text
Add to folder Cited References: (30) Times Cited in this Database: (9)
PDF Full Text (551.9KB)
8.
Academic Journal
ENT in primary care: part 3: upper respiratory tract infection.Full Text Available
(includes abstract); Warren E; Practice Nurse, 2008 Apr 25; 35 (8): 36, 38-9 (journal article - pictorial) ISSN: 0953-6612
Subjects: Common Cold; Respiratory Tract Infections
Database: CINAHL Plus with Full Text
Add to folder
HTML Full Text
9

Academic Journal
Strategies for prevention of RSV nosocomial infection.Full Text Available
(includes abstract); Groothuis J; Bauman J; Malinoski F; Eggleston M; Journal of Perinatology, 2008 May; 28 (5): 319-23 (journal article - review, tables/charts) ISSN: 0743-8346 PMID: 18368056
Subjects: Cross Infection; Respiratory Syncytial Viruses
Database: CINAHL Plus with Full Text


Add to folder Times Cited in this Database: (2)
PDF Full Text
10.
Academic Journal
Outside in.Full Text Available
(includes abstract); Newnham D; Nursing Standard, 2009 Jan 28-Feb 3; 23 (21): 26-7 (journal article - brief item) ISSN: 0029-6570 PMID: 19248446
Subjects: Handwashing
Database: CINAHL Plus with Full Text
Add to folder
PDF Full Text (1.4MB)
11.
Academic Journal
Outside in.Full Text Available
(includes abstract); Newnham D; Nursing Standard, 2008 Oct 29-Nov 4; 23 (8): 24-5 (journal article - brief item) ISSN: 0029-6570
Subjects: Handwashing
Database: CINAHL Plus with Full Text
Add to folder
PDF Full Text (583KB)


12.
Academic Journal
Handwashing campaign to include all hospital staff.Full Text Available
(includes abstract); Nursing Standard, 2009 Apr 1-7; 23 (30): 11 (journal article - brief item) ISSN: 0029-6570
Subjects: Personnel, Health Facility
Database: CINAHL Plus with Full Text
Add to folder
PDF Full Text (1MB)
13.
Academic Journal
Adoption of measures of the precaution in the teaching care practice by health care workers team: perceptions and limitations.Full Text Available
(includes abstract); Oliveira AC; Lucas TC; Online Brazilian Journal of Nursing, 2008; 7 (3): 1 (journal article - research) ISSN: 1676-4285
Subjects: Cross Infection; Health Personnel; Infection Control; Staff Development
Database: CINAHL Plus with Full Text
Add to folder
HTML Full Text

14.
Academic Journal
Weighing of soap dispenser bags sees staff handwashing rates soar.Full Text Available
(includes abstract); Snow T; Nursing Standard, 2008 Jun 11-17; 22 (40): 11 (journal article - pictorial) ISSN: 0029-6570
Database: CINAHL Plus with Full Text
Add to folder
PDF Full Text (591.5KB)
15.
Academic Journal
Patient campaigner calls for TV cameras to check handwashing.Full Text Available
(includes abstract); Parish C; Nursing Standard, 2008 May 28-Jun 3; 22 (38): 6 (journal article - pictorial) ISSN: 0029-6570
Database: CINAHL Plus with Full Text


MY SOLUTION TO THE PROBLEM IS HAND HYGIENE

WRITING

As :new Chief Executive Officer (CEO) provide a 750-word report detailing your strategies and recommendations to overcome the workforce shortages and to improve employee morale. The strategies and recommendations should be as specific as possible and include the resources needed for implementation.

SCENERIO:
You are the new Chief Executive Officer (CEO) of Middlefield Hospital. Middlefield Hospital is a 450-bed tertiary care facility in a major urban area in the Northeast. The hospital is an integrated health system that provides the full array of inpatient and outpatient services. The hospital enjoys a reputation for quality care in the area.

As the new CEO, you have learned that the hospital's employee turnover rate exceeds 20%, and there are over 100 nursing vacancies. You have also learned the following facts that may be impacting these workforce shortages:

A new hospital has recently opened in your market area that has produced competition for Middlefield Hospital.

Employee morale has deteriorated over the last 12 months.

Essex University (a local college) is considering eliminating its nursing degree program because there is continual difficulty in recruiting well qualified instructors


SOME VIEW POINTS OF CO_WORKERS:

NURSE VIEW POINT:
I have worked for Middlefield Hospital for 22 years. This hospital has always been committed to high quality in patient care. These nursing shortages have occurred many times through the years, and we will get through this one as well. I don't like that we are short of staff on many shifts, but we all have to pitch in and make sure our patients get the care they need.

BOARD MEMBER VIEW Point:

From my perspective, the employee morale at Middlesex has declined over the last 12 months. More and more employees are leaving Middlesex to go to the new hospital, and we have staffing shortages in most areas. The director of nursing is a great leader, but he is having difficulty retaining nursing staff. I am not sure what to do, but I don't want the reputation of the hospital to suffer.

Specifications:
Please i would like "oriented" to complete this essay. Thanks

This is reflective journal essay. Citing examples and critical
Thinking'. Please write about the following three key points
1. Nursing documentation
*why is it important
*how does it impact nursing practice
*how will it change my practice

2.limited nursing staff
*why is it important
*how does it impact nursing practice
*how will it change my practice

3. Nurse burn out or fatique
* why is it important
*how does impact nursing prctice
*how will it change my prctice

I have attach the rubrics and formt of the essay. You can type
Directly in the boxes or writ on a separte paper and please follow
The prompts and cite examples.

Course Project: Introduction to Course Project
Evidence-based practice involves a great deal more than simply reading nursing periodicals on a regular basis. Nurses can take a more proactive approach to evidence-based practice by identifying authentic problems and concerns, and then using that to guide their inquiries into current research. In this way, nurses can connect the results of relevant research studies to their nursing practice.
For the Course Project, you identify and apply relevant research to a specific nursing topic or problem. You begin by formulating an answerable question that is relevant to nursing and evidence-based practice. In later weeks of this course, you continue the Course Project by conducting a literature review and then determining how the evidence from the literature can be applied to nursing practice.
Before you begin, review the Course Project Overview document located in this weeks Learning Resources.
Note: This Course Project will serve as the Portfolio Assignment for the course. In addition to submitting portions of this Project in Weeks 2 and 5, you will turn in all three deliverables inWeek 10.
Project: Course Project: Part 1??"Identifying a Researchable Problem
One of the most challenging aspects of EBP is to actually identify the answerable question.
??"Karen Sue Davies
Formulating a question that targets the goal of your research is a challenging but essential task. The question plays a crucial role in all other aspects of the research, including the determination of the research design and theoretical perspective to be applied, which data will be collected, and which tools will be used for analysis. It is therefore essential to take the time to ensure that the research question addresses what you actually want to study. Doing so will increase your likelihood of obtaining meaningful results.
In this first component of the Course Project, you formulate questions to address a particular nursing issue or problem. You use the PICO model??"patient/population, intervention/issue, comparison, and outcome??"outlined in the Learning Resources to design your questions.
To prepare:
Review the article, Formulating the Evidence Based Practice Question: A Review of the Frameworks, found in the Learning Resources for this week. Focus on the PICO model for guiding the development of research questions.
Review the section beginning on page 75 of the course text, titled, Developing and Refining Research Problems in the course text, which focuses on analyzing the feasibility of a research problem.
Reflect on an issue or problem that you have noticed in your nursing practice. Consider the significance of this issue or problem.
Generate at least five questions that relate to the issue which you have identified. Use the criteria in your course text to select one question that would be most appropriate in terms of significance, feasibility, and interest. Be prepared to explain your rationale.
Formulate a preliminary PICO question??"one that is answerable??"based on your analysis. What are the PICO variables (patient/population, intervention/issue, comparison, and outcome) for this question?
Note: Not all of these variables may be appropriate to every question. Be sure to analyze which are and are not relevant to your specific question.
Using the PICO variables that you determined for your question, develop a list of at least 10 keywords that could be used when conducting a literature search to investigate current research pertaining to the question.
To complete:
Write a 3- to 4-page paper that includes the following:
A summary of your area of interest, an identification of the problem that you have selected, and an explanation of the significance of this problem for nursing practice
The 5 questions you have generated and a description of how you analyzed them for feasibility
Your preliminary PICO question and a description of each PICO variable relevant to your question
At least 10 possible keywords that could be used when conducting a literature search for your PICO question and a rationale for your selections
This Project Assignment is due by Day 7. It will also be a component of your Portfolio Assignment for this course, which is due by Day 7 of Week 10.
Reference:
Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75??"80. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144



Required Resources
Note: To access this week's required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Readings
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
o Chapter 3, Key Concepts and Steps in Qualitative and Quantitative Research (for review)
o Chapter 4, Research Problems, Research Questions, and Hypotheses

This chapter focuses on the steps in planning a study to generate evidence. These include developing a research question, identifying variables, articulating a problem statement, and generating hypotheses.
o Chapter 7, Ethics in Nursing Research

In this chapter, the focus is on the ethical dilemmas that occur when planning and conducting research and the ethical principles that have been enacted for protecting study participants.
Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing? Health Science Journal, 5(1), 3??"14.
Retrieved from the Walden Library databases.

This article describes a literature review conducted to determine the most important ethical issues that nurses encounter when undertaking or participating in research. The authors detail the results of the review and make recommendations for solving some of the problems highlighted.
Newcomb, P. (2010). Evolving fairness in research on human subjects. Journal of Child and Adolescent Psychiatric Nursing, 23(3), 123??"124.
Retrieved from the Walden Library databases.

In this article, the author describes some of the ethical controversies that may arise in conducting research in human subjects, especially with respect to ownership of genes. The author also stresses the importance of educating research subjects and their families about the ultimate purpose of research.
Yakov, G., Shilo, Y., & Shor, T. (2010). Nurses' perceptions of ethical issues related to patients' rights law. Nursing Ethics, 17(4), 501??"510.
Retrieved from the Walden Library databases.

The authors of this article detail a study conducted to determine how nursing staff deal with ethical issues in relation to the law. The article emphasizes the difficulty staff had in distinguishing between legal and ethical problems. The authors make several recommendations to deal with legal and ethical problems.
Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks.Evidence Based Library and Information Practice, 6(2), 75??"80. Retrieved fromhttps://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144

This article reviews the frameworks commonly used to assist in generating answerable research questions. The author recommends considering the individual elements of the frameworks as interchangeable (depending upon the situation), rather than trying to fit a situation to a specific framework.
Delwiche, F. (2008). Anatomy of a scholarly research article in the health sciences. Retrieved fromhttp://danaguides.uvm.edu/content.php?pid=41591&sid=3177873

This article highlights the primary components of scholarly research articles. The article details the distinguishing factors of scholarly journals, the peer-review process, and the definition of primary literature.
American Nurses Association. (2001). Code of ethics for nurss with interpretive statements.
Retrieved fromhttp://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf

This website provides the code of ethics for nurses to be used in carrying out their responsibilities. There is also a detailed explanation of each provision.
Document: Course Project Overview (Word document)
Note: You will use this document to complete the Project throughout this course.
Media
Laureate Education, Inc. (Executive Producer). (2012a). Anatomy of a research study. Baltimore, MD: Author.

This multimedia piece explains the anatomy of both quantitative and qualitative research studies. In addition, there is a brief quiz at the end of the tutorial to measure knowledge about research articles.
Laureate Education, Inc. (Executive Producer). (2012d). Evidence-based practice and research.Baltimore, MD: Author.

In this video, Dr. Marianne Chulay talks about the significance of evidence-based practice and research in nursing. She explains how nurses should apply research findings to health care decisions to improve outcomes.
Laureate Education, Inc. (Executive Producer). (2012h). Overview of evidence-based practice.Baltimore, MD: Author.

In this video, Dr. Kristen Mauk explains evidence-based practice and its importance to nursing. She also provides a brief overview of the process of conducting original research.
Optional Resources
National Institutes of Health Office of Extramural Research. (2011). Protecting human research participants. Retrieved from http://phrp.nihtraining.com/users/login.php

This website provides a course on ethical research for those involved in research in human subjects. The course supplies basic concepts, principles, and issues relevant to protecting research participants.
University of Oxford. (2005). PICO: Formulating an answerable question. Retrieved fromhttp://learntech.physiol.ox.ac.uk/cochrane_tutorial/cochlibd0e84.php
Please proceed to the Discussion.
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Evidence Based Library and Information Practice
Commentary
Formulating the Evidence Based Practice Question: A Review of the Frameworks
Karen Sue Davies?Assistant Professor, School of Information Studies University of Wisconsin??"Milwaukee?Milwaukee, Wisconsin, United States of America Email: [email protected]
Received: 17 Jan. 2011 Accepted: 04 Apr. 2011
2011 Davies. This is an Open Access article distributed under the terms of the Creative Commons-Attribution- Noncommercial-Share Alike License 2.5 Canada (http://creativecommons.org/licenses/by-nc-sa/2.5/ca/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly attributed, not used for commercial purposes, and, if transformed, the resulting work is redistributed under the same or similar license to this one.
Evidence Based Library and Information Practice 2011, 6.2






Introduction
Questions are the driving force behind evidence based practice (EBP) (Eldredge, 2000). If there were no questions, EBP would be unnecessary. Evidence based practice questions focus on practical real-world problems and issues. The more urgent the question, the greater the need to place it in an EBP context.
One of the most challenging aspects of EBP is to actually identify the answerable question. This ability to identify the question is fundamental to then locating relevant information to answer the question. An unstructured collection of keywords can retrieve irrelevant literature, which wastes time and effort eliminating inappropriate information. Successfully retrieving relevant information begins with a clearly defined, well-structured question. A standardized format or framework for asking questions
helps focus on the key elements. Question generation also enables a period of reflection. Is this the information I am really looking for? Why I am looking for this information? Is there another option to pursue first?
This paper introduces the first published framework, PICO (Richardson, Wilson, Nishikawa and Hayward, 1995) and some of its later variations including ECLIPSE (Wildridge and Bell, 2002) and SPICE (Booth, 2004). Sample library and information science (LIS) questions are provided to illustrate the use of these frameworks to answer questions in disciplines other than medicine.
Booth (2006) published a broad overview of developing answerable research questions which also considered whether variations to the original PICO framework were justifiable and worthwhile. This paper will expand on that work.
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Question Frameworks in Practice
PICO
The concept of PICO was introduced in 1995 by Richardson et al. to break down clinical questions into searchable keywords. This mnemonic helps address these questions:
P - Patient or Problem: Who is the patient? What are the most important characteristics of the patient? What is the primary problem, disease, or co-existing condition??I ??" Intervention: What is the main intervention being considered??C ??" Comparison: What is the main comparison intervention??O - Outcome: What are the anticipated measures, improvements, or affects?
Medical Scenario and Question: An overweight woman in her forties has never travelled by airplane before. She is planning an anniversary holiday with her husband including several long flights. She is concerned about the risk of deep vein thrombosis. She would like to know if compression stockings are effective in preventing this condition or whether a few exercises during the flight would be enough. P ??" Patient / Problem: Female, middle-aged, overweight?I ??" Intervention: Compression stockings?C ??" Comparison: In-flight exercises?O ??" Outcome: Prevent deep vein thrombosis
The PICO framework and its variations were developed to answer health-related questions. With a slight modification, this framework can structure questions related to LIS. The P in PICO refers to patient, but substituting population for patient provides a question format for all areas of librarianship. The population may be children, teens, seniors, those from a specific ethnic group, those with a common goal (e.g., job-seekers), or those with a common interest (such as a gardening club). The intervention is the new concept being considered, such as longer opening hours, a reading club, after-school activity, resources in a particular language, or the introduction of wi-fi.
LIS Scenario and Question: Art history masters students submit theses with more bibliography errors than those from students of other faculties. The Dean of art history raised this issue with the head librarian. The head librarian suggested that database training could help.?P ??" Population: Art History masters students I ??" Intervention: database searching training C ??" Comparison: students with no training or students from other Faculties?O ??" Outcome: Improved bibliographic quality
Table 1 illustrates the different components introduced in several PICO framework variations. Fineout-Overholt and Johnson (2005) considered the questioning behavior of nurses. They suggested a five-component scheme for evidence based practice questions using the acronym PICOT, with T representing timeframe. This refers to one or more time-related variables such as the length of time the treatment should be prescribed or the point at which the outcome is measured. A PICOT question in the LIS field is: In a specialist library, does posting the monthly library bulletin on the Website instead of only having printed newsletters available result in increased usage of the library and the new resources mentioned in the bulletin? In this question, the timeframe refers to a month.
Petticrew and Roberts (2005) suggested PICOC as an alternative ending to PICOT, with C representing context. For example, what is the context for intervention delivery? In LIS, context could be a public library, academic library, or health library.
A variation similar to PICOT is PICOTT. In this instance, neither T relates to timeframe. The Ts refer to the type of question and the best type of study deign to answer that particular question (Schardt, Adams, Owens, Keitz, and Fontelo, 2007). An example LIS question is: In a specialist library, does instant messaging or e-mail messaging result in the greatest customer satisfaction with a virtual reference service? This type of question is user analysis, and a relevant type of study design is
Evidence Based Library and Information Practice 2011, 6.2
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Evidence Based Library and Information Practice 2011, 6.2

Table 1?
Components of the Different PICO-based Frameworks
Richardson et al., 1995 Fineout- Overholt & Johnson, 2005 Petticrew & Roberts, 2005 Schardt et al., 2007 ADAPTE Collaboration, 2009
Dawes et al., 2007?Schlosser & O'Neil-Pirozzi, 2006
DiCenso, Guyatt, & Ciliska, 2005
a questionnaire. The PICOTT framework may be too restrictive when searching. If you are searching for effective Websites then transaction log analysis would be a reasonable type of study design. By limiting to that study type you would miss user observation studies, focus groups, and controlled experiments. These frameworks should focus the search strategy, while not excluding potentially useful and relevant information.
Specifically developed for building and adapting oncology guidelines is PIPOH (ADAPTE Collaboration, 2009). The second P refers to professionals (to whom the guideline will be targeted) and H stands for health care
setting and context (in which the adapted guideline will be used). An example of this in the LIS setting would be:?What is appropriate training for fieldwork students working on the librarys issue or circulation desk??P ??" Population: Library users?I ??" Intervention: Training?P ??" Professionals: Fieldwork students?O ??" Outcome:?S ??" Setting: Issue or circulation desk
Dawes et al. (2007) developed PECODR and undertook a pilot study to determine whether this structure existed in medical journal abstracts. E refers to exposure, replacing

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Patient / Population Intervention Comparison Outcome Timeframe
Context?Type of Question Type of Study Design Professionals?Health Care Setting Exposure?Duration?Results?Environment Stakeholders Situation
intervention to allow the inclusion of different study types such as case control studies and cohort studies. The D stands for duration, either the length of time of the exposure or until the outcome is assessed. The R refers to results. Here is a sample LIS question:
Does teaching database searching skills to postgraduate students in a hands-on workshop compared to a lecture result in effective skills to utilize throughout two or more years of study? Duration would be the length of the postgraduate course (2+ years), and results could be defined as effective searching skills.
Schlosser and O'Neil-Pirozzi (2006) proposed PESICO which applied to the field of fluency disorders and speech language pathology. E refers to the environment or the context in which the problem occurs, and S stands for stakeholders. Stakeholders are an important consideration in certain library settings.
LIS Scenario and Question: Each year, library staff accompany new university students on an introductory library tour. The tour is time- consuming and may not be appropriate for new students who have much information to absorb in their first few days. Library staff and student instructors suggested that staff post a virtual library tour on the Website. It can be accessed at a time and place to suit the student,andmay improvetheir understanding of library services.
P ??" Population: New university students E ??" Environment: Library?S ??" Stakeholders: Library staff and student instructors?I ??" Intervention: Virtual library tour?C ??" Comparison: Physical library tour?O ??" Outcome: Improved understanding of library services
Many of the adapted PICO frameworks introduce terms worth consideration depending on the subject, area, topic, or question. The elements which are additions to the original PICO framework could serve as filters to be reviewed after gathering the initial PICO search results. They can help determine the relevance of initial search results. For
example, consider filtering on context when determining if the results from a rural public library service are directly applicable to a large endowed university library.
DiCenso, Guyatt, and Ciliska (2005) suggested that questions which can best be answered with qualitative information require just two components. Such questions may focus on the meaning of an experience or problem.
P ??" Population: The characteristics of individuals, families, groups, or communities S ??" Situation: An understanding of the condition, experiences, circumstances, or situation
This framework focuses on these two key elements of the question. An LIS example is: In a public library, should all library staff who have face-to-face, telephone, or e-mail contact with users attend a customer awareness course??P - Population: Library staff with user contact S - Situation: Customer awareness course
ECLIPSE
PICO and its variations were all developed to answer clinical questions. Within the medical field there are other types of questions which need to be answered. ECLIPSE was developed to address questions from the health policy and management area (Wildridge and Bell, 2002).
E ??" Expectation: Why does the user want the information??C - Client Group: For whom is the service intended?
L ??" Location: Where is the service physically sited??I ??" Impact: What is the service change being evaluated? What would represent success? How is this measured? This component is similar to outcomes of the PICO framework. P ??" Professionals: Who provides or improves the service?
SE ??" Service: What type of service is under consideration?
Evidence Based Library and Information Practice 2011, 6.2
78
LIS Scenario and Question: There have been user complaints about the current Interlibrary Loan (ILL) service. What alternatives might improve customer satisfaction?
E ??" Expectation: Improve customer satisfaction C - Client group: Library users who request ILLs?L ??" Location: Library
I ??" Impact: Improve the ILL service P ??" Professionals: ILL staff?SE ??" Service: ILL
SPICE
The previous frameworks can all be adapted to answer LIS questions. One framework, SPICE, was developed specifically to answer questions in this field (Booth, 2004):
S ??" Setting: What is the context for the question? The research evidence should reflect the context or the research findings may not be transferable.?P ??" Perspective: Who are the users, potential users, or stakeholders of the service??I ??" Intervention: What is being done for the users, potential users, or stakeholders??C ??" Comparison: What are the alternatives? An alternative might maintain the status quo and change nothing.?E ??" Evaluation: What measurement will determine the interventions success? In other words, what is the result?
The SPICE framework specifically includes stakeholders under P for perspective and is therefore similar to the PESICO framework.
LIS Question: In presentations to library benefactors, does the use of outcome-based library service evaluations improve their perceptions of the importance and value of library services?
S ??" Setting: Library presentation to funders P ??" Perspective: Library benefactors?I ??" Intervention: Outcome-based evaluations of library services?C ??" Comparison: Other evaluations?E ??" Evaluation: Improved perception of the importance and value of library services
Some of these additional concepts are related. Context, environment, and setting have similar connotations, and duration is similar to timeframe. This suggests that the options for constructing well-defined questions are not as numerous as Table 1 suggests.
Combining comparable and related terms would provide the following concepts:?P ??" Population or problem?I ??" Intervention or exposure
C ??" Comparison?O ??" Outcome?C ??" Context or environment or setting?P ??" Professionals?R ??" Research ??" incorporating type of question and type of study design R ??" Results?S ??" Stakeholder or perspective or potential users?T ??"Timeframe or duration
Conclusion
These frameworks are tools to guide the search strategy formation. A minor adaption to the medical question frameworks, usually something as simple as changing patient to population, enables the structuring of questions from all the library and information science domains.
Rather than consider all of these frameworks as essentially different, it is useful to examine the different elements: timeframe, duration, context, (health care) setting, environment, type of question, type of study design, professionals, exposure, results, stakeholders, and situation. These can be used interchangeably when required. Maintaining an awareness of the different options for structuring searches broadens the potential uses of the frameworks. Detailed knowledge of the frameworks also enables the searcher to refine strategies to suit each particular situation rather than trying to fit a search situation to a framework.
Evidence Based Library and Information Practice 2011, 6.2
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References
The ADAPTE Collaboration. (2009). The ADAPTE process: Resource toolkit for guideline adaption (version 2). Retrieved from http://www.g-i- n.net/document-store/adapte- resource-toolkit-guideline-adaptation- version-2
Booth, A. (2004). Formulating answerable questions. In A. Booth & A. Brice (Eds.), Evidence based practice for information professionals: A handbook (pp.61-70). London: Facet Publishing.
Booth, A. (2006). Clear and present questions: Formulating questions for evidence based practice. Library Hi Tech, 24(3), 355-68. doi:10.1108/07378830610692127
Dawes, M., Pluye, P., Shea, L., Grad, R., Greenberg, A., & Nie, J.Y. (2007). The identification of clinically important elements within medical journal abstracts: Patient population problem, exposure intervention, comparison, outcome, duration and results (PECODR). Informatics in Primary Care, 15(1), 9-16.
DiCenso, A., Guyatt, G., & Ciliska, D. (2005).
Evidence-based nursing: A guide to clinical practice. St Louis, MO: Elsevier Mosby.
Eldredge, J. D. (2000). Evidence-based librarianship: An overview. Bulletin of the Medical Library Association, 88(4), 289-302.
Fineout-Overholt, E., & Johnson, L. (2005). Teaching EBP: Asking searchable, answerable clinical questions. Worldviews on Evidence-Based Nursing, 2(3), 157-60. doi: 10.1111/j.1741- 6787.2005.00032.x
Nollan,
R., Fineout-Overholt, E., & Stephenson, P. (2005). Asking compelling clinical questions. In B. M. Melnyk & E. Fineout-Overholt (Eds.). Evidence-based practice in nursing and healthcare: A guide to best practice (pp.25-37). Philadelphia: Lippincott, Williams & Wilkins.
Evidence Based Library and Information Practice 2011, 6.2




Petticrew M., & Roberts, H. (2005). Systematic reviews in the social sciences: A practical guide. Malden, MA: Blackwell Publishing.
Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. A. (1995). The well-built clinical question: A key to evidence-based decisions. ACP Journal Club, 123, A12-13.
Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, 16. doi:10.1186/1472-6947-7-16
Schlosser, R. W., & O'Neil-Pirozzi, T. (Spring, 2006). Problem formulation in
evidence-based practice and systematic reviews. Contemporary Issues in Communication Sciences and Disorders, 33, 5-10.
Wildridge, V., & Bell, L. (2002). How CLIP became ECLIPSE: A mnemonic to assist in searching for health policy/management information. Health Information and Libraries Journal, 19(2), 113-115. doi: 10.1046/j.1471- 1842.2002.00378.x

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Write an essay (using the uploaded literature that was written previously) that reflects on your literature review process. You need to address the following elements in your essay:

A. Describe the process you went through to select your research topic in your problem, search, and evaluation task (see uploaded essay on research topic reflection).

B. Discuss the purpose of conducting a literature review of the chosen research topic.

C. Discuss at least two specific examples of how the literature review affected different components of a research proposal (factors contributing to nursing staff morale and job satisfaction in an American Emergency Department).

D. Explain how resource availability and selection limited the scope of your research topic.

E. Discuss how performing a literature review affects nursing practice in an emergency room setting.

F. If you choose to use outside sources, include all in-text citations and references in APA format.
There are faxes for this order.

Customer is requesting that (ISAK) completes this order.

Applying Teaching Strategies for Diverse Learners in Various Education Settings


Using the formatted document posted in the unit seven assignment folder

1. Construct a 300-500 word summary explaining the influence of learner characteristics on the choice of teaching strategy in health care education for patients, families, communities, nursing staff, and basic nursing education learners.

2. Construct a 200-350 word summary discussing the expectations of the nurse educator in the development of educational opportunities for patients, families, communities, nursing staff, and basic nursing education learners.

3. Complete the Teaching Strategies Table describing the most appropriate choice of teaching strategy for diabetes education for the learner characteristic for each type of learner.

4. Construct a numbered reference list in APA format indicating the sources of the information in both summaries and the table. In the table place the number of the reference indicating the source of the information within each cell of the table.

5. There is to be a minimum of four current (2005 or later) peer reviewed journal articles cited as sources.

Hi, I have another order in with you, and I would appreciate the same writer. The other order this author is currently working on is: #A1066628.

STRICT APA 5th ed. at top of page.

This assignment is to read the article and based on the information in the following article, answer this question:

Why are baccalaureate nursing students "better"? APA 5th ed.

Here is the article:

Educational Levels of Hospital Nurses and Surgical Patient Mortality
Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Robyn B. Cheung, PhD, RN; Douglas M. Sloane, PhD; Jeffrey H. Silber, MD, PhD
JAMA. 2003;290:1617-1623.
ABSTRACT




Context Growing evidence suggests that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes.
Objective To examine whether the proportion of hospital RNs educated at the baccalaureate level or higher is associated with risk-adjusted mortality and failure to rescue (deaths in surgical patients with serious complications).
Design, Setting, and Population Cross-sectional analyses of outcomes data for 232 342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999, linked to administrative and survey data providing information on educational composition, staffing, and other characteristics.
Main Outcome Measures Risk-adjusted patient mortality and failure to rescue within 30 days of admission associated with nurse educational level.
Results The proportion of hospital RNs holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases).
Conclusion In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.


INTRODUCTION





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? Top

? Introduction
? Methods

? Results

? Comment

? Author information

? References









Nurse understaffing is ranked by the public and physicians as one of the greatest threats to patient safety in US hospitals.1 Last year we reported the results of a study of 168 Pennsylvania hospitals showing that each additional patient added to the average workload of staff registered nurses (RNs) increased the risk of death following common surgical procedures by 7%, and that the risk of death was more than 30% higher in hospitals where nurses' mean workloads were 8 patients or more each shift than in hospitals where nurses cared for 4 or fewer patients.2 These findings are daunting given the widespread shortage of nurses, increasing concern about recruiting an adequate supply of new nurses to replace those expected to retire over the next 15 years,3 and constrained hospital budgets. These findings also raise questions about whether characteristics of the hospital RN workforce other than ratios of nurses to patients are important in achieving excellent patient outcomes.
Nurses constitute the surveillance system for early detection of complications and problems in care, and they are in the best position to initiate actions that minimize negative outcomes for patients.4 That the exercise of clinical judgment by nurses, as well as staffing adequacy, is key to effective surveillance may explain the link between higher nursing skill mix (ie, a higher proportion of RNs among the nursing personnel of a hospital) and better patient outcomes.5-10
Registered nurses in the United States generally receive their basic education in 1 of 3 types of programs: 3-year diploma programs in hospitals, associate degree nursing programs in community colleges, and baccalaureate nursing programs in colleges and universities. In 1950, 92% of new RNs graduated from hospital diploma programs,11 whereas by 2001, only 3% graduated from hospital diploma programs, 61% came from associate degree programs, and 36% were baccalaureate program graduates.12 Surprisingly little is known about the benefits, if any, of the substantial growth in the numbers of nurses with bachelor's degrees. Indeed the conventional wisdom is that nurses' experience is more important than their educational levels.
Despite the diversity of educational programs preparing RNs, and a logical (but unconfirmed) connection between education and clinical judgment, little if anything is known about the impact of nurses' education on patient outcomes.13 Results of some studies have suggested that baccalaureate-prepared nurses are more likely to demonstrate professional behaviors important to patient safety such as problem solving, performance of complex functions, and effective communication.14-16 However, few studies have examined the effect of nurse education on patient outcomes, and their findings have been inconclusive.17
The 168 Pennsylvania hospitals included in our previous study2 of patient-to-nurse staffing and patient mortality varied substantially in the proportion of staff nurses holding baccalaureate or higher degrees. This variability provides an opportunity to conduct a similar study examining the association between the educational composition of a hospital's RN staff and patient outcomes. Specifically, we tested whether hospitals with higher proportions of direct-care RNs educated at the baccalaureate level or above have lower risk-adjusted mortality rates and lower rates of failure to rescue (deaths in patients with serious complications). We also examined whether the educational backgrounds of hospital RNs are a predictor of patient mortality beyond factors such as nurse staffing and experience. These findings offer insights into the potential benefits of a more highly educated nurse workforce.

METHODS





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? Top

? Introduction

? Methods
? Results

? Comment

? Author information

? References









Data Sources, and Variables
We analyzed outcomes data derived from hospital discharge abstracts that were merged with information on the characteristics of the treating hospitals, including unique data obtained from surveys of hospital nurses.2 The institutional review board of the University of Pennsylvania approved the study protocol.
Hospitals. The sample consisted of 168 (80%) of the 210 adult acute-care general hospitals operating in Pennsylvania in 1999 that (1) reported surgical discharges to the Pennsylvania Health Care Cost Containment Council in the specific categories studied here, (2) had data on structural characteristics available from 2 external administrative databases (American Hospital Association [AHA] annual survey18 and Pennsylvania Department of Health Hospital Questionnaire19), and (3) had at least 10 nurses responding to our questionnaire, which previous empirical work demonstrated was sufficient to provide reliable estimates of survey-based organizational characteristics of the hospitals. Six of the excluded hospitals were Veterans Affairs hospitals, which do not report discharge data to the state. Twenty-six hospitals were excluded because of missing data, most often because their reporting to external administrative sources was done as aggregate multihospital entities. Ten small hospitals, most of which had 50 or fewer beds, had an insufficient number of nurses responding to the questionnaire to be included.
A 50% random sample of RNs residing in Pennsylvania and on the rolls of the Pennsylvania Board of Nursing received questionnaires at their homes in the spring of 1999. Surveys were completed by 10 184 nurses, an average of more than 60 nurses per hospital, and the 52% response rate compares favorably with other voluntary, anonymous surveys of health professionals.20 We compared our data with information from the AHA annual survey and found that the number of nurses from each hospital responding to our survey was directly proportional to the number of RN positions in each hospital. This suggests similar response rates across hospitals and no response bias at the hospital level. Moreover, demographic characteristics of the respondents paralleled those of Pennsylvania hospital nurses in the National Sample Survey of Registered Nurses.21 For example, the mean ages of Pennsylvania hospital nurses in our sample and in the National Sample Survey of Registered Nurses were 40 and 41 years, respectively; the percentages of Pennsylvania hospital nurses working full-time were 66% and 69%, respectively; and those having earned bachelor of science in nursing (BSN) degrees were 30% and 31%, respectively.
Hospital staff nurses were asked to indicate whether their highest credential in nursing was a hospital school diploma, an associate degree, a bachelor's degree, a master's degree, or another degree. The proportion of nurses in each hospital who held each type of credential was computed. Because the educational preparation of the 4.3% of nurses who checked "other" was unknown, their answers were not included in our hospital-level measures of educational qualifications. It was later verified that this decision did not bias the results. Because there was no evidence that the relative proportions of nurses holding diplomas and associate degrees affected the patient outcomes studied, those 2 categories of nurses were collapsed into a single category and the educational composition of the hospital staff was characterized in terms of the percentage of nurses holding bachelor's or master's degrees.
Two further variables were derived from the nurse survey. Nursing workload was computed as the mean number of patients assigned to all staff nurses who reported caring for at least 1 but fewer than 20 patients on the last shift they worked. Because nurse experience was an important potential confounding variable related to both clinical judgment and education, the mean number of years of experience working as an RN for nurses from each hospital was also calculated and used in the analyses.
Three hospital characteristics were used as control variables: size, teaching status, and technology. Hospital-level data were obtained from the 1999 AHA annual survey and the 1999 Pennsylvania Department of Health Hospital Survey. Three size categories (<100 beds, 101-250 beds, 251 beds) were used. Hospitals without any postgraduate medical residents or fellows (nonteaching) were distinguished from those with 1:4 or smaller trainee-to-bed ratios (minor teaching) and those with ratios higher than 1:4 (major teaching). High-technology hospitals were those that had facilities for either open-heart surgery, major organ transplantations, or both.
Patients and Patient Outcomes. Discharge abstracts for the universe of 232 342 patients aged 20 to 85 years who underwent general surgical, orthopedic, or vascular procedures from April 1, 1998, to November 30, 1999, in the 168 nonfederal hospitals were obtained from the Pennsylvania Health Care Cost Containment Council, which checks the data for completeness and quality. A list of the diagnosis related groups studied was provided previously.2
We examined the association between the educational attainments of nurses across hospitals and both deaths within 30 days of hospital admission (derived by linking discharge abstract data and Pennsylvania vital statistics data) and deaths within 30 days of admission among patients who experienced complications (failure to rescue). Patient complications were determined with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the secondary diagnosis and procedure fields of discharge abstracts indicative of 39 clinical events using protocols drawing on expert consensus as well as empirical evidence to distinguish complications from preexisting comorbidities.22-24
The 2 patient outcomes studied were risk-adjusted by including 133 variables in our models, including age, sex, whether the admission was a transfer from another hospital, whether it was an emergency admission, a series of 48 variables indicating surgery type, dummy variables indicating the presence of 28 chronic preexisting conditions as classified by ICD-9-CM codes, and interaction terms chosen on the basis of their ability to predict mortality and failure to rescue in the present data set. Construction of the patient risk adjustment models used an approach similar to that reported by Silber and colleagues.22-26 The c statistic for the mortality risk adjustment model was 0.89 and for the failure to rescue model, 0.81.
We also estimated and controlled for the effect of having a board-certified surgeon on risk for mortality and failure to rescue. For each patient, the license number of the operating physician of record was matched to a physician's name using a public use file from the Pennsylvania Bureau of Professional and Occupational Affairs, and subsequently to records from the American Board of Medical Specialties directory of board-certified medical specialists.27 A dummy variable was constructed to indicate whether or not the operating physician was board-certified in general surgery or another surgical specialty. A second dummy variable was used to identify patients (8% of all patients) with operating physicians whose license numbers could not be linked to names to determine board-certification status. Use of these 2 variables in tandem produced a reasonable way of controlling for surgeon qualifications in our models.
Data Analysis
Descriptive statistics (means, SDs, and percentages) and significance tests ( 2 and F tests) were computed to compare groups of hospitals that varied in terms of their educational composition on hospital characteristics, including nurse experience and nurse staffing, and patient characteristics. Logistic regression models were used to estimate the effects of a 10% increase in the proportion of nurses who had a bachelor's or master's degree on patient mortality and failure to rescue, and to estimate the effects of nurse staffing, nurse experience, and surgeon board certification. The associations of educational composition, staffing, experience of nurses, and surgeon board certification with patient outcomes were computed before and after controlling for patient characteristics (demographic characteristics, nature of the hospital admission, comorbidities, and relevant interaction terms) and hospital characteristics (bed size, teaching status, and technology).
To account for the clustering of patients within hospitals in our sample, all model estimates were computed using Huber-White (robust) procedures to adjust the SEs of the estimated parameters. Direct standardization estimates derived from the final model are presented to indicate the size of the effects of educational composition of nursing staff independently of and jointly with nurse staffing levels. With all patients and using the final fully adjusted models for predicting death and failure to rescue, the probabilities of poor outcomes were calculated for patients in hospitals assuming that 20%, 40%, and 60% of the hospital RNs held bachelor's or master's degrees and under various patient-to-nurse ratios (4, 6, and 8 patients per nurse), with all other patient and hospital characteristics unchanged.28 All analyses were conducted using STATA version 7.0 (STATA Corp, College Station, Tex), using P<.05 as the level of statistical significance.

RESULTS






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Characteristics of Hospitals and Patients
Table 1 provides information on characteristics of the 168 hospitals in our sample. About 19% of the hospitals had more than 250 beds, 36% were teaching hospitals, and 28% had high-technology facilities. Across all hospitals, nurses had a mean (SD) of 14.2 (2.7) years of experience and a mean (SD) workload on their last shift of 5.7 (1.1) patients. The proportion of staff nurses with bachelor's degrees or higher degrees ranged from 0% to 70% across the hospitals. In 20% of the hospitals (34/168) less than 20% of staff nurses had BSN or higher degrees, while in 11% of the hospitals (19/168) 50% or more of the nurses had BSN or higher degrees. Hospitals with higher percentages of nurses with BSN or master's degrees tended to be larger and have postgraduate medical training programs, as well as high-technology facilities. Hospitals with higher proportions of baccalaureate- and master's-prepared nurses also had slightly less experienced nurses on average and significantly lower mean workloads. The strong association between the educational composition of hospitals and other hospital characteristics, including nurse workloads, makes clear the need to control for these latter characteristics in estimating the effects of nurse education on patient mortality.


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Table 1. Characteristics of the Study Hospitals, Overall and by Educational Composition of the Nurse Workforce



Table 2 describes characteristics of the patients in our sample and how they varied across hospitals with different nurse educational compositions. Of the patients studied, 43.7% were men and the mean (SD) age was 59.3 (16.9) years. Of the 232 342 patients, 53 813 (23.2%) experienced a major complication not present on admission, 4535 (2.0%) died within 30 days of admission, and the death rate among patients with complications (failure to rescue) was 8.4%. The 2 largest categories of surgical procedures patients underwent were orthopedic (51.2%) and digestive tract/hepatobiliary (36.4%) procedures.


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Table 2. Characteristics of Surgical Patients in the Study Hospitals, Overall and by Educational Composition of Staff Registered Nurses*



The most common patient comorbidities were hypertension (34.4%) and diabetes (13.5%). While the largest proportion of patients (58 329 or 25%) were cared for in hospitals in which 30% to 39% of the nurses were at least BSN-educated, the numbers ranged across the sample (Table 2). Moreover, characteristics of patients, including whether the operating physician was a board-certified surgeon, differed across the groups of hospitals defined by the percentage of nurses with BSN or higher degrees, although few of these characteristics varied across groups in a consistent pattern.
Effects of Hospital RN Education on Mortality and Failure to Rescue
Table 3 presents odds ratios (ORs) representing the raw or unadjusted effects of nurse education, staffing, and experience, and the effect of a board-certified surgeon as operating physician. Also in Table 3 the adjusted ORs show the effects of those factors in a model controlling for all of these factors and for other hospital and patient characteristics. There was a statistically significant relationship between the proportion of nurses in a hospital with bachelor's and master's degrees and the risks of both mortality and failure to rescue, both before and after controlling for other hospital and patient characteristics.


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Table 3. Odds Ratios Estimating the Effects of Nurse and Physician Variables on Patient Mortality and Failure to Rescue*



Each 10% increase in the proportion of nurses with higher degrees decreased the risk of mortality and of failure to rescue by a factor of 0.95, or by 5%, after controlling for patient and hospital characteristics. This adjusted OR of 0.95 (95% confidence interval, 0.91-0.99) is a multiplicative parameter. To estimate how much of a difference would be expected between hospitals in which 20% vs 60% of the nurses had at least BSNs, it should be taken to the fourth power (since the difference between 20% and 60% is equivalent to four 10% intervals). The resultant ratio (0.954 = 0.81) indicates that all else being equal, the odds of 30-day mortality and failure to rescue would be 19% lower in hospitals where 60% of the nurses had BSNs or higher degrees than in hospitals where only 20% of nurses did.
All 3 of the other clinician characteristics studied (nurse staffing, experience, and board-certified surgeon as operating physician) had significant associations with mortality before controlling for each other, the educational composition of RNs, and all other patient and hospital characteristics. The final model indicates only very slight changes in the parameters estimating the nurse staffing effect that we previously reported2 when nurse education is added (from a 7% increase in risk of both negative outcomes with a 1 patient-per-nurse increase in mean workload originally reported to a 6% increase in mortality risk and a 5% increase in risk of failure to rescue).
Nurses' years of experience were not found to be a significant predictor of mortality or failure to rescue in the full models. The strong and significant decrease in mortality associated with having a board-certified surgeon as operating physician is largely explained by the tendency of patients with board-certified surgeons to be treated at hospitals with other characteristics associated with better outcomes. None of the interaction terms created by combining these 4 variables achieved statistical significance, suggesting that nurse education, nurse staffing, and surgeon board certification operate independently of each other in predicting mortality and failure to rescue.
These effects imply that altering the educational background of hospital nurses by increasing the percentage of those earning a BSN would produce substantial decreases in mortality rates for surgical patients generally and for patients who develop complications. Direct standardization techniques were used to predict the excess deaths in all patients and patients with complications that would be expected with varying levels of nurse educational levels and workloads. As Table 4 shows, if the proportion of BSN nurses in all hospitals was 60% rather than 20%, 3.6 fewer deaths per 1000 patients (21.1 - 17.5) and 14.2 fewer deaths per 1000 patients with complications (failure to rescue) would be expected. Moreover, Table 4 indicates that the effect on mortality of a 20% increase in the percentage of BSNs in the workforce would be roughly equivalent to the effect of a reduction in mean nurse workload of 2 patients, and that both the mortality and failure-to-rescue rates would be decidedly lower if both the workloads were lighter and the workforce were composed of higher percentages of BSN-prepared nurses.


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Table 4. Estimated Rates of Mortality and Failure to Rescue per 1000 Patients, by Levels of Nurse Education and Staffing




COMMENT



? Introduction

? Methods

? Results

? Comment
? Author information

? References









To our knowledge, this study provides the first empirical evidence that hospitals' employment of nurses with BSN and higher degrees is associated with improved patient outcomes. Our findings indicate that surgical patients cared for in hospitals in which higher proportions of direct-care RNs held bachelor's degrees experienced a substantial survival advantage over those treated in hospitals in which fewer staff nurses had BSN or higher degrees. Similarly, surgical patients experiencing serious complications during hospitalization were significantly more likely to survive in hospitals with a higher proportion of nurses with baccalaureate education.
When the proportions of RNs with hospital diplomas and associate degrees as their highest educational credentials were examined separately, the particular type of educational credential for nurses with less than a bachelor's degree was not a factor in patient outcomes. Furthermore, mean years of experience did not independently predict mortality or failure to rescue, nor did it alter the association between educational background or of staffing and either patient outcome. These findings suggest that the conventional wisdom that nurses' experience is more important than their educational preparation may be incorrect. The improved outcomes associated with higher levels of BSNs in a hospital was found to be independent of and additive to the associations of superior outcomes in hospitals with better nurse staffing we reported previously.2 Thus, both lower patient-to-nurse ratios and having a majority of RNs educated at the baccalaureate level appear to be jointly associated with substantially lower mortality and failure-to-rescue rates for patients undergoing common surgical procedures.
In our sample of 168 Pennsylvania hospitals in which the proportion of nurses with bachelor's degrees and mean patient-to-nurse ratios varied widely, 2% (4535/232 342) of the surgical patients undergoing the procedures we studied died within 30 days of hospital admission. Our results imply that had the proportion of nurses with BSN or higher degrees been 60% and had the patient-to-nurse ratio been 4:1, possibly 3810 of these patients (725 fewer) might have died, and had the proportion of baccalaureate nurses been 20% and had staffing uniformly been at 8:1 patient-to-nurse ratios, 5530 (995 more) might have died. While this difference of more than 1700 deaths across 2 educational and staffing scenarios is approximate, it represents a conservative estimate of preventable deaths potentially attributable to nurses' education and RN staffing levels because our patient sample represents only about half of all surgical cases in the study hospitals.
One limitation of our analysis is the potential for response bias in the education and staffing measures derived from the nurse survey, given a 52% response rate. However, examining the Pennsylvania respondents in the probability-based National Sample Survey of Registered Nurses conducted in 2000,21 we found no evidence of overall differences between our sample and Pennsylvania hospital staff nurses at large in terms of job satisfaction or demographic characteristics, including education.
A second limitation relates to study design. Longitudinal data sets, preferably including hospitals from more than 1 state, will be essential for establishing the generalizability of these findings as well as establishing whether and how levels of baccalaureate-prepared nurses and nurse staffing in a hospital are causally related to patient outcomes. Also, as in any research drawing on administrative patient outcomes data, there is a potential for differences in completeness and consistency of diagnostic coding across hospitals to influence risk adjustment.29
A number of checks on the validity of these findings were completed. Allowing nurse education to have a nonlinear effect and testing whether the effect of education varied across levels of educational composition using quadratic and dummy variables did not significantly improve model fit, suggesting that incremental increases in more educated nurses in a hospital were associated with progressively better outcomes. Including the small proportion of nurses who checked "other" as their highest degree with nurses in the baccalaureate or higher category or in the associate degree or diploma category rather than omitting them from calculations yielded no change in the estimated associations between education and patient outcomes. In an attempt to determine whether unobserved variables that distinguished patients treated in hospitals with different levels of nurse education, we computed propensity scores30 representing the likelihood that patients with various characteristics were treated in hospitals with high and low levels of baccalaureate nurses. These scores were not a significant predictor of mortality or of failure to rescue, nor did they significantly alter our estimates of the association between education and outcomes.
Research suggests that nurse executives in university teaching hospitals prefer a nurse workforce with approximately 70% prepared at the baccalaureate level and estimate that current levels average 51%. Also, community hospital nurse executives prefer to have 55% of their RNs educated at the baccalaureate level.31 Data are not currently available to estimate the proportion of hospitals nationally that have 50% or more of their RN workforces prepared at the BSN level or higher, but since only 11% of Pennsylvania hospitals met this standard in our sample there appears to be a wide gap between the preferences of hospital executives and current staffing patterns.
Only 43% of all hospital staff nurses nationally in 2000 were prepared at the BSN level or higher. Enrollments in baccalaureate nursing programs declined by almost 10% from 1995 to 2000, although the past few years have seen an upturn.21, 32 The return of diploma- and associate degree?prepared RNs to colleges and universities after their initial preparation has been an important source of baccalaureate-prepared nurses. About 22% of currently employed hospital RNs with BSN or higher degrees received them after their basic educations.21 However, the proportion of hospital nurses pursuing further studies declined from 14% in 1984 to 9% in 2000, as did the proportion of hospital nurses who received tuition assistance from their employers (from 66% in 1992 to 53% in 2000).21, 33 Meeting the demand for baccalaureate-prepared hospital nurses requires renewed support and incentives by employers to encourage nurses to pursue education to the level of baccalaureate and beyond.
In the current nurse shortage, as in previous ones, public policy discussion has centered on how to increase the supply of RNs. However, little attention has been paid to considering where investments in public funds in the 2 major educational pathways into nursing practice?associate or bachelor's degree programs?will best serve the public good and the interests of employers. Nursing education policy reports published in the past decade concluded that the United States has an imbalance in the educational preparation of its nurse workforce with too few RNs with BSN and higher degrees.34-36 Our findings provide sobering evidence that this imbalance may be harming patients.
Our documentation of significantly better patient outcomes in hospitals with more highly educated RNs at the bedside underscores the importance of placing greater emphasis in national nurse workforce planning on policies to alter the educational composition of the future nurse workforce toward a greater proportion with baccalaureate or higher education as well as ensuring the adequacy of the overall supply. Public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. Finally, our results suggest that employers' efforts to recruit and retain baccalaureate-prepared nurses in bedside care and their investments in further education for nurses may lead to substantial improvements in quality of care.

See uploaded instructions...most important: MUST BE ORIGINAL WORK. No direct quotes...everything should be paraphrased and cited.

10 page paper comparing two middle range nursing theories on improving emergency department nursing staff satisfaction.

Paper must be scholarly...so no Wikipedia. Only research journals!

724.4.3-01-08 (2008)

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SUBDOMAIN 724.4 - NURSING INFORMATICS


Competency 724.4.3: Leadership - The graduate recognizes the importance of nurse involvement in the planning, design, selection, and implementation of information systems in a nursing practice environment; discusses the roles, benefits, and costs of new technologies; and recognizes effective security and confidentiality for protection of patient records.


Objectives:

724.4.3-01: Explain how the use of computerized management systems to record administrative data can increase quality of care in a given situation.

724.4.3-02: Explain why nurse involvement in the planning, design, selection, and implementation of information systems in a given nursing practice environment is important.

724.4.3-03: Identify key strategies or safeguards for securing patient records in a given health care setting.

724.4.3-04: Describe how specified new technology applied to a given organization?s clinical decision-support system can change the way nursing is practiced in that organization.

724.4.3-05: Describe the role of a specified handheld device in improving a nurse?s ability to deliver quality patient care in a given clinical or hospital setting.

724.4.3-06: Identify common standards that govern specified aspects of health care-related data storage.

724.4.3-07: Discuss how a specified new technology can affect health care delivery cost in a given situation.

724.4.3-08: Explain how having access to certain types of information at the point of care can impact nursing care delivery in a given situation.


--------------------------------------------------------------------------------


Introduction:


As a nurse in a 100-bed community hospital, you are part of a multidisciplinary team comprised of hospital professional staff tasked with investigating a new computerized management system for the hospital. Unfortunately, most of the team consists of doctors and you are the only nurse selected to participate, making it hard for you to voice your concerns. You decide to document your findings and concerns in a report and submit it to the group.


Task:



Conduct a search and evaluation of two new computerized management systems. Then write a report (suggested length of 4?8 pages) for the team in which you do the following:



A. Explain how using the computerized management systems could increase quality of care.


B. Explain why active nursing involvement in the planning, choice, and implementation of the systems is important.


C. Describe how handheld devices used by the nursing staff could be integrated into the management systems for better quality of care.



D. Discuss security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and how the Health Insurance Portability and Accountability Act (HIPAA) requirements impact the use of the systems.


E. Discuss how the new systems can affect healthcare cost.


F. Discuss the benefits these new systems can offer to patient care and nursing care delivery.

1. Recommend the system you think the team should purchase.

a. Justify your recommendation.


G. Include all in-text citations and references in APA format.


Note: Please save word-processing documents as *.rtf (Rich Text Format) or *.pdf (Portable Document Format) files.



Note: For definitions of terms commonly used in the rubric, see the attached Rubric Terms.



Note: When using outside sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.



Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly. Here are some helpful APA resources:

http://www.apastyle.org

http://www.citationmachine.net

http://owl.english.purdue.edu/owl/resource/560/01


settings to "landscape" mode if you have a rubric with many levels. Send to Printer Now

NUT1 - 724.4.3-01-08

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Levels

Criteria

Unacceptable
value: 1.00

Needs Revision
value: 2.00

Meets Standard
value: 3.00

Exemplary
value: 4.00

Score/Level




Articulation of Response (clarity, organization, word usage, ease of understandability)

There is no evidence of response to the prompts.

The articulation of the response is weak.

The articulation of the response is adequate.

The articulation of the response is skillful.





Accuracy of Mechanics (grammar, punctuation, spelling)

The work includes several major errors that disrupt the meaning or flow of the response.

The work includes a few major errors and/or many minor errors that interfere with the clarity of the response.

The work includes a few minor errors but no readily detectable major errors.

The work includes no readily detectable major or minor errors.





A. Increase in Quality of Care

The candidate does not explain how using the computerized management systems selected could increase quality of care.

The candidate provides an illogical explanation of how using the computerized management systems could increase quality of care.

The candidate provides a logical explanation of how using the computerized management systems could increase quality of care.

The candidate provides a credible and well-supported explanation of using the computerized management systems could increase quality of care.





B. Active Nursing Involvement

The candidate does not explain why active nursing involvement in the planning, choice, and implementation of the systems is important.

The candidate provides an illogical explanation of why active nursing involvement in the planning, choice, and implementation of the systems is important.

The candidate provides a logical explanation of why active nursing involvement in the planning, choice, and implementation of the systems is important.

The candidate provides a credible and well-supported explanation of why active nursing involvement in the planning, choice, and implementation of the systems is important.





C. Handheld Devices

The candidate does not describe how handheld devices used by the nursing staff could be integrated into the management system for better quality of care.

The candidate provides an imprecise description of how handheld devices used by the nursing staff could be integrated into the management system for better quality of care.

The candidate provides a reasonable description of how handheld devices used by the nursing staff could be integrated into the management system for better quality of care.

The candidate provides a precise description of how handheld devices used by the nursing staff could be integrated into the management system for better quality of care.





D. Security Standards

The candidate does not discuss security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and how the Health Insurance Portability and Accountability Act (HIPAA) requirements impact the use of the systems.

The candidate provides an illogical discussion of security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and how the Health Insurance Portability and Accountability Act (HIPAA) requirements impact the use of the systems.

The candidate provides a logical discussion of security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and how the Health Insurance Portability and Accountability Act (HIPAA) requirements impact the use of the systems.

The candidate provides a credible and well-supported discussion of security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and how the Health Insurance Portability and Accountability Act (HIPAA) requirements impact the use of the systems.





E. Cost

The candidate does not discuss how the new systems can affect healthcare cost.

The candidate provides an illogical discussion of how the new systems can affect healthcare cost.

The candidate provides a logical discussion of how the new systems can affect healthcare cost.

The candidate provides a credible and well-supported discussion of how the new systems can affect healthcare cost.





F. Benefits to Care

The candidate does not discuss the benefits these new systems can offer to patient care and nursing care delivery.

The candidate provides an illogical discussion of the benefits these new systems can offer to patient care and nursing care delivery.

The candidate provides a logical discussion of the benefits these new systems can offer to patient care and nursing care delivery.

The candidate provides a credible and well-supported discussion of the benefits these new systems can offer to patient care and nursing care delivery.





F1. Recommendation

The candidate does not recommend the system the team should purchase.

Not applicable.

Not applicable.

The candidate recommends the system the team should purchase.





F1a. Justification

The candidate does not justify the recommendation.

The candidate provides illogical justification for the recommendation.

The candidate provides logical justification for the recommendation.

The candidate provides credible and well-supported justification for the recommendation.





G. In-Text Citations and References in APA Format

The candidate does not provide in-text citations or references, or there are major APA formatting errors that significantly disrupt the comprehensibility of the submission.

The candidate provides in-text citations and references, but there are several major APA formatting errors.

The candidate provides in-text citations and references, and any APA formatting errors are minor and do not disrupt the comprehensibility of the submission.

The candidate provides in-text citations and references that do not contain readily detectable errors.

Hi, this is a Case study...all information is in reference to the scenario below. I have already completed a draft copy of a very brief outline of what this larger one should entail. (this draft was part of our assessment and has already been marked...so this next 1250 is based on the same scenario, we must just expand apon it) The information I have put in the draft essay needs to be split up and expanded on...I have included the marking criteria for help also. Thankyou very much!


Use your draft summary and associated feedback from the 1st assignment to assist preparing your 1 word essay.
Prepare a essay of the nursing care you would use to manage the case scenario

Use your draft summary from the 1st assignment to assist preparing your 1250 word essay. (I have included this further down the page - It is not to be used as one paragraph, each section expanded on as per marking criteria ...also added further down)

Background: A key role of nursing is to maintain client safety. People living in residential care settings are vulnerable to complications arising from infections, adverse drug effects, and underlying disease processes. Nurses take into consideration the individual needs of the client as well as the impact of individual health problems on the safety of others when planning care.


Aim: The aim of this assessment is for the student to prepare a 1250 word essay of the nursing care required to manage the health needs of your clients and maintain the safety of residents, visitors and staff. Use your draft and relevant feedback to assist in preparation of your report.

Scenario

You are allocated to provide the care for five clients in an aged care facility that also houses a dementia unit. One of your clients Mary Canley (85 years old) confides in you that she has been incontinent of faeces and also has increasing abdominal discomfort. Reading her nursing care plan you notice that Mary is usually continent. Mary lives in room one (see Unit/Ward Floor Plan - The dementia wing is located down the hall from Mary's room, Mary's room however is next to the dirty utility room). You discuss Marys concerns to the Nurse Unit Manager who advisors you that another resident in the dementia unit reported cramping abdominal pains and diarrhoea.

To complete this assessment task you should do the following:

1. Identify the relevant client problems supported by the clinical information obtained from the case scenario.

2. Indentify and explain potential cause(s) of the identified patient problems.

3. Discuss the consequences of the identified patient problems drawing on nursing knowledge and support with evidence.

4. Identify relevant patient goals and associated measurable outcomes relevant for managing the identified health problems.

5. Describe and explain appropriate nursing actions to manage the risks associated with the presenting health problems for clients and staff.

6. Describe the level of evidence supporting the nursing decision-making and care planning.

7. Discuss how identified patient problems and health risks, goals, nursing interventions and outcome criteria are linked.


The following is my draft essay... that needs to be broken down and expanded on as per marking criteria.

Marys symptoms of abdominal discomfort, faecal incontinence, and diarrhoea
indicate possible gastrointestinal disturbance (Crisp & Taylor 2009). Of additional
concern is that another resident is reporting similar symptoms in the dementia unit.
A single case of gastroenteritis in an elderly resident of an aged care facility
may signal the beginning of an outbreak. (Kirk, Roberts, and Horvath 2008, 476)
Possible causes for this may be the result of cross contamination via the oral-faecal
route of transmission, or through consuming contaminated foods and water (Kirk,
Hall, Veitch, Becker 2010, 12). The physical location of the dirty utility room
proximal to the eating and food preparation areas appears inappropriate, and should be
reviewed (Department of Health and ageing 2007). The most often cited causes are
salmonella infections and clostridium difficile (Simor 2010)
Depending on the infected residents current health conditions residents may
experience dehydration, abdominal pain, fevers, vomiting, diarrhoea and loss of
appetite associated with gastroenteritis. (Crisp & Taylor 2009) If the condition is left
untreated it may be life threatening. (Department of Health and Ageing, 2007)
Immediate nursing actions to manage the suspected infected resident would
include collecting a faecal specimen to confirm infection. (Crisp & Taylor 2009)
Isolating infected patients to reduce infection spreading to other residents and staff
(Kirk, Roberts and Horvath, 2008) Increased hygiene measures and implementing a
management plan, monitoring nutrition, fluid intake, hygiene and pain control. (Crisp
& Taylor 2009)
Patient goals are to implement nursing interventions to care for the two
residents who are already elderly and immunocompromised; ensuring comfort,
decreased abdominal pain, stable vital signs, skin integrity and patients personal
hygiene. (Crisp & Taylor 2009)
Measurable outcomes for these goals; 1. No further outbreaks of
gastroenteritis in the unit, 2. Symptom control and improved health status in the
affected residents 3. Identified possible causes of the gastroenteritis, 4. Review of the
units infection control practices (Garibaldi 1999)


References

Andrew E, Simor,MvD (2010)Diagnosis, Management, and Prevention of
Clostridium difficile Infection in Long-Term Care Facilities: A Review. The
Americans Geriatric Society 58, (8), 1557-1593. doi:10.1111/j.1532-
5415.2010.02958.x

Crisp.J, & Taylor, C. (2010), Potter & Perrys fundaments of nursing (3
rded.). Chatswood, N.S.W.: Elsevier Australia

M.D Kirk, G.V. Hall, M.G.K. Veitch, N. Becker (2010). Assessing the
incidence of gastroenteritis among elderly people living in long term care facilities.
Journal of Hospital Infection 76 12 17. doi 10.1016/j.jhin.2010.04.009

R.A Garibaldi ( 1999) Residential care and the elderly: the burden of infection.
Journal of Hospital Infection. 43 9-18.

Australian Government: Department of Health and Ageing. (2007).
Retrieved from
http://www.health.gov.au/internet/main/publishing.nsf/content/icg-guidelinesindex.htm


ASSIGNMENT MARKING CRITERIA: Please read and structure essay around this...

1.Provide an introduction for your report that
clearly outlines the scope of your report.
(50-60 words)
Clear
Precise
Accurate


2.Have relevant patient problems been identified
and supported with clinical observations?
(40 to 50 words)
New onset fecal
incontinence
Abdominal
discomfort/cramping
Diarrhoea

3.Have the potential cause(s) of the patient
problems been explained?
(150-200 words)
Infection resulting in
gastroenteritis
Constipation
Adverse drug effects

4. Has the consequences of the identified patient
problems been discussed and supported with
evidence?
(200 to 300 words)
Spread of infection
Skin breakdown
Sepsis
Cardiac arrest
Dehydration
Delirium
Psychological distress
Falls
Pain


5. Were relevant patient goals associated with
the management of the identified problems
and measurable outcomes described and
justified with evidence?
(150 to 200 words)
Patients will not become infected with the GIT
pathogen.
Stable vital signs
Haemodynamic stability
Functional continence
Fluid balance goals
described
Adequate nutrition
Infection control
Pain control
Falls prevention
Adequate hygiene
Intact skin

6. Were appropriate nursing actions planned to
manage the risks to the patient, others and
nursing staff associated with the presenting
problems and justified with the highest level of
evidence?
(250-350 words)

rectal examination,
stool inspection
Stool sampling for MCS
Hygiene
Skin care
Infection control
Fluid balance
Nutrition
Psychological comfort
Pai control
Medical review

7. Was the level of evidence supporting the
nursing decision making and care planning
described?
(70-100 words)
Relevant retrieved reports
cited.
Level of evidence
associated with retrieved
reports stated.

8. Conclusion for report: was the link between the
identified patient problems and health risks,
goals, nursing interventions and outcome
criteria discussed?
(100-150 words)
Clear
Precise
Accurate
Benefits summarized
Limitations listed
Suggestions for ongoing
care plan development.

The essay can be set out in paragraphs from the above prompts - word limits are included to help.

INTEXT REFERENCING IS A MUST! (APA style) Please only use 2 websites.

Thankyou for your help.
Annie

This paper is a combination of 3 projects and then an additional page for the summary of the whole project.

You will combine Parts 1, 2, and 3 of your Course Project (assigned in Weeks 2, 4, and 8 respectively) into one cohesive and cogent paper.

Note: In addition, include a 1-page summary of your project.

For this final iteration you will need to:

Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The School of Nursing Sample Paper provided at the Walden Writing Center provides an example of those required elements (available from the Walden University website found in this week?s Learning Resources). All papers submitted must use this formatting.
Note: The Course Project will be your Portfolio Assignment for this course.


Week 2
Suicide in psychiatric patients
Suicide rates are remarkably high worldwide and nationally, making suicide one of the leading causes of death (Schwartz-Lifshitz, Zalsman, Giner et al, 2012; Tillman, 2014). Although most suicides do not occur in the hospital setting, psychiatric disorders?especially mood disorders and psychotic disorders?are risk factors that increase the likelihood of a suicidal event (Appleby, 1992; Sarzetto, Delmonte, Seghi, et al, 2017). Suicide not only affects the patient, but reverberates throughout the patient?s family and social circle, also causing distress and potential performance issues among clinical staff (Tillman, 2014). Therefore, it is important that psychiatric nurses understand how to recognize risk factors, and establish a clinical practice environment that prevents suicide. Minimizing suicidal tendencies requires different types of treatment interventions individually tailored for at-risk patients, as well as implementing best practices for creating a clinical environment that reduces risk. Best practices may also include preparing, teaching, and training nursing staff, especially when working with at risk populations.
Both psychiatric patients and psychiatric nursing staff can be considered target populations for an intervention designed to prevent suicide in the clinical setting. Preliminary research questions using the PICO (patient/population, intervention/issue, comparison, and outcome) model include the following:
1. Among psychiatric patients (P), do mandatory intake assessments specifically for suicide risk (I) reduce rates of suicide (O) versus institutions without such policies (C)? This is a reasonable PICO question, but one that would require a large-scale assessment of different psychiatric institutions. Therefore, it might be too difficult to find sufficient evidence to make an informed decision for evidence-based practice.
2. Among psychiatric patients with mood disorders and other high-risk populations (P), do pharmacological interventions (I) reduce rates of suicide (O) versus patients who only receive talk or group therapies (C)? This is a commonly posed question related to suicide in the population group. The problem with this PICO question is there are too many different pharmacological interventions and individual differences among patients to come up with a clear, definitive guide for evidence-based practice.
3. Among psychiatric patients with suicidal ideations or a history of suicidal behavior (P), does family and group therapy (I) reduce risk (O) versus patients who do not receive any family or group therapy (C)? This is one of the most feasible PICO questions to use because family and group therapy options might offer some sound solutions for preventing suicide and reducing long-term risks.
4. Do community awareness, public service announcements, and other means of education and communication (I) help reduce rates of suicide (O) among discharged psychiatric patients (P) versus communities that do not receive such public relations services (C)? This is an important avenue of research for evidence-based practice in the community, helpful from a public health perspective. However, methodologically such interventions are less feasible.
5. Does mindfulness meditation (I) reduce long-term risk factors and suicidal behaviors (O) among high risk psychiatric patients (P) versus those who do not participate in the meditation programs (C)? As with question three, this is a suitable line of inquiry, which could actually lead to evidence-based practice guidelines for psychiatric institutions. Therefore, I will select this PICO question for the remainder of my research.
PICO Question: Does mindfulness meditation (I) reduce long-term risk factors and suicidal behaviors (O) among psychiatric patients (P) versus those who do not participate in the meditation programs (C)?
The patient population (P) can include all psychiatric patients on any given unit or within any given institution. Alternatively, the patient population can include psychiatric patients who have been diagnosed with one or more conditions known to increase risk of suicide: those conditions being mood disorders, psychotic disorders, substance use disorders, and personality disorders (Schwartz-Lifshitz, Zalsman, Giner, et al, 2012). This would allow the researcher to compile evidence from multiple studies.
The intervention (I) in this PICO question is mindfulness meditation. It is important to clarify exactly what this would mean, such as how many hours per day or per week of meditation, and which specific meditation instructions were given. The addition of the time (T) variable to the PICOT analysis might also be helpful. For example, does the meditation intervention yield results after three months, six months, or one year?
The comparison (C) is like a control group in this case, consisting of psychiatric patients who are not meditating formally within the designated intervention. Finally, the outcome (O) can be measured in different ways such as overall rates of suicide or surveys of patients regarding their subjective assessments of suicidal ideation.
The following keywords that can be used for conducting a literature search include: major depressive disorder, mood disorders, psychotic disorders, DSM-V, suicidal behavior, suicide, suicidal ideation, mindfulness, mindfulness meditation, meditation, suicide risk, and psychiatric patients.
References

Appleby, L. (1992). Suicide in psychiatric patients. British Journal of Psychiatry 1992(161): 749-758.
Jacobs, D.G., Baldessarini, R.J., Conwell, Y., et al (2010). Practice guideline for the assessment and treatment of patients with suicidal behaviors. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf
Sakinofsky, I. (2014). Preventing suicide among inpatients. Canadian Journal of Psychiatry 59(3): 131-140.
Sarzetto, A., Delmonte, D., Seghi, F. et al (2017). Suicide in depressed patients. European Psychiatry 41(April 2017 Supplement): S891-S892.
Schwartz-Lifshitz, M., Zalsman, G., Giner, L., et al (2012). Can we really prevent suicide? Current Psychiatry Reports 14(6): 624-633.
Tillman, J.G. (2014). Patient suicide: impact on clinicians. Psychiatric Times. Dec 31, 2014. http://www.psychiatrictimes.com/special-reports/patient-suicide-impact-clinicians



Week 4 : Literature review of week 2 project

A synthesis of what the studies reveal about the current state of knowledge on the question developed

The mindfulness meditation theory appears to have the potential to treat addictive disorder patients. Zgierska and coworkers (2009) state that such models seem to be safe if implemented within the context of clinical studies. One can find considerable methodological shortcomings in a majority of existing works on the subject. Further, which addiction-diagnosed individuals may derive maximum benefits out of mindfulness meditation isn?t clear. But, of late, related initiatives and practices in the role of complementary clinical aids for treating multiple physical and psychological ailments have grown in popularity. MBCT (mindfulness-based cognitive therapy) and MBSR (mindfulness-based stress reduction) as clinical initiatives have specifically been analyzed, with a sound evidential pool recording their efficacy. Integration of the latter initiative?s aspects and cognitive behavioral therapy and cognitive psychology strategies resulted in the former?s creation. At first, MBCT was labeled Attentional Control Training, concentrating chiefly on psychiatric disorder treatment. Xie and colleagues (2014) claim that the general psychological health improvements depicted by individuals undergoing MBCT may stem from various training-related advantages. Thus, anxiety and depression diagnosed individuals may profit from MBCT during rehab, for facilitating long-run maintenance of improved QOL (quality of life).
Being deployed to the battlefield is linked to an appreciable growth in fresh onset substance use disorder, PTSD (post-traumatic stress disorder), chronic pain and MDD (major depressive disorder). Vythilingam and Khusid (2016) note that a growing number of ex-servicemen have been increasingly recognizing mindfulness as being easily understandable, safe, inexpensive, and substantiated by an increasing pool of evidence. The absence of adequate quality patient-focused proofs hints at adjunctive MBCT?s benefits for patients experiencing a depressive spell, and in the form of a maintenance or continuation treatment among individuals who have recovered from MDD. Moreover, existing proofs support the adoption of adjunctive MBSR in managing PTSD.
MBC therapy is targeted at individuals undergoing remission from MDD. The goal is allowing them a chance at practicing the cultivation of non-judgmental awareness connected with harmless feelings, bodily sensations and thoughts, prior to trying to use similar processing in case of negative feelings, bodily sensations and thoughts. But in case of individuals who might mull over or attempt at long-term suppression of such negative emotions, embracing this sort of drastically different strategy might prove intimidating. In fact, certain individuals whose negative emotions are extremely near the surface might have to instantly face challenging emotions upon commencement of meditation (Crane & Williams, 2010).
In the last few decades, a considerable growth in interest has been witnessed in the area of scrutinizing mindfulness as both a clinical initiative and psychological construct. Villatte and Luoma (2012) assert that it is possible to readily arrive at the conclusion that mindfulness has numerous positive psychological impacts such as enhanced perceived well-being and conduct regulation and a decrease in emotional reactivity and psychological symptoms.
Inconsistencies and contradictions in the literature, and possible explanations for inconsistencies
Zgierska and coworkers (2009) reveals a lack of conclusive information linked to mindfulness meditation as addiction therapy. But the preliminary proofs suggest mindfulness meditation?s effectiveness. Clinical trials in the future need to have a sufficiently large sample size for successfully answering a given clinical issue. Furthermore, they need to encompass thoroughly-designed comparison clusters for allowing evaluation of mindfulness meditation?s means of action as well as impact size. Williams and Crane (2010) indicate that people exhibiting superior cognitive reactivity, depressive rumination and brooding levels might struggle a lot with MBCT engagement. However, puzzlingly, they depict the likelihood of profiting most from mindfulness skill acquisition if they continue to attend class. Dealing with how best to equip these individuals for therapy and support them in continuing therapy in the event of difficulties constitutes a major challenge.
As the mindfulness construct has its roots in Buddhist religious teachings, and lacks a sufficiently long history in the psychological science of the West, the fact that appreciable challenges exist in its definition, quantification and operationalization is not surprising. While numerous self-report repertoires for mindfulness evaluation have been created, they differ considerably in their factor and content structure, revealing inconsistencies in its nature and meaning. To date, scant information exists with regard to the conditions under which, and the individuals for whom, mindfulness training proves most effectual; however, one can find certain preliminary proofs indicating that its efficacy differs based on individual variances (Keng, Smoski & Robins, 2011).

Preliminary conclusions on whether the evidence provides strong support for a change in practice or whether further research is needed to adequately address your inquiry
While the need for further studies on the topic has been identified, the mindfulness approach seems to have the potential to aid individuals considering ending their lives and thus ending their suffering. Positive preliminary proofs indicate therapists may promote mindfulness within a fairly short duration; additionally, it may influence various processes apparently contributing to suicide (Luoma and Villatte, 2012). On the basis of an assessment of empirical studies over numerous methodologies, the review reaches the conclusion that mindfulness meditation and its adoption aids adaptive psychological operation. In spite of extant methodological inadequacies in individual literature works, one may find an explicit convergence of results of correlational researches, experimental, lab-based mindfulness researches and clinical intervention researches which all indicate a positive link between psychological health and mindfulness. Furthermore, mindfulness training can lead to positive psychological impacts which extend from enhanced behavioral regulation to enhanced subjective wellbeing and decreased emotional reactivity and psychological symptoms (Keng, Smoski & Robins, 2011). Lastly, enhanced behavioral self-regulation and values clarification might prove to be additional means by which this strategy betters psychological health.




References
Crane, C., & Williams, J. M. G. (2010). Factors Associated with Attrition from Mindfulness-Based Cognitive Therapy in Patients with a History of Suicidal Depression. Mindfulness, 1(1), 10?20. http://doi.org/10.1007/s12671-010-0003-8
Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical psychology review, 31(6), 1041-1056.
Khusid, M. A., & Vythilingam, M. (2016). The emerging role of mindfulness meditation as effective self-management strategy, part 1: clinical implications for depression, post-traumatic stress disorder, and anxiety. Military medicine, 181(9), 961-968.
Luoma, J. B., & Villatte, J. L. (2012). Mindfulness in the Treatment of Suicidal Individuals. Cognitive and Behavioral Practice, 19(2), 265?276. http://doi.org/10.1016/j.cbpra.2010.12.003
Xie, J. F., Zhou, J. D., Gong, L. N., Iennaco, J. D., & Ding, S. Q. (2014). Mindfulness-based cognitive therapy in the intervention of psychiatric disorders: A review. International Journal of Nursing Sciences, 1(2), 232-239.
Zgierska, A., Rabago, D., Chawla, N., Kushner, K., Koehler, R., & Marlatt, A. (2009). Mindfulness Meditation for Substance Use Disorders: A Systematic Review. Substance Abuse?: Official Publication of the Association for Medical Education and Research in Substance Abuse, 30(4), 266?294. http://doi.org/10.1080/08897070903250019


Week 8: Translating Evidence from week 2 project to Practice
Suicide in psychiatric patients
Suicide rates are remarkably high worldwide and nationally, making suicide one of the leading causes of death (Schwartz-Lifshitz, Zalsman, Giner et al, 2012; Tillman, 2014). Although most suicides do not occur in the hospital setting, psychiatric disorders?especially mood disorders and psychotic disorders?are risk factors that increase the likelihood of a suicidal event (Appleby, 1992; Sarzetto, Delmonte, Seghi, et al, 2017). Suicide not only affects the patient, but reverberates throughout the patient?s family and social circle, also causing distress and potential performance issues among clinical staff (Tillman, 2014). Therefore, it is important that psychiatric nurses understand how to recognize risk factors, and establish a clinical practice environment that prevents suicide. Minimizing suicidal tendencies requires different types of treatment interventions individually tailored for at-risk patients, as well as implementing best practices for creating a clinical environment that reduces risk. Best practices may also include preparing, teaching, and training nursing staff, especially when working with at risk populations.
Both psychiatric patients and psychiatric nursing staff can be considered target populations for an intervention designed to prevent suicide in the clinical setting. Preliminary research questions using the PICO (patient/population, intervention/issue, comparison, and outcome) model include the following:
1. Among psychiatric patients (P), do mandatory intake assessments specifically for suicide risk (I) reduce rates of suicide (O) versus institutions without such policies (C)? This is a reasonable PICO question, but one that would require a large-scale assessment of different psychiatric institutions. Therefore, it might be too difficult to find sufficient evidence to make an informed decision for evidence-based practice.
2. Among psychiatric patients with mood disorders and other high-risk populations (P), do pharmacological interventions (I) reduce rates of suicide (O) versus patients who only receive talk or group therapies (C)? This is a commonly posed question related to suicide in the population group. The problem with this PICO question is there are too many different pharmacological interventions and individual differences among patients to come up with a clear, definitive guide for evidence-based practice.
3. Among psychiatric patients with suicidal ideations or a history of suicidal behavior (P), does family and group therapy (I) reduce risk (O) versus patients who do not receive any family or group therapy (C)? This is one of the most feasible PICO questions to use because family and group therapy options might offer some sound solutions for preventing suicide and reducing long-term risks.
4. Do community awareness, public service announcements, and other means of education and communication (I) help reduce rates of suicide (O) among discharged psychiatric patients (P) versus communities that do not receive such public relations services (C)? This is an important avenue of research for evidence-based practice in the community, helpful from a public health perspective. However, methodologically such interventions are less feasible.
5. Does mindfulness meditation (I) reduce long-term risk factors and suicidal behaviors (O) among high risk psychiatric patients (P) versus those who do not participate in the meditation programs (C)? As with question three, this is a suitable line of inquiry, which could actually lead to evidence-based practice guidelines for psychiatric institutions. Therefore, I will select this PICO question for the remainder of my research.
PICO Question: Does mindfulness meditation (I) reduce long-term risk factors and suicidal behaviors (O) among psychiatric patients (P) versus those who do not participate in the meditation programs (C)?
The patient population (P) can include all psychiatric patients on any given unit or within any given institution. Alternatively, the patient population can include psychiatric patients who have been diagnosed with one or more conditions known to increase risk of suicide: those conditions being mood disorders, psychotic disorders, substance use disorders, and personality disorders (Schwartz-Lifshitz, Zalsman, Giner, et al, 2012). This would allow the researcher to compile evidence from multiple studies.
The intervention (I) in this PICO question is mindfulness meditation. It is important to clarify exactly what this would mean, such as how many hours per day or per week of meditation, and which specific meditation instructions were given. The addition of the time (T) variable to the PICOT analysis might also be helpful. For example, does the meditation intervention yield results after three months, six months, or one year?
The comparison (C) is like a control group in this case, consisting of psychiatric patients who are not meditating formally within the designated intervention. Finally, the outcome (O) can be measured in different ways such as overall rates of suicide or surveys of patients regarding their subjective assessments of suicidal ideation.
The following keywords that can be used for conducting a literature search include: major depressive disorder, mood disorders, psychotic disorders, DSM-V, suicidal behavior, suicide, suicidal ideation, mindfulness, mindfulness meditation, meditation, suicide risk, and psychiatric patients.
References

Appleby, L. (1992). Suicide in psychiatric patients. British Journal of Psychiatry 1992(161): 749-758.
Jacobs, D.G., Baldessarini, R.J., Conwell, Y., et al (2010). Practice guideline for the assessment and treatment of patients with suicidal behaviors. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf
Sakinofsky, I. (2014). Preventing suicide among inpatients. Canadian Journal of Psychiatry 59(3): 131-140.
Sarzetto, A., Delmonte, D., Seghi, F. et al (2017). Suicide in depressed patients. European Psychiatry 41(April 2017 Supplement): S891-S892.
Schwartz-Lifshitz, M., Zalsman, G., Giner, L., et al (2012). Can we really prevent suicide? Current Psychiatry Reports 14(6): 624-633.
Tillman, J.G. (2014). Patient suicide: impact on clinicians. Psychiatric Times. Dec 31, 2014. http://www.psychiatrictimes.com/special-reports/patient-suicide-impact-clinicians

Rubric
Excellent
Quality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.
27 (27%) - 30 (30%)
Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.
24 (24%) - 26 (26%)
Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.

---Quality of Work Submitted:
The purpose of the paper is clear.
5 (5%) - 5 (5%)
A clear and comprehensive purpose statement is provided which delineates all required criteria.


----Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student\'s ability to:

Understand and interpret the assignment\'s key concepts.
9 (9%) - 10 (10%)
Demonstrates the ability to critically appraise and intellectually explore key concepts.

---Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student\'s ability to:


Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.
18 (18%) - 20 (20%)
Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to suppport point of view.

---Assimilation and Synthesis of Ideas:
The extend to which the work reflects the student\'s ability to:

Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.
18 (18%) - 20 (20%)
Synthesizes and justifies (defends, explains, validates, confirms) information gleaned from sources to support major points presented. Applies meaning to the field of advanced nursing practice.

---Written Expression and Formatting

Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused--neither long and rambling nor short and lacking substance.
5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity
---Written Expression and Formatting

English writing standards: Correct grammar, mechanics, and proper punctuation
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.

Contains many (? 5) grammar, spelling, and punctuation errors that interfere with the reader?s understanding.

---Written Expression and Formatting

The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.
5 (5%) - 5 (5%)
Uses correct APA format with no errors.


Plagiarism should be less than 8%

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
2012 Laureate Education, Inc. 1
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?
2012 Laureate Education, Inc. 2
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 patents 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.
2012 Laureate Education, Inc. 2
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
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.
2012 Laureate Education, Inc. 2
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 to act wth moral courage may be influenced by the degree of conflict between personal standards and organizational directives; by fear of retaliation, such as job termination; or lack of peer and/or leadership support. In this manuscript the authors begin by describing the concept of moral courage. Next they explore personal characteristics that promote moral courage, including moral reasoning, an ethic of care, and nursing competence. Organizational structures that support moral courage, specifically organizational mission, vision, and values; models of care; structural empowerment; shared governance; communication; a just culture; and leadership are addressed.
Moral Courage in Nursing
Nurses who act with moral courage do so because their commitment to the patient outweighs concerns they may have regarding risks to themselves. Packard and Ferrara (1988) proposed that nursing is comprised of four components. These components include: (a) taking the right actions to effect health promotion and quality of life; (b) possessing the knowledge and skills necessary to discern when and when not to respond; (c) knowing what the appropriate action(s) should be; and (d) demonstrating a willingness to act, thus supporting the ethical principle of beneficence. Nurses who are morally courageous are able to confidently overcome their personal fears and respond to what a given situation requires; they act in the best interests of their patients (Day, 2007). Nurses who exhibit moral reasoning and act with moral courage demonstrate a willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way (Lachman, 2007).
Sekerka and Bagozzi (2007) have asked "What induces people to act in morally courageous ways as they face an ethical challenge in the workplace?" (p.132). They noted that nurses practice with moral courage when they confront situations that pose a direct threat to care. For example, the nurse who questions discharging home a hospitalized frail elder who lacks the appropriate level of home care services and resources, thus jeopardizing the patient's safety and wellbeing, is acting with moral courage. This nursing response is based upon a commitment to serve and advocate for patients and the profession.
Kidder (2005) has argued that an individual who acts with moral courage is committed to moral principles, cognizant of the actual or potential risk that upholding those principles may require, and willing to endure the risk. Nurses can help their colleagues develop moral courage by reaffirming their colleagues' strengths and resolve, taking risks in helping to confront obstacles, possessing vision, remaining focused and disciplined toward the intended outcome(s), and taking actions that may go against the status quo but are necessary to do what is virtuous and principled (Walston, 2003).
Purtilo (2000) identified moral courage as a necessary virtue for healthcare professionals, one that enables them to not only survive but to thrive in changing times. Purtilo noted that morally courageous individuals respond to situations that incite fear and anxiety without knowing the end result of their response because they believe in doing what is morally right. The nurse on a general medical unit, for example, who confronts the physician who is reluctant to transfer an acutely ill patient in need of intensive care to the ICU, is acting with moral courage so as to provide safe care for the patient. Purtilo stated that "a rich understanding of care includes creativity, faithfulness to one's moral foundation, and a focus on the full significance of a situation" (p. 5). Practicing with moral courage responds to the call to act with moral conviction, even when the human tendency would be to act in ways that are incongruent with one's convictions when one perceives that personal security is endangered (Purtilo).
Personal Characteristics that Promote Moral Courage in Nursing
Nurses can enhance their ability to demonstrate moral courage in nursing by advancing their moral reasoning skills, nurturing their personal ethic of care, and enhancing their professional and cultural competence. Each of these behaviors will be discussed below.
Moral Reasoning
Kohlberg's theory of moral development provides a useful framework for understanding how one's personal ability to make moral judgments is influenced over time by personal development, knowledge acquisition, experience, and the environment (Cohen & Erickson, 2006; Ketefian & Ormond, 1988). Individuals at the highest level of moral development use their conscience to determine the right course of action by independently examining and delineating moral values and principles rather than by relying on group norms (Ketefian & Ormond, 1988). Ethical environments are characterized by shared decision making, taking responsibility for the consequences of one's actions, and utilizing opportunities for collective participation that empower individuals to develop higher levels of moral judgment (Ketefian & Ormond, 1988; Murray, 2007). Nurses who work in ethical environments are "aware of an ethical culture" (Murray, 2007, p. 48). They understand their role responsibilities and how an ethical environment supports their identification of ethical issues and concerns. They engage in meaningful ethical discussions (Murray, 2007).
The Ethic of Care in Nursing
The ethic of care is characterized by attentiveness, responsibility, competence, and responsiveness. The 'ethic of care' is not a set of rules and principles. Rather, it is a way of practicing that requires specific moral qualities that facilitate taking the right action (Tronto, 1994). The ethic of care is characterized by attentiveness, responsibility, competence, and responsiveness. Resulting actions include caring for, emotionally committing to, and being willing to act on behalf of a person with whom one has a significant relationship (Beauchamp & Childress, 1994). Nursing practice that includes the ethic of care promotes moral courage. Moral courage is enhanced in situations in which the ethic of care is present as evidenced by building consensus, promoting interdisciplinary collaboration, and positively influencing outcomes that support rather than oppose moral decision making (LaSala, 2009). Consider, for example, a nurse caring for a patient with invasive ductal breast carcinoma and spinal metastases who desires to die at home surrounded by family and assisted by a hospice team, but whose husband is hesitant about taking his wife home, fearful that he will be unable to manage her care. The nurse acts with moral courage by advocating for the patient's wishes, despite the palliative care physician's recommendation that the patient remain hospitalized given the probability of imminent death. Through effective communication and collaboration with the physician, the nurse is successful in facilitating the patient's discharge home with patient-controlled analgesia and hospice care, thus responding to the patient's wishes (LaSala, 2009). The moral qualities associated with the ethic of care enable nurses to care for patients and families during times of sickness and uncertainty, provide the inner motivation to do what is right and good, and demonstrate moral courage both within the context of patient care and from the perspective of the nurses' collegial, collaborative relationships with other healthcare professionals.
Nursing Competence
Professional competence is a prerequisite for providing morally responsible care. The elements of a profession, such as formal education based on theoretical knowledge, a code of ethics, professional organizations that guide practice, and the provision of necessary service to society (Miller, Adams, & Beck, 1993), all serve to develop professional competence. Standards for ethical conduct are also necessary in order to provide morally responsible care (Maraldo, 1992).
Leininger (1991) defined transcultural nursing as a humanistic and scientific area of formal study and practice focused upon similarities and differences among cultures with respect to human care, health, and illness that are related to cultural values, beliefs, and practices (norms). These norms include the way rights and protections are exercised, and even what is considered to be a health problem (United States [U.S.] Department of Health and Human Services, 2001). Nurses need to understand and appreciate inherent similarities and differences not only locally, but regionally, nationally, and worldwide as well. In order to provide morally competent care that respects individual values and needs, it is imperative that nurses examine their own health-related values and beliefs, as well as those of the healthcare organization in which they work; it is only then that they can support the principle of respect for persons and provide the ideal of transcultural care (Bjarnason, Mick, Thompson, & Cloyd, 2009).
Organizational Structures that Support Moral Courage
McClure, Poulin, Sovie, and Wandelt (1983) observed that certain healthcare organizations seemed better able to withstand pressure on their professional environments, experiencing less upheaval and producing higher quality patient outcomes with lower morbidity and mortality rates than 'average' healthcare organizations. These same institutions showed remarkable resilience in limiting turnover and maintaining patient and staff satisfaction. These observations resulted in nursing's recognition of Magnet hospitals, a designation that recognizes organizations in which nurses want to work and patients find healing environments (Aiken & Salmon, 1994; Aiken, Smith, & Lake, 1994; American Nurses Association (ANA,) 1998). It was noted that these organizations have in place a number of structures that enhance the quality of the care provided as well as the working environment. Structures that are described below help create the context for actualizing moral courage in nursing.
Mission, Vision, and Values
Creating the foundation for an environment that fosters moral courage among nurses requires that all stakeholders have a clear understanding of the organizational mission, vision, and values, as well the philosophy of the nursing department (Lachman, 2009). Clearly stating and supporting the mission, vision, and values sets the tone for the work of nursing in the organization, pictures a state that implies a commitment to organizational improvement, and suggests the types of activities that will ensure that the organization reaches those goals. Developing a nursing philosophy allows the organization to define itself not only to its internal community, but to its external community as well.
A nursing philosophy describes professional behaviors that hold nurses responsible and accountable for exercising moral courage when acting to achieve the organization's mission and vision. According to Shirey (2005) "clarity in an organization's mission, vision, and values is key to effective management in today's increasingly complex healthcare environment. To clearly articulate mission, vision, and values, employees must experience consistency between what is espoused and what is lived" (p. 59).
Models of Care
Professional practice models include reward and recognition systems acknowledging performance improvementalong with empowerment and engagement in the workplace. Another aspect of professional nursing that promotes moral courage in the workplace includes a professional model of care that exemplifies nursing's goal of enhancing the lives of patients and colleagues. The American Nurses Credentialing Center (AACN) (2008) has defined a professional practice model as the driving force of nursing care; a schematic description of a theory, phenomenon, or system that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality of care for those served by the organization (e.g. patients, families, and community). Professional practice models illustrate the alignment and integration of nursing practice with the mission, vision, and values that nursing has adapted. Fasoli (2010) has noted that autonomy, accountability, professional development, emphasis on high quality care, and delivery models that are patient centered, adaptable, and flexible provide a framework for professional practice models in nursing. Professional practice models include reward and recognition systems acknowledging performance improvement, and nurses' commitment to uphold high standards of practice predicated on a strong value system, moral courage, and quality professional relationships, along with empowerment and engagement in the workplace.
Structural Empowerment
In her theory of structural power in organizations Kanter described four structural factors within organizations that lead to empowerment (Kanter, 1983; Matthews, Laschinger, & Johnstone, 2006). She explained that employees who (a) have access to information; (b) receive support from organizational leadership, subordinates, and peers; (c) are given adequate resources to do the work; and (d) have opportunities for personal and professional development are empowered to contribute to achieving organizational goals (Matthews et. al., 2006; Ning, Zhong, Libo, & Qiujie, 2009). Empowerment may come from within, collectively as in work groups, or from the work environment (Manonlovich, 2007). Nurses who are empowered take control of their practice and participate in decision making at the point of care, thus strengthening a professional practice model and promoting positive patient care outcomes.
An example of this empowerment would be that of Nurse M, who heard other nurses on the unit discussing how patients assigned to Nurse J had recently complained of not receiving pain medication when requested. The nursing staff had recently observed notable changes in Nurse J's behavior as evidenced by being unwilling to help out, less engaged, and easily angered. One evening after receiving report from Nurse J, one of Nurse M's patients stated to her that he was in acute pain and had not received any pain medication from the nurse on the previous shift. Upon reviewing the patient's medication record, Nurse M found that Nurse J had documented that the patient received narcotic analgesia every four hours that shift. This information was also recorded in the unit's automated medication system. The following day, Nurse M discussed her findings with her nurse manager, who has a reputation for supporting, developing, and empowering her staff. Nurse M did this not only out of concern for that patient's safety and wellbeing but also because of her compassion for Nurse J whom she had known in the past as a trusted colleague and competent nurse. The nurse manager recognized Nurse M's moral courage in coming forward, and spoke with Nurse J who became emotionally distraught, admitting to drug diversion and problems with substance abuse. Although Nurse J resigned her position, the nurse manager continued to offer her support and resources to assist in her rehabilitation. Organizational factors, such as those described in this example, including open and supportive leadership, adequate resources, and professional development empower nurses to act and promote moral courage in the workplace.
Shared Governance
Shared governance promotes collaborative decision making and shared responsibility; it empowers nurses to act with moral courage by taking ownership of their practice at the point of care. Shared governance has been described as "a managerial innovation that legitimizes nurses' control over practice, extending their influence into administrative areas previously controlled only by managers" (Hess, 2004, p. 2). Research has demonstrated several positive outcomes of shared governance, including increased nurse satisfaction and retention and a more motivated, engaged nursing staff (Bretschneider, Glenn-West, Green-Smolenski, & Richardson, 2010). Work environments in which shared governance is firmly embedded facilitate active involvement of frontline staff in the creation of a professional practice model that promotes quality patient care outcomes.
Practicing in a shared governanc environment enables the nurse to act with moral courage when aggressive treatment of a patient based on the family's wishes continues, despite the patient's expressed wishes that it be withdrawn. In such a situation, out of duty to the patient and to self, the morally courageous nurse will advocate for the patient by initiating conversations with other care providers, consulting with the hospital ethics committee, and utilizing other appropriate resources to engage the family and patient in meaningful discussion that can result in consensus around the goals of care. Nurses practicing in shared governance settings have access to the information and resources they need to make effective decisions, create change, and influence outcomes (Hess, 2004).
Communication
Nurses act with moral courage when they use the chain of command to share and discuss issues that have escalated beyond the problem-solving ability and/or scope of those immediately involved. The Joint Commission (TJC) requires that organizations respect the patient's right to, and need for effective communication; it directs organizations to take action to address communication needs (TJC, 2009). The strength of this directive is based upon overwhelming evidence from TJC's sentinel event database indicating that communication is cited as a root cause in nearly 70 percent of reported sentinel events, surpassing other commonly identified issues, such as staff orientation and training, patient assessment, and staffing (Joint Commission Resources, n.d.).
Every day nurses and their healthcare colleagues are confronted with challenging situations where effective communication is essential, while at the same time fraught with difficulty. Assertive communication is the act of stating a position with assurance. It is an honest, direct, and appropriate means of communicating that focuses on solving a problem (Lachman, 2009). The use of assertive communication is imperative not only to patient safety and to quality patient care, but also to invoking the chain of command. Nurses act with moral courage when they use the chain of command to share and discuss issues that have escalated beyond the problem-solving ability and/or scope of those immediately involved. Engaging the chain of command both ensures that the appropriate leaders know what is occurring and allows for initiating communication at the level closest to the event, moving the discussion upward as the situation warrants.
Just Culture
The concepts of effective communication and chain of command are inherent in a position statement recently published by the ANA. The 'just culture' model seeks to create environments that incentivize rather than punish error reporting. In a just culture, individuals are not held accountable for system problems over which they have no control. A just culture recognizes that patient care safety and quality is based on teamwork, communication, and a collaborative work environment (ANA, 2010). Just culture environments enhance moral courage in the workplace.
Leadership
Nurse leaders demonstrate moral courage when they oppose work environments that put patient safety at risk. For example, chief nurses act with moral courage when they firmly oppose cost-containment measures, such as nursing layoffs or reductions in healthcare services, that would jeopardize the delivery of safe, competent patient care. Nurse leaders can create environments that support moral courage by clearly providing guidelines for nurses to use when they observe unethical practices and by providing resources, such as ethics committees, shared governance structures, and mentoring opportunities that enable nurses to confront ethical dilemmas in practice (Murray, 2007).
All nurses can demonstrate leadership by role modeling ethical behaviors based on established nursing practice standards. They can also recognize colleagues and peers when they uphold ethical principles and demonstrate moral courage, and work to develop and implement policies and procedures that facilitate effective responses to moral distress at the point of care (Murray, 2007).
Conclusion
Nurses who possess moral courage embrace the challenge of transforming the profession and the workplace. They are the nurses who question the premature discharge of an elderly patient with no social support and limited resources, refuse to administer a medication whose efficacy or dosage they question, challenge those who treat others unjustly, or speak up when others remain silent.
Nurses who act with moral courage take risks knowing that they may encounter lateral violence, including bullying, harassment, or sabotage, as well as risk of termination. Nurses practicing with moral courage know that addressing these issues is leadership in action, the type of leadership that began with Florence Nightingale -- who role modeled moral courage on the battlefield, in the classroom, at the bedside, and among legislators in advocating for the rights of patients, colleagues, and humanity. In her writings on leadership, perhaps Nightingale said it best:
What is our needful thing? To have high principles at the bottom of all. Without this, without having laid our foundation, there is small use in building up our details. This is as if you were to try to nurse without eyes or handIf your foundation is laid in shifting sand, you may build your house, but it will tumble down (Ulrich, 1992, p.40).
the accountability and responsibility for creating environments that promote moral courageis an obligation shared by all nurses, in every role, in every specialty, in every setting. Nurses have obligations to patients, one another, and the global community to assure optimal health, personal wellbeing, and quality of life for all with whom they come in contact. In her seminal publication, Nursing Speaks for Itself, Margretta Styles (2006) described the transformation that needs to occur in nursing, writing, "There is a give and take to empowerment, so nursing must be prepared to reshape the health care environment and act as its full partner. Both the culture of the profession and the culture of the workplace must be transformed (p. 10)."
Challenges in the care environment are myriad. All professional nurses assume the responsibility for serving as patient advocates and role models. This duty exists whether nursing practice occurs at the bedside, in the classroom, in the board room, or in the research setting. Quite simply, the accountability and responsibility for creating environments that promote moral courage in practice and transform the workplace is an obligation shared by all nurses, in every role, in every specialty, in every setting.
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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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Source: Online Journal of Issues in Nursing, 2010; 15(3)
Item Number: 2010890002

QI Paper
To facilitate development of the Quality Improvement and Patient Safety Issue project, I am offering the following guidelines and recommendations.
? The quality improvement and patient safety project is another opportunity to apply these basic principles in a summary document that reflects an understanding of the design of a quality improvement process to reduce and/or eliminate the risk to patient safety. In doing so, the document should reflect data and processes mastered in the modules that address performance improvement.
? The project is to be presented in summary format and not more than 3 pages of content. As with all documents, APA formatting is required, and evidenced based references should be included. References are not counted in the page limit for the paper. Do not exceed the page length.
Directions:
? Begin with the Problem Statement & Literature Support. A sample problem statement is:
Quality patient care and successful clinical and financial outcomes are directly correlated with professional nursing staff competence and turnover (references). In organization X, the current staff turnover rate is 25% after one year on the unit. In settings where nurse turnover exceeds 12%, the following clinical, organizational and financial challenges have been noted: (1) lower patient care scores on national benchmark data; (2) etc. According to Aiken (2003), national studies
Continue with a brief but relevant and evidence-based literature that supports the problem statement.
? The Rationale for selection of this problem relates to findings that directly correlate to the actual performance outcomes with the problem. Support the need for addressing this from a quality improvement approach and its relationship with patient safety and/or outcomes. Is there data that suggests performance improvement may impact on the problem? Or, from your knowledge and research on the problem, is it likely amenable to a quality improvement approach?
? An appropriate Plan Design is the application of a performance improvement process. This is the meat of the project where you will discuss the performance improvement process steps that you will employ to address the problem, taking care to include: Who, What, How, and Time Frame. Include in the discussion the process and tools proposed to address the problem. An example would be:
"The initial approach is to (1) collect accurate data on the extent of the problem, (2) brainstorm with staff, administrators and patients to determine to potential causes of the problem, and (3) conduct focus groups with current and separated staff to elicit additional contributing factors
The conclusion of the discussion should project the desired outcomes and future plans. For example:
It is expected though the application of this improvement process that nurse turnover in this organization will be significantly reduced or reduced to not more than 5% yearly. The process plan has been adopted by the organization and is to be reviewed and reassessed quarterly for outcomes and needed changes.< /span>
Grading is as follows:
Problem statement and literature support 30%
Rationale 30%
Plan design 40%
Total 100%

I am sending articles that will be useful. Please refer to the TOP GUN article. The paper should resemble the top gun article but with Problem statement, Rationale, and Plan design as subject headings.
There are faxes for this order.

The focus of this assignment is specific to CHANGE THEORY, SYSTEMS THEORY AND BUILDING COMMUNITY PARTNERSHIPS.
Be concise, precise and write to the point of the assignment.
Address the following key issues:

Discussion Possible Points
Refine your statement to leadership to be clear and concise, providing facts and figures to support your proposed change

Identify potential allies in planning the proposed change. Who are they and how can they assist you in making this possible?


Where are key points of resistance within and outside the system? Why would there be resistance? Utilize systems theory in describing the role that groups and individuals would play in the process.


Elaborate on potential negatives that individuals or groups might bring up in discussions and how you would counteract this.


Based on change theory, how long do you anticipate that it would take to socialize the idea, propose the specific change, and initiate implementation?


Please see below information for source

Healthcare systems are stressed by limited resources and increasing demands on their services. Nurses, as the largest group of healthcare professionals, have experienced significant changes in their work life and environment as systems have tried to meet these challenges. As workloads become more substantial because of cutbacks and the number of nurses per patient diminishes, patients and healthcare workers are put increasingly at risk.
I would like the opportunity to make a statement to leadership regarding the Nurse patient ratio dilemma we are facing in our organization. According to the Massachusetts Nurses Association in a research study by federal Agency for Healthcare Research and Quality shows that patients do better with lower nurse to patient ratios. The research study found in given hospital unit the optimal workload for a nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission. A workload of 8 patients versus 4 was associated with a 31% increase in mortality. I have not been able to find any studies related to the effects of the nurse to patient ratio in a dialysis clinic.
Reducing the nurse patient ratio would set a safety net for patients and nurses. It would provide a safer environment for patients because there would be more staffing available for each patient. Patient can feel more confident that their needs are being met by the medical staff and the nurse will have fewer distractions. According to International Council of Nurses, California has set mandatory upwardly adjustable minimum nurse patient ratios. An example of this shows staffing for a medial surgical ward on day shift would be four patients for each Register Nurse. According to the International Council of Nurses improvements reported since the implementation of the ratios include more than 3000 extra nurses employed in hospitals, decreased staff turnover and absenteeism, and public approval of the State government has increased. This would also be incentives for nurses to work in the field of dialysis. It would have an impact on patient outcomes and on nurse retention and recruitment. I feel, as a nurse, that working in a safe environment for patients and staff is of the upmost importance. Nurses have dialysis technicians to rely on, but they are only able to rely on them to maintain equipment and alert her if a change in the patient occurs. The majority of responsibility for patient care falls on the Register nurse.
My strongest allies in the fight to change the nurse to patient ratio include dialysis nurses, patients, and the dialysis technicians. The majority of nurses that work in dialysis feel strongly about this issue. The nurses feel overworked and stressed due to the nurse patient ratio. The care and safety of ten patients fall upon one Register Nurse which puts a great deal of pressure on them. The register nurse is responsible for pre and post treatment physical assessments of all patients, giving all medications, supervision of the technicians, operating kidney dialysis machines, initiating, monitoring, and discontinuing dialysis treatments, assisting physicians on rounds, calling in prescriptions, making doctors appointments for patients, assisting patients with transportation issues, patient education, and writing physician orders. Patients also feel the effects and some have voiced to me their concerns. They feel their lives are in jeopardy due to the nurse being over extended between patients. Dialysis technicians also experience the effects because it requires them to take on more responsibility for patient care. Many of the technicians have no formal medical training and have a limited knowledge of patient care.
Nurses, patients, and technicians can help elevate this problem by joining together in a united front to voice their concerns and demand a change be made. No one group alone can make a difference but together new policies can be implemented and enforced. Also contacting the Nurse Association and asking them for help in the situation would be a great benefit. According to their website the ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public. ANA is the voice of nursing. This voice is heard through policy development, lobbying, publications/newsletters, involvement and partnerships with other organizations, and its presence on the Internet. ANAs work addresses the needs of nurses in their professional settings as well as patient care. The ANA involvement in this national issue is critical.
Change is always difficult and resistance is to be expected. One of the barriers to changing the ratios is the continuing nursing shortage that we are experiencing. The Bureau
of Health Professions predicts that the current shortage of 150,000 nurses nationwide
will by 2020 grow to 800,000 nurses the area hospitals are continually recruiting for nurses. Most of the hospitals offer between $5000.00 to $10,000.00 sign on bonus for a one year commitment. Dialysis organizations would be the main opponent to the change due to the cost. Dialysis units are smaller and without the financial resources the major hospitals have. The increased cost would place a greater burden on the clinics which have a limited budget each year. It is estimated by the American Hospital Association the projected cost to change the nurse to patient ratio would be around $270 million dollars.
The organization would play a key role proposed changed. The dialysis organization would have to change their views toward nurse patient ratio. The company would also have to find money in the budget to allow for a change. This would cause an increase in cost to patients as well. I believe patients would agree to the increase if it would guarantee them higher quality of care. Nurses may also be willing to take a small decrease in pay to help facilitate the change. Dialysis nurses receive some of the best pay rates that I personally found. I make more money working in a dialysis clinic than in the hospital. In order for the change to occur I believe that all parties involve must be willing compromise. We are all part of the same system of healthcare.
The cost of such a change would be the main negative of such a proposed plan. A majority of the cost would be passed on to the patients insurance company. Many of the patients receive Medicaid or Medicare which means the increase cost would fall on the tax payers. My main point to counteract this position is that patient safety must be our first and foremost priority. Although we may spend more money to begin with for more nursing staff patient outcomes would offset the expense. Patients that have better outcomes from dialysis treatments spend less time in the hospital. When patients are in the hospital we do not get paid for their treatments. Hospital tays cost the company a loss of revenue.
Unfreezing the organizations ideas on nurse patient ratio will take a great deal of time and effort. It would take at least two to three years to socialize the idea with all the dialysis organizations and put together a proposal for the specific changes. It would take another year to initiate implementation. Major changes never occur overnight and must be thought out and planned thoroughly before implementing.

References
American Hospital Association, Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. May 2007 retrieved Oct 6, 2008 from www.aha.org
The Patient Safety Act" is The Key to Protecting Your Patients and Your Nursing Practice, 2007 retrieved Oct 6, 2008 from http://www.massnurses.org,
International Council of Nurses Press Release retrieved Oct 8, 2008 from http://www.icn.ch/PR23_02.htm
The American Nurses Association retrieved Oct 9, 2008http://www.nursingworld.org/

Write a persuasive white paper (suggested length of 3 pages) on Magnet status to be sent to all nursing staff in which you do the following:

1. Discuss the research basis for hospitals attempting to attain Magnet status. Note: You should include research literature that describes how the process of Magnet status came about and examples of results of hospital studies that moved to Magnet status to support the issue with nurses in this hospital.

2. Discuss the principles the ANCC adheres to when considering a hospital for Magnet Certification.

3. Explain why it is beneficial for a hospital to attain Magnet status.

THIS PAPER NEEDS TO BE ORIGINAL (Completely in your own words) -- READ UPLOADED RESOURCE INSTRUCTIONS.

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Case Assignment



Communications between healthcare professionals account for the major part of the information flow in clinical and healthcare settings. Accordingly, it is essential that healthcare professionals communicate and share information in a manner that is efficient, timely and accurate. However, various information needs and barriers to communications do indeed exist, which create unique challenges.

The following study examined the perceived information needs and communication difficulties among inpatient physicians and nurses at New York Presbyterian Hospital. Read through this study carefully, and in three to four (full) pages answer and explain the following:

1. In what ways are the information needs of physicians and nurses at Presbyterian Hospital similar? In what ways are they different?

2. From the study, select three to four specific information needs and identify key data inputs, processes and outputs necessary for the information to be accurate and useful.

3. For each of the information needs selected above, describe what systems and methods of communication you believe would be best for sharing and communicating the information and knowledge. Explain why.

Please submit your assignment to CourseNet by the end of this module.



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Article

Perceived Information Needs and Communication Difficulties of Inpatient Physicians and Nurses

Source:

Journal of the American Medical Informatics Association 9:S64-S69 (2002)
Lawrence K. McKnight, MD, Peter D. Stetson, MD, Suzanne Bakken, RN, DNSc, Christine Curran, RN, PhD and James J. Cimino, MD


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Abstract
In order to understand the differing perceptions of information needs and communication patterns of healthcare professionals as they relate to medical errors, we conducted a survey and 5 focus group sessions of inpatient physicians and nurses. Although nurses and physicians stated differing information needs, both groups expressed significant problems with obtaining patient, domain and institution-specific information in a timely manner. Identification of appropriate providers and establishing contact with those people was perceived as the most pressing communication need. All focus group participants felt that communication difficulties were common and could give examples in which such difficulties led to adverse events. Our studies suggest that information needs and communication difficulties are common and can lead to medical errors or near misses. Many of these problems may be amenable to information technology solutions.

Introduction

The Institute of Medicine (IOM) report on medical errors1 has heightened awareness of the relationships between systematic processes and adverse events. The report argues both that medical errors are common2,3 and that many errors are preventable.4 Specifically, the report references the work of Leape5 and Reason,6 and calls for critical review of system processes to ensure that latent errors are prevented. Both Leape and Reason, in turn, argue that error reduction can be achieved by, among other things, reducing reliance on human memory and improving information access. Unfortunately there are few studies that characterize the types of information, the timeliness of their access, or the methods of delivery that are critical to prevent latent errors.

Information access may take many forms ranging from looking up information on a computer or in a textbook, to formal subspecialty consults, to the informal dialogs between health care professionals. The latter constitute the majority of the healthcare professionals information requests7 and time8. While the relationships between communication and medical errors remain poorly defined, retrospective reviews indicate that they contribute to a large percentage of adverse events.9

Coiera argues that information and communication needs are related and represent a continuum of activities, some of which are served best by communication dialogs and others that can be served by computable methods.10 He introduces the concept of "common ground" as the information that is shared by both participants and is relevant to the communication task. Common ground may be used to identify situations where computable information may be useful or where more effective communication channels are needed. Therefore, understanding the characteristic information types and communication patterns among health care professionals is necessary to effectively support system processes with informatics interventions. Appreciation of these concepts is particularly important if the intention is to have impact on latent errors.

In this light, we have proposed analysis of the impact of an informatics intervention on information need satisfaction, communication, collaboration, and selected quality indicators. As a preliminary study we sought to describe and compare the perceived information needs and communication difficulties among inpatient physicians and nurses at the Presbyterian Hospital (PH) campus of the New York Presbyterian Hospital. In order to triangulate the results, three qualitative methodologies were used: surveys, focus groups and observational studies. This paper reports on the survey and focus group findings. Observational studies are reported in a separate paper.11

Methods

Surveys
As a first step, we designed a semi-structured survey to gather information about the perceptions of information needs and communication difficulties at PH. The survey asked participants to list instances of information needs or communication difficulties and the surrounding circumstances including why the event occurred and the frequency of similar events. The survey questions were developed based upon the Krikelas model of supplemental information seeking behavior and revised based upon feedback from the members of the research team.12 General computer experience, functions used in the current clinical information system (WebCIS13), and discipline role were also recorded. Surveys were identical for the physician and nurse respondents except for discipline-specific role information and the method of completing the questionnaire. For the physician group, we developed a Web page for the survey, and e-mails were sent to all 125 medical interns and residents at PH, notifying them of the existence of the Web site and encouraging them to respond. We distributed 70 surveys in paper format to the nursing staff at PH through representatives of the Nursing Information Systems Committee.

Focus Groups
To flesh out information obtained in the surveys, we conducted three focus group meetings with physicians (interns, residents, and hospitalist physicians respectively) and two focus group meetings with nurses (nurse managers and staff nurses respectively) at PH. Studies were performed according to standard focus group principles as described by Kitzinger14 and Kruger.15 All groups consisted of 4-6 participants in addition to the facilitators with exception of the staff nurse group where two participants attended. Sessions were audio taped and transcribed. Common themes were identified and summarized from the transcriptions. Questions in the focus group session attempted to explore barriers to obtaining information or effective communication, to elicit examples of cases where such systematic processes lead to poor outcomes, and to suggest improvements.

Results

Survey Data

Twenty-six physicians and 17 nurses responded to the survey (response rates of 21% and 24% respectively).

Data related to general computer experience and WebCIS experience indicated a general level of computer literacy among both groups and greater use of WebCIS functions by physicians. All respondents to the survey reported having access to the Internet. All except one nurse reported having had experience with MS Windows. E-mail and Web browsing were the most frequently reported uses. WebCIS was used by all physician responders and by 76% of nurses. The most frequently used WebCIS function was laboratory results reporting by both nurses and physicians. While nearly all physicians (92%) reported using specialty reports (Endoscopy and Cardiac imaging), only 35% of nurses reported using these functions. Relatively fewer physicians reported using the diagnosis system (42%), alert system (23%) or infobuttons (15%). Only one nurse reported using these systems.

Sixty-four statements about information needs and 46 statements regarding communications difficulties were recorded. A summary of the survey themes is provided in the Table 1.


Table 1 Perceived Information Needs and Communication Difficulties (Survey Data)

Physicians
Nurses


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Information Needs

Patient Specific
? A list of current medications and time administered
? Patient diagnoses

? Laboratory and other test results

? Problem lists

? Outpatient notes (especially sub-specialty consultations.

? A central list of current providers for the patient (consultants, nurses)

? Laboratory and other test results

Institution Specific
? Current providers that are on-call and how to contact them.
? Policies and protocols (IV access device care policy, blood bank protocol)

? Census reports

Domain Specific
? Disease management information
? Drug information (dosage and side effects of specific drugs, patient/caregiver teaching information)

? Prescribing information

? Medical formulas linked to patient data
? Diagnostic definitions

? Educational materials (e.g. colostomy care educational materials)

Communication Difficulties
? Identifying and contacting other health care providers (especially consult services)
? Identifying and contacting other health care providers




Physician responses to the survey questions of information and communication needs focused on gaps in system function and often included recommendations on how they would want the gaps addressed. For example, one physician stated an information need of "Medication list for my signout" (a function that does not currently exist) with the comment "Integrate with pharmacy." In contrast nursing responses tended to focus on problems in using existing applications. For example, a typical information need was listed as "Blood bank protocol" with the comment "manual not up to date."

Physicians cited a majority of information needs related to patient specific data. Many comments about the need for improved availability of inpatient and outpatient consultation reports, needing patient problem and medication lists, improved drug-drug interaction alerts, and better recording of order status were mentioned. Domain-specific information, such as online textbooks guidelines and decision aids, formulas (linked to patient specific data), medication (and cost) prescribing information, and laboratory significance information were also mentioned by physicians but less frequently than by nurses.

Responses to questions about information sources fell into 3 categories: source characteristics (i.e., peer reviewed, up-to-date), source format (i.e., on-line, palm-device, paper), and specific content (i.e., NEJM, Harrison?s). Physicians often commented about source characteristics in generalities; for example, to include peer review and validation. In contrast, nurse?s comments tended to focus more on the source type (i.e., care plan, policy, protocols) but included a wider audience (i.e., patient teaching materials and continuing education). Physicians often made comments indicating that sources should be on-line or on a handheld device, whereas nurses often expressed concern over Web-based materials because some health care workers might not be able to access these materials.

Both groups stated a variety of difficulties in obtaining information including: 1) difficulty in finding information, 2) finding inaccurate or outdated information, and 3) limited time. Additionally, nurses reported that there was a lack of knowledge about how to get into the system.

Both physicians and nurses commented extensively on the difficulty in identifying and contacting other health care providers. Often these frustrations resulted from an inefficient paging system. Both physicians and nurses suggested information technology-based solutions for the rapid identification of people and common access to frequently referenced, but changing information. For example, one nurse asked for a Web page list of clean beds, a prerequisite for admitting patients and starting therapeutic regimens in a timely fashion. Physician respondents stated a very strong preference (93%) for e-mail as their primary method of communication despite currently using the telephone and paging system far more frequently. This may have been a result of selection bias since responding physicians answered using the Web-based survey, however 50% of responding nurses also stated that their preferred communication method was the Web or e-mail.

Thirty-six additional general comments about wishes for improvements to WebCIS functionality were made. These comments mirrored other comments about information and communication needs discussed above.

Focus Groups
Focus group discussions were lively and emotionally charged. Many themes from the survey data were reviewed and expanded upon.

Regarding information needs, both nurses and physicians emphasized that the time to look up information was limited, and that quick, relevant information sources were most useful. Interns in particular liked MD Consult for its "One-Stop-Shopping" approach with the ability to look up information at many levels of detail and then choose the appropriate source for their particular situation. Hospitalists preferred Up-to-Date because it was more focused and relevant than MD Consult.

Nurses commented that, when they have information needs, they often turn to someone with expertise in that area as a first source. Physicians did not mention this.

All groups felt that Medline searches were useful in limited situations, but generally were not useful for day-to-day clinical activities. Most of the physician participants used palm-based organizers and commented on their practicality, particularly for looking up drug information.

In contrast to physicians, nurses identified the need for patient education materials. Current patient education materials were felt to be difficult to access, and often inappropriate for the literacy level of patients. They also expressed the need for materials in foreign languages, particularly Spanish.

Communication difficulties identified by physicians focused around four main problems: 1) a slow and inefficient paging system, 2) inconsistent communication at transfer of patient care, 3) the need for feedback on order status, and 4) the need for face-to-face communication where mistrust or disagreement in care plans existed.

Several cases where the lack of communication led to medical errors or near misses were identified. Patient transfers were particularly problematic. One physician reported:

[just] last night there was a patient who left the CCU . . . in the morning?was assigned to me at 11 PM?and the patient was on heparin . . . and was on the floor for 12 hours without a physician aware or covering this patient.

Others in the group agreed that similar problems were not infrequent. Multiple cases were described where physicians were unaware of medicines being given to the patient because they were omitted from medicine lists in sign out sheets.

Communication between consult services was also highlighted as a problem area. As one intern describes:

We had a patient who . . . had a lot of [consult teams] and all . . . of them were remarkably opinionated and all disagreed with each other. And so they used me for the last two weeks as a mode of communication. I was the conduit. . . . But I think it did affect the patient?s care.

The nurses also identified quality of care issues related to ineffective or delayed communication. For example, one nurse in talking about how communication affected patient satisfaction with care stated:

It?s really a dissatisfier when a patient is in pain and you can?t find the right person to give you an updated order. . . . you?re flipping the kardex and you?re calling 11 people, and it just [gives] the image that . . . the nurse-patient relationship is now fractured because you can?t even get the right doctor. . . . It implies that you don?t even know what you?re doing. That message is given very strongly . . . like you know, "can?t you find me a doctor?" It?s not that you don?t want to, it?s just that you don?t have the right information easily accessible to you.

Another nurse pointed out how this relates to adverse outcomes.

It does specifically affect our patients who we know could code at any time. And we are trying to be able to get in touch with an intern.

A significant tension between nurses and physicians was identified when analyzing the focus group data. For example, some nurses felt that telephone and verbal orders should be eliminated, and that physicians were flagging all orders as "stat" inappropriately. Physicians on the other hand felt that telephone orders were essential in order to get work done in a timely fashion, and felt the need to seek nurses out face to face or mark orders as stat in order to ensure that orders were actually carried out. Regarding finding the physician for a patient, one nurse pointed out:

I?ve never been able to figure out why that?s so complicated. The nurses have an assignment?whether it?s written on paper or computer-generated or what ever ? we have an assignment. At any given moment you can just look at it and see what nurse is assigned to what patient. But it?s much more complicated with the doctors. You have to go through hoops to find out.

In contrast, a physician trying to find a nurse for a patient stated:

I think the nurses should have their pictures on the floors, saying ?this is my face?, ?this is who I am?, ?I?m taking care of these rooms?. [Instead] they tell me??S____ is taking care of this patient.? Like, who is S____? Until I figure that out, basically I have to ask nurse to nurse until some nurse can say ?I?m taking care of this patient.?

All groups felt that the current paging system needed to be changed, and that a common "whiteboard" area with patient problems, responsibilities, and tasks with check off to identify completion was considered to be a potential solution to less urgent communication issues regarding patients.

Discussion

The survey data suggest that providers are having significant difficulty in obtaining certain types of information. Implied in the comments is the notion that information is available, however due to time constraints it is too difficult to obtain. The Information needs listed (ie. knowledge sources, provider lists, medication lists, etc.) appear predictable and have much common ground between providers, therefore computable information sources would be appropriate.

In contrast, comments in the focus group sessions highlight frustration with the interruptive nature of their work environment that is inevitable in clinical medicine. At the same time they illustrate personal goals to improve efficiency without consideration of systemic efficiency. Some of these processes may need to be addressed though non-informatics means, however others such as the feedback of task status may be targets for interventions such as improved asynchronous channels such as a virtual whiteboard.

There is significant work to be done to implement successful technologies, however. In analyzing the data collected from these studies, we identified several ambiguities in the problem terminology. For example, in response to the question "name a communication difficulty you have had" one respondent identified the source as "Pharmacy", the difficulty as "I couldn?t remember what meds the patient was on", and commented, "Need medication section like the demographics section [of WebCIS]." We had difficulty classifying this as an information need or communication problem. Future studies will benefit from an ontology for this domain16.

Conclusions

Although quite limited by design, the focus group and survey data outlined here confirm that health care professionals perceive significant gaps between information needs and timely access, and that communication difficulties are commonly linked to poor outcomes. While physicians and nurses have different needs, methods and goals, they share common problems in obtaining information and communicating effectively.

We believe that successful tools can be developed. Both groups had favorable responses to the idea of a common "virtual whiteboard" that would facilitate communication of low-priority tasks without interruption but with confirmation of task completion. Physicians in particular were receptive to the idea of a wireless handheld device for this. Our data indicate that exploring the use of such technology has potential for favorably impacting the process of care.

Acknowledgments

This work has been supported by National Library of Medicine Training Grant NO1-LM07079.

Reprinted from the Proceedings of the 2001 AMIA Annual Symposium, with permission.

References

Kohn, KT, Corrigan, JM, Donaldson, MS (editors for the Committee on Quality of Health Care in America). To Err is Human: Building a Safer Health System. Institute of Medicine. National Academy Press, 1999.
Brennen, TA, Leape, LL et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. NEJM. 1991. Vol. 324(6) pgs. 370-376.
Thomas, EJ et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care . 2000 Vol. 38(3):261?271. [Medline]
Bates, DW. Et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for prevention. JAMA. 1995. Vol. 274(1):29 ? 34. [Abstract]
Leape, LL. Error in Medicine. JAMA 1995. Vol. 272(23):1851 ? 1857.
Reason, J. Human Error. Cambridge, Mass: Cambridge University Press; 1982.
Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med. 1985;Vol. 103:596?9. [Medline]
Tang P, Jaworski MA Fellencer CA Kreider N, LaRosa MP Marquardt WC. Clinical information activities in diverse ambulatory care practices. Proc AMIA Fall Symposium . 1996; 12?6.
Wilson, RM, Runciman, WB, Gibberd, RW et al. The quality in Australian health care study. Med. J. Aust. 1998. Vol. 169: 458?471.
Coiera E. When Coversation Is Better Than Computation. JAMIA. 2000: Vol. 7(3) 277?286. [Abstract/Full Text]
Kubose TT, Cimino JJ, Patel VL. Assessment of information needs for informed, coordinated activities in the clinical environment. AMIA 2001 Fall Symposium (in press).
Krikelas, J. Information-seeking behavior: Patterns and concepts. Dexel Library Quarterly 1983; 19(2), 5?20.
Hripcsak G, Cimino JJ, Sengupta S. WebCIS: large scale deployment of a Web-based clinical information system. JAMIA. 1999; Vol. 6 (supl.):804?8.
Kitzinger J. "Qualitative Research: Introducing Focus Groups." BMJ. 1995; 299?302.
Kruger R. Focus Groups: a practical guide for applied research, 3rd Ed. London: Sage, 2000.
Stetson PD, McKnight LK, Bakken S, Curran C Kubose TT, Cimino JJ. Development of an Ontology to Model Medical Errors, Information Needs, and the Clinical Communication Space. AMIA 2001 Fall Symposium (in press).

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Assignment: Developing an Evaluation Plan

Details:

Using 500-1,000 words, discuss methods to evaluate the effectiveness of your proposed solution and variables to be assessed when evaluating project outcomes.

Example: If you are proposing a new staffing matrix that is intended to reduce nurse turnover, improve nursing staff satisfaction, and positively impact overall delivery of care, you may decide the following methods and variables are necessary to evaluate the effectiveness of your proposed solution:

Methods:

1. Survey of staff attitudes and contributors to job satisfaction and dissatisfaction before and after initiating change.

2. Obtain turnover rates before and after initiating change.

3. Compare patient discharge surveys before change and after initiation of change.

Variables:

1. Staff attitudes and perceptions.

2. Patient attitudes and perceptions.

3. Rate of nursing staff turnover.

Develop the tools necessary to educate project participants and to evaluate project outcomes (surveys, questionnaires, teaching materials, PowerPoint slides, etc.).

Refer to the "Module 4: Checklist." I will send it by attachment, sir.

Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. I will also send you the APA 5TH AND 6th edition by attachment please.

Sir,
The example given in the instruction is just an example, use whichever is applicable to my project work please.
Again, I will like hophead to see to this order since he has all my previous papers, orders and instructions. I will download additional order materials that will assist the writer to complete the order successfully. Below are the previours papers he has with him please:
1. PICO Question
2 Identifying a question
3 Selecting 15 articles and rapid appraisal
4 Detailed Appraisal of the 15 Articles
5 Review of the Literature of the 15 articles.
6 Incorporating Theory
7 Developing an Implementation plan
AND this present one.

Additional instructions:

The focus of this order (a) developing an evaluation plan to determine if your intervention (solution) to address the problem identified is working or not working. How will you do this?

Assignment A: Developing an Evaluation Plan.
Please read and closely adhere to the Check List and Course Syllabus instructions which provide specific instructions to assist in completing this assignment.
Please include any tools you will be using during the implementation and evaluation phases with this order.
Let me know if you have any question about the order please.
Thank you,
Lucy Amenyo.

***Please address the following points in the essay:***
1. Describe the reason for selecting the University of Alabama at Birmingham School of Nursing for graduate studies
in nursing.

Please include information in point (1) touching on the MSN program goals as well as information about the school,
found at http://www.uab.edu/nursing/home/about. Please also touch on being apart of the a school that will
further prepare me for leadership in health care. **Incorporate being apart of their ... **vision to sustain nursing
leadership worldwide.** The UAB School of Nursing is an outstanding choice for pursuing your education as the
next step in developing yourself as a nursing leader:***


M.S.N. Program Goals

The MSN program of study is designed to prepare nurses who: synthesize research, theoretical formulations, and
principles of scientific inquiry to provide evidence-based practice; assume leadership in managing and evaluating
continuous quality improvement processes; use information systems/technology to evaluate programs of care,
outcomes of care and care systems; advocate and implement health care policies that improve access, equity,
efficiency, and social justice in the delivery of health care; design innovative educational programs for patients,
nursing staff, and nursing students using teaching and learning principles; provide ethical, culturally sensitive care
in an advanced nursing role independently and collaboratively with professionals from multiple disciplines; monitor
the quality of one's own nursing practice based on professional practice standards and relevant statutes and
regulations; and apply theories and principles of marketing, economics, consultation, management, and leadership
to comprehensively perform an advanced nursing role.

2. Explain your plans for pursuing the MSN degree.

I believe in Utilitarianism and doing the Greatest Good for the Greatest Number. With the current state of Health
Care Reform, the Affordable Health Care Act, and the increasing shortage of physicians, there will be an increased
emphasis on Nurse Practitioners to provide care to a greater number of individuals. Pursing my education further
with an MSN and becoming a Nurse practitioner I will be enabled to demonstrate leadership while being positioned
to care for a larger number of sick that may other wise not have access to care with the increased demand.
(Please add references to shortage and how Nurses will play greater roll. etc) If space permitting, please elaborate
on positive patient experience/outcomes with ARNPs as health care providers etc.

3.Briefly summarize your background professional experience relevant to your specialty selection and rationale for the
specialty selected and future career goals. If you have selected a second specialty option on your application,
please address both your first and second specialty choices in order in your essay. An account of the patient
populations you have worked with and the roles you have performed assists in the understanding of your
experience. Additionally, using APA format, provide a clear and succinct explanation to illustrate the need for
masters prepared nurses in each specialty area selected. Please use evidenced based literature to support your
discussion, and we recommend that your essay covers all of the specialty tracks you selected on your application.

***Please incorporate my background listed below with the information related to each specialty found in the pdf below. Future career goals include practicing as a Family Nurse Practitioner in my community, locally and globally. I have gone on mission trips prior to becoming a nurse. While I plan on practicing locally, my ultimate career goal is to organize medical mission trip(s) and practice abroad.

Specialty Track selected:
1. NURSE PRACTITIONER FAMILY PRIMARY CARE
(http://www.uab.edu/nursing/home/images/stories/info_sa/MSN_Flyer_NP_Family.pdf)
2. NURSE PRACTITIONER ADULT-GERONTOLOGY PRIMARY CARE
(http://www.uab.edu/nursing/home/images/stories/info_sa/MSN_Flyer_NP_Adult_Primary_Care.pdf)


Background**
UF Health Jacksonville
Registered Nurse : Trauma/Surgery Progressive Care
Care for post-intensive medical/surgical patients in a progressive care environment.
Perform duties such as medication administration utilizing EPIC EMAR server; PICC line care; IV insertion; PEG tube feedings; TPN/Lipid Management; Chest tube care ; tracheostomy care; medication administration; PCA assessment/management; catheter insertion; wound vac care; pulmonary, cardiac, neurological, and GI assessment/management.

Brooks Rehabilitation Hospital,
Registered Nurse | Cardiac/Stroke Unit
? Care for post-surgical and medically complex Cardiac/Stroke patients in a rehabilitation environment
? Perform duties such as medication administration utilizing Meditech EMAR server; PICC line care; Heparin IV drip management; IV insertion; PEG tube feedings; tracheostomy care; catheter insertion; wound vac care; pulmonary, cardiac, neurological, and GI assessment/management
? Educate patients and family regarding home, medications, precautions, and new medical issues
? Work collaboratively with physicians, therapists, and social workers to determine patient plan of care

St. Vincents Medical Center, Jacksonville, Florida
Registered Nurse | Medical/Surgical GI Department
? Oversee care for pre/post-surgical and medically complex GI/Telemetry patients
? Perform duties such as PICC line care; IV insertion; PEG tube feedings; CBI Care; medication administration; PCA assessment/management; catheter insertion; pulmonary, cardiac, neurological, and GI assessment/management
? Educate patients and family regarding pre/post-operative teaching
? Perform accurate assessments of patients upon arrival to unit/prior to surgical procedures to maintain highest level of safety; discuss and plan with physicians the plan of care; create patient focused goals
? Work as a team member to create a safe and positive work environment

Using Chapters 7 & 8 of "Learning Theories for Teachers" by Bigge and Shermis to reply to the paper.

1. Select a topic or subject that one might teach a nursing student, nursing staff member, or patient (keep it simple - something like making a bed or doing a procedure). Relate how you would use Benner's three 'modes of representation' to teach this content. (One paragraph).

2. The text applies Bruner's theory to education of children; think of how it might be appled to adult education. Select one of the seven major aspects of Bruner's Theory of Instruction, (indicate which one was selected), and briefly discuss how to apply it to adult learning. (one paragraph)

3. Will be faxed