Patient rights include the right to informed consent, which entails that patients receive adequate information to make medical decisions. But many questions can arise if patients appear to lack the capacity to understand their medical condition or options. How is capacity determined? Who decides on behalf of the patient if the patient is determined to lack capacity? How should a surrogate decide on behalf of a patient?

In this Application Assignment, you will analyze the legal and ethical issues around patient capacity and surrogate decision making by focusing on the following scenario:

An 83-year-old diabetic male, Mr. Jones, is brought in to the emergency department because of respiratory distress, by his care-giving daughter, with whom he lives. In examining him, the emergency department physician discovers that Mr. Jones has gangrene on his right foot up to his ankle.

Mr. Jones' daughter reports that her father has been diagnosed with Alzheimer's disease. A preliminary capacity assessment is consistent with mild dementia, but one of the nurses suggests that Mr. Jones' confusion might be the result of his respiratory distress, coupled with the disorienting atmosphere of the emergency department.

The clinical recommendation is to perform a below-the-knee amputation. The patient refuses this surgery, saying he has lived long enough and wants to die with his body intact. His daughter disagrees and says she wants everything done so that she can take him home as soon as possible, and says that she will sue the hospital if they do not perform the amputation. A social worker comments that the daughter might be afraid of an elder-neglect investigation if her father dies.

Mr. Jones does not have an advance directive of any kind and is not under guardianship. Assume that the applicable law in your state is the same as Sections 5, 7, and 11, of the Uniform Health-Care Decisions Act, available at http://www.law.upenn.edu/bll/archives/ulc/fnact99/1990s/uhcda93.htm

To prepare for the Application:
Review Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?40.
Also review the section of the Merck Manual on surrogate decision making, http://www.merck.com/mmhe/sec01/ch009/ch009f.html. Refer to these readings as well as to the laws as described in Sections 5, 7, and 11 of the Uniform Health-Care Decisions Act in order to identify legal and ethical issues that apply to the scenario above.
Consider the role that capacity assessment must play in health care. Why is it important? What are the consequences of not adequately assessing a patient's capacity?
Read Chapter 4, "Health Care Ethics Committee," in Legal and Ethical Issues for Health Professionals (required reading in Week 6). In what ways would a health care consultation or committee be able to address the ethical challenges in this scenario? How do you think a bioethicist would deal with this case in terms of the procedures he or she would engage in?

This is the question to be answered...in terms of the legal and ethical issue please define them and relate it to the scenario to answer the question. For eg is Malpractice is a legal aspect define it in answering the question.



To complete this Application Assignment, write a 3- to 4-page paper in which you would address the following questions:
What are the relevant legal issues at stake? What are the legal rights of the patient and his daughter?
What are the relevant ethical issues at stake?
Why does capacity assessment matter?
How might the hospital's ethics committee or ethics consultation service help in addressing this? Include a description of how an ethics consultant or committee might become involved in this case.





Please use these resources along with what you have


Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?1840. Retrieved from http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=1375629681&sid=1&Fmt=4&clientId=70192&RQT=309&VName=PQD
Also available at http://www.nejm.org/doi/pdf/10.1056/NEJMcp074045 as a PDF document.

This article discusses legal and ethical issues that arise in the challenge of assessing a patient's capacity or competence to understand health care options and give consent.
Article: Coiera, E., & Clarke, R. (2004). e-Consent: The design and implementation of consumer consent mechanisms in an electronic environment. JAMIA: Journal of the American Medical Informatics Association, 11(2), 129?140. Retrieved from http://jamia.bmj.com.ezp.waldenulibrary.org/content/11/2/129.full.pdf


Caring Connections: What Are Advance Directives?
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3285

This website explains the meaning of advance directives and offers tips for personally developing an advance directive.
Caring Connections: Download Your State's Advance Directives
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289

This website provides access to advance directives in states across the U.S. Use this site for one of this week's Discussion options.
Merck Manual: Surrogate Decision Making
http://www.merckmanuals.com/home/sec01/ch009/ch009f.html



Hampton, T. (2008). Groups push physicians and patients to embrace electronic health records. JAMA: Journal of the American Medical Association, 299(5), 507?509. Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/299/5/507?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT



Please use APA.



This article discusses the unresolved issues, including privacy concerns, that have slowed the adoption of electronic health records by health care providers and organizations, as well as by patients.
Article: Rothstein, M. A., & Talbott, M. K. (2006). Compelled disclosure of health information: Protecting against the greatest potential threat to privacy. JAMA: Journal of the American Medical Association, 295(24), 2882?2885.
Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/295/24/2882?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT
This article examines the challenges that the electronic health record poses to patient health information privacy and confidentiality.

Your instructor will assign and send you a peer's paper on Health Care Provider and Faith Diversity. Your job is to critically read the assignment and make corrections/comments using track changes and comments in Microsoft Word. Be sure to assess the paper using the following criteria:

1. Does the paper provide sufficient evidence for its hypothesis or claim?

2. Does the flow of the paper and sentence structure make sense?

3. Should it be organized in a different manner?

4. Are all the items listed in the assignment guidelines and rubric covered and in sufficient depth?

This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.

Below is the full peer paper that have to be critic. Thanks.
Health Care Provider and Faith Diversity
Michelle Jennings
Grand Canyon University
HLT- 310V
July 28, 2013
















Abstract:
The diversity of people come with everything diverse, cultural awareness brings about the light of
the different norms values and practices of people. The Health care system is no exception. With
the influx of cultural diversity of patients, the call for acceptance of a diversity of Faith expression is in
order for the provision of adequate holistic care of patients. The knowledge and understanding of
the different faith approach to care and healing is of great assistance to the healthcare provider
when facilitating this most sacred process ?healing? at such vulnerable time of the patient life.

Introduction:
The writer will attempt to show own faith base perspective of the critical component of care and
healing, also that of the Christian perspective and compare same with these three selected faith
Buddhism, Sikh and Native American that are less familiar to the writer. A summary of the information
researched, on the different faith base having similar and different perspective when providing care for
to its people, ways application of learnt findings to nursing practice along with conclusion as per writers?
non-biased perspective.

The writer belongs to a sub-group of the Christian faith but is grounded by rooted Christianity. The
belief, trust in and relies on GOD the creator of all things for spiritual healing. Understanding the
culture of difference and that individual belief system is sacred to them, the writer?s own belief
system is never on display, but at times an internal comparison is done.
Spiritual perspective on healing: A strong believer in the power of GOD to heal. Praying provides an
intimate and personal channel of communicating with GOD and it?s at this time healing begins. The

acceptance of God healing on His own time, therefore there is no specific requirement to
facilitate praying this is done anywhere and anytime, noise or quiet, sickness and in health because
God will heal you when you least expect and is capable of using man as a vessel also to provide
healing. The most critical component of healing is believing.
The research findings suggest that prayer, a belief system used and the value of healing is a similarity
observed of the different faith, the difference is how praying is done, to whom they believe in and the
specific needs to facilitate healing.
The Christian perspective on healing:
Christianity in general is a believing faith. The belief that everything comes from GOD, everything
happens for a reason and sickness is no exception. Christian forms a spiritual connection to GOD
some sub-group through His son Jesus Christ, others through God himself the creator, provider
and healer. The connection is through prayer and cleansing of the mind, body and spirit fosters
ultimate healing. The use of sacred ointments, this vessel is use to foster healing of the sick. God
has provides for man to sustain himself through the proper use of nature. Medicine is just a vessel
for GODs will but not an aberration to Faith. The different branches of Christianity each have their own
perspective of care and healing and this has to be acknowledge when providing care.

The Sikh perspective of care and healing:
Modesty and cleansing critical aspect of healing for this faith, similar to Christian they pray
to GOD for tranquility and conciliation at the time of illness. Cleansing by washing gives strength
to spirit and body prior to praying for healing, this is not a requirement in all sub-group
of Christianity . The preparation for prayer, praying, singing, reading and singing the holy word
repetitively is very sacred , it is at this time healing occurs especially when sick. The provision of a
spacious, clean and private room to create the arena accommodating the healing process will

be greatly appreciated by the Sikh patient.

Buddhism perspective of care and healing:
Buddhist approach to health and healing is its emphasis on spiritual practices. Healing is done inwardly.
Buddhism asserts that spiritual practice makes it possible for an individual not only to see opportunity
for practice in the face of adversity including sickness and injury, but use the opportunity for personal
transformation and transcendence (Kusala 2013). The belief that the body is sacred and must be pure,
the avoidance of claudication or any factor that will alter awareness, clarity is obtained through
meditation a critical aspect for healing. Buddhism differ from Christian in that they don?t believe in God
for healing. Buddhism is a present moment of action in life, sickness and death, being solely responsible
for their wellbeing. They rely on clarity and affection through meditation, humming and constant rolling
of sacred beads to achieve a sense of stability that will foster healing. The need for peace and
quiet during crisis is very critical. Ensure an uninterrupted setting to facilitate this healing process.

The Native American perspective of care and healing:
Healing occurs when there is clarity in the three elements of life, the mind, body and spirit. Any
impairment of the three will affect the healing process. Native American have a strong belief in
meditation. Meditation provides cohesion of the three elements, while praying show appreciation
of nature and life. Spiritual elders are looked upon to foster healing. If this is a request form a patient
during the time of illness, the health care provider should allow the spiritual leader visitation to facilitate
healing and providing an environment that allows the three element cohesion as this is critical
aspect of the healing process.




As a health care provider of a different faith than the three above mentioned, the ability to identify
and take into consideration that there is a difference in faith other than self is very important.
At times patients belief system goes un-noticed and just the disease is being treated, not the patient
body, mind and spirit . It is also imperative that one does not impose own belief upon patients, and that
patients belief system being a critical element in the perception of healing be ignored. Be respectful
and non-judgmental, allow the patient to utilize their belief system, try to accommodate of facilitate
resources that will help patients in such a vulnerable time. Showing that we care in the eyes of the
patient an family you will be viewed highly respected, because in our eyes they too are the same.

Conclusion:
The writer has always respected others. Understanding and knowledge is empowering. Being culturally
aware of the diversity the reaction and response at times were misinterpreted and misunderstood.
Diversification of the different faith perspective must be taken into consideration, the comparison of
similarities and differences only brings light of the reason why we are in existence and why we should
and can co-exist. Health care workers must be weary of crossing the line of respect when addressing
faith diversification.
If lacking understanding of the people in general is a moral illness, then the writer has started the
healing process by properly applying knowledge gained from this findings to nursing practice.







References
Religious Diversity: Practical Points for Health Care Provider. Retrieved July 26, 2013 from
http://www.uphs.upenn.edu
Sikh Patient Protocol for Health Care Providers: Caring for the Sikh patient. Retrieved
July 26, 2013 from http://sikhwomen.com/health/care/protocol.htm
Kusala, Bhikshu. A Buddhist approach to patient health. Retrieved July 25, 2013 from
http://www.urbandharma.org/udharma8/health.html
A Christian perspective of healing : Prayer. Retrieved July 28, 2013 from
http://www.pursuingthetruth.org/sermons/files/healing-prayer.htm

Unsatisfactory
0.00%
2
Less than Satisfactory
65.00%
3
Satisfactory
75.00%
4
Good
85.00%
5
Excellent
100.00%
100.0 %Health Care Provider and Faith Diversity: Peer Review Rubric

40.0 %Comprehension of concepts of peer reviewing
Student peer reviewer reveals inaccurate comprehension of material and does not provide any content feedback to the student writer.
Student peer reviewer displays a lack of comprehension but attempts to provide some content feedback. The comments do not substantively add to the work.
Student peer reviewer exhibits comprehension of the material by presenting appropriate content revisions necessary to improve student performance.
Student peer reviewer exhibits thorough and thoughtful processing of material and provides additional information for consideration that demonstrates enhanced creativity and critical thinking skills.
Student peer reviewer demonstrates integrative comprehension and thoughtful application and deepens or expands the writer?s claim by presenting additional perspectives and content ideas.
30.0 %Coverage of subject matter.
Subject matter is absent, inappropriate, and/or irrelevant.
There is weak, marginal coverage of subject matter with large gaps in presentation.
All subject matter is covered in minimal quantity and quality.
Comprehensive coverage of subject matter is evident.
Coverage extends beyond what is needed to support subject matter.
7.0 %Thesis Development and Purpose
Paper lacks any discernible overall purpose or organizing thesis and/or main claim.
Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear.
Thesis and/or main claim are apparent and appropriate to purpose.
Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose.
Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis. Thesis and/or main claim makes the purpose of the paper clear.
8.0 %Argument Logic and Construction
Statement of purpose is not justified by the conclusion. The conclusion does not support the thesis and/or main claim made. Argument is incoherent and uses noncredible sources.
Sufficient justification of thesis and/or main claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.
Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of thesis and/or main claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.
Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of thesis and/or main claims from introduction to conclusion. Most sources are authoritative.
Clear and convincing argument presents a persuasive thesis and/or main claim in a distinctive and compelling manner. All sources are authoritative.
5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use)
Surface errors are pervasive enough that they impede communication of the meaning. Inappropriate word choice and/or sentence construction are used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register); sentence structure, and/or word choice are present.
Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.
Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.
Writer is clearly in command of standard, written, academic English.
5.0 %Paper Format (Use of appropriate style for the major and assignment)
Template is not used appropriately, or documentation format is rarely followed correctly.
Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.
Appropriate template is used. Formatting is correct, although some minor errors may be present.
Appropriate template is fully used. There are virtually no errors in formatting style.
All format elements are correct.
5.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style)
No reference page is included. No citations are used.
Reference page is present. Citations are inconsistently used.
Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present
Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct.
In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error.
100 %Total Weightage

Instructions
requesting JOwriter63 to do this paper

Patient rights include the right to informed consent, which entails that patients receive adequate information to make medical decisions. But many questions can arise if patients appear to lack the capacity to understand their medical condition or options. How is capacity determined? Who decides on behalf of the patient if the patient is determined to lack capacity? How should a surrogate decide on behalf of a patient?

In this Application Assignment, you will analyze the legal and ethical issues around patient capacity and surrogate decision making by focusing on the following scenario:

An 83-year-old diabetic male, Mr. Jones, is brought in to the emergency department because of respiratory distress, by his care-giving daughter, with whom he lives. In examining him, the emergency department physician discovers that Mr. Jones has gangrene on his right foot up to his ankle.

Mr. Jones' daughter reports that her father has been diagnosed with Alzheimer's disease. A preliminary capacity assessment is consistent with mild dementia, but one of the nurses suggests that Mr. Jones' confusion might be the result of his respiratory distress, coupled with the disorienting atmosphere of the emergency department.

The clinical recommendation is to perform a below-the-knee amputation. The patient refuses this surgery, saying he has lived long enough and wants to die with his body intact. His daughter disagrees and says she wants everything done so that she can take him home as soon as possible, and says that she will sue the hospital if they do not perform the amputation. A social worker comments that the daughter might be afraid of an elder-neglect investigation if her father dies.

Mr. Jones does not have an advance directive of any kind and is not under guardianship. Assume that the applicable law in your state is the same as Sections 5, 7, and 11, of the Uniform Health-Care Decisions Act, available at http://www.law.upenn.edu/bll/archives/ulc/fnact99/1990s/uhcda93.htm

To prepare for the Application:


Review Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?40.
Also review the section of the Merck Manual on surrogate decision making, http://www.merck.com/mmhe/sec01/ch009/ch009f.html. Refer to these readings as well as to the laws as described in Sections 5, 7, and 11 of the Uniform Health-Care Decisions Act in order to identify legal and ethical issues that apply to the scenario above.
Consider the role that capacity assessment must play in health care. Why is it important? What are the consequences of not adequately assessing a patient's capacity?
Read Chapter 4, "Health Care Ethics Committee," in Legal and Ethical Issues for Health Professionals (required reading in Week 6). In what ways would a health care consultation or committee be able to address the ethical challenges in this scenario? How do you think a bioethicist would deal with this case in terms of the procedures he or she would engage in?

This is the question to be answered...in terms of the legal and ethical issue please define them and relate it to the scenario to answer the question. For eg is Malpractice is a legal aspect define it in answering the question.



To complete this Application Assignment, write a 3- to 4-page paper in which you would address the following questions:
What are the relevant legal issues at stake? What are the legal rights of the patient and his daughter?
What are the relevant ethical issues at stake?
Why does capacity assessment matter?
How might the hospital's ethics committee or ethics consultation service help in addressing this? Include a description of how an ethics consultant or committee might become involved in this case.





Please use these resources along with what you have


Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834?1840. Retrieved from http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did=1375629681&sid=1&Fmt=4&clientId=70192&RQT=309&VName=PQD
Also available at http://www.nejm.org/doi/pdf/10.1056/NEJMcp074045 as a PDF document.

This article discusses legal and ethical issues that arise in the challenge of assessing a patient's capacity or competence to understand health care options and give consent.
Article: Coiera, E., & Clarke, R. (2004). e-Consent: The design and implementation of consumer consent mechanisms in an electronic environment. JAMIA: Journal of the American Medical Informatics Association, 11(2), 129?140. Retrieved from http://jamia.bmj.com.ezp.waldenulibrary.org/content/11/2/129.full.pdf


Caring Connections: What Are Advance Directives?
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3285

This website explains the meaning of advance directives and offers tips for personally developing an advance directive.
Caring Connections: Download Your State's Advance Directives
http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289

This website provides access to advance directives in states across the U.S. Use this site for one of this week's Discussion options.
Merck Manual: Surrogate Decision Making
http://www.merckmanuals.com/home/sec01/ch009/ch009f.html



Hampton, T. (2008). Groups push physicians and patients to embrace electronic health records. JAMA: Journal of the American Medical Association, 299(5), 507?509. Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/299/5/507?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT



Please use APA format for referencing.



This article discusses the unresolved issues, including privacy concerns, that have slowed the adoption of electronic health records by health care providers and organizations, as well as by patients.
Article: Rothstein, M. A., & Talbott, M. K. (2006). Compelled disclosure of health information: Protecting against the greatest potential threat to privacy. JAMA: Journal of the American Medical Association, 295(24), 2882?2885.
Retrieved from http://jama.ama-assn.org.ezp.waldenulibrary.org/cgi/content/full/295/24/2882?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=hipaa+health+information+patient+2009&searchid=1&FIRSTINDEX=10&resourcetype=HWCIT
This article examines the challenges that the electronic health record poses to patient health information privacy and confidentiality.

What explains the directionality of flows in health care? Patients, health workers, managerial practices? What are the five segments of patients who are willing to travel across borders to obtain health care? Are there other patient segments beside these five? Why is there growing rivalry for inbound international patients? Under what conditions should a hospital invest in plant and equipment to attract international patients? What explains the global price differential among hospitals? Why would countries like the U.S. have 10x the charges for procedures like hip replacements?

What explains the directionality of flows in health care? Patients, health workers, managerial practices? What are the five segments of patients who are willing to travel across borders to obtain health care? Are there other patient segments beside these five? Why is there growing rivalry for inbound international patients? Under what conditions should a hospital invest in plant and equipment to attract international patients? What explains the global price differential among hospitals? Why would countries like the U.S. have 10x the charges for procedures like hip replacements?

APA style is required and you should have a minimum of 7 references

When electronic health records (EHRs) first entered the market, their primary focus was to collect and analyze patient information within health care settings. As technological capabilities grew, so did the interest in making these records available to patients. In addition, many health care professionals saw benefits in allowing the patient to enter his or her own health data into EHR platforms. Though many patients are already utilizing personal health records (PHRs) to manage and track their own health, some believe that an integrated system would provide a better, more comprehensive picture of a patient?s health history.
As a result, many EHR platforms are now equipped with a PHR tool. This PHR tool allows patients to enter health information as they would in a stand-alone PHR system. In addition, web-based portals within the EHR allow patients to access information entered by their physicians and health care providers.
Like many emerging trends and technologies, there is much discussion about the potential benefits and challenges of this type of integrated system. While many health care professionals are excited about the empowerment provided to patients, others express significant concerns about access, security, ethics, and other implications.
In this Discussion, you explore how integrating PHRs into EHR platforms could impact you and your patients.

PURPOSE
The purpose of this assignment is to investigate safeguards and apply ethical principles to the use health care technology.
COURSE OUTCOMES
This assignment enables the student to meet the following course outcomes:
CO #2: Investigate safeguards and decision-making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers. (PO #4)
CO #6: Discuss the principles of data integrity, professional ethics, and legal requirements related to data security, regulatory requirements, confidentiality, and client?s right to privacy. (PO #6)


SCENARIO
The government has created a committee to investigate the potential of implanting an electronic health record (EHR) into every U.S. citizen. This procedure would involve inserting a chip or radio frequency identification device RFID) into the individual that would contain all medical information. Access to this complete and accurate health information would help to reduce issues pertaining to patient safety and identification.
This is how the chip would work. When the patient arrives at a point-of-care, the chip would be scanned. All of the patient?s health information would be uploaded into the provider?s health information system (HIS). During the encounter, new information would be stored in the HIS. When the patient is discharged, the patient?s up-to-date health information would be uploaded from the HIS onto the patient?s implanted chip.
You have been invited to a round table discussion of the pros and cons of implanting a chip into a patient to store an EHR. You conduct an analysis of this technology by exploring the HealthCare IT News site at http://www.healthcareitnews.com/ and investigate other sources on the internet and in the current literature. You discover there are companies currently producing chips. Read their marketing information for additional insight.
DIRECTIONS
1. You are to research, compose and type a scholarly paper based on the scenario described above.
2. Use Microsoft Word and APA formatting.
3. The length of the paper should be 2-3 pages, excluding the title page and the reference page. Limit the references to 3-4 key sources.
4. The paper is to contain an Introduction that catches the attention of the reader with interesting facts and supporting sources of evidence, which should be included as in-text citations). The Body of Analysis should present the pros and cons regarding implanting the chip. The Conclusion and Recommendations should summarize your findings and state your position regarding whether the chip should be implanted. Make your case based on the evidence you have collected.
PLEASE include references AND Title page.
Thanks.

The government has created a committee to investigate the potential of implanting an electronic health record (EHR) into every U.S. citizen. This procedure would involve inserting a chip or radio frequency identification device RFID) into the individual that would contain all medical information. Access to this complete and accurate health information would help to reduce issues pertaining to patient safety and identification.
This is how the chip would work. When the patient arrives at a point-of-care, the chip would be scanned. All of the patient?s health information would be uploaded into the provider?s health information system (HIS). During the encounter, new information would be stored in the HIS. When the patient is discharged, the patient?s up-to-date health information would be uploaded from the HIS onto the patient?s implanted chip.
You have been invited to a round table discussion of the pros and cons of implanting a chip into a patient to store an EHR. You conduct an analysis of this technology by exploring the HealthCare IT News site at http://www.healthcareitnews.com/ and investigate other sources on the internet and in the current literature. You discover there are companies currently producing chips. Read their marketing information for additional insight.

1.You are to research, compose and type a scholarly paper based on the scenario described above.

Nursing Research Utilization Project Proposal
The Department of Health and Human Services?the Center for Medicare and Medicaid
Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) partnered together in developing a comprehensive survey for ?Hospital Consumer Assessment of Healthcare Providers? known as ?HCAHPS?. The purpose of this survey is to collect patients? reports and perspectives that they developed while being in the hospital. The public is encouraged to express their feelings and concerns about hospitals and to rate their hospital experience. National healthcare quality surveys have found that noise in hospitals is an urgent concern. Noise level is among the physical environment factors that influence the ?healing environment? of any health care (Reiling, Huges, & Murphy, April 2008).

Problem statement:
The Coronary Care Unit of North Shore University Hospital, Manhasset, New York a 12-bed unit has seen a 20% increased in hospital complains about the noise level over the last three quarters of the year. Make sure you know the baseline (so you will be able to measure a difference)

Solution statement:
The Coronary Care Unit of North Shore University Hospital will implement a noise reduction protocol that will include the following evidence based (EB) elements:
A. manage noise level ??
B. reducing staff conversations
C. exterior noises ? be specific
D. overall hospital sound ? what does this mean? (Xie, Kang, and Mills, 2009).

You must propose an EB solution and I can?t see that this is without references (I see they are below ? but you need them here too?
Project objective
It is the management?s job to address the fact that noise became an issue on the patient?s survey. The goals in the Critical Coronary Care of North Shore Hospital are patient?s satisfaction and obtaining financial retribution for the services rendered. Getting a clear understanding of an organization?s business or performance goals is the practitioner?s first step in setting measurable objectives for a communications program. All we need here is your goal
The Critical Coronary Care of North Shore Hospital launched this project of reducing the noise level in the unit, which will be measured by no complains marked on patients? surveys, by July 1, 2013. Go back to your problem ? make sure this objective measures for an improvement. Was your problem based on the survey (it was unclear)

Solution Description:
A. staff education and new employee orientation will mandate staff awareness of managing noise, including use of personal phones, monitor noise levels, and IV pumps, as sound control needs to be regarded with accountability in maintaining an appropriate sound environment (Mazer, 2006).
B. reducing staff conversation and overhead voice paging by introducing the electronic documentation and collaboration via emails, electronic messaging, and electronic orders will improve the quality of noise levels in the unit (Solet, Buxton, Ellenbogen, Wang, & Carballiera, 2010).
C. exterior noises, coming from outside the hospital building (road traffic) will be counteracted by the installation of double window glass is this feasible?, which is soundproof and insulates around the window frames. The exterior noises were found to be the least arousing stimuli, as opposed to other stimuli (towel dispenser, door close, toilet flush, ice machine) that tended to be more arousing (Solet, Buxton, Ellenbogen, Wang, & Carballiera, 2010). These ?sources? of noise are addressed, and being aware of them gives the staff the power of control.
D. installation of the sound waves blocking generators near the nursing station, and in the patients? rooms. Sound masking appears to be the most effective technique for improving sleep, decrease the noise level and promote healing((Xie, Kang, and Mills, 2009). There for, creating small pilots of stations at both ends of the corridors will decongest the main nursing station. Doctors? station is created on a side so they can seat quietly, and be able to concentrate on the patients? charts.

Proposed solution is consistent with current research knowledge
?Unnecessary noise is the most cruel abuse of care which can be inflicted on either the sick or the well,? Florence Nightingale wrote in her 1859 book, Notes on Nursing (Miller, 2006). Sleep disturbance is a factor in the development of delirium, as well as producing specific effects the respiratory, cardiovascular and immunological systems. Critical care patients are especially prone to delirium, better known as ?sundown syndrome? as their normal circadian pattern of adrenocorticotropic hormone and melatonin levels is changed markedly by sepsis, and the change in white blood count due to heart attacks (Xie, Kang, and Mills, 2009). The impact of noise on patients' sleep and the effectiveness of noise reduction strategies is part of the safety program implemented by hospitals to decrease the effects of sundown syndrome. Higher blood pressure leads to a higher risk of cardiac problems as Berlin hospitals found that chronic noise in hospital environment, where people are already ill and psychologically stressed, unnecessary noise can be very harmful leading to heart attacks (Miller, 2006).
The ?sources? of noise are of interior and exterior causes. The phones, the beepers, the cardiac monitors, and IV pumps were found to alter the noise level in critical care units. Other stimuli, such as towel dispenser, closing doors, toilet flush, and ice machine tended to be even more arousing (Solet, Buxton, Ellenbogen, Wang, & Carballiera, 2010). The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in ICUs have shown that staff conversation and alarms are generally the most disturbing noises for patients' sleep in ICUs. Literature explains that working with the staff on reducing the level of noise generated by these sources will become part of the personnel training (Mazer, 2006).
The built of the hospital itself, with hard long lasting materials will contribute in addition to the human and machinery sound emanating in a working environment to monitor and promote patient health. The reason that hospital interiors and furnishings are made of reflective materials is to avoid pathogens to adhere to surfaces. They are easily cleaned and cannot harbor infections. Housekeeping caddies, X ray machines, electrocardiograms and echo machines rolling on a hard surface are causing sounds enhancement, overlapping and lingering longer than normal. Adding to them are the pneumatic tube system, automatic doors, and the rolling ventilators and IABP (Miller, 2006). Controlling noise involves actually adding sound to the environment with a series of speakers installed in the ceiling that distributes electronically a background sound, unperceived by humans that serve to cover or reduce the impact of noise spikes. It is a specially engineered sound creating an ambient environment that is quieter and that enhances speech privacy in healthcare facilities (Xie, Kang, and Mills, 2009). Dispersing the main nursing station by adding small cells of nursing station at the ends of the corridor is beneficial in dispersing the activity horizontally on the floor.


References
Anderson, F. W., & Hardley, L. (2009). Guidelines for Setting Measurable Public Relations Objective. Retrieved from http://www.instituteforpr.org/wp-content/uploads/Settings_PR_Objectives.pdf
Miller, H. (2006). Sound Practices Research Summary. Retrieved from
http://www.hermanmiller.com/content/dam/hermanmiller/documents/research
Mazer, S. (March-April, 2006). Stop the Noise: Reduce Errors by Creating A Quieter Hospital, Environment. Biomedical Instrumentation & Technology, 40(2): 145-6 doi# or journal url
Reiling, J., Huges, R. G., & Murphy, M. R. (2008, April). The Impact of Facility Design on Patient Safety. An Evidence-Based Handbook for Nurses, 28(4), 1.
Solet, J.M., Buxton, M.O., Ellenbogen, M.J., Wang, W., Carballiera, A., (2010), Acoustic
Guidelines For Healthcare Facilities. Retrieved from http://www.healthdesign.org
Xie, H., Kang, J., Mills, G.H., (2009), Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units, Critical Care; 13(2): 208, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles






I started to write this paper myself, but the teacher corrected it and I am confused what to keep and what not. It continues in more sections down, as per instructions. Please build on my idea about the level of noise in a nursing station, and how this will afect the patients' staying.



Individual

Nursing Research Utilization Project Proposal:

Complete Section A: Problem Identification.

? Use the problem (with corrections from feedback) identified in week 1 to begin your proposal.
? Describe the problem or issue.
? Provide support that the problem or issue is an important one to solve (significance of the problem).
? State a project objective that is specific, realistic, and measureable.

Complete Section B: Solution Description.

? Describe the proposed solution (with corrections from week 1 feedback).
? Describe the way(s) in which the proposed solution is consistent with current research knowledge.
? Discuss the feasibility of implementing the proposed solution in the work setting.
? Discuss the way(s) in which the proposed solution is consistent with organization or community culture and resources.

Format your paper consistent with APA 6.0 guidelines.

Submit the assignment in the assignment section.


Complete Section C: Research Support.

? Develop a research base for the proposed solution that is sufficient to support its use.

o Provide a sufficient and compelling research base for the proposed solution (3-5 articles).
o Summarize all research reports used in a concise manner and provide acceptable internal and external validity.
o Describe the essential components of each study so readers can evaluate its scientific merit.



Individual
Nursing Research Utilization Project Proposal: Section D Draft Proposal and Assignment Grading Criteria: Nursing Research Utilization Project Proposal

Complete Section D: Implementation Plan.

Describe the methods to be used to implement the proposed solution.

? Describe the overall plan for implementing the proposed solution.
? Identify resources needed for the proposed solution?s implementation.
? Describe the methods for monitoring solution implementation.
? Describe the way(s) in which a theory of planned change was used to develop the implementation plan.
? Discuss the feasibility of the implementation plan.


Individual
Nursing Research Utilization Project Proposal: Sections E & F Drafts
Proposal and Assignment Grading Criteria: Nursing Research Utilization Project Proposal

Complete Section E: Evaluation Plan.

Describe the methods to be used to evaluate the solution.

Outcome Measure:

? Develop or revise an outcome measure that evaluates the extent to which the project objective is achieved. A copy of the measure must be included in the appendix.

? Describe the ways in which the outcome measure is valid, reliable, sensitive to change, and appropriate for use in this proposed project.

Evaluation Data Collection:

? Describe the methods for collecting outcome measure data and the rationale for using those methods.
? Identify resources needed for evaluation.
? Discuss the feasibility of the evaluation plan.
? Identify two possible grant funding sources and why your proposal would be a good fit for these sources.

Complete Section F: Decision Making.

Describe the methods to be used to decide the future of the solution.

? Discuss methods and specific plans to maintain a successful project solution.
? Discuss methods and specific plans to extend a successful project solution.
? Discuss methods and specific plans to revise an unsuccessful project solution.
? Discuss methods and specific plans to terminate an unsuccessful solution.
? Describe specific plans for feedback in the work setting and for communicating the project and its results to professional groups external to the project.




Individual
Nursing Research Utilization Project Proposal Proposal and Assignment Grading Criteria: Nursing Research Utilization Project Proposal. This is the entire paper (all sections) put together with all corrections made.
Put all sections of your proposal/paper together; add an abstract, introduction and conclusion. It should not to exceed 5,000 words.
Note. The cover sheet, abstract, references page, and appendices are not included in the word limit.

Include the following content which should incorporate all faculty, class and learning team feedback:

? Abstract, between 250 and 400 words
? Introduction
? Section A: Problem Identification ? Identify a work-setting problem.
? Section B: Solution Description ? Develop a description of the proposed solution.
? Section C: Research Support ? Develop a research base for the proposed solution that is sufficient to support its use.
? Section D: Implementation Plan ? Describe the methods to be used to implement the proposed solution.
? Section E: Evaluation Plan ? Describe the methods to evaluate the solution.
? Section F: Decision Making ? Describe the methods to be used to decide the future of the solution.
? Conclusion

Incorporate all faculty, class, and Learning Team feedback.

Format the paper consistent with APA 6.0 guidelines.

Submit the Research Utilization Project Proposal Paper via the assignment section.

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.

Attached is an essay I submitted to my instructor for grading as part of a two part project. Part one was for the instructor to critically review the paper and comment on it which she did and Part two involves reading the comments them rewrite the same paper addressing the criticism and comments the instructor raised to a final paper which will be part two of the project. What I want you to do is to review those comments and rewrite the paper as the instructor wants please add an abstract to the paper. Thanks. Below is all the information you need to write part two of the essay.

Your instructor will send you your peer-reviewed assignment from Module 4.

Use the comments from the peer review to revise your document to a final draft. Not all comments need to be followed. Use your best judgment in revising your first draft to an assignment that better meets the requirements of the original assignment, found in Module 3.

This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment.



HEALTH CARE PROVIDER AND FAITH DIVERSITY
Michael Saracouli
Grand Canyon University
SPIRITUALITY IN HEALTH CARE
HLT-310V-0104
EMORY DAVIS
July 23, 2013
Mr. Saracouli, your paper addresses the 3 diverse faiths and identifies some of their components of care and healing. These could be developed more. This will give greater opportunity to discuss more specific comparisons and contrasts of these components with those of Christianity, which is a significantly key element of this assignment (as highlighted in the Mod 2 Assignment Assist and Assignment Clarification). The paper (final draft) can be benefitted by weaving in specific comparisons and contrasts within each faith section... as you go along. Consider organizing 3 faiths in separate paragraphs (see Buddhism below). [Review the Faith Diversity Recommended Content Format attached to Mod 2 Announcement.]

Module 2 Faith Diversity Assignment requirements, per syllabus and assignment assist:
* Research three diverse faiths. Yes.
* Compare the philosophy of providing care from the perspective of each of these three faiths with that of the Christian perspective and your own personal perspective. Needs further development.
* summarize your findings and compare and contrast the different belief systems (with respect to the healing process), reinforcing major themes with insights gained from your research. Needs further development.
* In your paper, Do Research and Address questions 1-2 listed in your assignment: Yes.
(1) What is their spiritual perspective on healing?
(2) What are the critical components of healing, such as prayer, meditation, belief, family, diet, death, afterlife, modesty, same sex caregivers, hygiene, etc?

* In your conclusion, describe what you have learned from your research and how this learning can be applied to a health care provider practice. Yes.
* An abstract. No. Abstract should address briefly: purpose/thesis statement, methodology, observations, and outcomes/results. Review APA guidelines (see Student Success Center>Writing Center; or, google Purdue Owl). Separate page, after title page.
* 1250-1500 words. Yes.
HEALTH CARE PROVIDER AND FAITH DIVERSITY
Healthcare, Faith and Healing
Often times, healing and faith go directly hand in hand with one another. Every religious tradition has its own set of beliefs on treatment, healing and the general administration of medicine. While we take our understanding of healthcare and faith from the well-defined intersection of medicine and Christianity, there are broad variations in belief and practice that enter into the medical traditions and values of every religious denomination. The discussion here, which addresses elements of spirituality in healthcare treatment for adherents to the Sikh, Shinto and Buddhist faiths, proceeds from a Christian healthcare perspective.
To initiate the discussion, it is appropriate to first consider some of the Christian care-giving values that drive this perspective. Christian ethicality and theology are important forces in healing, especially through its invocation of spiritual hope. Hope is a sentiment, which has commanded recognition as bearing a place of importance in human affairs throughout recorded history. This creates a documented association between hope and such important institutions as politics, philosophy and religion. To this end, the Bible makes numerous references to the concept and importance of hope. An oft-quoted passage provides that there are ?three things that last forever-faith, hope, and love.? (1 Corinthians 13:13, New Living Translation). The point to the close association between hope and these other crucial dynamics of human sentiment. Somewhat less immediately straightforward is another verse describing hope, which conjectures, ?but hope that is seen is no hope at all. Who hopes for what he already has? But if we hope for what we do not yet have, we wait for it patiently? (Romans 8: 24-25, New International Version). In the context of healing, bringing this kind of hope to patients is a distinctly Christian principle that connects the spiritual, emotional and practical dimensions of healing into a distinctly humanistic healing strategy.
This mode of spirituality is shared by other faiths but there are some variations that are highly driven by mode of belief. Indeed, hope is a doctrine that is used to by Christian adherents to encourage fortitude in fighting illness. But it may also sometimes serve the purpose of helping one accept and prepare for mortality. This is an orientation, which is shared by the Sikh religion. Here, the concept of karma influences the manner in which adherents face their own mortality. According to QLD (2011), ?Sikhs are encouraged to accept death and illness as part of life and the will of God. Due to the Sikh belief in the doctrine of karma, some Sikh patients may be accepting of death.? (p. 16)
While these spiritual ideals of Sikhs and Christians are not altogether different in their medical implementation, the concept of karma does distinguish the belief system of patients subscribing to the former faith as opposed to the latter. It is also on the issue of death that such religious traditions as Shintoism drawn their greatest distinction. Looking to the issue of medically fatality, the source by Tanabe (1998) suggests that the Shinto faith has a decidedly less accepting view on the ?impurity? affiliated with death. Accordingly, healthcare providers to those of the Shinto faith have historically faced a great dilemma that surely owes itself to the ancient history reflected in Shinto?s ideals. According to Tanabe, ?It is a common saying that Japanese are born Shinto but die Buddhist. In Shintoism, the emphasis is on purity and cleanliness. Terminal illnesses, dying and death are considered ?negative? or impure and akin to ?contamination.? Thus, open frank discussions that occur with informed consent procedures, choices in treatment, and advance directives may be difficult at first.? (p. 3)
This source ultimately demonstrates that the Shinto faith presents some highly restrictive conditions especially in the area of treating those who are terminally ill. Removing ourselves from the discussion on hope, the sheer practical challenges posed by this philosophical understanding of death makes it difficult to establish a clear path for end-of-life treatment tactics. Ultimately, as the Tanabe source implies here above, the resolution for a great many Shinto adherents is to move gradually toward the more philosophically amenable ideals of Buddhism.
Buddhism, like Shintoism, derives its practices and principles from early Confucianism. Contrary to the Shinto faith though, Buddhism perceives death as simply another life stage. In this regard, Buddhism shares a pointed crossover of beliefs with the Sikh faith. The notion of karmic reincarnation and the continuity of life substantially impact the treatment of mortality in Buddhist healthcare. This is one way in which Buddhism differs from Christianity in terms of healthcare provision. However, there are also dimensions of everyday religious practice that contribute to their differences as well. Indeed, a stark distinction may be drawn between the Christian healthcare approach and the approach taken by Buddhist ideologies regarding health and healing. While Christianity does employ elements of prayer and worship in its healthcare orientation, Buddhism is far more philosophically speculative and instead calls for certain lifestyle decisions reflecting a purity of mind, body and spirit. Therefore, healing reflects the practical implications of the spiritual tradition. This is driven by the experiences attributed to the Buddha himself. According to Bhikshu (2006), ?when the Buddha was young, he learned the science of medicine. He became knowledgeable about the nature and cure of diseases. The Buddha?s realization of the perpetual cycle of rebirth and the stages of aging, illness, and death, enabled him to guide others to live a healthy life. His pragmatic approach includes the insistence on proper hygiene and medicine, but more to the point, he never resorted to what might be considered ?faith healing.? Instead, he offered rational, practical instruction for dealing with both physical injury and mental illness.? (Bhikshu, 1)
This suggests that in one sense, the Christian model of treatment is not universal. Though it calls for universal application of compassion and humanitarian values, its focus on faith through theology may not be appropriate for all patients. This is an important distinction to make especially when a divergence between caregiver and patient spirituality may exist. Regardless of religious orientation, the promise in bringing hope and humaneness to the patient should be seen as appealing. It is important to pursue this orientation without imposing theological ideals on a patient. The Buddhist philosophy helps to highlight the value of this strategy.
There are yet additional distinctions in every religious tradition that may be derived as much from cultural context as from scriptures or faith practices. For instance, Shinto is a faith that is almost entirely comprised of individuals of Japanese descent. This means that religious beliefs aren?t the only cultural factors shaping healthcare needs and demands. An ethnic culture and a set of related practices and proclivities must also play a part in the lifestyle, habits and medical requirements for those of Shinto faith. For instance, the source by Tanabe indicates that dietary predilections for those of Japanese descent may have very specific medical implications. According to the source, ?for those Japanese Americans with hypertension or at risk for hypertension, it may be worth noting that educational counseling on a low salt diet may need to be elaborated upon as the traditional diet is high in salt. Some of the high salt dietary items may not be understood as being very salty, such as soy sauce (shoyu), preserved meat and fish, and pickled vegetables. In discussing dietary issues, such as calcium intake for prevention of osteoporosis, it should be noted that the prevalence of lactose intolerance is high.? (p. 5)
This underscores a point, which is important to the broader discussion, even beyond the specific characteristics of Shintoism. Here, we can see that there may be a high correlation between religious faith and lifestyle habits. This is an observation that may be less applicable to Christianity, a faith that largely permeates many ethnic and national borders. But in cases where religion and ethnic culture are inextricable, medical needs may be as much influenced by cultural context as by theology, practice of worship or measure of faith. It should be incumbent upon nurses, physicians and other care providers to understand the ways that faith, culture and ethnicity interact to produce certain health beliefs, behaviors and knowledge. From any perspective, religious or otherwise, it is the duty of healthcare providers to ensure respect and sensitivity for cultural or religious values while still taking all practical steps to ease suffering, reduce symptoms and promote positive health outcomes.
As the discussion here above shows, while we all share a set of common ideals about the importance of healthcare in preserving human health, we come from a wide array of ideological backgrounds. As a result, we fall across a broad spectrum of beliefs on how medical care should be administered.









References

Bhikshu, K. (2006). A Buddhist Approach to Patient Health Care. Ubran Darma.org.

Queensland Government (QLD). (2011). Health Care Providers? Handbook on Sikh Patients. Health.qld.gov.au.

Tanabe, M.K.G. (1998). Health and Health Care of Japanese-American Elders. Stanford.edu.

RUBIC

1
Unsatisfactory
0.00%
2
Less than Satisfactory
65.00%
3
Satisfactory
75.00%
4
Good
85.00%
5
Excellent
100.00%
100.0 %Health Care Provider and Faith Diversity: Final Draft

40.0 %Comprehension of concepts of diversity of faith
Reveals inaccurate comprehension of material and lacks the ability to apply information.
Displays a lack of comprehension but attempts to apply information. Presentation of material does not meet minimal requirements of the assignment. Demonstrates no critical thinking aspects.
Exhibits comprehension of the material and attempts to integrate it with outside material. Information represents basic thought and formulation surrounding understanding of varying components of faith across diverse religions and how health care providers handle those diversities.
Demonstrates integrative comprehension. Student exhibits thorough and thoughtful processing of material. Evidentiary support is creatively interwoven and presented in a manner that demonstrates the diversities of faith, the role they play in patient beliefs and practices, and their importance in managing patients? spiritual care.
Demonstrates integrative comprehension and thoughtful application of concepts surrounding spiritual diversity and circumstances involving application in real-world situations. Presentation of material and components includes expanded and unique perspective relative to similarities and differences of practices across various religions.
30.0 %Coverage of subject matter.
Subject matter is absent, inappropriate, and/or irrelevant.
There is weak, marginal coverage of subject matter with large gaps in presentation.
All subject matter is covered in minimal quantity and quality.
Comprehensive coverage of subject matter is evident.
Coverage extends beyond what is needed to support subject matter.
7.0 %Thesis Development and Purpose
Paper lacks any discernible overall purpose or organizing thesis and/or main claim.
Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear.
Thesis and/or main claim are apparent and appropriate to purpose.
Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose.
Thesis and/or main claim are comprehensive. The essence of the paper is contained within the thesis and/or main claim. Thesis and/or main statement makes the purpose of the paper clear.
8.0 %Argument Logic and Construction
Statement of purpose is not justified by the conclusion. The conclusion does not support the thesis and/or main claim made. Argument is incoherent and uses noncredible sources.
Sufficient justification of thesis and/or main claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.
Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of thesis and/or main claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.
Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of thesis and/or main claims from introduction to conclusion. Most sources are authoritative.
Clear and convincing argument presents a persuasive thesis and/or main claim in a distinctive and compelling manner. All sources are authoritative.
5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use)
Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register); sentence structure, and/or word choice are present.
Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.
Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.
Writer is clearly in command of standard, written, academic English.
5.0 %Paper Format (Use of appropriate style for the major and assignment)
Template is not used appropriately, or documentation format is rarely followed correctly.
Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting. is apparent.
Appropriate template is used. Formatting is correct, although some minor errors may be present.
Appropriate template is fully used. There are virtually no errors in formatting style.
All format elements are correct.
5.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style)
No reference page is included. No citations are used.
Reference page is present. Citations are inconsistently used.
Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present
Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct.
In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error.
100 %Total Weightage

Paper with instructors comment were uploaded. Thanks.

Assignment:
Please respond to the following questions:
1. Who is do you think the main target market of this organization is?
2. Do you think Catholic Healthcare West can design more services without losing its original mission and customers? If so, how would suggest they do it?

Use information below to complete assignment.
Assume that you are a consultant for a major health care provider-Catholic Healthcare West, and in that capacity you have been asked to prepare for a meeting with the key marketing person of that organization.
Please audit the service management strategy of Catholic Healthcare West. This is the home page of Catholic Healthcare West: http://www.chwhealth.com/
Using the information you were able to find on the web about the organization and your reading assignments.



Please respond in no more than 2 pages. Times Roman/12 font. Have introduction and conclusion.


Additional Reading Assignments:
The movement away from acute care and toward prevention and wellness is leading hospitals and health systems to where they are making wellness a fundamental part of their strategic platforms. The conventional wisdom is that the current sickness model of health care can''t sustain itself, according to Bob Cook, vice president for research, planning and development for Catholic Health Initiatives Southeast Region.
"It''s just become the beast that''s insatiable," he said. "But we''re making valiant attempts at changing the way this works."
CHI Southeast Region is the former Sisters of Charity of Nazareth Health System, a seven-hospital system based in Nazareth, Ky., with affiliates located in Kentucky, Tennessee and Arkansas. CHI Southeast Region has just completed a study to determine how to implement a system-wide prevention and wellness initiative.
"Visions of the future certainly contain a different desired state-that moving upstream to keep people well and prevent illness is the preferred way to approach our nation''s health," Cook said. "Simply stated, you can only sit on the river bank and pull people out of the water for a short time before you start to question whether or not you couldn''t go upstream and prevent them from falling in in the first place."
Identifying opportunities to use wellness strategically
Researchers from the Benfield Group, a health care consulting firm in St. Louis, conducted a study on wellness and prevention to assess national trends, and regional forces and internal forces at CHI Southeast Region. They found that, as consumers become more educated and motivated (especially aging Baby Boomers), their expectations of the health care system change, said Chuck Reynolds, a principal at the Benfield Group.
"People are looking for a trusted health care advisor who will do more than patch them when they break," he said.
When combined with reimbursements that are at best flat, if not down, hospitals and systems are realizing that they need to take a more active, visible role in the areas of wellness and prevention.
According to Reynolds, wellness and prevention can be used in several strategic ways:
Retail opportunities
Community health improvement
Wellness as a marketing tool
Clinical integration and continuum expansion
Health risk management.
One caveat that both Cook and Reynolds repeated is that the strategic focus on wellness and prevention must come from the system level, but implementation of specific programs was turned over to individual institutions.
"At the affiliate level, needs were different from location to location," Reynolds said. Some were looking to wellness as a strategy for gaining capitated contracts for Medicare and Medicaid patients. Others were looking at wellness as a way to differentiate themselves in the marketplace.
The system''s focus was on determining which things needed to be centralized for efficiency and which things needed to be decentralized for effectiveness.
"Where you really gain scale advantages is on knowledge transfer," Cook said, "and that''s what we''re not organized to do very well."
Knowledge transfer includes not only the sharing of patient information within the system, it includes the development of best practices and analyzing the costs and benefits of different approaches to prevention and wellness.
A changing economic model
Incentives also need to be realigned to reduce the need for episodic care, as more payers favor capitation over fee-for service health care. The value equation is changing so that wellness and prevention is making more economic sense every day, Cook said.
"Where we find ourselves, unfortunately, is in a middle state that''s uncomfortable for everybody The only thing that we know for sure is we''re on our way to something else," Cook said. "This is a very, very strenuous, anxiety ridden middle ground that we find ourselves on. But the incentives and the philosophies of the economic model are changing. We just know that the future contains more wellness and prevention than the past."
Most health care organizations are not looking at wellness and prevention strategically and are missing opportunities, according to Reynolds. They may conduct health fairs for corporations, for example, but their efforts are fragmented.
Please Read the Following Articles:

Product Management by Douglas Anderson and Bruce Bailey is a good introduction to choosing new opportunities for marketing.
Log into the university)


New Product Development by Gemmy Allen is also worth reading.
Product Development
Copyright ? 1999 by Gemmy Allen, all rights reserved.
Product development plays an important role in helping the organization achieve its overall goals. New products are the lifeblood of an organization. Product development includes input from the external environment since external feedback is an integral part of all products. Companies that focus on outstanding product designs increase customer satisfaction and retention, which leads to increased sales, market share, profitability and future company growth. Also, "first-to-market" companies enjoy less initial competition and are able to charge a premium or attain higher profit margins.
Getting new products to market takes speed. This requires coordination with engineers, as well as marketers. Without input and feedback from marketing, developers can often work in a void, lacking market requirements and competitive information. Marketing has a role in each phase of product development including: conceptualization, specialization, selling internally, competitive analysis, engineering-marketing feedback loop, feasibility testing, packaging and pricing, service, support, manufacturing requirements, buy versus make decisions, technology licensing, beta testing, product scheduling and rollout, user feedback and future products.
Integrated Product Development
In the external environment of fast-paced technological change, nimble competitors, and demanding customers, world-class firms have adopted an integrated product development (IPD) process to provide best-in-class new products. IPD is a management strategy that uses customer inquiry, cross-functional teaming and technology integration to improve the performance of product development lifecycles. The U.S. Department of Defense first proposed IPD as a name that better reflected the participation of manufacturing, design, marketing and finance in product development. IPD improves an organization''s ability to quickly respond to market demands with high quality new products. Increasingly diverse needs of customers are met by exercising speed, efficiency, and quality in the development of new products. IPD includes all of the processes that link the activities for designing and building what the customer requirements specify. The integrated, or concurrent, development process has easy access to management, with a centrally networked information system in place that is readily accessible by everyone.
The marketing function''s on-going contact with customers allows them to act as the "voice of the customer" in the initial phases of the product development process communicating customer needs to the design function. Their input enables the design function to develop new products that are based on customer-originated ideas leading to greater market successes. In later stages of the product development process, marketing ensures that new designs remain focused on customer needs and that they provide the benefits that customers want. This interaction between marketing and design is an iterative process that prevents development of products for which there is no market. If the product cannot be built to the quality and cost levels that customers demand, marketing will not be able to sell it no matter how innovative the design is. The interaction between marketing and manufacturing in the product development process is primarily a dialog regarding the production capacity that will be required to meet demand for the new product and the company''s ability to meet this demand. By forecasting sales and communicating these forecasts to manufacturing early in the product development process, the interaction between marketing and manufacturing will prevent lost sales due to insufficient inventory and high carrying costs due to overproduction. Funds are often limited due to other projects under development within a company, so financial decisions must be integrated with the design, marketing and manufacturing strategies to maximize the long-run return on the development of new products.
The Concept of Product
A product is anything that can be offered to a market that might satisfy a need or want. It could be a tangible good (soap), service (haircut), person (George W. Bush for President), place (Viva! Las Vegas), organization (Intel Inside), or idea (Don?t Do Drugs). Most tangible goods include an intangible component, such as the warranty or guarantee of satisfaction.
Mass Customization
The concept of service has broadened to include both breadth of product offerings and the ability to customize to meet specific needs. Undifferentiated mass-produced outputs can be adapted to the needs of each customer through such tools as the Internet and the various online databases. Mass customization is serving large numbers of customers, but giving each exactly what he or she wants. The strongest possible one-to-one marketing role for a manufacturer will be to tailor new products to the tastes and needs of individual consumers. Thus, marketers are finding new ways to customize their offerings. Computer-controlled production processes are used to manufacture individually customized products by combining any of a wide array of production modules. Also in place is an efficient mechanism for learning an individual customer''s product specifications prior to manufacturing a product for that customer. Levi Strauss & Co.?s Personal Pair jeans program uses in-store computers to create jeans cut to the customer?s measurements. Ritz-Carlton makes a computerized record of individual guest preferences available to all of its hotels. The Montreal Ritz will have an extra pillow ready for a guest who requested it months earlier at the Atlanta Ritz. Mattel lets you make a Barbie doll in your own image by allowing you to name your Barbie after yourself, select the color of her hair and skin, her outfit, profession and hobbies. If you like what you see, you can order the custom Barbie.
Even funerals are can be customized. Across the nation, people are increasingly asking for one thing when they plan funerals: choice. People are becoming more interested in personalizing the funeral service. They are substituting personality for tradition and seeking services that reflect their lives and beliefs. White Light Casket Company creates art caskets - a line of caskets decorated with images such as the Irish flag, religious symbols and a golf fairway. Individuals can also special-order caskets. Indiana-based Batesville, America''s biggest casket firm, is increasingly selling caskets with options such as engraved lids or embroidered designs on the interior.
Total Product
When a consumer buys a product, he or she is purchasing the total product, which includes everything that adds value to the seller?s offering. The core product is the actual benefit the consumer is seeking from the purchase. For example, when consumers purchase Kodak film, they are buying ?A Kodak Moment,? the core benefit.
The actual product consists of product attributes such as quality level, design, brand name, and packaging. All of these features help differentiate the product from its competitors. For example, Kodak film is the actual product. Its brand name, packaging and other attributes differentiate it from its competitors. All of these features have been combined to deliver the core benefit ? ?moments of your life.? Product quality is the set of features and characteristics of a product that determine its ability to satisfy needs. Total Quality Management (TQM) is a philosophy that commits the organization to continuous improvement in all of the activities. ISO 9000 is a set of related standards of quality management that have been adopted by about 60 nations, including the United States. Product design refers to the arrangement of elements that collectively form a product. Color is important aspect of design. A brand is a name and/or mark intended to identify the product of one seller and differentiate the product from competing products. Manufacturers, producers, retailers and wholesalers (middlemen) can own brands. A brand makes a product easier to identify and helps ensure consistent quality. Brand equity is the value a brand adds to the product. The sources of brand equity include the product, its name, and its personification, logo, country of origin, advertising themes, and style and packaging approach. A brand name consists of words, letters, and/or numbers that can be vocalized. A good brand name is easy to pronounce, spell, and remember. It should be distinctive and suggest something about the product, especially its benefits or use. Generics are unbranded products. A family brand uses the company name (General Electric) or a product name (Armor All) for all its products. Multiple-brands may be used for each product (Proctor & Gamble?s Tide and Cheer detergents). A brand mark is the part of the brand that appears in the form of a symbol, design, or distinctive coloring or lettering. A trademark is a brand that has been adopted by seller and, in turn, given legal protection. Trademark licensing or brand licensing occurs when the owner of a trademark grants permission (a license) to other firms to use the owner?s brand name and brand mark of the licensee?s products. Packaging is all the activities of designing and producing the container or wrapper for a product. It protects and promotes the product. Family packaging uses identical packages for all products. A label is the part of the product that carries information about the product and the seller.
The augmented product consists of the additional services and benefits (such as installation, delivery and credit, warranty, and after-sale service) that come with the actual product to best satisfy consumers. These post-sale features differentiate the product from its competitors. For example, Kodak provides customers with a solution to their picture-taking problems by offering a money-back guarantee for defective film.
Major Value Propositions
Designing ? and continuously redesigning ? product concepts ensures delivering the ?right? value proposition to targeted consumers. Products, just like diamonds, have many facets. A product value proposition (proposed business deal) is the way an organization answers the customer?s question, ?Why should I buy from you?? The answer is the positioning ? the product?s position in the mind of the consumer. A product?s position is the complex set of perceptions that consumers hold for the product when it is compared with competing products. A product?s position could be in relation to competition, in relation to product class or attribute, or by price and quality.
Successful marketers do not leave their product positions to chance. They determine a core benefit that they can deliver better than anyone else does. One example is Du Pont. They don?t sell a chemical; they sell a solution, ?Charging you more, costing you less.? Thus, Du Pont?s major value proposition is best value for the money. Another example is Volvo?s major value proposition of safest automobile.
Classifications of Product
Products are classified as either consumer products or business (also known as industrial products) based on who will use them and how they will be used. Consumer products are intended for personal (non-business) consumption. Business products are intended for resale, for further processing in producing other products, or for use in conducting a business. Products can be in both classes, if organizations and consumers purchase and use the product. For example, a light bulb would be considered a consumer product if purchased by a family for their home, but is categorized as a business product if bought by a businessperson for the organization.
Consumer Products
Consumer products can be further classified on the basis of how consumers view and shop for these products. The product?s price and purchase importance determine the level of involvement a consumer will devote to purchasing the product. Convenience products are bought frequently, immediately, and with a minimum of comparison and buying effort (groceries). Shopping products are less frequently purchased and are carefully compared on suitability, quality, price, and style (clothing). Specialty products are unique in some way and substitutes are not accepted (expensive automobiles). Unsought products are those not normally thought of either because consumers don?t want to think of them (burial insurance) or consumers are unaware of them (a telephone number allowing you to check your email messages).
Business Products
Business (or industrial) products can be classified based on their use by businesses. Materials and parts are directly used in the production of final products by the firm. Raw materials will become part of another tangible good. Two types of raw materials include agricultural products (grain, fruits, and livestock) and natural products (minerals, land, and products of the forests and seas).
Capital items aid in the production and operation of the firm. Installations are long-lived, major equipment of the business user (printing press, canning machinery). Accessory equipment is used in the production operations of a business firm, but it does not have a significant influence on the scale of operations (forklift trucks, photocopiers).
Supplies are short-lived, low-priced items that aid in the firm?s operations but do not become a part of the finished product (office supplies, lubricating oils). Component parts and materials become an actual part of the finished product. Parts will be assembled with no further change in form (zippers, semiconductors). Materials will undergo further processing (pig iron into steel). Business-to-business services include maintenance and repair services (janitorial services, equipment maintenance) as well as business advisory services (accounting, advertising services).
Product Life Cycle
The product life cycle is the cornerstone for understanding product/market behavior in consumer marketing. Product life cycles can vary from a few weeks to decades depending on new technologies, consumer dissatisfaction, or competitive activities. A product life cycle consists of the aggregate demand for all brands comprising the generic product category overtime. The introduction or pioneering stage is characterized by little competition. Product development costs are high. Promotion focuses on stimulating demand for the product category, rather than a single brand. In the growth or market acceptance stage, both sales and profits rise. Competitors enter the market and profits start to decline. In the maturity stage, sales increase at a decreasing rate. Price competition intensifies, and profits decline. In the decline stage, new replacement products enter the market. Demand drops and a number of competitors withdraw from the market.
The technological life cycle is the critical factor affecting fluctuations overtime in a given business product category. The cutting-edge stage refers to that level of technology development that is ahead of even the most sophisticated applications in the marketplace. Markets for cutting-edge technology tend to be small and sophisticated. Firms that specialize in adapting developed cutting-edge techniques to market needs and applications are known as state of the art. They either integrate the cutting-edge product into their own offerings or use the cutting-edge technology to discover new market applications. In the advanced stage, there is increased competition and a less sophisticated customer base. First-to-clone companies beat competitors to an improved or lower cost alternative while avoiding the development and market risks of first-to-market companies. Market size increases and substantial profits emerge. The company shifts from a technology-driven to a market-driven company. The firm?s product is no longer technologically different from its competition. The firm with the lowest marginal cost can become a market leader and make profits while eliminating competition. However, market segmentation is a viable strategy and a safer alternative to price competition. In the mainstream stage the market is fully developed. Products are standardized and the firm?s focus must shift to low-cost production. The mature stage is characterized by its lack of strategic production advantages. Competition shifts to customer service as prices stable lives. The product approaches an undifferentiated ?commodity? status. In the decline stage, new technologies replace the dying technology. The old technology survives by pricing itself substantially below the new technology.
Life cycles can be successfully managed. Marketers must predict the proposed product?s cycle, even before it is introduced. Furthermore, they must successfully adapt marketing strategies at each stage of the life cycle. They want to enter during the introductory stage to build a dominant market position, or wait until the early part of the growth stage when a viable market has been proved. To extend the product life cycle, marketers can expand the product line through modifications or find new uses for the product.

Mattel, Inc.?s Barbie doll was introduced on March 9, 1959 at the New York Toy Fair. That year 351,000 dolls were purchased. On average, 172,800 Barbie dolls are sold worldwide every day. Barbie products make up 40 percent of Mattel, Inc. annual sales. An estimated 90 percent of American girls have owned at least one Barbie doll over the last 40 years.
The product mix is the set of all products offered for sale by a company. Breadth of product mix is the number product lines carried. Depth of product mix is the variety of sizes, colors, and model offered within each product line. A product line is a broad group of products, intended for essentially similar uses having similar physical characteristics. Product line extension means to add a similar item to an existing product line. For example, a soft drink company could introduce a new flavor.
Planned Obsolescence
The purpose of planned obsolescence is to make an existing product out of date and thus increase the market for replacement products. Technological or functional obsolescence results from significant technical improvements that result in a more effective product. An example would be compact discs (CDs) replacing audio tapes and audio tapes replacing records. Planned obsolescence that is technologically based can be beneficial when a more effective product is developed. Style obsolescence occurs when superficial characteristics of a product are altered so that the new product is easily differentiated from the previous product. Style obsolescence is often criticized as being environmentally unsound.
Consumers are too sophisticated to be drawn easily into a planned obsolescence situation. For example, women?s apparel manufacturers have learned the hard way that women select clothing based on how it looks on them rather than what is ?in.? A style is a distinctive manner of construction or presentation in any art, product, or endeavor. A fashion is any style that is popularly accepted and purchased by successive groups of people over a reasonably long period of time. The fashion adoption process explains how fashion travels through the socioeconomic classes. Trickle-down is when a fashion travels downward through several socioeconomic levels (tie-less tuxedo shirts). Trickle-across is when a fashion travels horizontally and simultaneously within several socioeconomic levels (blue jeans). Trickle-up is when a fashion travels from lower socioeconomic levels upward to higher levels (hip-hop). Consumer products where fashion and style are most noticeable include perfumes, for accurate household items, linens, and gift items. A fad is any fashion that enters quickly, is adopted with great the zeal, peaks early, and declines quickly. The classic example of a fad is the pet rock.
Product Innovation
The ability to change and innovate to meet the needs of the marketplace separates the winners from the losers in today?s business environment. Since products go through life cycles, new products are necessary to sustain sales and profits. The competition and customers must be assessed to determine what new products might satisfy customer needs. The new product development process includes generating new product ideas, screening ideas, business analysis, prototype development, market tests, and commercialization. Key questions in the process include:
? Is there a current need for the product?
? Does the new product meet the users'' needs uniquely? completely?
? Will the user and buyer believe that you have the solution?
? Is the size of the market big enough for the company to make a profit?
? Have you tested and validated?
To be development leaders, companies use design integration techniques, such as voice-of-the-customer. The surest way to delight the customer is to understand what they want. Leading companies regularly seek feedback from customers to continuously improve services. Another design technique is Quality Function Deployment (QFD). Three key areas of product development excellence are time-based performance (How rapidly are different types of new products being brought to market now and in the future?), development effectiveness (How efficient is the process of developing new products? How effective are the results?), and project management (How effective is the process for managing across and within specific projects?) Critical areas of product development include delivering products more swiftly to market, achieving greater revenue impact from new products, and minimizing lost product development dollars.
New Product Diffusion and Adoption
The consumer buying decision process for new products helps marketers understand how consumers learn about and decide to adopt new products. The diffusion of a new product is the process by which the innovation is spread through the marketplace over time. The adoption process refers to the series of stages a prospective buyer goes through in deciding to buy and make regular use of a new product. These stages include awareness (knowing about the existence of the new product), interest (finding the product interesting enough to seek more information on it), evaluation (deciding whether the product is worth trying), trial (actually sampling the product), and adoption (deciding to use the product on a regular basis). The role of a marketer is to help consumers move through these stages quickly.
The diffusion process refers to the rate at which various members of society adopt a new product. The first person on the block to buy the latest product is probably an innovator. Approximately three percent of the market is innovators. They are venturesome and try new ideas at some risk. Early adopters are respected and tend to be leaders in social settings. They are the opinion leaders in their communities and adopt new ideas early but carefully. Early adopters are approximately 13 percent of the market. The early majority, approximately 34 percent of the market, deliberates and does not rush out and buy the newest product. They adopt new ideas before the average person. The late majority, approximately 34 percent of the market, is skeptical of new products and does not adopt a product until a majority of consumers have adopted it. Finally, the laggards are tradition bound. They constitute approximately 16 percent of the market and are suspicious of changes and adopt the innovation only when it has become something of a tradition itself. Individuals who never accept the innovation are known as nonadopters.
Product innovation characteristics influence the rate of adoption. Some products go through the adoption process quickly. The relative advantage of the product compared to existing products will affect the rate of adoption. If the product is seen as a significant improvement over current options, it is likely to be adopted fairly quickly. The degree to which the new product is compatible with the existing values and experiences of potential consumers will affect the adoption rate. The more complex the innovation, the slower it will be adopted. The divisibility of the product or its ability to be sampled will also affect the rate of innovation. The more divisible, the faster the rate of adoption. Finally, communicability refers to the degree to which the consumption of the innovation can be seen or observed by others. See Comparative Diffusion of the Telephone and the World Wide Web: An Analysis of Rates of Adoption by Hsiang Chen and Kevin Crowston http://chen.syr.edu/comparative.html
The Internet
Information and communication are at the core of the product development process. The Internet can bring people responsible for product development into contact with customers. Electronic communication can speed up the entire process of developing a new product and bringing it to market. Virtual product development teams can transcend the boundaries of time and geography. Surveys can be used to gather information online. Mailing lists can be used to gather comments and suggestions that can become the ideas for new products. Also, they can be used to gather feedback during a beta test. Clipping services, databases and checking Web sites can be used to keep track of the competition.






Finally, Reconsidering the Role of Competition is a very useful article.
Reconsidering the role of competition in health care markets: Introduction
Journal of Health Politics, Policy and Law; Durham; Oct 2000; Thomas Rice; Brian Biles; E Richard Brown; Finn Diderichsen; Hagen Kuehn;
Volume: 25
Issue: 5
Start Page: 863-873
ISSN: 03616878
Subject Terms: InternationalHealth care deliveryOrganizational structureOrganizational changeTrendsCompetitionStudies
Classification Codes: 9180: International8320: Health care industry9130: Experimental/theoretical2320: Organizational structure1220: Social trends & culture
Abstract:
In recent years there has been a surge of interest in reforming the organization and delivery of health systems by relying more on market competition. Although much of the impetus has emanated from the United States, the phenomenon is worldwide. Recognizing the significance of these trends, in May 1998, and international conference in Berlin on "Reconsidering the Role of the Competition in Health Care Markets" was organized. The 2-day meeting was jointly sponsored by the UCLA Center for Health Policy Research, the Karolinska Institute in Sweden, and the Wissenschaftszentrum Berlin fur Sozialforschung. The conference, which was hosted by the WZB, included 31 individuals from 10 countries. Presented is a summary of the main issues on which the meeting focused, followed by 10 brief reports on the interplay of markets and government in specific developed countries.
Full Text:
Copyright Duke University Press Oct 2000
In recent years there has been a surge of interest in reforming the organization and delivery of health systems by relying more on market competition. Although much of the impetus has emanated from the United States, the phenomenon is worldwide (Brown 1998). Recognizing the significance of these trends, in May 1998 we organized an international conference in Berlin on "Reconsidering the Role of Competition in Health Care Markets." The two-day meeting was jointly sponsored by the UCLA Center for Health Policy Research, the Karolinska Institutet in Sweden, and the Wissenschaftszentrum Berlin fur Sozialforschung (WZB; in English, the Berlin Science Center for Social Research). The conference, which was hosted by the WZB, included thirty-one individuals from ten countries. This special section presents a summary of the main issues on which the meeting focused, followed by ten brief reports on the interplay of markets and government in specific developed countries. It concludes with a short analysis of the implications of the forgoing material on health care policy internationally and two commentaries that bring additional perspective to these issues.
The WZB room in which the meeting was held had special significance for the conference. It was originally built as the administrative courtroom for the world''s first social insurance system, under Chancellor Otto von Bismarck. Although damaged in World War II, the meeting room has since been reconstructed. Preserved from the original structure and overseeing the room are four sculpted heads, one on each side: one of a boy, another of a young man, another of a full-grown man, and the fourth, an old man. It was hoped that the rulings made in the venue would reflect the intergenerational social solidarity on which the German social insurance system was founded.
Social insurance systems worldwide are now under stress. The purpose of the conference was to stimulate dialogue and debate among scholars from developed countries about the appropriate mix of government and markets in health care systems. Participants came from universities, research institutes, foundations, government, and the private sector from three continents and represented such fields as economics, sociology, political science, public health, medicine, business, and journalism (see participant list in Table 1). The countries represented a mix of those moving toward more competitive systems and those that con
Context
Background material for the conference was the recently published book The Economics of Health Reconsidered by Thomas Rice ( 1998). The book questions the belief that economic theory demonstrates that market competition provides a preferred set of policies in health care. It examines four key aspects of economic theory: competition, demand, supply, and redistribution. In each of these areas, it presents and analyzes the assumptions that need to be fulfilled in order for markets to necessarily produce the most desired set of social outcomes. These assumptions are listed in Table 2.
The book critiques each of these assumptions and provides a number of applications to health care policy. One of the main implications of Rice''s book is that there are a wide range of policy tools available to improve social welfare that are not suggested by traditional economic theory. In the conventional market model, there are actually very few levers available to health care policy makers. Because the model is driven by consumer demand, the primary tools involve influencing demand, either by changing out-of-pocket price or by providing additional information to consumers. There is no place to influence supply because it is presumed that suppliers will simply produce those things that are demanded.
Table 1
Enlarge 200%
Enlarge 400%

Table 2
Enlarge 200%
Enlarge 400%

What we actually see in health policy throughout the world, however, is the reliance instead on supply-side policies. These include using such policy tools as capitation, diagnosis-related groups (DRGs), utilization review, practice guidelines, technology and manpower controls, and global budgets -to name just a few. These policies are aimed primarily at influencing the behavior of the suppliers of care rather than the demanders. As a result, none of these policies directly arises out of the competitive model, nor, according to conventional economic theory, would any result in superior outcomes compared to purely demand-based policies. Nevertheless, many would argue that these policies have resulted in superior outcomes in the health care marketplace.
The book, however, does not take the next step and show where market forces will be most effective in health care, and where it is preferable to rely on government. Equally important, it does not explore the many ways in which markets and government can work together to bring about a preferred set of health policies. These were the types of issues that the conference was designed to address.
Care Issues in Health Care Policy
The conference focused primarily on three broad policy-relevant issues: ( 1 ) the relative advantages of markets versus government in bringing about efficiency in health care; (2) alternative ways of achieving equity in the distribution of health and health services; and (3) how markets and government can work together to achieve a more optimal health care system. Here we will not attempt to explore these issues in detail; rather, we will characterize some of the main themes about them that were discussed in Berlin.
Efficiency
On the topic of efficiency, it was generally agreed that the choice of government versus markets is a false dichotomy (Health Care Study Group 1994). In particular, participants pointed out that markets need government in order to function properly because of the strong incentive of providers to profit from the selection of healthier enrollees (for insurers) and patients (for providers). In fact, when markets are relied upon, government must be especially dynamic, responding quickly to new and innovative ways that competitors devise to achieve favorable selection. Governments must also continually be aware of and ready to act on the consequence of greater reliance on market forces in the delivery of care that produces the erosion of cross-subsidies from wealthier and healthier members of society to the poor and sick.
Participants tended to agree that markets had a much stronger role -and potential to improve social welfare-in the delivery than in the financing of health care. Indeed, a study of European health care systems has shown that almost all such countries rely on ability to pay rather than use services in financing health care (Wagstaff and van Doorslaer 1992). The key issue, then, is the appropriate mix between markets and government in health care delivery, and most of the discussion focused on this topic. Many of the policy specialists at the conference pointed out that in most countries, including the United States, government involvement was originally predicated on a failure of markets to provide necessary health care coverage to the elderly and poor. Furthermore, although government is often considered cumbersome, it has achieved much success through such administered pricing systems as global budgets (Europe and Canada) and DRGs (United States).
Finally, everyone at the conference agreed that government offers no panacea, in part because of the workings of the political process. Just as markets tend to reward firms that seek to maximize profits more than patients'' health, government is also beholden to special interests, such as associations representing providers of care. Thus, while critics of policies that rely on market forces focus on the motives inherent in market competition, one must also consider the motives and actions of interest groups in a health care system governed primarily by political muscle.
Achieving Equity
The second main issue addressed was solidarity and the dangers that a market-reliant health care system poses through its focus on individuality. Most of the discussion, however, focused on equity, and in particular, on what one is trying to equalize and how one can best achieve the various definitions of equity. In considering these issues, one must distinguish between equality, a state in which everyone has the same amount of something, and equity, in which distributions may be uneven in order to achieve a fairer ultimate distribution (Stone 1996).
Participants noted that there are at least four things a society can equalize in order to improve social welfare with regard to health: (1) initial resources, (2) access to care, (3) use of service, and (4) health itself. Traditional economic theory tends to focus on the first of these attributes. Society can, if it wishes, equalize the distribution of incomes through taxation and subsidies, but then allow people subsequently to make their own purchasing decisions. Problems with this approach include the difficulty in actually achieving an equal distribution of initial resources, and even if it were accomplished, the likelihood that people might make choices that do not reflect their best interests.
Equalizing access to care has been advocated by others; LuAnn Aday, Ronald Andersen, and Gretchen V Fleming (1980: 26) argue for this strategy, which "is said to exist when need, rather than structural or individual factors, determine[s] who gains entry to the health care system." One shortcoming is that even when economic factors are eliminated through comprehensive insurance coverage, sociodemographic inequalities in the use of health services remain.
There has been much debate on the advantages of equalizing utilization of services as opposed to the equalization of health itself (Culyer 1989, 1993; Mooney et al. 1991). Much of the discussion at the meeting focused on Alan Williams''s ( 1997: 119) notion of the "fair innings," which "reflects the feeling that everyone is entitled to some `normal'' span of health. . . . The implication is that anyone failing to achieve this has in some sense been cheated, whilst anyone getting more than this is `living on borrowed time: " One implication is that more medical resources should be devoted to the young, who have not yet had their fair innings, with correspondingly less spent on the elderly. Although some participants were enthusiastic about this notion of equity, others expressed concerns, one of the main ones being that we know little about how to equalize the health status of different population subgroups in a cost-effective manner.
How Markets and Government Can Work Together
The third main topic of the conference focused on how markets and government can work together to achieve more optimal health care systems. Discussion during this session was quite free-ranging and perhaps more difficult to summarize than the others. In addition, several participants noted that terms such as "markets" and "competition" have very different connotations on different sides of the Atlantic, so it is necessary to be precise.
There was general (although not universal) agreement that the dichotomy between markets and government is a false one; both are needed and both need each other. Government often needs markets to help ensure that the services produced are the ones that are wanted, and that resources are not unnecessarily squandered. Markets need government to ensure that pricing is fair, that all segments of the population are served, and that objective information is disseminated. The key issue, then, is determining the blend of the two that should be utilized, and to do that, empirical evidence is fundamentally important. Participants felt that in spite of the policy discussions on the role of competition that have taken place for decades, information on the optimal mix of government and markets is still scarce, and researchers and policy makers should look at other countries as well as their own to find the appropriate knowledge base.
Comparing Health Care Systems
The core of this special section are ten short reports on eleven countries. We asked the authors to write a brief essay on the health systems in their country, focusing on three issues:
* the role of government in financing and delivering health services, including successes and problems;
* the introduction of markets into the financing and/or delivery of health services, and its successes and problems; and
* how the roles of markets and government may change over the next decade; policy options now being considered; and the perceived advantages and disadvantages of such changes.
The reports on the eleven countries provide a fascinating view of how different societies view competition and regulation and indicate some very different trends in health care policy. As Deborah A. Stone reports, nearly any way one measures market versus government involvement in health care, the United States has relied primarily on markets rather than government. More significantly, she points to a trend in which markets gaining greater significance, as more patients in publicly funded programs are funneled through private managed care organizations, and as both federal and state governments become increasingly shy about exerting their regulatory powers. In reading the reports on the eleven countries, it is clear that the United States relies more on markets than the other countries, but also that recent developments are resulting in an even stronger role for markets.
On the other end of the spectrum, some countries have not (yet) embraced markets to any meaningful extent. Miriam M. Wiley reports that Ireland is such an example. The Irish have been unusually successful over the past two decades in reducing the proportion of national income spent on health, but this has largely been the result of their country''s fast-growing economy rather than successful expenditure control. Although she states that "there are no indications currently that any form of market-based model is likely to emerge in the foreseeable future as the dominant framework," inability to control future expenditure growth could create such pressures. Although the lack of historical reliance on markets is also true in Canada, Robert G. Evans points out that there are many forces that seek much greater reliance on markets-including provider groups, insurers, certain political figures, and some wealthier citizens who would prefer a system in which they do not cross-subsidize other population groups. Thus far, however, these appear to be threats to the current system that largely have not been actualized.
The area in which market involvement has been the highest in Canada is for services not covered by the provincial health plans, which, depending on province, may include dental care, prescription drugs, and noninpatient institutional care. Jean-Pierre Poullier and Simone Sandier report on a similar system in France, where "it is only in dental care, eyeglasses, and over-the-counter drugs that the market prevails." France differs greatly from Canada and several other countries reported on here in the extent to which patient copayments are required, as well as in the availability of privately funded supplemental insurance that covers these expenses. The authors indicate, however, that there is no strong movement toward more market involvement, as "public opinion stands massively against devolution of responsibility to private insurance or reduction in coverage."
Most of the other countries examined in this special section have experimented with increased market involvement in recent years, although in a few the pendulum has begun to swing back to a more government-oriented system. The country that has received the most attention in this regard is the United Kingdom, where the Thatcher government introduced "internal markets" to health care in 1991. As described by Clive Smee, this infusion of competition was generally among providers, not among the fenders or health plans. Unfortunately, there are few good evaluations of these changes; what does seem clear, according to Smee, is that although some improvement in hospital productivity did occur, "there was no sustained improvement in public satisfaction, no sustained decline in waiting lists or waiting times, and no measurable improvement in the clinical quality of care or in health outcomes." But the resulting increase in administrative costs, and the increasing perception that the British medical system was becoming more "two-tiered;'' led the current government to move away from this model.
Other countries considered following Britain''s lead. As reported by Todd A. Krieble, New Zealand was also on the verge of introducing internal markets in 1993, soon after Britain, with a system that would have been even more marketlike because "individuals were to be able to choose among competing health plans that would contract with competing providers:'' This idea was quickly abandoned, and the system reverted to one where government retained its dominant role in financing and delivery. Sweden went further in following Britain''s lead, including splitting the roles of purchasers and providers, giving financial incentives to general practitioners through capitation payments, and introducing more patient copayments. However, as Finn Diderichsen notes, any resulting increase in efficiency was matched by a reduction in the equity of the system. Continued financial strains, however, make it too early to know which path Sweden will ultimately choose.
Outside of the United States, the countries that have perhaps gone the furthest in introducing markets and managed competition are Switzerland, the Netherlands, and Belgium. The Swiss reforms discussed by Peter Zweifel were enacted in 1996 and included both competition among sick funds that purchase coverage (which in turn has led to the development of both PPOs and HMOs), to help defray potentially high costs for those with low incomes, and a means-tested health insurance purchase. However, because uniform premiums are required for all adults, there is still an incentive to cream-skim, which can perhaps someday be ameliorated by more effective risk-adjustment of premiums. Although Zweifel notes other obstacles that need to be overcome for managed competition to be a strong success, he notes that "at the very last, there is a willingness to try out new solutions that had not been known for decades in Swiss health care:'' There are some similarities between the Swiss experience and those in the Netherlands and Belgium. The Netherlands in particular has tried to embrace managed competition in a framework ensuring universal access while empowering sickness funds to selectively contract with providers, negotiate prices, and compete for enrollees. More recently, the funds are beginning to engage in various utilization management activities. Belgium has, since 1995, also given sick funds incentives for efficiency through risk-adjusted capitation payments, albeit for only a small portion of their total revenue. Eddy van Doorslaer and Frederik T.
Schut report that there are still a number of impediments facing both countries-both technical and political-in the quest to implement more effective reforms based on managed competition.
In some ways, the hardest of the countries to categorize is Germany, the setting of the conference. As Martin Pfaff and Dietmar Wassener indicate in the beginning of their essay, "the principle of solidarity rather than competition is considered the basic constituent element of Germany''s health care system, but competition de facto has always existed . . . among private health insurance funds, among private and social health insurance funds, and among. . . ambulatory care physicians." In general, the German system involves little direct government financial involvement but much explicit oversight of both supply- and demand-side organizational relationships.
In summary, the countries examined in this special section exemplify both varying degrees of market and government involvement in health care and different trends. Each of the essays has much to offer in both its overall description of the respective systems, as well as an analysis of the factors that are likely to spur future change. Clearly, there is no model in the developed world on the advisability of introducing more market forces into national health care systems, but the capstone essay by James A. Morone, and the two commentaries by Donald W. Light and David Wilsford, help us to explore the larger implications for health care and health care policy. The material in this special section is intended to spur greater thought on this most key health policy issue.

Research of Relevant Literature
Please complete a review of literature paper on this topic.
I searched the following literature to make your job easier.
Let me know if you have any questions.

Ovid Technologies, Inc. Email Service

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

Search for: 10 or 14

Results: 22



Database: Ovid MEDLINE(R) <1950 to August Week 5 2010>

Search Strategy:

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

1 Health Literacy/ (136)

2 health liter$.mp. (1738)

3 or/1-2 (1738)

4 newest vital sign.mp. (17)

5 3 and 4 (13)

6 REALM.mp. (2702)

7 Rapid estimate of Adult Literacy in Medicine.mp. (101)

8 6 or 7 (2730)

9 3 and 8 (63)

10 5 and 9 (2)

11 from 5 keep 1-3,8-9 (5)

12 from 9 keep 1,6,8,14,16,19,26-28,33,37,46,51-52,60-61 (16)

13 from 5 keep 1-3,9-10,12-13 (7)

14 11 or 12 or 13 (22)

15 10 or 14 (22)



***************************

Result <1. >

Unique Identifier

19885705

Status

MEDLINE

Authors

Rawson KA. Gunstad J. Hughes J. Spitznagel MB. Potter V. Waechter D. Rosneck J.

Authors Full Name

Rawson, Katherine A. Gunstad, John. Hughes, Joel. Spitznagel, Mary Beth. Potter, Vanessa. Waechter, Donna. Rosneck, James.

Institution

Department of Psychology, Kent State University, P.O. Box 5190, Kent, OH, 44242-0001, USA. [email protected]

Title

The METER: a brief, self-administered measure of health literacy.

Source

Journal of General Internal Medicine. 25(1):67-71, 2010 Jan.

Other ID

Source: NLM. PMC2811598 [Available on 01/01/11]

Abstract

BACKGROUND: Given rapidly accumulating evidence that health literacy is correlated with important health-related measures, assessing patients' health literacy level is of increasing concern for researchers and practitioners. Practical limitations for use of existing health literacy measures include length of time and practitioner involvement in administration. OBJECTIVE: To develop and validate a brief, self-administered measure of health literacy, the Medical Term Recognition Test (METER). PARTICIPANTS: 155 participants were recruited from an outpatient cardiology program at an urban hospital. MEASURES: Patients completed measures of health literacy (METER and REALM), neuropsychological function, psychosocial health, and self-report questionnaires about health behaviors. Indicators of cardiovascular health were also recorded from patients' medical charts. KEY RESULTS: The measure took 2 min to complete. The internal consistency of the METER was 0.93, and it correlated hig!

hly with REALM (r = 0.74). Regarding sensitivity and specificity for identifying individuals below REALM's cutoff for functional literacy, METER resulted in 75% correct identifications and 8% false positives. METER and REALM were both associated with various health-related measures (including significant correlations with measures of neuropsychological function and cardiovascular health). CONCLUSIONS: These initial findings show that the METER is a quick and practical measure of health literacy for use in clinical settings.

Publication Type

Comparative Study. Journal Article. Research Support, N.I.H., Extramural.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=19885705



Result <2. >

Unique Identifier

20574878

Status

MEDLINE

Authors

VanGeest JB. Welch VL. Weiner SJ.

Authors Full Name

VanGeest, Jonathan B. Welch, Verna L. Weiner, Saul J.

Institution

School of Community Health and Policy, Morgan State University, Baltimore, Maryland, USA.

Title

Patients' perceptions of screening for health literacy: reactions to the newest vital sign.

Source

Journal of Health Communication. 15(4):402-12, 2010 Jun.

Abstract

Difficulties in caring for patients with limited health literacy have prompted interest in health literacy screening. Several prior studies, however, have suggested that health literacy testing can lead to feelings of shame and stigmatization. In this study, we examine patient reaction to the Newest Vital Sign (NVS), a screening instrument developed specifically for use in primary care. Data were collected in 2008 in the Morehouse School of Medicine, Department of Family Medicine Primary Care Clinics, where health literacy screening was implemented as part of routine intake procedures. Following the visit, patients completed a series of questions assessing their screening experiences. A total of 179 patients completed both the NVS and the reaction survey. Nearly all (> 99%) patients reported that the screening did not cause them to feel shameful. There were also no differences in the reported prevalence of shame (p
ould recommend clinical screening, 97% of patients answered in the affirmative. These results suggest that screening for limited health literacy in primary care may not automatically elicit feelings of shame. Even patients with the lowest levels of literacy were both comfortable with and strongly supportive of clinical screening.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=20574878



Result <3. >

Unique Identifier

20606152

Status

MEDLINE

Authors

Powers BJ. Trinh JV. Bosworth HB.

Authors Full Name

Powers, Benjamin J. Trinh, Jane V. Bosworth, Hayden B.

Institution

Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St, Durham, NC 27705, USA. [email protected]

Title

Can this patient read and understand written health information?. [Review] [46 refs]

Source

JAMA. 304(1):76-84, 2010 Jul 7.

Abstract

CONTEXT: Patients with limited literacy are at higher risk for poor health outcomes; however, physicians' perceptions are inaccurate for identifying these patients. OBJECTIVE: To systematically review the accuracy of brief instruments for identifying patients with limited literacy. DATA SOURCES: Search of the English-language literature from 1969 through February 2010 using PubMed, Psychinfo, and bibliographies of selected manuscripts for articles on health literacy, numeracy, reading ability, and reading skill. STUDY SELECTION: Prospective studies including adult patients 18 years or older that evaluated a brief instrument for identifying limited literacy in a health care setting compared with an accepted literacy reference standard. DATA EXTRACTION: Studies were evaluated independently by 2 reviewers who each abstracted information and assigned an overall quality rating. Disagreements were adjudicated by a third reviewer. DATA SYNTHESIS: Ten studies using 6 different ins!

truments met inclusion criteria. Among multi-item measures, the Newest Vital Sign (English) performed moderately well for identifying limited literacy based on 3 studies. Among the single-item questions, asking about a patient's use of a surrogate reader, confidence filling out medical forms, and self-rated reading ability performed moderately well in identifying patients with inadequate or marginal literacy. Asking a patient, "How confident are you in filling out medical forms by yourself?" is associated with a summary likelihood ratio (LR) for limited literacy of 5.0 (95% confidence interval [CI], 3.8-6.4) for an answer of "a little confident" or "not at all confident"; a summary LR of 2.2 (95% CI, 1.5-3.3) for "somewhat confident"; and a summary LR of 0.44 (95% CI, 0.24-0.82) for "quite a bit" or "extremely confident." CONCLUSION: Several single-item questions, including use of a surrogate reader and confidence with medical forms, were moderately effective for quickly id!

entifying patients with limited literacy. [References: 46]

Publication Type

Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, Non-P.H.S.. Review.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=20606152



Result <4. >

Unique Identifier

20207930

Status

MEDLINE

Authors

Shah LC. West P. Bremmeyr K. Savoy-Moore RT.

Authors Full Name

Shah, Lisa Ciccarelli. West, Patricia. Bremmeyr, Katazryna. Savoy-Moore, Ruth T.

Institution

Department of Family Medicine, St. John Hospital, Detroit, MI, USA. [email protected]

Title

Health literacy instrument in family medicine: the "newest vital sign" ease of use and correlates.

Source

Journal of the American Board of Family Medicine: JABFM. 23(2):195-203, 2010 Mar-Apr.

Abstract

BACKGROUND: Health literacy has been defined as the ability to obtain, process, and understand the basic information needed to make appropriate health decisions. Half of adults lack the health literacy skills needed for our complex health care environment. In 2005, Weiss et al introduced the Newest Vital Sign (NVS), an instrument that can be used to quickly assess health literacy. The purpose of this study was to determine the acceptability and timeliness of using the NVS to measure the level of health literacy in various suburban, urban, and rural primary care settings. A secondary purpose was to determine the influence of taking a health class on one's level of health literacy. METHODS: In this cross-sectional design, adults were recruited from 4 primary care settings and student athletes were recruited during preparticipation sports physicals. The NVS was administered and health literacy rates were compared with known trends. A subset of 50 patients was timed during tes!

t administration, and refusals were logged throughout. The adults and the athletes were analyzed separately. RESULTS: One thousand fourteen patients (including athletes) agreed to participate (response rate, 97.5%). Average time needed to complete the NVS was 2.63 minutes. Of the adults tested, 48.1% demonstrated adequate health literacy. In logistic regression analysis, younger age, more formal education, health class participation, and body mass index were positive predictors of adequate health literacy among adults. An interaction term was used for gender/race, with white women used as the comparator. The gender/race odds ratio negatively affected literacy, with white men at 0.497 (95% CI, 0.328-0.753), non-white women at 0.177 (95% CI, 0.111-0.282), and non-white men at 0.210 (95% CI, 0.110-0.398). Among the participating middle- and high-school athletes, 59.7% had adequate health literacy. In logistic regression of this population, body mass index was a positive predic!

tor whereas gender/race was a negative predictor. CONCLUSION: The NVS

revealed health literacy status in less than 3 minutes, was widely accepted, and provided results comparable to more extensive literacy tests. Particularly, taking a health education class was associated with higher levels of health literacy among adults.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=20207930



Result <5. >

Unique Identifier

20010182

Status

MEDLINE

Authors

Walker J. Pepa C. Gerard PS.

Authors Full Name

Walker, Jane. Pepa, Carole. Gerard, Peggy S.

Institution

School of Nursing, Purdue University Calumet, Hammond, Indiana, USA. [email protected]

Title

Assessing the health literacy levels of patients using selected hospital services.

Source

Clinical Nurse Specialist. 24(1):31-7, 2010 Jan-Feb.

Abstract

PURPOSE: The aim of this study was to assess the health literacy abilities of patients in an urban and suburban hospital. BACKGROUND: Inadequate health literacy is a widespread problem that is associated with insufficient self-care knowledge and behavior, inappropriate use of emergency services, higher rates of hospitalization, and increased healthcare costs. Knowledge of patients' reading ability is necessary to ensure that appropriately leveled printed health education materials are available. METHODS: The health literacy of a convenience sample of 21 inpatients and 34 outpatients from an urban and suburban hospital was measured using the Test of Functional Health Literacy in Adults and the Rapid Estimate of Adult Literacy in Medicine. Variables for analysis included demographic characteristics, perceived health status, highest grade of school completed, socioeconomic status, healthcare costs, and number of inpatient and outpatient admissions over the previous year. RESU!

LTS: Based on the Rapid Estimate of Adult Literacy in Medicine, 33% of patients had health literacy levels that were eighth grade or below, whereas according to the Test of Functional Health Literacy in Adults, 23% had marginal or inadequate functional health literacy. Literacy was significantly related to socioeconomic status (P < .001) and education (P < .001), although 30% of participants had a reading level below the highest grade completed. No other significant correlations were found. IMPLICATIONS: Clinical nurse specialists should ensure that health information materials are written at appropriate levels and educate nurses and other healthcare professionals to use effective communication and teaching strategies.

Publication Type

Journal Article.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=20010182



Result <6. >

Unique Identifier

19531559

Status

MEDLINE

Authors

Barber MN. Staples M. Osborne RH. Clerehan R. Elder C. Buchbinder R.

Authors Full Name

Barber, Melissa N. Staples, Margaret. Osborne, Richard H. Clerehan, Rosemary. Elder, Catherine. Buchbinder, Rachelle.

Institution

Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia. [email protected]

Title

Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey.

Source

Health Promotion International. 24(3):252-61, 2009 Sep.

Abstract

The objective of this paper is to measure health literacy in a representative sample of the Australian general population using three health literacy tools; to consider the congruency of results; and to determine whether these assessments were associated with socio-demographic characteristics. Face-to-face interviews were conducted in a stratified random sample of the adult Victorian population identified from the 2004 Australian Government Electoral Roll. Participants were invited to participate by mail and follow-up telephone call. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA) and Newest Vital Sign (NVS). Of 1680 people invited to participate, 89 (5.3%) were ineligible, 750 (44.6%) were not contactable by phone, 531 (32%) refused and 310 (response rate 310/1591, 19.5%) agreed to participate. Compared with the general population, participants were slightly older, better ed!

ucated and had a higher annual income. The proportion of participants with less than adequate health literacy levels varied: 26.0% (80/308) for the NVS, 10.6% (51 33/310) for the REALM and 6.8% (21/309) for the TOFHLA. A varying but significant proportion of the general population was found to have limited health literacy. The health literacy measures we used, while moderately correlated, appear to measure different but related constructs and use different cut offs to indicate poor health literacy.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=19531559



Result <7. >

Unique Identifier

19051972

Status

MEDLINE

Authors

Reeves K.

Authors Full Name

Reeves, Kathleen.

Title

Health literacy: the newest vital sign.

Source

MEDSURG Nursing. 17(5):288, 296, 2008 Oct.

Publication Type

Journal Article.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=19051972



Result <8. >

Unique Identifier

18660507

Status

MEDLINE

Authors

Ibrahim SY. Reid F. Shaw A. Rowlands G. Gomez GB. Chesnokov M. Ussher M.

Authors Full Name

Ibrahim, S Y. Reid, F. Shaw, A. Rowlands, G. Gomez, G B. Chesnokov, M. Ussher, M.

Institution

Faculty of Health and Social Care, Institute of Primary Care and Public Health, London South Bank University, London, UK. [email protected]

Title

Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease.

Source

Journal of Public Health. 30(4):449-55, 2008 Dec.

Abstract

BACKGROUND: Health literacy (HL) has been recognized as an important public health issue in other developed countries such as the US. There is currently no HL screening tool valid for use in the UK. This study aimed to validate a US-developed HL screening tool (the Rapid Estimate for Adult Literacy in Medicine; REALM) for use in the UK against the UK's general literacy screening tool (the Basic Skills Agency Initial Assessment Test, BSAIT). METHODS: A cross-sectional survey involving 300 adult patients admitted to hospital for investigation of coronary heart disease were given the REALM and BSAIT tools to complete as well as specific questions considered likely to predict HL. These questions relate to the difficulty in understanding medical information, medical forms or instructions on tablets, frequency of reading books and whether the participant's job involves reading. RESULTS: The REALM was significantly correlated with the BSAIT (r = 0.70; P < 0.001), and significantl!

y related to seven of the eight questions likely to be predictive of HL. CONCLUSIONS: This study has shown that the REALM has face, criterion and construct validity for use as an HL screening tool in the UK, in research and in everyday clinical practice. Further studies are needed to assess the prevalence of low HL in a wider population and to explore the links that may exist between low HL and poor health in the UK.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't. Validation Studies.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=18660507



Result <9. >

Unique Identifier

18588408

Status

MEDLINE

Authors

Volandes AE. Paasche-Orlow M. Gillick MR. Cook EF. Shaykevich S. Abbo ED. Lehmann L.

Authors Full Name

Volandes, Angelo E. Paasche-Orlow, Michael. Gillick, Muriel R. Cook, E F. Shaykevich, Shimon. Abbo, Elmer D. Lehmann, Lisa.

Institution

General Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. [email protected]

Title

Health literacy not race predicts end-of-life care preferences.

Source

Journal of Palliative Medicine. 11(5):754-62, 2008 Jun.

Abstract

BACKGROUND: Several studies have reported that African Americans are more likely than whites to prefer aggressive treatments at the end of life. OBJECTIVE: Since the medical information presented to subjects is frequently complex, we hypothesized that apparent differences in end-of-life preferences and decision making may be due to disparities in health literacy. A video of a patient with advanced dementia may overcome communication barriers associated with low health literacy. DESIGN: Before and after oral survey. PARTICIPANTS: Subjects presenting to their primary care doctors. METHODS: Subjects were asked their preferences for end-of-life care after they heard a verbal description of advanced dementia. Subjects then viewed a 2-minute video of a patient with advanced dementia and were asked again about their preferences. For the analysis, preferences were dichotomized into comfort care and aggressive care. Health literacy was measured using the Rapid Estimate of Adult Lit!

eracy in Medicine (REALM) and subjects were divided into three literacy categories: low (0-45, sixth grade and below), marginal (46-60, seventh to eighth grade) and adequate (61-66, ninth grade and above). Unadjusted and adjusted logistic regression models were fit using stepwise algorithms to examine factors related to initial preferences before the video. RESULTS: A total of 80 African Americans and 64 whites completed the interview. In unadjusted analyses, African Americans were more likely than whites to have preferences for aggressive care after the verbal description, odds ratio (OR) 4.8 (95% confidence interval [CI] 2.1-10.9). Subjects with low or marginal health literacy were also more likely than subjects with adequate health literacy to have preferences for aggressive care after the verbal description, OR 17.3 (95% CI 6.0-49.9) and OR 11.3 (95% CI 4.2-30.8) respectively. In adjusted analyses, health literacy (low health literacy: OR 7.1, 95% CI 2.1-24.2; marginal !

health literacy OR 5.1, 95% CI 1.6-16.3) but not race (OR 1.1, 95% CI

0.3-3.2) was an independent predictor of preferences after the verbal description. After watching a video of advanced dementia, there were no significant differences in the distribution of preferences by race or health literacy. CONCLUSIONS: Health literacy and not race was an independent predictor of end-of-life preferences after hearing a verbal description of advanced dementia. In addition, after viewing a video of a patient with advanced dementia there were no longer any differences in the distribution of preferences according to race and health literacy. These findings suggest that clinical practice and research relating to end-of-life preferences may need to focus on a patient education model incorporating the use of decision aids such as video to ensure informed decision-making.

Publication Type

Comparative Study. Journal Article.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=18588408



Result <10. >

Unique Identifier

18467532

Status

MEDLINE

Authors

Johnson K. Weiss BD.

Authors Full Name

Johnson, Kristen. Weiss, Barry D.

Institution

Polyclinic Family Medicine Northgate, North Seattle, Washington, USA.

Title

How long does it take to assess literacy skills in clinical practice?.

Source

Journal of the American Board of Family Medicine: JABFM. 21(3):211-4, 2008 May-Jun.

Abstract

BACKGROUND: Health literacy screening is often not performed in clinical settings. One possible reason is the concern about the time involved in performing such assessments. Our objective was to measure the time required to administer the Newest Vital Sign (NVS) literacy assessment instrument to English-speaking primary care patients. METHODS: The NVS was administered to 78 consecutive English-speaking patients in an outpatient primary care clinic. The length of time to complete the NVS was timed with a stopwatch. RESULTS: The average time to complete the NVS was 2.9 minutes (95% confidence limit, 2.6-3.1 min). CONCLUSION: The NVS is a health literacy screening tool of sufficient brevity to be considered for use in primary care practices.

Publication Type

Journal Article.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=18467532



Result <11. >

Unique Identifier

18335281

Status

MEDLINE

Authors

Chew LD. Griffin JM. Partin MR. Noorbaloochi S. Grill JP. Snyder A. Bradley KA. Nugent SM. Baines AD. Vanryn M.

Authors Full Name

Chew, Lisa D. Griffin, Joan M. Partin, Melissa R. Noorbaloochi, Siamak. Grill, Joseph P. Snyder, Annamay. Bradley, Katharine A. Nugent, Sean M. Baines, Alisha D. Vanryn, Michelle.

Institution

Department of Medicine, Division of General Internal Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA. [email protected]

Title

Validation of screening questions for limited health literacy in a large VA outpatient population.

Comments

Comment in: J Gen Intern Med. 2008 Sep;23(9):1545; PMID: 18636297]

Source

Journal of General Internal Medicine. 23(5):561-6, 2008 May.

Other ID

Source: NLM. PMC2324160

Abstract

OBJECTIVES: Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population. METHODS: We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of "inadequate or marginal" health literacy based on the S-TOFHLA and 2) inadequate and the combination of "inadequate or marginal" health literacy based on the REALM. MEASUREMEN!

TS AND MAIN RESULTS: Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, "How confident are you filling out medical forms by yourself?" had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69-0.79) and 0.84 (95% CI: 0.79-0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting "inadequate or marginal" health literacy than for detecting inadequate health literacy for each of the 3 questions. CONCLUSION: A single question may be useful for detecting patients with inadequate health literacy in a VA population.

Publication Type

Journal Article. Multicenter Study. Research Support, U.S. Gov't, Non-P.H.S.. Validation Studies.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=18335281



Result <12. >

Unique Identifier

17557682

Status

MEDLINE

Authors

Gong DA. Lee JY. Rozier RG. Pahel BT. Richman JA. Vann WF Jr.

Authors Full Name

Gong, Debra A. Lee, Jessica Y. Rozier, R Gary. Pahel, Bhavna T. Richman, Julia A. Vann, William F Jr.

Institution

Department of Pediatric Dentistry CB 7450, University of North Carolina, Chapel Hill, NC 27599-7450, USA.

Title

Development and testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD).

Source

Journal of Public Health Dentistry. 67(2):105-12, 2007.

Abstract

OBJECTIVE: This study aims to evaluate the reliability and validity of the Test of Functional Health Literacy in Dentistry (TOFHLiD), a new instrument to measure functional oral health literacy. METHODS: TOFHLiD uses text passages and prompts related to fluoride use and access to care to assess reading comprehension and numerical ability. Parents of pediatric dental patients (n = 102) were administered TOFHLiD, a medical literacy comprehension test (TOFHLA), and two word recognition tests [Rapid Estimate of Adult Literacy in Dentistry (REALD), Rapid Estimate of Adult Literacy in Medicine (REALM)]. This design provided assessments of dental and medical health literacy by all subjects, both measured with two different methods (reading/numeracy ability and word recognition). Construct validity of TOFHLiD was assessed by entering the correlation coefficients for all pairwise comparisons of literacy instruments into a multitrait-multimethod matrix. Internal reliability of TOFHL!

iD was assessed with Cronbach's alpha. Criterion-related predictive validity was tested by associations between the TOFHLiD scores and the three measures of oral health in multivariate regression analyses. RESULTS: The correlation coefficient for TOFHLiD and REALD-99 scores (monotrait-heteromethod) was high (r = 0.82, P < 0.05). Coefficients between TOFHLiD and TOFHLA (heterotrait-monomethod: r = 0.52) and REALM (heterotrait-heteromethod: r = 0.53) were smaller than coefficients for convergent validity Cronbach's alpha for TOFHLiD was 0.63. TOFHLiD was positively correlated with OHIP-14 (P < 0.05), but not with parent or child oral health. TOFHLA was not related to dental outcomes. CONCLUSIONS: TOFHLiD demonstrates good convergent validity but only moderate ability to discriminate between dental and medical health literacy. Its predictive validity is only partially established, and internal consistency just meets the threshold for acceptability. Results provide solid suppor!

t for more research, but not widespread use in clinical or public heal

th practice.

Publication Type

Evaluation Studies. Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't. Validation Studies.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=17557682



Result <13. >

Unique Identifier

17557681

Status

MEDLINE

Authors

Richman JA. Lee JY. Rozier RG. Gong DA. Pahel BT. Vann WF Jr.

Authors Full Name

Richman, Julia A. Lee, Jessica Y. Rozier, R Gary. Gong, Debra A. Pahel, Bhavna T. Vann, William F Jr.

Institution

Department of Pediatric Dentistry CB 7450, University of North Carolina, Chapel Hill, NC 27599-7450, USA.

Title

Evaluation of a word recognition instrument to test health literacy in dentistry: the REALD-99.

Source

Journal of Public Health Dentistry. 67(2):99-104, 2007.

Abstract

OBJECTIVE: This study aims to evaluate a dental health literacy word recognition instrument. METHODS: Based on a reading recognition test used in medicine, the Rapid Estimate of Adult Literacy in Medicine (REALM), we developed the Rapid Estimate of Adult Literacy in Dentistry (REALD-99). Parents of pediatric dental patients were recruited from local dental clinics and asked to read aloud words in both REALM and REALD-99. REALD-99 scores had a possible range of 0 (low literacy) to 99 (high literacy); REALM scores ranged from 0 to 66. Outcome measures included parents' perceived oral health for themselves and of their children, and oral health-related quality of life of the parent as measured by the short-form Oral Health Impact Profile (OHIP-14). To determine the validity, we tested bivariate correlations between REALM and REALD-99, REALM and perceived dental outcomes, and REALD-99 and perceived dental outcomes. We used ordinary least squares regression and logit models to !

further examine the relationship between REALD-99 and dental outcomes. We determined internal reliability using Cronbach's alpha. RESULTS: One hundred two parents of children were interviewed. The average REALD-99 and REALM-66 scores were high (84 and 62, respectively). REALD-99 was positively correlated with REALM (PCC = 0.80). REALM was not related to dental outcomes. REALD-99 was associated with parents' OHIP-14 score in multivariate analysis. REALD-99 had good reliability (Cronbach's alpha = 0.86). CONCLUSIONS: REALD-99 has promise for measuring dental health literacy because it demonstrated good reliability and is quick and easy to administer. Additional studies are needed to examine the validity of REALD-99 using objective clinical oral health measures and more proximal outcomes such as behavior and compliance to specific health instructions.

Publication Type

Evaluation Studies. Journal Article. Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't. Validation Studies.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=17557681



Result <14. >

Unique Identifier

17557680

Status

MEDLINE

Authors

Lee JY. Rozier RG. Lee SY. Bender D. Ruiz RE.

Authors Full Name

Lee, Jessica Y. Rozier, R Gary. Lee, Shoou-Yih Daniel. Bender, Deborah. Ruiz, Rafael E.

Institution

Department of Pediatric Dentistry, CB 7450 Brauer Hall, Carolina Campus, Chapel Hill, NC 27599-7450, USA. [email protected]

Title

Development of a word recognition instrument to test health literacy in dentistry: the REALD-30--a brief communication.

Source

Journal of Public Health Dentistry. 67(2):94-8, 2007.

Abstract

OBJECTIVE: This study aims to develop and pilot test a dental word recognition instrument. METHODS: The development of our instrument was based on the Rapid Estimate of Adult Literacy in Medicine (REALM), an efficient word recognition instrument used to assess health literacy in the medical arena. Our instrument, Rapid Estimate of Adult Literacy in Dentistry (REALD-30), consisted of 30 common dental words with various degrees of difficulty. It was administered to 202 English-speaking adults recruited from outpatient medical clinics. We examined the instrument's internal reliability using Cronbach's alpha and its validity by correlating the REALD-30 score to two dental outcomes (perceived dental health status and oral health-related quality of life) and medical health literacy. RESULTS: REALD-30 scores were significantly correlated with REALM scores. REALD-30 was significantly related to perceived dental health status in the bivariate analysis. It also was significantly rel!

ated to oral health-related quality of life in a multivariate analysis. In contrast, medical health literacy was not related to either of the dental outcome measures. CONCLUSIONS: The new REALD-30 instrument displays good reliability but only partial validity. Results suggest that dental health literacy may be distinct from medical health literacy and may have an independent effect on dental health outcomes.

Publication Type

Journal Article. Research Support, N.I.H., Extramural. Research Support, U.S. Gov't, P.H.S..

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=17557680



Result <15. >

Unique Identifier

17178765

Status

MEDLINE

Authors

Shea JA. Guerra CE. Ravenell KL. McDonald VJ. Henry CA. Asch DA.

Authors Full Name

Shea, Judy A. Guerra, Carmen E. Ravenell, Karima L. McDonald, Vanessa J. Henry, Camille A N. Asch, David A.

Institution

Center for Health Equity Research and Promotion, Philadelphia Vetrans Affairs Medical Center, Philadelphia, PA, USA. [email protected]

Title

Health literacy weakly but consistently predicts primary care patient dissatisfaction.

Source

International Journal for Quality in Health Care. 19(1):45-9, 2007 Feb.

Abstract

OBJECTIVES: To study relationships between health literacy and multiple satisfaction domains. Health literacy is related to some domains of patient satisfaction such as communication and understanding, but little is known about relationships of health literacy with other satisfaction domains. Moreover, the importance of health literacy in predicting satisfaction compared with other patient sociodemographics is underexplored. DESIGN: Cross-sectional survey. SETTING: Primary care waiting areas with a Veterans Administration Medical Center and a university health system. PARTICIPANTS: One thousand five hundred and twenty-eight primary care patients. MAIN OUTCOME MEASURES: A brief demographics questionnaire, the Rapid Estimate of Adult Literacy in Medicine, the Veterans Affairs ambulatory care patient satisfaction survey, and an adaptation of the Charlson Comorbidity Index. RESULTS: In unadjusted regression analyses, lower health literacy level was a significant predictor of w!

orse satisfaction in 7 of 10 domains (P < 0.01). When adjusting for patient sociodemographics, predicted relationships remained significant in six of the seven domains (P < 0.05), with each unit change in the 4-stage literacy classification associated with a 3-6 point decrease in dissatisfaction scores (0-100 scale). Health literacy did not predict overall dissatisfaction (P = 0.55). CONCLUSIONS: These results suggest that health literacy, as assessed through a pronunciation exercise that is closely related to more comprehensive measures of literacy, has a consistent, albeit weak relationship with patient satisfaction. Future work is needed to clarify if patients with lower literacy are really receiving different care than those with higher literacy and to pinpoint the sources of their more negative responses.

Publication Type

Journal Article. Research Support, U.S. Gov't, Non-P.H.S..

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=17178765



Result <16. >

Unique Identifier

16881950

Status

MEDLINE

Authors

Wallace LS. Rogers ES. Roskos SE. Holiday DB. Weiss BD.

Authors Full Name

Wallace, Lorraine S. Rogers, Edwin S. Roskos, Steven E. Holiday, David B. Weiss, Barry D.

Institution

Department of Family Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN 37920, USA. [email protected]

Title

Brief report: screening items to identify patients with limited health literacy skills.

Source

Journal of General Internal Medicine. 21(8):874-7, 2006 Aug.

Other ID

Source: NLM. PMC1831582

Abstract

BACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literac!

y skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P<.01) and also a greater AUROC than questions based on demographic characteristics. CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Publication Type

Comparative Study. Journal Article.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medl&AN=16881950



Result <17. >

Unique Identifier

19531559

Status

MEDLINE

Authors

Barber MN. Staples M. Osborne RH. Clerehan R. Elder C. Buchbinder R.

Authors Full Name

Barber, Melissa N. Staples, Margaret. Osborne, Richard H. Clerehan, Rosemary. Elder, Catherine. Buchbinder, Rachelle.

Institution

Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia. [email protected]

Title

Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey.[Erratum appears in Health Promot Int. 2009 Dec;24(4):445]

Source

Health Promotion International. 24(3):252-61, 2009 Sep.

Abstract

The objective of this paper is to measure health literacy in a representative sample of the Australian general population using three health literacy tools; to consider the congruency of results; and to determine whether these assessments were associated with socio-demographic characteristics. Face-to-face interviews were conducted in a stratified random sample of the adult Victorian population identified from the 2004 Australian Government Electoral Roll. Participants were invited to participate by mail and follow-up telephone call. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA) and Newest Vital Sign (NVS). Of 1680 people invited to participate, 89 (5.3%) were ineligible, 750 (44.6%) were not contactable by phone, 531 (32%) refused and 310 (response rate 310/1591, 19.5%) agreed to participate. Compared with the general population, participants were slightly older, better ed!

ucated and had a higher annual income. The proportion of participants with less than adequate health literacy levels varied: 26.0% (80/308) for the NVS, 10.6% (51 33/310) for the REALM and 6.8% (21/309) for the TOFHLA. A varying but significant proportion of the general population was found to have limited health literacy. The health literacy measures we used, while moderately correlated, appear to measure different but related constructs and use different cut offs to indicate poor health literacy.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=medc&AN=19531559



Result <18. >

Unique Identifier

16338915

Status

MEDLINE

Authors

Weiss BD. Mays MZ. Martz W. Castro KM. DeWalt DA. Pignone MP. Mockbee J. Hale FA.

Authors Full Name

Weiss, Barry D. Mays, Mary Z. Martz, William. Castro, Kelley Merriam. DeWalt, Darren A. Pignone, Michael P. Mockbee, Joy. Hale, Frank A.

Institution

University of Arizona College of Medicine, Department of Family and Community Medicine, Tucson 85719, USA. [email protected]

Title

Quick assessment of literacy in primary care: the newest vital sign.[Erratum appears in Ann Fam Med. 2006 Jan-Feb;4(1):83]

Source

Annals of Family Medicine. 3(6):514-22, 2005 Nov-Dec.

Other ID

Source: NLM. PMC1466931

Abstract

PURPOSE: Current health literacy screening instruments for health care settings are either too long for routine use or available only in English. Our objective was to develop a quick and accurate screening test for limited literacy available in English and Spanish. METHODS: We administered candidate items for the new instrument and also the Test of Functional Health Literacy in Adults (TOFHLA) to English-speaking and Spanish-speaking primary care patients. We measured internal consistency with Cronbach's alpha and assessed criterion validity by measuring correlations with TOFHLA scores. Using TOFLHA scores <75 to define limited literacy, we plotted receiver-operating characteristics (ROC) curves and calculated likelihood ratios for cutoff scores on the new instrument. RESULTS: The final instrument, the Newest Vital Sign (NVS), is a nutrition label that is accompanied by 6 questions and requires 3 minutes for administration. It is reliable (Cronbach alpha >0.76 in English a!

nd 0.69 in Spanish) and correlates with the TOFHLA. Area under the ROC curve is 0.88 for English and 0.72 for Spanish versions. Patients with more than 4 correct responses are unlikely to have low literacy, whereas fewer than 4 correct answers indicate the possibility of limited literacy. CONCLUSION: NVS is suitable for use as a quick screening test for limited literacy in primary health care settings.

Publication Type

Journal Article. Research Support, Non-U.S. Gov't.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=med4&AN=16338915



Result <19. >

Unique Identifier

15343422

Status

MEDLINE

Authors

Davis TC. Wolf MS.

Authors Full Name

Davis, Terry C. Wolf, Michael S.

Title

Health literacy: implications for family medicine. [Review] [17 refs]

Source

Family Medicine. 36(8):595-8, 2004 Sep.

Abstract

As many as 90 million Americans have difficulty understanding and acting on health information. This health literacy epidemic is increasingly recognized as a problem that influences health care quality and cost. Yet many physicians do not recognize the problem or lack the skills and confidence to approach the subject with patients. In this issue of Family Medicine, several articles address health literacy in family medicine. Wallace and Lennon examined the readability of American Academy of Family Physicians patient education materials available via the Internet. They found that three of four handouts were written above the average reading level of American adults. Rosenthal and colleagues surveyed residents and found they lacked the confidence to screen and counsel adults about literacy. They used a Reach Out and Read program with accompanying resident education sessions to provide a practical and effective means for incorporating literacy assessment and counseling into p!

rimary care. Chew and colleagues presented an alternative to existing health literacy screening tests by asking three questions to detect inadequate health literacy. Likewise, Shea and colleagues reviewed the prospect of shortening the Rapid Estimate of Adult Literacy in Medicine (REALM), a commonly used health literacy screening tool. Both the Chew and Shea articles highlight the need for improved methods for recognizing literacy problems in the clinical setting. Further research is required to identify effective interventions that will strengthen the skills and coping strategies of both patients and providers and also prevent and limit poor reading and numeracy ability in the next generation. [References: 17]

Publication Type

Editorial. Review.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=med4&AN=15343422



Result <20. >

Unique Identifier

15343419

Status

MEDLINE

Authors

Shea JA. Beers BB. McDonald VJ. Quistberg DA. Ravenell KL. Asch DA.

Authors Full Name

Shea, Judy A. Beers, Benjamin B. McDonald, Vanessa J. Quistberg, D Alex. Ravenell, Karima L. Asch, David A.

Institution

Center for Health Equity Research and Promotion (CHERP), Philadelphia Veterans Affairs Medical Center, PA 19104-6021, USA. [email protected]

Title

Assessing health literacy in African American and Caucasian adults: disparities in rapid estimate of adult literacy in medicine (REALM) scores.

Comments

Comment in: Fam Med. 2005 Apr;37(4):234; PMID: 15812684]

Source

Family Medicine. 36(8):575-81, 2004 Sep.

Abstract

BACKGROUND AND OBJECTIVES: The influence of literacy on health and health care is an important area of investigation. Studies with a literacy focus are most valuable when literacy is assessed with psychometrically sound instruments. METHODS: This study used a prospective cohort sample of 1,610 primary care patients. Patients provided sociodemographics and took the Rapid Estimate of Adult Literacy in Medicine (REALM), a 66-item word pronunciation literacy test. RESULTS: The sample was 65% African American; 66% were men; 51% had a high school education or less. REALM scores were significantly related to education, age, and race but not gender. When stratified by education, differences between African Americans and Caucasians remained significant. Using 19 different strategies to shorten the 66-item instrument, reliability coefficients above.80 were maintained. CONCLUSIONS: The REALM is a robust assessment of health literacy. However, the discordance in scores between African!

Americans and Caucasians with similar educational attainment needs to be further addressed. A much shorter instrument would still have internally consistent scores and potentially be more useful in clinical settings.

Publication Type

Comparative Study. Journal Article. Research Support, U.S. Gov't, Non-P.H.S..

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=med4&AN=15343419



Result <21. >

Unique Identifier

14528569

Status

MEDLINE

Authors

Baker DW. Williams MV. Parker RM. Gazmararian JA. Nurss J.

Authors Full Name

Baker, D W. Williams, M V. Parker, R M. Gazmararian, J A. Nurss, J.

Institution

Department of Medicine, Department of Epidemiology and Biostatistics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109-1998, USA. [email protected]

Title

Development of a brief test to measure functional health literacy.

Source

Patient Education & Counseling. 38(1):33-42, 1999 Sep.

Abstract

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Publication Type

Comparative Study. Journal Article. Validation Studies.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=med4&AN=14528569



Result <22. >

Unique Identifier

9768381

Status

MEDLINE

Authors

Davis TC. Michielutte R. Askov EN. Williams MV. Weiss BD.

Authors Full Name

Davis, T C. Michielutte, R. Askov, E N. Williams, M V. Weiss, B D.

Institution

Department of Internal Medicine and Pediatrics, Louisiana State University Medical Center, School of Medicine, LA 71130-3932, USA. [email protected]

Title

Practical assessment of adult literacy in health care. [Review] [58 refs]

Source

Health Education & Behavior. 25(5):613-24, 1998 Oct.

Abstract

Low literacy is a pervasive and underrecognized problem in health care Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations !

for specific use are made. [References: 58]

Publication Type

Journal Article. Review.

Link to the Ovid Full Text or citation

http://webproxy.ouhsc.edu/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=fulltext&D=med4&AN=9768381
There are faxes for this order.

The Final Paper must have depth of scholarship, originality, theoretical and conceptual framework, clarity and logic in its presentation and adhere to grammar guidelines. You will select a topic for your Final Paper related to the Future of Managed Health Care Delivery Systems, which will be submitted to your instructor for approval during Week Two. The 10-15 page paper (excluding title and reference pages) must follow APA guidelines for written assignments and contain eight to ten scholarly and/ or peer-reviewed sources, excluding the course textbook.

Your paper must address the following bolded topics, which should be titled appropriately in your paper:
1.Include an Abstract which is a synopsis of the overall paper.
2.Managed Health Care Quality should address such factors as whether or not patient health care needs and even preferences are being met; the care is right for the illness, care is timely, and unnecessary test and procedures are not ordered.
3.Provider Contracting is when doctors and health care practitioners have a contract agreement through a third party payer to accept a specified payment for services provided to patients.
4.Cost Containment deals with managing the costs of doing business within a specified budget while restraining expenditures to meet a specified financial target.
5.Effects on Medicare and Medicaid in managed health care appear to be moving in a direction where both types of recipients will be enrolled in some type of managed health care plan in the near future.
6.The Future Role of Government Regulations, to include ERISA and HIPAA health care policies.
7.Include Three Recommendations each, related to quality and change in Medicare and Medicaid managed health care plans.


Writing the Final Paper
1.Must be ten- to fifteen double-spaced pages in length and formatted according to APA style as outlined in the Ashford Writing Center.
2.Must have a cover page that includes:
a.Title of paper
b.Students name
c.Course name and number
d.Instructors name
e.Date submitted

3.Must include an introductory paragraph with a succinct thesis statement.
4.Must address the topic of the paper with critical thought.
5.Must end with a conclusion that reaffirms your thesis.
6.Must use at least eight scholarly and /or peer-reviewed sources, published within the last five years, including a minimum of three from the Ashford University Online Library.
7.Must document all sources in APA style, as outlined in the Ashford Writing Center.
8.Must include a separate reference page, formatted according to APA style as outlined in the Ashford Writing Center.

Imagine a health care reform plan that mandates increased access to services you studied in this course. The goal is better overall patient health, measurable by shorter hospitalizations and improved adherence to medical regimens. You have volunteered to join the Health Psychology Committee formed by your local hospital, which is in the process of initiating a psychiatry division that will employ five psychologists. The committee is responsible for assigning duties to the psychologists. Use critical thinking skills as you decide how to apply health psychology principles to hospital-based psychologists duties
Specify duties for five hospital-associated psychologists that reflect health psychology principles discussed in this course, according to the following guidelines.

Conduct research by consulting a variety of sources, and gather evidence to support your decisions. Remember to suspend judgment while inquiring into multiple aspects of each of the five roles. Use your text, previous assignments, major research hospital Web sites, and the University Library. Cite a minimum of five references, including your text.

Assign one or more of the items in the bulleted duty list below to each of these four job titles: substance abuse counselor; inpatient-only psychologist; child psychologist; adult psychologist:

Duty list:

o Collaborate with local schools

o Provide psychological preparation methods for children prior to medical procedures

o Provide treatment for chronic pain

o Provide psychological preparation methods for adults prior to medical procedures and surgery

o Coordinate the use of recovery programs and structured programs for substance abuse, in conjunction with social worker

o Diagnose stress disorders and aid in stress-relief interventions

o Utilize various methods to facilitate adjustment and coping skills with patients suffering a chronic or terminal illness

If you feel one or more of the duties could be assigned to more than one of the four job titles, feel free to do so but keep a reasonable work and patient load in mind.

Evaluate the list above for areas of need not already addressed. Recommend a fifth job title and assign other health psychology-related duties not listed or related to those above.

Identify decision-making criteria and explain rationale behind your assignment of duties to each of the five job titles.

Discuss and give further details on how each of the five psychologists will contribute to improvement in overall patient health. What kinds of responsibilities and services would each of the five psychologists provide for patients? How will each of their roles result in shorter hospitalizations and improved adherence to medical regimens? Is there overlap in any or all of the five job titles? Should there be? Why or why not?

Consider and discuss the impact of implementing each role versus not implementing it. What makes each role supportive toward improvement and maintenance of wellness? Why would patients be better off with the psychologists services after doing without in the past? Compile your findings to present ot the Committee in APA format

Be sure, when you post as your theorist to:

1.Speak in MYRA LEVINE NURSING theorist's "voice"
2.Indicate what type of THEORY IS MYRA LEVINE nursing theory, it is (i.e., grand, mid-range, or practice-based theory)
3.Share how it can be applied in nursing practice

4.speak about
?Assumptions of the theory
?Origins of the theory
?Research relating to and influenced by the theory
?Definitions of key terms such as patient, health, nurse, and environment

Please use the topic below to write a 2 page paper using the APA format and also provide a reference list.

Understanding Workflow Design
As you explored last week, the implementation of a new technology can dramatically affect the workflow of an organization. Newly implemented technologies can initially limit the productivity of users as they adjust to their new tools. Such implementations tend to be so significant that they often require workflows to be redesigned in order to achieve improvements in safety and patient outcomes. However, before workflows can be redesigned, they must first be analyzed. This analysis includes each step in completing a certain process. Some systems duplicate efforts or contain unnecessary steps that waste time and money and could even jeopardize patient health care. By reviewing and modifying the workflow, you enable greater productivity. This drive to implement new technologies has elevated the demand for nurses who can perform workflow analysis.
In this Discussion you explore resources that have been designed to help guide you through the process of workflow assessment.
To prepare:
Take a few minutes and peruse the information found in the article Workflow Assessment for Health IT Toolkit listed in this weeks Learning Resources.
o As you check out the information located on the different tabs, identify key concepts that you could use to improve a workflow in your own organization and consider how you could use them.
o Go the Research tab and identify and read one article that is of interest to you and relates to your specialty area.
Post on or before Day 3 a summary of three different concepts you found in Workflow Assessment for Health IT Toolkit that would help in redesigning a workflow in the organization in which you work (or one with which you are familiar) and describe how you would apply them. Next, summarize the article you selected and assess how you could use the information to improve workflow within your organization. Finally, evaluate the importance of monitoring the effect of technology on workflow.

NURS 6051: Transforming Nursing and Healthcare through Information Technology?System Design and Workflow?Program Transcript
NARRATOR: In the health care industry, the term workflow is used to describe the many complex systems of interconnected processes that contribute to the delivery of care. Workflow is a model used to summarize all of the steps that go into a specific health care procedure, such as checking in a patient or having blood work done.
Workflow is especially relevant in today's health care environment, which is focused on streamlining operations and increasing quality and value for patients. This often involves implementing technologies, such as wireless communication devices and electronic health records, or EHRs.
Leaders and stakeholders of health care organizations often design workflow with effectiveness and efficiency in mind. Workflow design begins with outlining current procedures related to health care delivery. Then, this information is used to define future workflow requirements and changes that could be made to improve the quality of care. This step is known as process modeling.
Oftentimes, process modeling is completed using a workflow diagram, which illustrates relevant tasks and branch points where decisions or options occur. To better understand process modeling, let's explore an example of a current workflow diagram and how it could be improved by integrating technology. In this example, we will explore workflow for a patient visit to receive an injection or immunization.
The process begins when the patient arrives for the appointment. The patient signs in with the receptionist, who pulls the patient's file and asks him or her to verify the information. If the patient needs to make a co-pay, then he or she does so. If not, or after the co-pay has been collected, the patient takes a seat in the waiting room.
2012 Laureate Education, Inc. 1
Then, the receptionist verbally notifies the nurse that the patient has arrived and puts the patient's medical record, super bill, and labels into a tray for the nurse to collect. When a room is available, the nurse takes the documents in the tray and rooms the patient.
The nurse checks the patient's vital signs, verifies the patient's medications and allergies, and confirms that the patient has come for an injection or immunization. Then, the nurse performs the procedure and records it in the patient's chart.
If the patient has a reaction to the injection, or if there is another problem, the nurse must find the physician to address the issue. The physician then sees the patient and records the incident in the chart.
When the visit is complete and all issues have been addressed, the nurse gives the patient any relevant materials and the super bill for the visit. The nurse also asks the patient to check out with the receptionist. If the patient does not check out, his or her super bill will be lost.
If the patient does check out, the receptionist collects the super bill, verifies the charges, and schedules of any follow-up appointments. Then, the patient leaves, and if the visit is complete, the receptionist sends the patient's record and super bill to billing. If there is still outstanding paperwork for the nurse to complete, the receptionist must wait to send out the record and super bill. After the bill is sent out, the workflow ends.
As you can see, this workflow scenario has several inefficiencies that could be addressed by integrating technology. The first procedure that would be affected by these changes is the receptionist pulling the patient's file. In an EHR workflow, the receptionist could simply call up the record on the computer.
Later in the workflow, the receptionist could use the wireless communication system to notify the nurse if the patient had arrived. With an EHR, the nurse also would not have to collect the documents from the tray at the front desk. Instead, the nurse would access the record on the computer in the medical exam room.
2012 Laureate Education, Inc. 2
This would also affect how the nurse makes notes in the patient's chart. If a reaction or a problem occurred, the nurse could use the wireless communication system to notify the physician. This would improve the efficiency of the workflow and would add to the quality of care, because the nurse could stay with the patient instead of leaving the room to find the physician.
At the end of the visit, the nurse would no longer hand the patient the super bill. Instead, the nurse would update the super bill within the EHR, and this data would be immediately available to the receptionist at the front desk. This would eliminate the loss of information if the patient did not check out. In this case, the receptionist would simply make a note to contact the patient for any need follow- up.
As this example has shown, by using the steps of workflow design, leaders of health care organizations can identify inefficiencies in current systems and determine how the systems will be affected by tools like EHRs and wireless communication devices.
2012 Laureate Education, Inc. 3

Workflow Assessment for Health IT Toolkit

Workflow Home
A key to successful implementation of health information technology (health IT) is to recognize its impact on both clinical and administrative workflow. Once implemented, health IT can provide information to help you reorganize and improve your workflow. This toolkit is designed for people and organizations interested or involved in the planning, design, implementation, and use of health IT in ambulatory care.








Workflow Assessment for Health IT Toolkit

Workflow Home Research Search Results Publication
REFERENCE [LINK]
Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Aff 2004;23(2):116-126.
ABSTRACT
"The electronic medical record (EMR) is an enabling technology that allows physician practices to pursue more powerful quality improvement programs than ispossible with paper-based records. However, achieving quality improvement through EMR use is neither low-cost nor easy. Based on a qualitative study of physician practices that had implemented an EMR, we found that quality improvement depends heavily on physicians' use of the EMR - and not paper - for most of their daily tasks. We identified key barriers to physicians' use of EMRs. We then suggest policy interventions to overcome these barriers, including providing work/practice support systems, improving electronic clinical data exchange, and providing financial rewards for quality improvement."
OBJECTIVE
To "suggest policy interventions that can promote opportunities for and lower barriers to using EMRs for quality improvement."
TOOLS USED
Interview
SETTING
Type
Primary care and specialty care
Size
Small, medium and large
Other Information
"Organizations included nine large medical groups of more than seventy physicians each, eighteen solo/small-group practices of ten or fewer physicians, and three medium-size groups. Most of the small groups were primary care only, while eight of the large groups were multispecialty."
TYPE OF HEALTH IT
Electronic medical records (EMR)
CONTEXT OR OTHER IT IN PLACE
The context varied across practices.
WORKFLOW-RELATED FINDINGS
"Basic use of electronic ordering typically consisted of physicians' typing in prescription orders, responding to drug interactions and drug allergy alerts, and printing out prescriptions... In large practices, basic ordering often also included electronic ordering of referrals and laboratory and radiology tests. More advanced ordering capabilities included additional decision support, electronic transmission of orders to pharmacies and laboratories, and better tracking of test-order status and test results, all of which can improve quality and decrease errors."
"Basic use of electronic messaging among providers improved the availability, timeliness, and accuracy of messages and increased completeness of documentation, thus potentially reducing "dropped balls" and safety problems. Much less common was advanced messaging, which included messaging with outside providers (to improve care coordination) and with patients (to improve patient satisfaction and, potentially, patient self-care and compliance)."
"Another barrier to EMR use was the lack of adequate electronic data exchange between the EMR and other clinical data systems (such as lab, radiology, and referral systems). Having parallel electronic and paper-based systems forced physicians to switch between systems, thereby slowing workflow, requiring more time to manually enter data from external systems, and increasing physicians' resistance to EMR use.... For example, physicians in nine of the eighteen solo/small-group practices we studied could not view any electronic lab results within their EMR, seventeen could not view hospital data, and nine had EMRs that could not exchange any data with their practice management system. Some labs or hospitals refused to set up data exchange; less often, the practice failed to make necessary programming changes in its own EMR because vendor or internal IT support was lacking. In contrast, larger groups tended to have in-house lab and practice management systems that exchanged data with their EMRs, and had the leverage to obtain the cooperation of hospitals and other external data producers for electronic data exchange."
"As patient data [available for viewing] accumulated over time, financial savings accrued from less staff time spent finding, pulling, and filing charts and less physician time spent locating information."
"Interviewees reported that most physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increased time costs resulted in longer workdays or fewer patients seen, or both, during that initial period."
"Over time, some practices - especially larger ones - used reporting capabilities more widely. For example, some practices generated reports to physicians on diabetic patients with hemoglobin A1C levels greater than 8 percent and on the percentage of a physician's patients having such levels."
"All practices used EMR viewing capabilities, which improve chart availability, data organization, and legibility. ...The amount of initially viewable data depended on efforts to type in existing paper-based medical record data and to electronically import data from lab, billing, and other systems."
"Although most clinicians maintained electronic problem and allergy lists, physicians varied greatly in how they documented progress notes. Basic EMR users had their dictated notes transcribed and imported into the EMR, or they typed their own progress notes into unstructured text boxes. More advanced users typed data into templates (electronic forms) that included physical exam and documentation prompts. Basic use of the EMR improved the legibility and accessibility of progress notes and increased the availability of electronic problem and allergy lists. More advanced use of documentation templates led to greater opportunities for improving quality of care. For example, problem-specific templates (such as a sore throat template) with embedded prompts reminded clinicians to ask about particular symptoms, order particular tests and prescriptions, or perform preventive or disease management activities. Also, templates that help clinicians enter data in coded rather than free-text form facilitated more advanced computer-based decision support for such tasks as care coordination and chronic disease management."
"Most respondents or their colleagues considered even highly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options, and navigational aids. Problems with EMR usability -especially for documenting progress notes - caused physicians to spend extra work time to learn effective ways to use the EMR."
STUDY DESIGN
Only postintervention (no control group)
STUDY PARTICIPANTS
Thirty physician organizations took part in the study, and 90 interviews were conducted with EMR managers and physician champions in 2000-2002. There was a mix of primary care and specialty clinics, although the authors indicated that they were focusing mainly on primary care physicians' EMR use.

PDF Help
You may view or download the PDF File format by selecting that file, indicated by the PDF file icon . For information on accessing PDF Files, please read the PDF Help instructions.
MS Word, Excel, and PowerPoint Help
Microsoft provides free software that allows viewing certain files without owning the full version of the software.
Download MS Word Viewer
Download Excel Viewer
Download PowerPoint Viewer






AHRQ Home | Contact AHRQ | Site Map | Accessibility | Privacy Policy | Freedom of Information Act | Disclaimers | Viewers and Players
U.S. Department of Health & Human Services | The White House | USA.gov: The U.S. Government's Official Web Portal | Plain Writing Act
Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 Telephone: (301) 427-1364

started need help please Introduction (please remove this line when editing)Home health visits can be a useful method of identifying potential and actual health issues. Visiting the patient?s home may provide the opportunity to identify issues which may not be readily apparent at a medical office. The home health visit is to help promote the patient?s health maintenance; limit further disability, and increase baseline health. The visiting nurse will be able to build a caring, professional, trusting, patient focused relationship. The home health nurse will be able to assist the patient by identifying, procuring and providing education for interventional items. The nurse will be able to facilitate the communication of identified patient needs, in the home, to interdisciplinary members of the health care team (Liebel, Powers, Friedman, & Watson, 2012).Problem #1. (Please remove line when editing)The patient has been prescribed oxygen for home use by her physician. The patient states the she has not arranged oxygen in her home because it will cost her more money. The nursing intervention is to find out the total associated cost and arrange oxygen delivery and then provide education regarding safety and use. The use of oxygen will improve the patient?s respiratory function and improve her quality of life (Criner, 2012). Conclusion (please remove this line when editing)There were several issues that were identified only because a home health visit was done in Mrs. Fishers home. The home health nurse in this case scenario has the ability and resources to make positive changes which will promote improved health for this patient and reduce further disability. The visiting nurse can build a caring, trusting, professional patient focused relationship with the patient and with multiple visits continue to evaluate the effectiveness of interventions and make alternative interventions if needed. Home health visits, when appropriately performed, can be a useful method of identifying potential and actual health issues this will aid the health team in providing effective and appropriate interventions.1)Identified and prioritized at least four problems from the simulated home visit with Salle Mae.2)Summarized each problem identified with evidence to substantiate findings (assessment data).3)Identified and discussed at least four medical and/or nursing interventions to meet client needs.4)Provides rational for interventions identified. Discussion of rationale includes support from outside resources (current evidence-based literature). Tripping hazards, cloudy mind, misses husband, depressed, lonely,dehydration, not using home oxygentionMs. Fisher is an 82-year-old female with a history of chronic congestive heart failure (CHF), atrial fibrillation, and hypertension. During the last 6 months, she has been hospitalized four times for exacerbation of her CHF. She was discharged home last Saturday from the hospital after a 3-day stay to treat increased dyspnea, an 8-pound weight gain, and chest pain.Ms. Fisher is recently widowed and lives alone. She has a daughter, Thelma Jean, who lives in town but works full time and has family issues of her own. Therefore, family support is limited.Hospital Discharge Instructions?Mountain Top Home Health to evaluate cardio-pulmonary status, medication management, and home safety.?Medical Equipment Company to deliver oxygen concentrator and instruct patient in use. O2 at 2 liters per nasal prongs PRN.?Prescriptions given at discharge:oDigoxin 0.25 mg once a dayoLasix 80 mg twice a dayoCalan 240 mg once a day ?Order written to continue other home meds.Sallie Mae?s Home Medication List?Zocar 50 mg once a day?Minipres 1 mg once a day?Vasotec 10 mg twice a day?Prilosec 20 mg once a day?Furosemide 40 mg once a day?Effexor 37.5 mg at bedtime?Lanoxin 0.125 mg every other day?Multivitamin once a day?Potassium 40 mEq once a day?Ibuprofen 400 mg q 4 hours as needed for pain?Darvocet N 100 mg q 4 hours as needed for pain?Nitroglycerin ointment, apply 1 inch every dayIdentify and prioritize 4 problems and 4 interventionsProblem 1 ? provide assessment data in paragraph form (20 words)Problem 2 ? provide assessment data in paragraph form (20 words)Problem 3 ? provide assessment data in paragraph form (20 words)Problem 4 ? provide assessment data in paragraph form (20 words)Intervention 1 ? describe and discuss rationale (90 words, include reference)Intervention 2 ? describe and discuss rationale (90 words, include reference)Intervention 3 ? describe and discuss rationale (90 words, include reference)Intervention 4 ? describe and discuss rationale (90 words, include reference)Introduction (~150 words) and conclusion (~100 words)ReferencesCriner, G. J. (2012). Ambulatory Home Oxygen: What Is the Evidence for Benefit, and Who Does It Help?. . Respiratory Care, 58(1), 48-64. http://dx.doi.org/10.4187/respcare.01918Liebel, D., Powers, B., Friedman, B., & Watson, N. (2012). Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention. . Journal Of Advanced Nursing, 68(1), 80-93. http://dx.doi.org/10.1111/j.1365-2648.2011.05717.x

Discussion: Ethical Scenarios in Nursing Education

By definition an ethical dilemma is not easy to resolve, and as a nurse educator you are likely to be faced with many. What action would you take if you discovered that one of your best students has cheated on a test? And what if she is a single mother working full time while going to school to provide a better future for her family? By drawing on ethical theories and principles, you may still find it difficult to take the best action, but you will have reasonable grounds for arriving at your choice.

For this Discussion, analyze one of the following four ethical scenarios. Explain what you would do in that situation and what the rationale is for this choice, identifying the ethical theories and principles that guided your choice. Then describe a personal example of an ethical situation you encountered during your education and identify the salient principles that did, or should have, guided your response to it.

Scenario # 1: Academe

You are a new Faculty Member just completing your first year of teaching. In addition to the requested complimentary copies of adopted texts for your course you have received unsolicited texts from competitive publishers. A young woman with a backpack knocks on your door and introduces herself. She indicates she would like to buy any current books you are not using and is prepared to give you cash for your books. What would you do?

Scenario # 2: Academe

You are scheduled to be out of town at a nursing conference on a day that you are supposed to be teaching. You made arrangements for a faculty colleague to cover your class. You have made assignments for group work and presentations and discuss your plans for class with the colleague who has promised to cover for you. When you return the following week, you discover that class was not conducted as you had planned and that the students were allowed to leave early. Only two groups presented in person and the other groups were told to post their presentations on the Web. The content is scheduled to be on the next exam and there is no time for the student presentations. How would you handle the situation?

Scenario # 3: Staff Development

As the director of staff development, you are responsible for the orientation process for new RNs. As you make rounds on the units one day, one of the new nurses says that she really needs to talk to you about a situation she has encountered in the unit. She shares that she went with a more experienced nurse to access a central port and change the dressing. The nurse did not use gloves to remove the old dressing or to place on the new one. The patient is immunosuppressed as the result of chemotherapy. This new RN also heard his wife comment under her breath, ?Wow, she?s not using gloves.? She is concerned over the possible threat to the patient?s health, but doesn?t know what to do since the experienced nurse is highly respected on the unit, has been there for a long time, and often serves as charge nurse. She asks you what you think she should do or how the situation should be handled.

Scenario # 4: Patient Education

You are the lactation nurse, working with mothers of babies in the neonatal intensive care unit (NICU). Because of the benefits of breastfeeding, mothers are encouraged to pump and freeze their milk which is later prepared and given to the babies as appropriate. One day you overhear a new mother expressing her appreciation to a visitor for furnishing her baby with breast milk. Later when you are alone with the baby?s mother you ask how the pumping is going. She replies ?Oh, I'm unable to produce any milk so my friend pumps and brings me her milk. That is how I?m feeding the baby breast milk.? How would you handle the situation?

With these thoughts in mind:

Post your analysis of one of the four ethical situations, addressing the following:
Identify the scenario you selected and summarize what you would do in that situation.

Describe the decision-making process you used in determining your action. What ethical theory served as the foundation for your decision? What ethical principles did you apply in making this decision?

Briefly describe a personal experience of an ethical situation in education.

Analyze this situation. What theories or principles are most relevant here? What actions did you take, or should you have taken, in light of these ethical guidelines?
Read through a selection of your colleagues? postings, comparing and contrasting your own thoughts with theirs.

Respond to at least three of your colleagues? postings in one or more of the following ways:
Share an insight from having read your colleague?s posting.

Offer and support an opinion.

Expand on your colleague?s posting.

Explain why you agree or disagree with their assessments.

Validate an idea with your own experience.
Review and consider the responses to your original posting. Note what you have learned and/or any insights you have gained as a result of the comments made by your colleagues.

Your written assignments must follow APA guidelines. Be sure to support your work with specific citations from this week?s Learning Resources and any additional sources. Refer to the Pocket Guide to APA Styleto ensure your citations in the text and reference list are correct.

Course Text: McKeachie's Teaching Tips
Chapter 22?"The Ethics of Teaching and the Teaching of Ethics"

Written for educators in a range of disciplines, this chapter discusses ethical situations in education, identifying responsibilities educators owe to students, such as modeling the best scholarly and ethical standards and avoiding exploitation, harassment, and discrimination.
Course Text: Nursing Faculty Secrets
Chapter 14?" Concerns of and about Students"

To help you perform ethically and effectively as an educator, you need to be aware of, and prepared to deal with, common concerns of students. This chapter offers guidance on a wide number of situations you will likely face, such as how to establish appropriate boundaries for the faculty-student relationship and how to handle students who are doing poorly in clinical or classroom performance.
Course Text: Staff Development Nursing Secrets

Chapter 7?"Legal and Ethical Issues in Education"

This chapter, which you read last week in connection with legal issues in education, is also pertinent to this week's focus. The authors identify the kinds of ethical issues likely to occur in education and what you should do when faced with an ethical dilemma.
Course Text: Teaching in Nursing: A Guide for Faculty

Excerpt from Chapter 3?"The Academic Performance of Students: Legal and Ethical Issues" (pages 50?53)

The final section of this chapter discusses ethical issues in education, and focuses in particular on academic dishonesty and the student-faculty relationship.
Optional Re

SCENARIO
The government has created a committee to investigate the potential of implanting an electronic health record (EHR) into every U.S. citizen. This procedure would involve inserting a chip or radio frequency identification device RFID) into the individual that would contain all medical information. Access to this complete and accurate health information would help to reduce issues pertaining to patient safety and identification.
This is how the chip would work. When the patient arrives at a point-of-care, the chip would be scanned. All of the patient?s health information would be uploaded into the provider?s health information system (HIS). During the encounter, new information would be stored in the HIS. When the patient is discharged, the patient?s up-to-date health information would be uploaded from the HIS onto the patient?s implanted chip.
You have been invited to a round table discussion of the pros and cons of implanting a chip into a patient to store an EHR. You conduct an analysis of this technology by exploring the HealthCare IT News site at http://www.healthcareitnews.com/ and investigate other sources on the internet and in the current literature. You discover there are companies currently producing chips. Read their marketing information for additional insight.
DIRECTIONS
1. You are to research, compose and type a scholarly paper based on the scenario described above.
2. Use Microsoft Word and APA formatting. Consult your copy of the Publication Manual of the APA, 6th edition, as well as the resources in Doc Sharing if you have questions, e.g., margin size, font type and size (point), use of third person, and so forth. Take advantage of the writing service Smarthinking, which is accessed by clicking on the link called the Tutor Source, found under the Course Home tab.
3. The length of the paper should be 2-3 pages, excluding the title page and the reference page. Limit the references to 3-4 key sources.
4. The paper is to contain an Introduction that catches the attention of the reader with interesting facts and supporting sources of evidence, which should be included as in-text citations). The Body of Analysis should present the pros and cons regarding implanting the chip. The Conclusion and Recommendations should summarize your findings and state your position regarding whether the chip should be implanted. Make your case based on the evidence you have collected.
5. NOTE: Review the section on Academic Honesty found in the Chamberlain Course Policies. All work must be original (in your own words).
6. Submit the completed paper to the We Can But Should We? Dropbox by Sunday, 11:59 p.m. MT by the end of Week 4. Please post questions about this assignment to the weekly Q&A Forums so that the entire class may view the answers.

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




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



3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?

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







...it is impossible for medicine, nursing, or any health carerelated discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process.
nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidencebased outcomes for nursing.
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 1/10

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







www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 2/10

3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
nursing, and evaluate the effectiveness of nursing care through the measurement of nursing outcomes. In addition to these guidelines the language should describe nursing outcomes by use of a computercompatible coding system so a comprehensive analysis of the data can be accomplished.
Current Standardized Nursing Languages and Their Applications
The Committee for Nursing Practice Information Infrastructure (CNPII of the American Nurses Association (ANA) has recognized thirteen standardized languages, one of which has been retired. Two are minimum data sets, seven are nursing specific, and two are interdisciplinary. The ANA (2006b) Recognized Terminologies and Data Element Sets outlines the components of each of these languages.
The submission of a language for recognition by CNPPII is a voluntary process for the developers. This terminology is evaluated by the committee to determine if it meets a set of criteria. The criteria, which are updated periodically, state that the data set, classification, or nomenclature must provide a rationale for its development and support the nursing process by providing clinically useful terminology. The concepts must be clear and ambiguous, and there must be documentation of utility in practice, as well as validity, and reliability. Additionally, there must be a named group who will be responsible for maintaining and revising the system (Thede & Sewell, 2010, p. 293).
Another ANA committee, the Nursing Information and Data Set Evaluation Center (NIDSEC), evaluates implementation of a terminology by a vendor. This approval is similar to obtaining the good seal of approval from Good Housekeeping or the United Laboratories (UL) seal on products. The approval signifies that the documentation in the standardized language supports the documentation of nursing practice and conforms to standards pertaining to computerized information systems. The language is evaluated against standards that follow the Joint Commission's model for evaluation. The language must support documentation on a nursing information system (NIS) or computerized patient record system (CPR). The criteria used by the ANA to evaluate how the standardized language(s) are implemented, include how the terms can be connected, how easily the records can be stored and retrieved, and how well the security and confidentiality of the records are maintained. The recognition is valid for three years. A new application must be submitted at the end of the three years for further recognition. Some, but not all of the standardized languages are copyrighted. (The previous paragraphs were updated 2/23/09. See previous content.)
Vendors may also have their software packages evaluated by NIDSEC. The evaluation is a type of quality control on the vendor. An application packet must be purchased, priced at $100, then the fee for the evaluation is $20,000 (American Nurses Association, 2004). The only product currently recognized is Cerner Corporation CareNet Solutions (American Nurses Association, 2004). The recognition signifies that the software in the Cerner system has met the standards set by NIDSEC. The direct care/bedside nurse must understand the importance of the inclusion of standardized nursing languages in the software sold by vendors and demand the use of a standardized nursing language in these systems.
Benefits of Standardized Languages
The use of standardized nursing languages has many advantages for the direct care/bedside nurse. These include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. These advantages for the bedside/direct care nurse are discussed below.
Better Communication among Nurses and Other Health Care Providers
Improved communication with other nurses, health care professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language. Physicians realized the value of a standardized language in 1893 (The International Statistical Classification of Diseases and Related Health Problems, 2003) with the beginning of the standardization of medical diagnosis that has become the International Classification of Diseases (ICD10) (Clark & Phil, 1999). A more recent language, the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), provides a common language for mental disorders. When an obstetrician lists "failure to progress" on a patient's chart or a psychiatrist names the diagnosis "paranoid schizophrenia, chronic," other physicians, health care practitioners, and thirdparty payers understand the patient's diagnosis.












Improved communication with other nurses, health care professionals, and administrators of the
ICD10 and DSMIV are coded by a system of numbers for input into computers. The IDC10 is a coding system used mainly for billing purposes by organizations and practitioners while the DSMIV is a categorization system for psychiatric diagnoses. The DSMIV categories have an ICD10 counterpart code that is used for billing purposes.
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 3/10

3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
institutions in whih nurses work is a key benefit of using a standardized nursing language.
Nurses lacked a standardized language to communicate their practice until the North American Nursing Diagnosis (NANDA), was introduced in 1973. Since then several more languages have been developed. The Nursing Minimum Data Set (NMDS) was developed in 1988 (Prophet & Delaney, 1998) followed by the Nursing Management Minimum Data Set (NMMDS) in 1989 (Huber, Schumacher, & Delaney, 1997). The Clinical Care Classification (CCC) was developed in 1991 for use in hospitals, ambulatory care clinics, and other settings (Saba, 2003). The standardized language developed for home, public health, and school health is the Omaha System (The Omaha System, 2004). The Nursing Intervention Classification (NIC) was published for the first time in 1992; it is currently in its fourth edition (McCloskeyDochterman & Bulachek, 2004). The most current edition of the Nursing Outcomes Classification system (NOC), as of this writing, is the third edition published in 2004 (Moorhead, Johnson, & Maas, 2004). Both are used across a number of settings.
Use of standardized nursing languages promises to enhance communication of nursing care nationally and internationally. This is important because it will alert nurses to helpful interventions that may not be in current use in their areas. Two presentations at the NANDA, NIC, NOC 2004 Conference illustrated the use of a standardized nursing language in other countries (Baena de Morales Lopes, Jose dos Reis, & Higa, 2004; Lee, 2004). Lee (2004) used 360 nurse experts in quality assurance to identify five patient outcomes from the NOC (Johnson, Maas, & Moorhead, 2000) criteria to evaluate the quality of nursing care in Korean hospitals. The five NOC outcomes selected by the nurse experts as standards to evaluate the quality of care were vital signs status; knowledge: infection control; pain control behavior; safety behavior: fall prevention; and infection status.
Baena de Morales Lopes et al. (2004) identified the major nursing diagnoses and interventions in a protocol used for victims of sexual violence in Sao Paulo, Brazil. The major nursing diagnoses identified were: rape trauma syndrome, acute pain, fear/anxiety, risk for infection, impaired skin integrity, and altered comfort. Through the use of these nursing diagnoses, specific interventions were identified, such as administration of appropriate medications with explanations of expected side effects, emotional support, helping the client to a shower and clean clothes, and referrals to needed agencies. The authors used these diagnoses in providing care for 748 clients and concluded that use of the nursing diagnoses contributed to the establishment of bonds with their clients. These are just two examples illustrating how a standardized language has been used across nursing specialties and around the world.












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



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


Because nurses use informal notes to verbally report to one another,
Interventions that should be undertaken to in support nursing judgments and that demonstrate the depth of nursing judgment are built into the standardized nursing languages. For example, one activity listed under labor induction in the NIC language is that of reevaluating cervical status and verifying presentation before initiating further induction
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 4/10

3/11/13 Standardized Nursing Language: What Does It Mean for Nursing Practice?

rather than patient records and care plans, their work remains invisible.
measures (McCloskeyDochterman & Bulechek, 2004). This activity guides the nurse to assess the dilatation and effacement of the cervix and presentation of the fetus, before making a judgment about continuing the induction procedure.

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





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




Patient outcomes are also related to the uniqueness of the individual, the care given by other health care professionals, and the environment in which the care is provided. The American Nurses Association's National Center for Nursing Quality (NCNQ) maintains a database called the National Database of Nursing Quality
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 5/10

3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
IndicatorsTM (NDNQI) (American Nurses Association, 2006a). This database collects nursesensitive and unit specific indicators from health care organizations, compares this data with organizations of similar size having similar units, and sends the comparison findings back to the participating organization. This activity facilitates longitudinal benchmarking as the database has been ongoing since the early 1990's (National Database, 2004).
The alreadymentioned NOC system outcomes are nursesensitive outcomes, which means the they are sensitive to those interventions performed primarily by nurses (Moorehead et al., 2004). Because the NOC system measures nursing outcomes on a numerical rating scale, it, too, facilitates the benchmarking of nursing practices across facilities, regions, and countries. The current edition of NOC (2004), which assesses the impact of nursing care on the individual, the family, and the community, contains 330 outcomes classified in seven domains and 29 classes.
A NOC outcome common to nurses who work with elderly patients who have a swallowing impairment is aspiration prevention (Moorehead et al., 2004). Patient behaviors indicating this outcome include identifying risk factors, avoiding risk factors, positioning self upright for eating/drinking, and choosing liquids and foods of proper consistency. Rating each indictor on a scale from one (never demonstrated) to five (consistently demonstrated) helps track risk for aspiration in individuals at various stages of illness during the hospitalization. It also gives an indication of a person's compliance in following the prevention measures and the nurse's success in patient education.
A NOC outcome that labor nurses frequently use is pain level (Moorehead et al., 2004), related to the severity and intensity of pain a woman experiences with contractions. The pain level can be assessed before and after the use of coping techniques such as breathing exercises and repositioning. Indicators for this specific pain outcome include: reported pain, moaning and crying, facial expressions of pain, restlessness, narrowed focus, respiratory rate, pulse rate, blood pressure, and perspiration (p. 421) and are rated on a scale from severe (1) to none (5). The difference between the numerical ratings for each indicator before and after use of the coping techniques estimates the success of the intervention in achieving the outcome of reducing the pain level for laboring mothers.
Greater Adherence to Standards of Care
Related to the quality of nursing care is the level of adherence to the standards of care for a given patient population. The NIC and NOC standardized nursing language systems are based on both the input of expert nurses and the standards of care from various professional organizations. For example, the NIC intervention of electronic fetal monitoring: intrapartum (McCloskeyDochterman & Bulechek, 2004) is supported by publications of expert authors and researchers in the field of fetal monitoring and by standards of care from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The first activity listed under electronic fetal monitoring: intrapartum is to verify maternal and fetal heart rates before initiation of electronic fetal monitoring (p. 328), which is understood to be one of the gold standards for electronic fetal monitoring. There are several reasons why both heart rates need to be identified. The nurse must be sure that it is the fetal heart rate being monitored and not the heart rate of the mother. Moreover, it is important to ascertain the exact position of the fetus before positioning the fetal monitor's transducer. This illustration exemplifies how important standards are reinforced by the NIC activities.
Facilitated Assessment of Nursing Competency
Standardized language can also be used to assess nursing competency. Health care facilities are required to demonstrate the competence of staff for the Joint Commission. The nursing interventions delineated in standardized nursing languages can be used as a standard by which to assess nurse competency in the performance of these interventions. A Midwestern hospital is already doing this (Nolan, 2004). Using an example from the NIC system, specifically intrapartal care (McCloskeyDochterman & Bulechek, 2004), a nurse's competency can be established by a preceptor's watching to see whether the nurse is performing the recommended activities, such as a vaginal examination or the assessment of the fetus presentation. The preceptor can also evaluate the nurse's teaching skills regarding what the patient should expect during labor, using the activities listed under the teaching intervention.
Implications of Standardized Language for Nursing Education, Research, and Administration
In addition to enhancing the care provided by direct care nurses, standardized language has implications for nursing education, research, and administration. Nurse educators can use the knowledge inherent in standardized nursing languages to educate future nurses. Such a system can be used to describe the unique roles of the nurse. Nurse educators can teach students to use systems such as the CCC and Omaha System when in the community health fields, or the use of the NANDA, NIC, NOC terminology when in the acute care setting. References to the primary resources upon which each intervention is based are listed at the end of each individual intervention to provide information supporting each intervention. By referring to the references








www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 6/10

3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
associated with these nursing standards, nurse educators can role model the use of standardized language to help students recognize the body of knowledge upon which the standards are built. Tying the standardized language to education and practice will enhance its implementation and expand practicing nurses' knowledge of interventions, outcomes, and languages. Armed with an appreciation of the value of standardized language, students can champion further development and use of the standardized nursing languages once they enter professional practice.
The use of standardized languages can provide a launching point for conducting research on standardized languages. The research conducted by the two teams of educators at the Uniersity of Iowa on the NIC and NOC are excellent examples of the research that can be done on the standardized nursing languages using computerized databases designed for research (McCloskeyDochterman & Bulechek, 2004; Moorehead et al., 2004).





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


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


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

www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 7/10

3/11/13
Standardized Nursing Language: What Does It Mean for Nursing Practice?
The Nursing Intervention Classification (NIC) and Nursing Outcome Classification (NOC) were developed as companion languages. These have linkages to other nursing languages, such as NANDA nursing diagnoses, the Omaha System, and Oasis for home health care, among others. Both are included in Systematized Nomenclature of Medicine's (SNOMED) multidisciplinary record system. NIC has been translated into nine foreign languages and NOC into seven foreign languages.
By using one standardized nursing language, nurses from all over the world will be able to communicate with one another, with the goal of improving care for patients globally. Nurses will be able to convey the important work they do, making nursing more visible.
Correction Notice: The paragraphs below appeared in this article on the original publication date of January 31, 2008. The information in these paragraphs has been revised in the above article as of February 23, 2009 to clarify the difference between CNPII and NIDSEC. (See current content.)
Current Standardized Nursing Languages and Their Applications
The Nursing Information and Data Set Evaluation Center (NIDSEC) of the American Nurses Association (ANA) (2004) recognizes thirteen standardized languages that support nursing practice, ten of which document nursing care. The ANA (2006b) Recognized Terminologies and Data Element Sets outlines the components of each of these languages.
The submission of a language for approval by the NIDSEC is a voluntary process for the developers. This approval is similar to obtaining the good seal of approval from Good Housekeeping or the United Laboratories (UL) seal on products. The approval signifies that the documentation in the standardized language supports the documentation of nursing practice and conforms to standards pertaining to computerized information systems. The language is evaluated against standards that follow the Joint Commission's model for evaluation. The language must support documentation on a nursing information system (NIS) or computerized patient record system (CPR). The criteria used by the ANA to evaluate the standardized languages include the terminology used, how the terms can be connected, how easily the records can be stored and retrieved, and how well the security and confidentiality of the records are maintained. The recognition is valid for three years. A new application must be submitted at the end of the three years for further recognition. Some, but not all of the standardized languages are copyrighted.
Author
Marjorie A. Rutherford, RN, MA
Email: [email protected]
Marjorie A. Rutherford is currently a doctoral student at the University of South Florida. Her area of study is nursing informatics with a focus on the Nursing Intervention Classification (NIC) system and the Nursing Outcome Classification (NOC) system. She has over 32 years of obstetrical experience, primarily in labor and delivery, and has five years of mental health experience. She has taught nursing as a clinical instructor at Polk Community College and as an adjunct instructor at the University of South Florida. She is currently employed on the nursing faculty of Keiser College in Lakeland, FL.
References
American Nurses Association (2006a). NCNQ, Home of the NDNQI. Retrieved January 15, 2006, from www.nursingworld.org/quality/
Amercian Nurses Association. (2006b) Recogized terminologies and data element sets.
American Nurses Association (2004). NIDSEC. Retrieved September 14, 2004. Association of Perioperative Registered Nurses (n.d.). Perioperative nursing data set. Retrieved September 30, 2004, from www.aorn.org/research/ Baena de Morales Lopes, M., Jose dos Reis, M., & Higa, R. (2004). Nursing diagnosis: An aid when assisting the female victim of sexual violence. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. Cavendish, R. (2001). The use of standardized language to describe abdominal pain. The Journal of School Nursing, 17(5), 266273. Clark, J., & Lang, N. (1992). Nursing's next advance: An internal classification for nursing practice. International Nursing Review, 39(4), 109111, 128. Clark, J. & Phil, M.. (1999). A language for nursing. Nursing Standard, 13(31), 4247. Duke University School of Nursing. (n.d.). How to choose a nursing language. Retrieved December 28, 2006, from www.duke.edu/~goodw010/vocab/howtochoose.html Huber, D., Schumacher, L., & Delaney, C. (1997). Nursing







www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008No1Jan08/ArticlePreviousTopic/Standardize... 8/10

3/11/13 Standardized Nursing Language: What Does It Mean for Nursing Practice?
management data set. JONA, 27(4), 4248. International Council of Nurses. (2006). International classification of nursing practice (ICNP). Retrieved January 15, 2006, from www.icn.ch/icnp_def.htm Johnson, M., Maas, M., & Moorhead, S. (2000). Nursing outcomes classification (NOC) (2nd ed.). St. Louis: Mosby. Keenan, G. (1999). Use of standardized nursing language will make nursing visible. Michigan Nurse, 72(2), 1213. Kennedy, R. (2003). The nursing shortage and the role of technology. Nursing Outlook, 51(3), S3334. LaDuke, S. (2000). NIC puts nursing into words. Nursing Management, 31(2). Lee, B. (2004). Availability of NOC for the evaluation of quality of nursing care in Korea. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. McCloskey Dochterman, J., & Bulechek, G. (2004). Nursing interventions classification (NIC) (4th ed.). St. Louis, MO: Mosby. Moorehead, S., Johnson, M., & Maas, M. (2004). Nursing outcomes classification (NOC) (3rd ed.). St. Louis, MO.: Mosby. National Database of Nursing Quality Indicators. (2004). Transforming data into quality care Washington, DC: American Nurses Association. Nolan, P. (2004). NIC and the performance continuum. Paper presented at the NANDA, NIC, NOC 2004, Chicago, IL. Nursing Quality Forum. (20002004). Welcome to the national quality forum, project summaries. Retrieved January 15, 2006, from www.qualityforum.org/ Nursing Quality Forum. (May 2003). Core measures for nursing care performance. Retrieved January 15, 2006, from www.qualityforum.org/ Pearson, A. (2003). The role of documentation in making nursing work visible. International Journal of Nursing Practice, 9(5), 271. Prophet, C. & Delaney, C. (1998). Nursing outcomes classification: Implications for nursing information systems and the computerbased patient record. Journal of Nursing Care Quality, 12(5), 2129. Saba, V. (2003). Clinical care classification (CCC) System. Retrieved December 1, 2004 from www.sabacare.com The international statistical classification of diseases and related health problems (10th Ed.). (2003). Retrieved September 30, 2004 from www.who.int/classifications/icd/en/ The Omaha system: Omaha system overview. (2004). Retrieved from www.omahasystem.org/systemo.htm
Thede, L. Q., & Sewell, J. P. (2010). Informatics and Nursing: Opportunities and Challenges (3rd ed.). Philadelphia: Lippincott, Williams & Wilkins.
Zytkowski, M. E. (2003). Nursing informatics: The key to unlocking contemporary nursing practice. AACN Clinical Issues, 14(3), 271281.







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

Related Articles
Characteristics of a Good Nursing Nomenclature from an Informatics Perspective
Rita D. Zielstorff, RN, MS, FAAN (September 30, 1998)
Nursing Nomenclature and Classification System Development
Marjory Gordon, PhD, RN, FAAN (September 30, 1998)
Home Health Care Classification System (HHCC): An Overview
Virginia K. Saba, EdD, RN, FAAN, FACMI (August 30, 2002)
Critical Need to Address Accuracy of Nurses Diagnoses
Margaret Lunney, RN, PhD (January 31, 2008)
The International Classification for Nursing Practice (ICNP) Programme: Advancing a Unifying Framework for Nursing?Amy Coenen, PhD, RN , FAAN (April 3, 2003)
The International Classification For Nursing Practice Project
June Clark, DBE, PhD, RN, RHV, FRCN (September 30, 1998)
Is One Taxonomy Needed for Health Care Vocabularies and Classifications?
Kathleen A. McCormick, PhD, RN, FAAN, FRCNA, FACMI; Cheryl B. Jones, PhD, RN (September 30, 1998)
Factors Influencing NursingSensitive Outcomes in Taiwanese Nursing Homes
KePing A. Yang, PhD, RN; Lillian M. Simms, PhD, RN, FAAN; JeoChen T. Yin, PhD, RN (August 3, 1999)
Classifying Nursing Work
Geoffrey C. Bowker, Ph.D.; Susan Leigh Star, Ph.D.; Mark A. Spasser, Ph.D., AHIP (March 20, 2001)

.






www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardize... 9/10

3/11/13 Standardized Nursing Language: What Does It Mean for Nursing Practice?

Follow Us on:





2013 The American Nurses Association, Inc. All Rights Reserved?American Nurses Association 8515 Georgia Avenue Suite 400 Silver Spring, MD 20910 ISSN: 10913734 | 18002744ANA | Copyright Policy | Privacy Statement
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardiz... 10/10


Connecting Health and Humans 337 K. Saranto et al. (Eds.)?IOS Press, 2009? 2009 The authors and IOS Press. All rights reserved.
doi:10.3233/978-1-60750-024-7-337

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

Cultural Health Promotion Plan Paper

This is an INDIVIDUAL assignment based on community data and the Healthy People 2010/2020 National Objectives.

DUE DATE: July 6, 2010 by 10:00 p.m. with late submission policy application to this assignment.
Complete the paper according to APA 6th Edition Guidelines as a word processed document. The paper must be submitted electronically via course Web Courses Assignment function.

The paper is limited to a MAXIMUM of Ten (10) pages (including the title page and references pages; NO Abstract is needed for this assignment). Do not exceed the ten page limit as only ten pages will be read and graded! The paper must double spaced in font size 12. Include Title Page with a running head and a page number according to APA Sixth Edition format. Page one begins on the title page. References using APA format are included in the total page count.

The Cultural Health Promotion Plan paper topics are derived from the work that was previously identified by faculty, students, and other pertinent resources in the community. The problems/needs/risks are drawn from Community Data/Healthy People 2010/2020.

1. Each student will select ONE problem/need/risk from the list provided by Dr. Ark. The list is located in Web Courses Course Web Site on a separate Discussion Board. The problem/need/risk is written in the four-part community diagnosis format. The student should not alter the diagnosis.

2. Develop a cultural health promotion plan as if the plan would be implemented for a target group within any community, not particular to your assigned Community Nursing Coalition. Writing the plan paper assignment will aid in the development of the program planning and evaluation skills that you will use in the development of the senior project in Public Health Nursing Clinical in the last semester of the Basic BSN Program ?" the topic area of your paper is not necessarily the topic area for the community intervention plan in the Public Health Nursing clinical, however the skills you learn in this course will prepare you for the important service-learning work in the community during the last semester of the program. RN-BSN students conduct a teaching project/evaluation in NUR 4604L Community/Public Health Nursing Practicum.


3. Submit the plan paper by the due date and time.







Here are thoughts to guide the development of the paper regarding health variations by cultural heritage:

Cultural Diversity refers to the differences among people based upon shared ideology and valued sets of beliefs, norms, customs, and meanings evidenced in way of life (ANA, 1996, Position Statement on Cultural Diversity). This diversity is expressed in various ways. Diversity in history, beliefs, practices, and opportunities not only exist among cultural groups, but also typically exist across a wide continuum within the group. Health behaviors are influenced by culture and cultural values as well as by socioeconomic status.

In this assignment, students develop a health promotion plan for a cultural group living in the United States, not necessarily in your CNC community location. You are to learn as much as you can about the cultural norms and patterns and how these norms and patterns influence health practices. The purpose of this assignment is for the student to develop a deeper understanding and sensitivity regarding the role of culture in life of the client and in nursing through the examination of a cultural/ethnic group.

Thoughts to consider as you develop the paper:

Health and Culture: The nurse must recognize that members of various cultures define health differently. Individuals may define themselves or others in their group as healthy even though the nurse identifies symptoms of disease. Cultural priorities of the client may differ from that of the nurse.

Culture and Healing: Individuals and families in various cultural groups may also use traditional healing systems, sometimes called lay or folk-healing systems, with or without allopathic (modern) medicine. In addition to seeking help from the nurse as a health care provider, clients may also seek help from traditional or religious healers. Most nurses have experienced clients who combine medical care with prayer. Nurses need to be sensitive to, respectful of and nonjudgmental regarding patients health beliefs and practices in order to maximize patient outcomes.

Health status of all clients is influenced by the interaction of physiological, cultural, psychological, economic and societal factors. Diversity within and among groups necessitates data collection activities and programs that are tailored to meet the unique health care needs of different subgroups.

Health beliefs are translated into health care practices, which then affect health status. What constitutes appropriate care for specific health conditions may be guided by cultural and social class expectations held by members of the culture.

Health Information and Education:
Planning health education programs requires identifying and building on cultural strengths and ensuring sensitivity to cultural factors. Meeting the language and cultural needs of each identified minority group, using minority specific community resources to tailor educational approaches, and developing materials and methods of presentation that are at the educational level of the target population are essential considerations in the planning process. Health programs should be sustainable over a long period of time and accountable to the clients.

Paper Guidelines
Format the paper according to APA Sixth edition guidelines; you will have Level 1 and Level 2 Headers in this paper.


Insert a Title Page

Then, page two (repeat title of paper on page two)

Community Diagnosis

State the community diagnosis addressing the problem/need/risk that you selected from the approved list for this paper. Be sure to include the in text cite for Healthy People 2010 in your References list.
First address the
Aspects of Cultural Assessment

Ethnic/racial identity How does the group identify itself in terms ethnicity and racial background? What is the range of interaction outside of the cultural group? Are recreational, educational, and other social activities within the ethnic reference group, the wider community, or both?
History and Value Orientation How are values derived? What is the historical experience of the group that may have impacted values?
Language-communication process What languages are spoken in the home? And by whom? What language is preferred when speaking to outsiders? Do second and third generations in the U.S. speak the language of their grandparents?
Health Belief and Practices What are the traditional health beliefs? How common are these beliefs and practices within this group? To what extent are folk healing practices and practitioners used? Is access to care and equality of care an issue for this group?
Religious Beliefs Religious articles & practices, how spirituality is defined. Remember that Religious Beliefs and Spirituality are different concepts.
Spirituality How is spirituality defined? Remember that Religious Beliefs and Spirituality are different concepts.
Lifecycle events Which life cycle events are important to the culture? What are the customs associated with births, coming of age, marriage, and death?
Nutritional Behavior/Diet Are there restrictions? Are there common practices?


Review of Literature on the Health Problem

Complete a review of the literature highlighting the health problem and the target group. Be sure to use headers to organize this section of the paper. Students must use the Maurer & Smith textbook and optional use of other textbooks from the first semester courses as references. You may use literature from Allied Health however you must have THREE evidence-based nursing references (nursing literature/nursing journals) published within the last five years included in your in text citations within the paper and on the list of references. In other words, include cites inthe body of the paper and the full citations of all sources in the References section of the paper according to APA format. Remember that not all journals listed in the CINAHL database are nursing journals.

You should answer these questions in the review of literature ?" these three categories are headers:
Why is this diagnosis a health problem for this target group?
What are the current nursing interventions for this problem?
What interventions have been successful and what interventions have NOT been successful?

Planning

Plan Title
Give the plan a title ?" this title must be consistent on the title page, on the second page, and here.

Short Term Goal
List one short term goal with the time frame of the final semester (15 week 45-hour clinical) in the BSN program. Remember that education is a strategy not an outcome or goal.

Measurable Objectives
Write three measurable, time specific learner objectives. State the learning domain for each of the three objectives; you should write in the domains of Cognitive; Affective; and/or Psychomotor. Remember that in order to have an effective program intervention, you would not have all three of the objectives in the cognitive domain, nor would you necessarily have one objective for each of the domains.
Objectives Summary
Consider all of the objectives together; write two paragraphs (maximum) addressing these areas:
The Objectives are: (1.) Specific; (2.) Measurable; (3.) Reasonable/Feasible; (4.) Fit with a community-based setting; and (5.) Easily understood by clients.

Budget
Create a Brief Budget (must be in Table format according to APA)
Determine a budget for the project.
Time: Consider $14.00/hour for the student nurse rate (remember that you will have a 45-hour clinical course in which to complete the project ~ you may have other student nurses assisting you on the project).
Materials: while brochures may be donated - in kind - there is still a cost.
List other resources needed for the project.
Be sure to total out the amount of the project using the Table format guidelines in the APA manual.

Intervention
Health Promotion Strategies/Methods
Describe in detail the strategies/methods for each of the three objectives. Remember to use headers throughout this section to clearly articulate the intervention. You should list Objective One, then describe the primary and secondary prevention strategies; then, Objective Two, describing the primary and secondary prevention strategies; then, Objective Three, describing the primary and secondary prevention strategies. Explain the rationale for selecting the strategies/methods. Remember that you are writing strategies at the levels of Primary Prevention & Secondary Prevention levels, and not Tertiary Prevention level strategies in this paper.

Evaluation
Use three headers
Objective One
Objective Two
Objective Three
The text in paragraph form will follow each of the headers as displayed above. In the text, tell the reader how the outcomes of each objective are measured/assessed at both the primary and secondary level of prevention. Remember that an evaluation is based on objectives. An evaluation is the appraisal of the effects of activities and/or program interventions. An evaluation is conducted in order to determine the relevance, progress, efficiency, effectiveness & impact of program activities.

References
Formatted according to APA Sixth edition guidelines

There are faxes for this order.

As a unique perspective of inquiry, nursing has distinct concepts that are defined. As you begin your introspective analysis of your definition of nursing, define your interpretation of the following components of the nursing metaparadigm:

Person (client, patient)
Health
Environment
Nursing

-Use APA format

This is a Literature Review paper being done as a preface to a hypothetical research study.

I need 10 sources. I need to use the 6 sources that I am attaching, please provide another 4. Sources MUST be "peer reviewed", from 2004 on. These literature/research studies can be grouped thematically, chronologically...whatever works best, but they need to be grouped in some order.

This paper does not require an abstract or running head.

I am attaching VERY specific instructions from the instructor on what the paper needs to include. In the introduction of paper, the reason this topic is being researched is due to its relevance in the field of nursing as it applies to patient health care and STD risk awareness. In the conclusion of paper, please use Nursing when providing insight into the relationship of this central topic and a profession. (see instruction page). Thank you.

There are faxes for this order.

Resource: Preopening Budget Example

Design a 3- to 5-year financial plan to implement the goals and objectives:
(1) Form relationships with the community (local and global): This will be accomplished through:
? Social Media Networking
? Partnerships with other Non-profit health care providers
(2) Ensure that patient health care information is kept secure: This will be accomplished through the following:
? Employing a team of IT/IS experts who work full-time in ensuring HIPAA privacy;
? Ensuring the system is using the most up-to-date and secure information technology available.

The deliverables for the financial plan include a projected budget created in Microsoft? Excel? and a report in Microsoft? Word that clarifies and explains the financial plan.

Section One: Projected Budget
?The projected budget should be a Microsoft? Excel? spreadsheet that contains a 3- to 5-year financial projection that includes detailed expenditures, income, contingency, gain or loss, and ROI (if applicable).

Section Two: Financial Plan Explanation
?Write a 1,050- to 1,400-word narrative discussing the fiscal detail of the plan and the assumptions that were used in developing the projected budget.
?Include all the elements required in the projected budget.
?Include capital expenditure planning and contingency plans for unexpected events.
?Financial details that cannot be found may be assumed.
?Budget summary: When explaining the budget, answer the following questions: ?What is the organization?s current business model? Did you make any financial adjustments that go against the way the organization planned its finances in the past? If so, what were they, and why did you make the changes?
?How did the organization?s internal resources and financial capabilities affect your financial plan? How will they affect implementation of the plan?

Include a conclusion at the completion of the paper.