Delivering Value Through Evidence-Based Practice
Macias, Charles G; Loveless, Jennifer N; Jackson, Andrea N; Srinivasan, Suresh. Clinical Pediatric Emergency Medicine; Maryland Heights Vol. 18, Iss. 2, (2017): 89-97. DOI:10.1016/j.cpem.2017.05.002
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Unwanted variation in care is a challenge to high-quality care delivery in any healthcare system. Across the Emergency Medical Services for Children (EMSC) continuum, there is wide variation in care delivery for which best practices have demonstrated opportunities to minimize that variation through clinical standards (evidence-based pathways, protocols, and guidelines for care). A model of development of clinical standards is delineated and tools used in that process are described. Implementation strategies for improving utilization are also described with clinical decision support tools being a promising strategy for accelerating uptake of guidelines. Critical to implementing guidelines through improvement science strategies is the ability to make iterative improvements directed by data and analytics. The progression of sophistication in a system's informatics and analytics capabilities is driven by a maturity of data reporting to analytics that drives decision support for implementing clinical standards. Integration of financial data into the clinical standards processes and analytics platforms is necessary to determine value of the work. Within the EMSC continuum, a number of initiatives will drive national clinical standards activities and are fueled by current pockets of successful development and implementation activities within organizations and systems.
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Reply1
Re: Topic 1 DQ 2
Topic 1 DQ 2
The inclusion of evidence-based practice provides nurses with the scientific research and experience to make a comprehensive decision. The practice enables the nurses to re-evaluate the risks and only adopt the best mechanism to ensure an improved patient outcome. Patients are also able to receive the best available outcomes. It is very advisable to move the nursing practice to be evidence-based to ensure that there is patient-centered care that is safe, inclusive, and effective. However, there have been barriers towards this progress since only 15% of U.S practice is evidence-based. One of the barriers which have led to lagging behind in adopting evidence-based practice is nurse shortage. Evidence-based practice requires massive documentation and research together with increased testing and experience. This requires a large human resource which is not available due to nurse shortage across the united states (Stavor et al., 2017). This has acted as a barrier towards the goal of moving practice to evidence-based. The government should employ more nurses and also dedicate some of the workforces specifically to matters to do with shifting traditional caregiving to EBP.
The second barrier is unsupportive administration. Research indicates that over 70% of nurses know about evidence-based practice, but the barriers to the practice in a clinical setting make it hard for them to adopt it. To move practice to EBP requires active collaboration from all stakeholders and more so from the administration of the healthcare setting. However, most administrations have been termed as unsupportive for the move due to the challenges of resources involved in the move. EPB presents a huge cost in the beginning due to its data requirements. However, it is able to reduce the cost of healthcare by 35% after its implementation. Lack of support from the management makes it hard to move nursing practice to EBP in a clinical setting since it’s a collaborative activity that requires dedicated and goal-oriented leadership (Duncombe, 2018). Policies and regulations should be created which force the push to enable the administration of various healthcare to have no otherwise but to comply in the shift.
References
Stavor, D. C., Zedreck-Gonzalez, J., & Hoffmann, R. L. (2017). Improving the use of evidence-based practice and research utilization through the identification of barriers to implementation in a critical access hospital.
JONA: The Journal of Nursing Administration
,
47
(1), 56-61.
Duncombe, D. C. (2018). A multi‐institutional study of the perceived barriers and facilitators to implementing evidence‐based practice.
Journal of Clinical Nursing
,
27
(5-6), 1216-1226.
Reply 2
aur
1 posts
Re: Topic 1 DQ 2
As unprecedented development in the diagnosis, treatment, and long-term management of disease bring Americans closer than ever to the promise of personalized health care, we are faced with similarly unprecedented c.
This document presents a business plan for creating a multidisciplinary nephrology disease management team at James H. Quillen VA Medical Center. The plan aims to prevent progressive renal disease where possible, manage it where necessary, and provide timely dialysis and transplantation in a cost-effective manner using best practices. It proposes consolidating nephrology care into one location with dedicated staff to better coordinate care using a multidisciplinary approach. This is expected to improve outcomes and lower costs by delaying dialysis onset and promoting more cost-effective treatment options like transplantation and peritoneal dialysis.
This document proposes creating a multidisciplinary renal disease management team at the James H. Quillen VAMC. The team would work to prevent progressive renal disease where possible, manage it where necessary, and provide timely dialysis and transplantation in a cost-effective manner using best practices. The team would adopt a specialty PACT structure to more efficiently manage high-risk patients and delay progression to dialysis. It would have dedicated administrative support and colocate all renal care services in one location to improve access and outcomes for veterans. The proposal estimates this integrated care model could save $50,000-80,000 per year for each patient whose dialysis is delayed, and $20,000-50,000 per patient by
Scheduling Of Nursing Staff in Hospitals - A Case Studyinventionjournals
This document summarizes a study that developed a goal programming algorithm to schedule 11 nurses across a two-week period at a hospital. The goals were to satisfy each nurse's contracted time, ensure minimum nurse requirements by role each day, give full-time nurses a weekend off while avoiding more than two consecutive days off, and honor nurses' weekend preference when possible. The algorithm solved the 154-variable, 120-constraint scheduling problem in under 30 seconds. The results showed schedules that met goals for minimum nurse levels each day and individual nurses' two-week schedules.
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
An Emerging Science Of Improvement In Health CareKelly Lipiec
This document summarizes an article that discusses the emerging field of improvement science in healthcare. It outlines some key challenges facing healthcare systems, including increasing demand, high costs, and reports of shortcomings. It then provides an overview of improvement science, which aims to establish systematic methods for improving both clinical treatment and how healthcare systems deliver care to patients. The document discusses extending improvement science approaches from industry, using data from quality registers, and adding a normative perspective. It concludes by reflecting on future research directions for this emerging field.
Develop a presentation no longer than 10-12 minutes with compr.docxsimonithomas47935
Develop a presentation no longer than 10-12 minutes with comprehensive speaker's notes that covers all of the major areas of your proposal.
You will need to post your Evidence-Based Practice Presentation to the main forum in Topic 8 as directed by the instructor for class discussion and peer feedback.
While APA format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Organizational Culture and Readiness Assessment
The purpose of the assessment is to evaluate the strengths and weakness, in the readiness of evidence-based practice (EBP) innovation, practice change and the capacity to facilitate EBP changes in the Cuyahoga County Correctional Center (CCCC). The Organization Culture and Readiness Assessment (OCRA), will measure questions about EBP focusing on the culture and its readiness for application (Melnyk & Fineout-Overholt, 2015, p. 569). The use of the assessment scale will view what support is needed to assist in the changing attitudes, behaviors, skills and the thought processes of individuals who are responsible for caring for patient/inmates (Helfrich, Li, Sharp, & Sales, 2009).
Based on the OCRA the CCCC is getting ready for EBP organizational change in some areas, but the scores of the assessment questions both can hinder and support efforts for implementation. For example, scores were noted for the nursing administrators, providers and the healthcare staff focus themselves on committing to EBP. However, mentorship from Advanced Practiced Nurses scored lower due to those currently employed and possible time constraints. However, the security rating was much lower with obligating themselves to EBP in healthcare, they are more focused on the safety of the environment but rank high on the shared responsibility of the outcome of the care, possibly due to the entire system is employed under the sheriff’s department.
Another area that had interesting sores were the overall workshops, technology for implementing communication and collaboration to support EBP. The scores were higher in the EMR for medical staff interoperability for healthcare shared medical records with the county hospital. However, the ratings were much lower in the internal connection of innovation that promotes EBP between medical providers and security. Another attractive area was the extent of decision generation in this type of environment suggesting there is a lack of administration healthcare leadership in implementing EBP, which leads to decisions generated from the administration who has little to no knowledge of scientific understanding or skill that encourage EBP. The overall rating for .
The Imperative of Linking Clinical and Financial Data to Improve Outcomes - H...Health Catalyst
Quality and cost improvements require the intelligent use of financial and clinical data coupled with education for multi-disciplinary teams who are driving process improvements. Once a data warehouse is established, healthcare organizations need to set up multi-disciplinary clinical, financial, and IT specialist teams to make the best use of the data. Sometimes, financial involvement is minimized or even excluded for a number of reasons that can turn out to be counterproductive. However, including financial measurements and participation up front can help enhance the recognized value and sustainability of quality improvement or waste reduction efforts. the In this session you will learn keys to success and real-life examples of linking clinical, financial and patient satisfaction data via multi-disciplinary teams that produce impressive results.
Reply1
Re: Topic 1 DQ 2
Topic 1 DQ 2
The inclusion of evidence-based practice provides nurses with the scientific research and experience to make a comprehensive decision. The practice enables the nurses to re-evaluate the risks and only adopt the best mechanism to ensure an improved patient outcome. Patients are also able to receive the best available outcomes. It is very advisable to move the nursing practice to be evidence-based to ensure that there is patient-centered care that is safe, inclusive, and effective. However, there have been barriers towards this progress since only 15% of U.S practice is evidence-based. One of the barriers which have led to lagging behind in adopting evidence-based practice is nurse shortage. Evidence-based practice requires massive documentation and research together with increased testing and experience. This requires a large human resource which is not available due to nurse shortage across the united states (Stavor et al., 2017). This has acted as a barrier towards the goal of moving practice to evidence-based. The government should employ more nurses and also dedicate some of the workforces specifically to matters to do with shifting traditional caregiving to EBP.
The second barrier is unsupportive administration. Research indicates that over 70% of nurses know about evidence-based practice, but the barriers to the practice in a clinical setting make it hard for them to adopt it. To move practice to EBP requires active collaboration from all stakeholders and more so from the administration of the healthcare setting. However, most administrations have been termed as unsupportive for the move due to the challenges of resources involved in the move. EPB presents a huge cost in the beginning due to its data requirements. However, it is able to reduce the cost of healthcare by 35% after its implementation. Lack of support from the management makes it hard to move nursing practice to EBP in a clinical setting since it’s a collaborative activity that requires dedicated and goal-oriented leadership (Duncombe, 2018). Policies and regulations should be created which force the push to enable the administration of various healthcare to have no otherwise but to comply in the shift.
References
Stavor, D. C., Zedreck-Gonzalez, J., & Hoffmann, R. L. (2017). Improving the use of evidence-based practice and research utilization through the identification of barriers to implementation in a critical access hospital.
JONA: The Journal of Nursing Administration
,
47
(1), 56-61.
Duncombe, D. C. (2018). A multi‐institutional study of the perceived barriers and facilitators to implementing evidence‐based practice.
Journal of Clinical Nursing
,
27
(5-6), 1216-1226.
Reply 2
aur
1 posts
Re: Topic 1 DQ 2
As unprecedented development in the diagnosis, treatment, and long-term management of disease bring Americans closer than ever to the promise of personalized health care, we are faced with similarly unprecedented c.
This document presents a business plan for creating a multidisciplinary nephrology disease management team at James H. Quillen VA Medical Center. The plan aims to prevent progressive renal disease where possible, manage it where necessary, and provide timely dialysis and transplantation in a cost-effective manner using best practices. It proposes consolidating nephrology care into one location with dedicated staff to better coordinate care using a multidisciplinary approach. This is expected to improve outcomes and lower costs by delaying dialysis onset and promoting more cost-effective treatment options like transplantation and peritoneal dialysis.
This document proposes creating a multidisciplinary renal disease management team at the James H. Quillen VAMC. The team would work to prevent progressive renal disease where possible, manage it where necessary, and provide timely dialysis and transplantation in a cost-effective manner using best practices. The team would adopt a specialty PACT structure to more efficiently manage high-risk patients and delay progression to dialysis. It would have dedicated administrative support and colocate all renal care services in one location to improve access and outcomes for veterans. The proposal estimates this integrated care model could save $50,000-80,000 per year for each patient whose dialysis is delayed, and $20,000-50,000 per patient by
Scheduling Of Nursing Staff in Hospitals - A Case Studyinventionjournals
This document summarizes a study that developed a goal programming algorithm to schedule 11 nurses across a two-week period at a hospital. The goals were to satisfy each nurse's contracted time, ensure minimum nurse requirements by role each day, give full-time nurses a weekend off while avoiding more than two consecutive days off, and honor nurses' weekend preference when possible. The algorithm solved the 154-variable, 120-constraint scheduling problem in under 30 seconds. The results showed schedules that met goals for minimum nurse levels each day and individual nurses' two-week schedules.
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
An Emerging Science Of Improvement In Health CareKelly Lipiec
This document summarizes an article that discusses the emerging field of improvement science in healthcare. It outlines some key challenges facing healthcare systems, including increasing demand, high costs, and reports of shortcomings. It then provides an overview of improvement science, which aims to establish systematic methods for improving both clinical treatment and how healthcare systems deliver care to patients. The document discusses extending improvement science approaches from industry, using data from quality registers, and adding a normative perspective. It concludes by reflecting on future research directions for this emerging field.
Develop a presentation no longer than 10-12 minutes with compr.docxsimonithomas47935
Develop a presentation no longer than 10-12 minutes with comprehensive speaker's notes that covers all of the major areas of your proposal.
You will need to post your Evidence-Based Practice Presentation to the main forum in Topic 8 as directed by the instructor for class discussion and peer feedback.
While APA format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Organizational Culture and Readiness Assessment
The purpose of the assessment is to evaluate the strengths and weakness, in the readiness of evidence-based practice (EBP) innovation, practice change and the capacity to facilitate EBP changes in the Cuyahoga County Correctional Center (CCCC). The Organization Culture and Readiness Assessment (OCRA), will measure questions about EBP focusing on the culture and its readiness for application (Melnyk & Fineout-Overholt, 2015, p. 569). The use of the assessment scale will view what support is needed to assist in the changing attitudes, behaviors, skills and the thought processes of individuals who are responsible for caring for patient/inmates (Helfrich, Li, Sharp, & Sales, 2009).
Based on the OCRA the CCCC is getting ready for EBP organizational change in some areas, but the scores of the assessment questions both can hinder and support efforts for implementation. For example, scores were noted for the nursing administrators, providers and the healthcare staff focus themselves on committing to EBP. However, mentorship from Advanced Practiced Nurses scored lower due to those currently employed and possible time constraints. However, the security rating was much lower with obligating themselves to EBP in healthcare, they are more focused on the safety of the environment but rank high on the shared responsibility of the outcome of the care, possibly due to the entire system is employed under the sheriff’s department.
Another area that had interesting sores were the overall workshops, technology for implementing communication and collaboration to support EBP. The scores were higher in the EMR for medical staff interoperability for healthcare shared medical records with the county hospital. However, the ratings were much lower in the internal connection of innovation that promotes EBP between medical providers and security. Another attractive area was the extent of decision generation in this type of environment suggesting there is a lack of administration healthcare leadership in implementing EBP, which leads to decisions generated from the administration who has little to no knowledge of scientific understanding or skill that encourage EBP. The overall rating for .
The Imperative of Linking Clinical and Financial Data to Improve Outcomes - H...Health Catalyst
Quality and cost improvements require the intelligent use of financial and clinical data coupled with education for multi-disciplinary teams who are driving process improvements. Once a data warehouse is established, healthcare organizations need to set up multi-disciplinary clinical, financial, and IT specialist teams to make the best use of the data. Sometimes, financial involvement is minimized or even excluded for a number of reasons that can turn out to be counterproductive. However, including financial measurements and participation up front can help enhance the recognized value and sustainability of quality improvement or waste reduction efforts. the In this session you will learn keys to success and real-life examples of linking clinical, financial and patient satisfaction data via multi-disciplinary teams that produce impressive results.
Do you ever wonder whynurses engage in practicesthat areDustiBuckner14
D
o you ever wonder why
nurses engage in practices
that aren’t supported by
evidence, while not implementing
practices substantiated by a lot
of evidence? In the past, nurses
changed hospitalized patients’ IV
dressings daily, even though no
solid evidence supported this prac-
tice. When clinical trials finally
explored how often to change IV
dressings, results indicated that
daily changes led to higher rates
of phlebitis than did less frequent
changes.1 In many hospital EDs
across the country, children with
asthma are treated with albuterol
delivered with a nebulizer, even
though substantial evidence shows
that when albuterol is delivered
with a metered-dose inhaler plus
a spacer, children spend less time
in the ED and have fewer adverse
effects.2 Nurses even disrupt
patients’ sleep, which is important
for restorative healing, to docu-
ment blood pressure and pulse
rate because it’s hospital policy to
take vital signs every two or four
hours, even though no evidence
supports that doing so improves
the identification of potential
complications. In fact, clinicians
often follow outdated policies and
procedures without questioning
their current relevance or accu-
racy, or the evidence for them.
When a spirit of inquiry—an
ongoing curiosity about the best
evidence to guide clinical decision
making—and a culture that sup-
ports it are lacking, clinicians are
unlikely to embrace evidence-based
practice (EBP). Every day, nurses
across the care continuum perform
a multitude of interventions (for
example, administering medica-
tion, positioning, suctioning)
that should stimulate questions
about the evidence supporting
their use. When a nurse possesses
a spirit of inquiry within a sup-
portive EBP culture, she or he
can routinely ask questions about
clinical practice while care is being
delivered. For example, in patients
with endotracheal tubes, how
does use of saline with suctioning
compared with suctioning without
saline affect oxygen saturation?
[email protected] AJN � November 2009 � Vol. 109, No. 11 49
By Bernadette Mazurek Melnyk, PhD,
RN, CPNP/PMHNP, FNAP, FAAN,
Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Susan B. Stillwell, DNP,
RN, CNE, and Kathleen M.
Williamson, PhD, RN
Igniting a Spirit of Inquiry: An Essential Foundation for
Evidence-Based Practice
How nurses can build the knowledge and skills they need to
implement EBP.
Every day, nurses perform interventions (for
example, administering medication, positioning,
suctioning) that should stimulate questions
about the evidence supporting their use.
This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach
to the delivery of health care that integrates the best evidence from studies and patient care data with clinician
expertise and patient preferences and values. When delivered in a context of caring a ...
This document provides a performance appraisal for Dr. Zamfirova, an internal medicine physician. It summarizes research on different methods used to evaluate physician performance, including appointment length, clinical performance assessments using composite measures, a physician's capacity for change, and compensation based on RVUs. The research presented acknowledges there are many factors that influence performance evaluations and no single measure can accurately capture a physician's overall quality of care.
This document discusses the importance of evidence-based practice in nursing. It begins by explaining how evidence-based practices have reverberated across nursing practice, education, and science. The need for improved healthcare calls for evidence-based practices to be incorporated into health systems to increase effectiveness, safety, and efficiency. New practice approaches should be evidence-based to help move healthcare in the desired direction. The document also provides an example of how one facility successfully reduced hospital-acquired pressure ulcers through implementing evidence-based skin assessment and wound care protocols. It concludes by stating the importance of evidence-based practices in tackling issues like hospital-acquired pressure ulcers.
The Healthcare Team as the Healthcare Provider: A Different View of the Patie...guesta14581
Presentation to the Ohio State Society of Medical Assistant's annual convention about the Patient Centered Medical Home and the role of the medical assistant
Impact Of Improved Documentation On An Academic Neurosurgical PracticeAntoinette Williams
This document discusses the impact of an educational intervention on documentation accuracy at an academic neurosurgery department. The intervention provided training to physicians on properly documenting patient comorbidities. After the intervention, measures of case complexity including severity of illness, risk of mortality, and case mix index all significantly increased, reflecting more accurate documentation. As a result, the average margin per discharge improved by 42.2%, showing the financial impact of improved documentation. The study demonstrates that targeted training can meaningfully improve documentation quality and its effects on quality metrics and revenue.
Matching the Research Design to the Study QuestionAcademyHealth
This document discusses matching research designs to study questions in comparative effectiveness research (CER). It notes that the appropriate research design depends on factors like who is asking the question, the amount of existing evidence, and whether the focus is on individual outcomes or system-level decisions. Both experimental and non-experimental designs have important roles to play in CER. An ideal CER enterprise would support a variety of study designs, methods research, data infrastructure, and efforts to translate evidence into practice.
Harvard style research paper nursing evidenced based practiceCustomEssayOrder
This document discusses evidence-based practice in health and social care. It defines evidence-based practice as using the best available research evidence to guide decisions about patient care and service delivery. The document outlines how evidence-based practice helps improve patient outcomes and keep practices current. It also examines how social care providers are expected to demonstrate the effectiveness and accountability of their services.
The Use of Health Information Technology to Improve Care and .docxpelise1
The Use of Health Information Technology to Improve Care and
Outcomes for Older Adults
Kathryn H. Bowles, PhD, FAAN, FACMI,
van Ameringen Professor in Nursing Excellence, Director of the Center for Integrative Science in
Aging, University of Pennsylvania School of Nursing, Philadelphia, PA
Patricia Dykes, PhD, FAAN, FACMI, and
Senior Nurse Scientist, Director of the Center for Patient Safety Research and Practice; Director
of the Center for Nursing Excellence, Brigham and Women’s Hospital, Boston, MA
George Demiris, PhD, FACMI
Alumni Endowed Professor in Nursing; Professor in Biomedical and Health Informatics, School of
Medicine; Director, Clinical Informatics and Patient Centered Technologies; Graduate Program
Director, Biomedical and Health Informatics University of Washington, Seattle, Washington
Introduction
Using health information technology (HIT) to improve care and outcomes for older adults is
a growing program of research propelled by recent transformative policies such as the
Health Information Technology for Economic and Clinical Health (HITECH) Act
(Blumenthal, 2010; Institute of Medicine, 2011) and the Institute of Medicine report, "The
Future of Nursing: Leading Change, Advancing Health." (Institute of Medicine, 2010). Both
documents call for the implementation of electronic health records (EHR) and HIT solutions
to improve the safety, quality and efficiency of care. Several nurse scientists are at the
forefront of advancing this work, particularly using electronic health records, decision
support and telehealth. This commentary highlights examples of recent research (2010–
2014) led by nurse scientists using HIT to improve patient safety, and the quality and
efficiency of patient care. We also discuss future opportunities for Gerontological nurse
scientists interested in blending the care of older adults and HIT and suggest strategies to
increase our capacity to engage in such innovative research.
Using the EHR to improve outcomes for older adults
Recent incentives provided by the HITECH Act have resulted in rapid growth in the
development and implementation of the EHR. Nurse led studies are beginning to
demonstrate that effective use of the EHR can improve outcomes of relevance to older
adults such as pressure ulcers and falls. Dowding and colleagues evaluated the impact of an
integrated EHR in 29 Kaiser Permanente hospitals on process and outcome indicators for
patient falls and hospital acquired pressure ulcers (Dowding, Turley, & Garrido, 2012).
They found that the EHR system was associated with improved documentation of both fall
and pressure ulcer risk assessments and statistically significant improvements for pressure
ulcer risk assessment documentation. They demonstrated that improved documentation
using the EHR was associated with a 13% decrease in hospital acquired pressure ulcer rates.
HHS Public Access
Author manuscript
Res Gerontol Nurs. Author manuscript; avai.
CLINICAL GOVERNANCE: AS DRIVE FOR PATIENT SAFETY.Ruby Med Plus
The focus on patient safety is an international phenomenon. Patient safety is an integral component of the quality of care. The governance of patient safety‘encompasses panoply of regulatory processes that directly or indirectly intend to manage, prevent or limit iatrogenic events in oral health care services. The Influence of Health Inquiries on Clinical Governance Systems in a case Study of the Douglas Inquiry focus on patient safety within the health industry, which has led to the extensive adoption of the term clinical governance. This term is used to describe the systems and processes that a healthcare organization has in place that add to the maintenance of patient safety, accountability and responsibility for patient safety. The introduction of clinical governance is therefore aimed at improving the quality of clinical care at all levels of an organization by consolidating, codifying, and standardizing organizational policies and approaches, particularly clinical and corporate accountability. (Scally, 1998). Clinical governance demands a major shift in the values, culture and leadership, to place greater focus on the quality of clinical care and to make it easier to bring about improvement and change in clinical practice. Clinical governance helps in examining and measuring patient outcomes to ensure optimum quality of care (Balding, 2005).
Evidence-based practice is important for nurses to utilize when making decisions about client care. Using the most up-to-date evidence alongside a client's values and preferences can help guide the healthcare process. When evidence-based guidelines are included in a client's plan of care, the clinician has substantial data to make sound decisions and develop the best strategy for delivering care. One study found that pain from venous ulcers was not always properly addressed, negatively impacting healing. This highlighted the need for evidence-based wound care practices that adequately treat pain.
This document discusses processes that have been implemented at a rural hospital with 1200 births per year to improve obstetric patient safety and outcomes. Some of the key processes discussed include establishing a team approach involving all hospital personnel, conducting regular simulations to improve communication and adherence to protocols, implementing mentorship programs for nurses and managers, standardizing communication using SBAR, leveraging electronic medical records and data to monitor quality and outcomes, and promoting a culture of accountability and professionalism. The goal of these initiatives is to reduce errors, minimize harm, and improve outcomes through multidisciplinary collaboration and a systems-based approach. While changing healthcare culture and achieving measurable outcomes can be challenging, continuous monitoring and refinement of processes may help advance safety and quality of
An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.
The document discusses evidence-based nursing practice. It defines evidence-based practice as integrating the best research evidence, clinical expertise, and patient values and needs. The key steps in evidence-based practice are asking questions, acquiring evidence, appraising the evidence, applying it to a patient, and evaluating outcomes. Barriers to evidence-based nursing include lack of time and resources, as well as difficulties interpreting and applying research. Facilitators include administrative support and accessible, clearly written research. Maximizing evidence-based nursing requires overcoming barriers, incorporating different types of evidence, and accounting for issues beyond measurement like patient preferences.
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evi.docxchristinemaritza
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evidence
Mollie R. Cummins
Ginette A. Pepper
Susan D. Horn
The next step to comparative effectiveness research is to conduct more prospective large-scale observational cohort studies with the rigor described here for knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) studies.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Define the goals and processes employed in knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) designs
2.Analyze the strengths and weaknesses of observational designs in general and of KDDM and PBE specifically
3.Identify the roles and activities of the informatics specialist in KDDM and PBE in healthcare environments
Key Terms
Comparative effectiveness research, 69
Confusion matrix, 62
Data mining, 61
Knowledge discovery and data mining (KDDM), 56
Machine learning, 56
Natural language processing (NLP), 58
Practice-based evidence (PBE), 56
Preprocessing, 56
Abstract
The advent of the electronic health record (EHR) and other large electronic datasets has revolutionized efficient access to comprehensive data across large numbers of patients and the concomitant capacity to detect subtle patterns in these data even with missing or less than optimal data quality. This chapter introduces two approaches to knowledge building from clinical data: (1) knowledge discovery and data mining (KDDM) and (2) practice-based evidence (PBE). The use of machine learning methods in retrospective analysis of routinely collected clinical data characterizes KDDM. KDDM enables us to efficiently and effectively analyze large amounts of data and develop clinical knowledge models for decision support. PBE integrates health information technology (health IT) products with cohort identification, prospective data collection, and extensive front-line clinician and patient input for comparative effectiveness research. PBE can uncover best practices and combinations of treatments for specific types of patients while achieving many of the presumed advantages of randomized controlled trials (RCTs).
Introduction
Leaders need to foster a shared learning culture for improving healthcare. This extends beyond the local department or institution to a value for creating generalizable knowledge to improve care worldwide. Sound, rigorous methods are needed by researchers and health professionals to create this knowledge and address practical questions about risks, benefits, and costs of interventions as they occur in actual clinical practice. Typical questions are as follows:
•Are treatments used in daily practice associated with intended outcomes?
•Can we predict adverse events in time to prevent or ameliorate them?
•What treatments work best for which patients?
•With limited financial resources, what are the best interventions to use for specific types of patients?
•What types of indi ...
The document discusses how health systems can achieve standardized patient-centric care through clinician-led transformation. It highlights the success of Trinity Health in saving $20,000 per day and improving outcomes by empowering clinicians to lead collaborative efforts to develop and implement evidence-based standardized care protocols and monitor their impact. Key aspects that contributed to Trinity Health's success include creating an open forum for clinicians to develop solutions, proving rather than just stating that clinicians are decision-makers, using data to prioritize opportunities, and establishing rigorous project management and measurement of results.
Quality Improvement and Professional Nursing Practice Chapte.docxmakdul
Quality Improvement
and Professional Nursing Practice
Chapter 9
1
Healthcare Quality (1 of 2)
Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Healthcare Quality (2 of 2)
Quality improvement refers to the use of data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems
Crossing the Quality Chasm (IOM, 2001)
Safe, timely, effective, efficient, equitable, and patient-centered (STEEEP)
10 rules for redesign to move the healthcare system toward the identified performance expectations
10 Rules for Redesign (1 of 3)
Care is based on continuous healing relationships with patients receiving care whenever and wherever it is needed
Care can be customized according to the patient’s needs and preferences even though the system is designed to meet the most common types of needs
The patient is the source of control and as such, should be given enough information and opportunity to exercise the degree of control he or she chooses regarding decisions that affect him or her
10 Rules for Redesign (2 of 3)
Knowledge is shared and information flows freely so that patients have access to their own medical information
Decision making is evidence based; that is, it is based on the best available scientific knowledge and should not vary illogically between clinicians or locations
Safety is a system property and patients should be safe from harm caused by the healthcare system
10 Rules for Redesign (3 of 3)
Transparency is necessary where systems make information available to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic, or when choosing alternative treatments.
Patient needs are anticipated rather reacted to
Waste of resources and patient time is continuously decreased
Cooperation among clinicians is a priority to ensure appropriate exchange of information and coordination of care
Healthcare Transparency (1 of 2)
Medicare’s Hospital Compare at: www.hospitalcompare.hhs.gov
Medicare’s Home Health Compare at: https://www.medicare.gov/homehealthcompare/
Quality Check’s Find a Health Care Organization at: http://www.qualitycheck.org/
consumer/searchQCR.aspx
The Leapfrog Group’s Hospital Safety Score at: http://www.hospitalsafetyscore.org
Healthcare Transparency (2 of 2)
America’s Health Rankings by the United Health Foundation at: http://www.americashealthrankings.org
Improving Healthcare for the Common Good (IPRO) at: http://ipro.org/for-consumers
IPRO’s Why Not the Best? at: http://www.whynotthebest.org
The Commonwealth Fund at: http://www.commonwealthfund.org
Measures of Quality
Benchmarking
Core measures
Accountability
Composite measures
Measures of Nursing Care
Consumer Assessment of Healthcare Providers and Systems (CAHP ...
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
By administering assessments and analyzing the results, targeted aTawnaDelatorrejs
By administering assessments and analyzing the results, targeted and individualized interventions can be determined to best serve the needs of students with disabilities. The actual implementation of the interventions provides teachers opportunities to collect data and gauge the effectiveness of the interventions in addressing documented student needs. Teachers can also gain important skills and knowledge on how to best advocate for practical classroom interventions. Teachers will also be able to collaborate with colleagues and families in mentoring students to take ownership of learning strategies.
Allocate at least 2 hours in the field to support this field experience,
Part 1: Assessment and Interventions
Select at least one student to whom you will administer the informal RTI assessment created in Clinical Field Experience A. Score the assessment and share the results with the student to increase understanding of his or her strengths and areas for improvement.
Collaborate with the certified special education teacher and the student to develop 2-3 interventions based on the student assessment data to support the student’s progress in the classroom. In addition, detail one intervention that can be incorporated at home with family support.
Use any remaining field experience hours to assist the teacher in providing instruction and support to the class.
Part 2: Reflection
In 250-500 words, summarize and reflect upon the following:
· Describe each intervention, including teacher, student, and family roles, where applicable.
· Your experiences administering the assessment, analyzing the results, and providing the student feedback on his or her performance.
· Explain how you expect the interventions you developed to meet the needs of the student, incorporating his or her assessment results in your response.
· Explain how you will use your findings in your future professional practice.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
6
Annotated Bibliography
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
October 7, 2021.
Annotated Bibliography
Ali, H., Ibrahem, S. Z., Al Mudaf, B., Al Fadalah, T., Jamal, D., & El-Jardali, F. (2018). Baseline assessment of patient safety culture in public hospitals in Kuwait. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-2960-x
The researchers conducted a cross-sectional study in 16 public hospitals in Kuwait using the Hospital Survey on Patient Safety Culture (HSOPSC). The study aimed to assess patient safety culture in public hospitals as perceived by hospital staff and relate the findings similar to regional and international ...
Measuring to Improve Medication Reconciliationin a Large Sub.docxalfredacavx97
Measuring to Improve Medication Reconciliation
in a Large Subspecialty Outpatient Practice
Elizabeth Kern, MD, MS; Meg B. Dingae, MHSA; Esther L. Langmack, MD; Candace Juarez, MT; Gary Cott, MD;
Sarah K. Meadows, MS
Background: To assess performance in medication reconciliation (med rec)—the process of comparing and reconciling
patients’ medication lists at clinical transition points—and demonstrate improvement in an outpatient setting, sustainable
and valid measures are needed.
Methods: An interdisciplinary team at National Jewish Health (Denver) attempted to improve med rec in an ambulatory
practice serving patients with respiratory and related diseases. Interventions, which were aimed at physicians, nurses (RNs),
and medical assistants, involved changes in practice and changes in documentation in the electronic health record (EHR).
New measures designed to assess med rec performance, and to validate the measures, were derived from EHR data.
Results: Across 18 months, electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3%
(p < 0.0001). Consistent with this improvement, patients with medication lists missing dose/frequency for at least one prescription-
type medication decreased from 18.1% to 15.8% (p < 0.0001). Patients with duplicate albuterol inhalers on their list decreased
from 4.0% to 2.6% (p < 0.0001). Percentages of patients increased for printing of the medication list at the visit (18.7% to
94.0%; p < 0.0001) and receipt of the printed medication list at the visit (52.3% to 67.0%; p = 0.0074). Documentation
that patient education handouts were offered increased initially then declined to an overall poor performance of 32.4% of
clinic visits. Investigation of this result revealed poor buy-in and a highly redundant process.
Conclusion: Deriving measures reflecting performance and quality of med rec from EHR data is feasible and sustainable
over the time periods necessary to demonstrate change. Concurrent, complementary measures may be used to support the
validity of summary measures.
Medication reconciliation (med rec) is the process of sys-tematically and comprehensively reviewing the
medications a patient is taking, to ensure that medications
added, changed, or discontinued are evaluated for poten-
tial safety concerns. One of the three current Joint
Commission National Patient Safety Goals (NPSGs) on med-
ication safety (Goal 3), concerns medication reconciliation,
which ambulatory care organizations have been expected to
perform since 2005. The current version of the goal
(NPSG.03.06.01), effective July 1, 2011, stipulates that am-
bulatory care organizations maintain and communicate
accurate patient medication information.1 One require-
ment is that the organization obtain the patient’s medication
information at the beginning of an episode of care, with the
information to be updated when the patient’s medications
change. Ideally, med rec should occur at each transition of
care or han.
Standardized Bedside ReportingOne of the goals of h.docxwhitneyleman54422
Standardized Bedside Reporting
One of the goals of healthcare is to ensure that the patients get the best service possible while not compromising on the satisfaction and goodwill of the nurses and other healthcare professionals. A key aspect of ensuring quality healthcare is the consistent handling of patient information from nurse to nurse during shifts; information handled wrongly can jeopardize the patients’ health (Baker, 2010). It is important to implement procedures that ensure consistent and smooth handling of patient information from nurse to nurse to increase patient safety and improve nurse satisfaction. This paper will explore the merits of standardized bedside reporting as opposed to board reporting in ensuring a positive outcome and consistent quality healthcare.
Change model overview
A key aspect in determining whether bedside shift reporting has any merits over board reporting is the John Hopkins Nursing Evidence-Based Practice Process (JHNEBP). The John Hopkins Nursing Evidence-Based Practice Process is a framework for guiding the translation and synthesis of evidence into valid healthcare practice. JHNEBP has three cornerstones that include research, education, and practice; the framework ensures that research evidence is the basis of clinical decision-making. (Dearholt & Dang, 2012) The implementation of the John Hopkins Nursing Evidence-Based Practice Process has three key phases, the first phase is the identification of an important question, the second phase involves the systematic review of research evidence, and the third phase is translating the results into action. Nurses should use the JHNEBP process because it provides a clear way for healthcare professionals to translate research results into healthcare practice.
Practice Question
The team includes several key stakeholders who will benefit greatly from my research. Among the team members include myself as ER nurse, charge nurse, ERT ( Emergency room tech), nurse case manager, nurse supervisor, physician and hospital manager.
The evidence-based practice question that the team members will explore is "Does the use of a standardized bedside report versus board reporting help increase patient safety, nurse satisfaction, and positive outcome?" The evidence-based practice question assesses the ability of bedside shift reporting to improve healthcare provision. The practice area of the question is clinical. The practice issue came about because of assessing risk management concerns in ensuring good health practices. To answer the question, the team members gathered evidence from patient preferences, peer-reviewed journals, and clinical guidelines. The team members searched peer-reviewed journal databases to gather relevant information from previous research that could affect the results.
Understanding the merits of bedside shift reporting as opposed to board reporting is important as most healthcare organization use either strategy in collecting and passin.
1. A corporations distribution of additional shares of its own s.docxcuddietheresa
1.
A corporation's distribution of additional shares of its own stock to its stockholders without the receipt of any payment in return is called a: (Points : 2)
.
1. Like the modernists, postmodern writers focused on subjective e.docxcuddietheresa
1. Like the modernists, postmodern writers focused on subjective experience rather than objective cultural norms. (1 point)
expressing or dealing with facts or conditions as perceived without distortion by personal feelings, prejudices, or interpretations
characteristic of or belonging to reality as perceived rather than as independent of mind
characteristic of or belonging to the superficial world
none of the above
2. They reeled, whirled, swiveled, flounced, capered, gamboled, and spun. (1 point)
insult
twists; intricate designs
leapt; frolicked
sharp; pounding
3. He began to think glimmeringly about his abnormal son who was now in jail, about Harrison. (1 point)
beginning
watchfulness; caution
leapt; frolicked
intermittently; unsteadily
4. Stokesie’s married, with two babies chalked up on his fuselage already, but as far as I can tell that’s the only difference. (1 point)
central body portion of an airplane
evil; spiteful
handicaps; obstructions
none of the above
Read the following paragraph and answer questions 5–8.
Scientists report (1) that creatures living in the deep sea are in danger of starving to death. Millions of undiscovered species live, in the deep sea. Creatures in the seabed are suffering from growing food shortages. Which may be a result of rising sea temperatures. Scientists believe that some species will die out, those that can survive on a low food supply will continue living. Not much is known about the creatures that live in the deep sea, not much is known about the changes in their diets. Scientists estimate that up to 10 million species live in the depths of the sea. Most animals of the deep rely on food chains that begin. In the lighted realms of the sea. Microscopic plants called phytoplankton. Capture the sun and start the food cycle. (2) Wherever there are animal droppings, there is a constant rain of organic matter (3) that feeds the bottom dwellers.
5. The underlined part of sentence 1 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
6. The underlined part of sentence 2 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
7. The underlined part of sentence 3 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
Essay
Note: Your teacher will grade your response to ensure that you receive proper credit for your answer. Your response should include the following to receive the points in parentheses:
Respond in 3–5 complete sentences. (5 pts)
8. Rewrite the paragraph above, correcting any fragments and run-on sentences. Be sure to use correct punctuation. (5 points)
True or False
9. The Beat Generation was a group of writers who fought to maintain traditionalism in America. (1 point)
true
false
10. Satire is used to make serious situations appear humorous using irony. (1 point)
true
false
11. Absurdism is the attempt to show the absurdity of t.
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o you ever wonder why
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[email protected] AJN � November 2009 � Vol. 109, No. 11 49
By Bernadette Mazurek Melnyk, PhD,
RN, CPNP/PMHNP, FNAP, FAAN,
Ellen Fineout-Overholt, PhD, RN,
FNAP, FAAN, Susan B. Stillwell, DNP,
RN, CNE, and Kathleen M.
Williamson, PhD, RN
Igniting a Spirit of Inquiry: An Essential Foundation for
Evidence-Based Practice
How nurses can build the knowledge and skills they need to
implement EBP.
Every day, nurses perform interventions (for
example, administering medication, positioning,
suctioning) that should stimulate questions
about the evidence supporting their use.
This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach
to the delivery of health care that integrates the best evidence from studies and patient care data with clinician
expertise and patient preferences and values. When delivered in a context of caring a ...
This document provides a performance appraisal for Dr. Zamfirova, an internal medicine physician. It summarizes research on different methods used to evaluate physician performance, including appointment length, clinical performance assessments using composite measures, a physician's capacity for change, and compensation based on RVUs. The research presented acknowledges there are many factors that influence performance evaluations and no single measure can accurately capture a physician's overall quality of care.
This document discusses the importance of evidence-based practice in nursing. It begins by explaining how evidence-based practices have reverberated across nursing practice, education, and science. The need for improved healthcare calls for evidence-based practices to be incorporated into health systems to increase effectiveness, safety, and efficiency. New practice approaches should be evidence-based to help move healthcare in the desired direction. The document also provides an example of how one facility successfully reduced hospital-acquired pressure ulcers through implementing evidence-based skin assessment and wound care protocols. It concludes by stating the importance of evidence-based practices in tackling issues like hospital-acquired pressure ulcers.
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The Use of Health Information Technology to Improve Care and .docxpelise1
The Use of Health Information Technology to Improve Care and
Outcomes for Older Adults
Kathryn H. Bowles, PhD, FAAN, FACMI,
van Ameringen Professor in Nursing Excellence, Director of the Center for Integrative Science in
Aging, University of Pennsylvania School of Nursing, Philadelphia, PA
Patricia Dykes, PhD, FAAN, FACMI, and
Senior Nurse Scientist, Director of the Center for Patient Safety Research and Practice; Director
of the Center for Nursing Excellence, Brigham and Women’s Hospital, Boston, MA
George Demiris, PhD, FACMI
Alumni Endowed Professor in Nursing; Professor in Biomedical and Health Informatics, School of
Medicine; Director, Clinical Informatics and Patient Centered Technologies; Graduate Program
Director, Biomedical and Health Informatics University of Washington, Seattle, Washington
Introduction
Using health information technology (HIT) to improve care and outcomes for older adults is
a growing program of research propelled by recent transformative policies such as the
Health Information Technology for Economic and Clinical Health (HITECH) Act
(Blumenthal, 2010; Institute of Medicine, 2011) and the Institute of Medicine report, "The
Future of Nursing: Leading Change, Advancing Health." (Institute of Medicine, 2010). Both
documents call for the implementation of electronic health records (EHR) and HIT solutions
to improve the safety, quality and efficiency of care. Several nurse scientists are at the
forefront of advancing this work, particularly using electronic health records, decision
support and telehealth. This commentary highlights examples of recent research (2010–
2014) led by nurse scientists using HIT to improve patient safety, and the quality and
efficiency of patient care. We also discuss future opportunities for Gerontological nurse
scientists interested in blending the care of older adults and HIT and suggest strategies to
increase our capacity to engage in such innovative research.
Using the EHR to improve outcomes for older adults
Recent incentives provided by the HITECH Act have resulted in rapid growth in the
development and implementation of the EHR. Nurse led studies are beginning to
demonstrate that effective use of the EHR can improve outcomes of relevance to older
adults such as pressure ulcers and falls. Dowding and colleagues evaluated the impact of an
integrated EHR in 29 Kaiser Permanente hospitals on process and outcome indicators for
patient falls and hospital acquired pressure ulcers (Dowding, Turley, & Garrido, 2012).
They found that the EHR system was associated with improved documentation of both fall
and pressure ulcer risk assessments and statistically significant improvements for pressure
ulcer risk assessment documentation. They demonstrated that improved documentation
using the EHR was associated with a 13% decrease in hospital acquired pressure ulcer rates.
HHS Public Access
Author manuscript
Res Gerontol Nurs. Author manuscript; avai.
CLINICAL GOVERNANCE: AS DRIVE FOR PATIENT SAFETY.Ruby Med Plus
The focus on patient safety is an international phenomenon. Patient safety is an integral component of the quality of care. The governance of patient safety‘encompasses panoply of regulatory processes that directly or indirectly intend to manage, prevent or limit iatrogenic events in oral health care services. The Influence of Health Inquiries on Clinical Governance Systems in a case Study of the Douglas Inquiry focus on patient safety within the health industry, which has led to the extensive adoption of the term clinical governance. This term is used to describe the systems and processes that a healthcare organization has in place that add to the maintenance of patient safety, accountability and responsibility for patient safety. The introduction of clinical governance is therefore aimed at improving the quality of clinical care at all levels of an organization by consolidating, codifying, and standardizing organizational policies and approaches, particularly clinical and corporate accountability. (Scally, 1998). Clinical governance demands a major shift in the values, culture and leadership, to place greater focus on the quality of clinical care and to make it easier to bring about improvement and change in clinical practice. Clinical governance helps in examining and measuring patient outcomes to ensure optimum quality of care (Balding, 2005).
Evidence-based practice is important for nurses to utilize when making decisions about client care. Using the most up-to-date evidence alongside a client's values and preferences can help guide the healthcare process. When evidence-based guidelines are included in a client's plan of care, the clinician has substantial data to make sound decisions and develop the best strategy for delivering care. One study found that pain from venous ulcers was not always properly addressed, negatively impacting healing. This highlighted the need for evidence-based wound care practices that adequately treat pain.
This document discusses processes that have been implemented at a rural hospital with 1200 births per year to improve obstetric patient safety and outcomes. Some of the key processes discussed include establishing a team approach involving all hospital personnel, conducting regular simulations to improve communication and adherence to protocols, implementing mentorship programs for nurses and managers, standardizing communication using SBAR, leveraging electronic medical records and data to monitor quality and outcomes, and promoting a culture of accountability and professionalism. The goal of these initiatives is to reduce errors, minimize harm, and improve outcomes through multidisciplinary collaboration and a systems-based approach. While changing healthcare culture and achieving measurable outcomes can be challenging, continuous monitoring and refinement of processes may help advance safety and quality of
An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.
The document discusses evidence-based nursing practice. It defines evidence-based practice as integrating the best research evidence, clinical expertise, and patient values and needs. The key steps in evidence-based practice are asking questions, acquiring evidence, appraising the evidence, applying it to a patient, and evaluating outcomes. Barriers to evidence-based nursing include lack of time and resources, as well as difficulties interpreting and applying research. Facilitators include administrative support and accessible, clearly written research. Maximizing evidence-based nursing requires overcoming barriers, incorporating different types of evidence, and accounting for issues beyond measurement like patient preferences.
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evi.docxchristinemaritza
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evidence
Mollie R. Cummins
Ginette A. Pepper
Susan D. Horn
The next step to comparative effectiveness research is to conduct more prospective large-scale observational cohort studies with the rigor described here for knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) studies.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Define the goals and processes employed in knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) designs
2.Analyze the strengths and weaknesses of observational designs in general and of KDDM and PBE specifically
3.Identify the roles and activities of the informatics specialist in KDDM and PBE in healthcare environments
Key Terms
Comparative effectiveness research, 69
Confusion matrix, 62
Data mining, 61
Knowledge discovery and data mining (KDDM), 56
Machine learning, 56
Natural language processing (NLP), 58
Practice-based evidence (PBE), 56
Preprocessing, 56
Abstract
The advent of the electronic health record (EHR) and other large electronic datasets has revolutionized efficient access to comprehensive data across large numbers of patients and the concomitant capacity to detect subtle patterns in these data even with missing or less than optimal data quality. This chapter introduces two approaches to knowledge building from clinical data: (1) knowledge discovery and data mining (KDDM) and (2) practice-based evidence (PBE). The use of machine learning methods in retrospective analysis of routinely collected clinical data characterizes KDDM. KDDM enables us to efficiently and effectively analyze large amounts of data and develop clinical knowledge models for decision support. PBE integrates health information technology (health IT) products with cohort identification, prospective data collection, and extensive front-line clinician and patient input for comparative effectiveness research. PBE can uncover best practices and combinations of treatments for specific types of patients while achieving many of the presumed advantages of randomized controlled trials (RCTs).
Introduction
Leaders need to foster a shared learning culture for improving healthcare. This extends beyond the local department or institution to a value for creating generalizable knowledge to improve care worldwide. Sound, rigorous methods are needed by researchers and health professionals to create this knowledge and address practical questions about risks, benefits, and costs of interventions as they occur in actual clinical practice. Typical questions are as follows:
•Are treatments used in daily practice associated with intended outcomes?
•Can we predict adverse events in time to prevent or ameliorate them?
•What treatments work best for which patients?
•With limited financial resources, what are the best interventions to use for specific types of patients?
•What types of indi ...
The document discusses how health systems can achieve standardized patient-centric care through clinician-led transformation. It highlights the success of Trinity Health in saving $20,000 per day and improving outcomes by empowering clinicians to lead collaborative efforts to develop and implement evidence-based standardized care protocols and monitor their impact. Key aspects that contributed to Trinity Health's success include creating an open forum for clinicians to develop solutions, proving rather than just stating that clinicians are decision-makers, using data to prioritize opportunities, and establishing rigorous project management and measurement of results.
Quality Improvement and Professional Nursing Practice Chapte.docxmakdul
Quality Improvement
and Professional Nursing Practice
Chapter 9
1
Healthcare Quality (1 of 2)
Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Healthcare Quality (2 of 2)
Quality improvement refers to the use of data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems
Crossing the Quality Chasm (IOM, 2001)
Safe, timely, effective, efficient, equitable, and patient-centered (STEEEP)
10 rules for redesign to move the healthcare system toward the identified performance expectations
10 Rules for Redesign (1 of 3)
Care is based on continuous healing relationships with patients receiving care whenever and wherever it is needed
Care can be customized according to the patient’s needs and preferences even though the system is designed to meet the most common types of needs
The patient is the source of control and as such, should be given enough information and opportunity to exercise the degree of control he or she chooses regarding decisions that affect him or her
10 Rules for Redesign (2 of 3)
Knowledge is shared and information flows freely so that patients have access to their own medical information
Decision making is evidence based; that is, it is based on the best available scientific knowledge and should not vary illogically between clinicians or locations
Safety is a system property and patients should be safe from harm caused by the healthcare system
10 Rules for Redesign (3 of 3)
Transparency is necessary where systems make information available to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic, or when choosing alternative treatments.
Patient needs are anticipated rather reacted to
Waste of resources and patient time is continuously decreased
Cooperation among clinicians is a priority to ensure appropriate exchange of information and coordination of care
Healthcare Transparency (1 of 2)
Medicare’s Hospital Compare at: www.hospitalcompare.hhs.gov
Medicare’s Home Health Compare at: https://www.medicare.gov/homehealthcompare/
Quality Check’s Find a Health Care Organization at: http://www.qualitycheck.org/
consumer/searchQCR.aspx
The Leapfrog Group’s Hospital Safety Score at: http://www.hospitalsafetyscore.org
Healthcare Transparency (2 of 2)
America’s Health Rankings by the United Health Foundation at: http://www.americashealthrankings.org
Improving Healthcare for the Common Good (IPRO) at: http://ipro.org/for-consumers
IPRO’s Why Not the Best? at: http://www.whynotthebest.org
The Commonwealth Fund at: http://www.commonwealthfund.org
Measures of Quality
Benchmarking
Core measures
Accountability
Composite measures
Measures of Nursing Care
Consumer Assessment of Healthcare Providers and Systems (CAHP ...
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
By administering assessments and analyzing the results, targeted aTawnaDelatorrejs
By administering assessments and analyzing the results, targeted and individualized interventions can be determined to best serve the needs of students with disabilities. The actual implementation of the interventions provides teachers opportunities to collect data and gauge the effectiveness of the interventions in addressing documented student needs. Teachers can also gain important skills and knowledge on how to best advocate for practical classroom interventions. Teachers will also be able to collaborate with colleagues and families in mentoring students to take ownership of learning strategies.
Allocate at least 2 hours in the field to support this field experience,
Part 1: Assessment and Interventions
Select at least one student to whom you will administer the informal RTI assessment created in Clinical Field Experience A. Score the assessment and share the results with the student to increase understanding of his or her strengths and areas for improvement.
Collaborate with the certified special education teacher and the student to develop 2-3 interventions based on the student assessment data to support the student’s progress in the classroom. In addition, detail one intervention that can be incorporated at home with family support.
Use any remaining field experience hours to assist the teacher in providing instruction and support to the class.
Part 2: Reflection
In 250-500 words, summarize and reflect upon the following:
· Describe each intervention, including teacher, student, and family roles, where applicable.
· Your experiences administering the assessment, analyzing the results, and providing the student feedback on his or her performance.
· Explain how you expect the interventions you developed to meet the needs of the student, incorporating his or her assessment results in your response.
· Explain how you will use your findings in your future professional practice.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
6
Annotated Bibliography
Student’s Name
Course
Instructor’s name.
Institutional Affiliation
October 7, 2021.
Annotated Bibliography
Ali, H., Ibrahem, S. Z., Al Mudaf, B., Al Fadalah, T., Jamal, D., & El-Jardali, F. (2018). Baseline assessment of patient safety culture in public hospitals in Kuwait. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-2960-x
The researchers conducted a cross-sectional study in 16 public hospitals in Kuwait using the Hospital Survey on Patient Safety Culture (HSOPSC). The study aimed to assess patient safety culture in public hospitals as perceived by hospital staff and relate the findings similar to regional and international ...
Measuring to Improve Medication Reconciliationin a Large Sub.docxalfredacavx97
Measuring to Improve Medication Reconciliation
in a Large Subspecialty Outpatient Practice
Elizabeth Kern, MD, MS; Meg B. Dingae, MHSA; Esther L. Langmack, MD; Candace Juarez, MT; Gary Cott, MD;
Sarah K. Meadows, MS
Background: To assess performance in medication reconciliation (med rec)—the process of comparing and reconciling
patients’ medication lists at clinical transition points—and demonstrate improvement in an outpatient setting, sustainable
and valid measures are needed.
Methods: An interdisciplinary team at National Jewish Health (Denver) attempted to improve med rec in an ambulatory
practice serving patients with respiratory and related diseases. Interventions, which were aimed at physicians, nurses (RNs),
and medical assistants, involved changes in practice and changes in documentation in the electronic health record (EHR).
New measures designed to assess med rec performance, and to validate the measures, were derived from EHR data.
Results: Across 18 months, electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3%
(p < 0.0001). Consistent with this improvement, patients with medication lists missing dose/frequency for at least one prescription-
type medication decreased from 18.1% to 15.8% (p < 0.0001). Patients with duplicate albuterol inhalers on their list decreased
from 4.0% to 2.6% (p < 0.0001). Percentages of patients increased for printing of the medication list at the visit (18.7% to
94.0%; p < 0.0001) and receipt of the printed medication list at the visit (52.3% to 67.0%; p = 0.0074). Documentation
that patient education handouts were offered increased initially then declined to an overall poor performance of 32.4% of
clinic visits. Investigation of this result revealed poor buy-in and a highly redundant process.
Conclusion: Deriving measures reflecting performance and quality of med rec from EHR data is feasible and sustainable
over the time periods necessary to demonstrate change. Concurrent, complementary measures may be used to support the
validity of summary measures.
Medication reconciliation (med rec) is the process of sys-tematically and comprehensively reviewing the
medications a patient is taking, to ensure that medications
added, changed, or discontinued are evaluated for poten-
tial safety concerns. One of the three current Joint
Commission National Patient Safety Goals (NPSGs) on med-
ication safety (Goal 3), concerns medication reconciliation,
which ambulatory care organizations have been expected to
perform since 2005. The current version of the goal
(NPSG.03.06.01), effective July 1, 2011, stipulates that am-
bulatory care organizations maintain and communicate
accurate patient medication information.1 One require-
ment is that the organization obtain the patient’s medication
information at the beginning of an episode of care, with the
information to be updated when the patient’s medications
change. Ideally, med rec should occur at each transition of
care or han.
Standardized Bedside ReportingOne of the goals of h.docxwhitneyleman54422
Standardized Bedside Reporting
One of the goals of healthcare is to ensure that the patients get the best service possible while not compromising on the satisfaction and goodwill of the nurses and other healthcare professionals. A key aspect of ensuring quality healthcare is the consistent handling of patient information from nurse to nurse during shifts; information handled wrongly can jeopardize the patients’ health (Baker, 2010). It is important to implement procedures that ensure consistent and smooth handling of patient information from nurse to nurse to increase patient safety and improve nurse satisfaction. This paper will explore the merits of standardized bedside reporting as opposed to board reporting in ensuring a positive outcome and consistent quality healthcare.
Change model overview
A key aspect in determining whether bedside shift reporting has any merits over board reporting is the John Hopkins Nursing Evidence-Based Practice Process (JHNEBP). The John Hopkins Nursing Evidence-Based Practice Process is a framework for guiding the translation and synthesis of evidence into valid healthcare practice. JHNEBP has three cornerstones that include research, education, and practice; the framework ensures that research evidence is the basis of clinical decision-making. (Dearholt & Dang, 2012) The implementation of the John Hopkins Nursing Evidence-Based Practice Process has three key phases, the first phase is the identification of an important question, the second phase involves the systematic review of research evidence, and the third phase is translating the results into action. Nurses should use the JHNEBP process because it provides a clear way for healthcare professionals to translate research results into healthcare practice.
Practice Question
The team includes several key stakeholders who will benefit greatly from my research. Among the team members include myself as ER nurse, charge nurse, ERT ( Emergency room tech), nurse case manager, nurse supervisor, physician and hospital manager.
The evidence-based practice question that the team members will explore is "Does the use of a standardized bedside report versus board reporting help increase patient safety, nurse satisfaction, and positive outcome?" The evidence-based practice question assesses the ability of bedside shift reporting to improve healthcare provision. The practice area of the question is clinical. The practice issue came about because of assessing risk management concerns in ensuring good health practices. To answer the question, the team members gathered evidence from patient preferences, peer-reviewed journals, and clinical guidelines. The team members searched peer-reviewed journal databases to gather relevant information from previous research that could affect the results.
Understanding the merits of bedside shift reporting as opposed to board reporting is important as most healthcare organization use either strategy in collecting and passin.
Similar to Delivering Value Through Evidence-Based PracticeMacias, Charles .docx (20)
1. A corporations distribution of additional shares of its own s.docxcuddietheresa
1.
A corporation's distribution of additional shares of its own stock to its stockholders without the receipt of any payment in return is called a: (Points : 2)
.
1. Like the modernists, postmodern writers focused on subjective e.docxcuddietheresa
1. Like the modernists, postmodern writers focused on subjective experience rather than objective cultural norms. (1 point)
expressing or dealing with facts or conditions as perceived without distortion by personal feelings, prejudices, or interpretations
characteristic of or belonging to reality as perceived rather than as independent of mind
characteristic of or belonging to the superficial world
none of the above
2. They reeled, whirled, swiveled, flounced, capered, gamboled, and spun. (1 point)
insult
twists; intricate designs
leapt; frolicked
sharp; pounding
3. He began to think glimmeringly about his abnormal son who was now in jail, about Harrison. (1 point)
beginning
watchfulness; caution
leapt; frolicked
intermittently; unsteadily
4. Stokesie’s married, with two babies chalked up on his fuselage already, but as far as I can tell that’s the only difference. (1 point)
central body portion of an airplane
evil; spiteful
handicaps; obstructions
none of the above
Read the following paragraph and answer questions 5–8.
Scientists report (1) that creatures living in the deep sea are in danger of starving to death. Millions of undiscovered species live, in the deep sea. Creatures in the seabed are suffering from growing food shortages. Which may be a result of rising sea temperatures. Scientists believe that some species will die out, those that can survive on a low food supply will continue living. Not much is known about the creatures that live in the deep sea, not much is known about the changes in their diets. Scientists estimate that up to 10 million species live in the depths of the sea. Most animals of the deep rely on food chains that begin. In the lighted realms of the sea. Microscopic plants called phytoplankton. Capture the sun and start the food cycle. (2) Wherever there are animal droppings, there is a constant rain of organic matter (3) that feeds the bottom dwellers.
5. The underlined part of sentence 1 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
6. The underlined part of sentence 2 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
7. The underlined part of sentence 3 is what kind of clause? (1 point)
adverbial clause
adjectival clause
noun clause
Essay
Note: Your teacher will grade your response to ensure that you receive proper credit for your answer. Your response should include the following to receive the points in parentheses:
Respond in 3–5 complete sentences. (5 pts)
8. Rewrite the paragraph above, correcting any fragments and run-on sentences. Be sure to use correct punctuation. (5 points)
True or False
9. The Beat Generation was a group of writers who fought to maintain traditionalism in America. (1 point)
true
false
10. Satire is used to make serious situations appear humorous using irony. (1 point)
true
false
11. Absurdism is the attempt to show the absurdity of t.
1. As the degree of freedom increase indefinitely, the t distribu.docxcuddietheresa
1.
As the degree of freedom increase indefinitely, the t distribution approaches the normal distribution. (Points : 1)
[removed] [removed] [removed] [removed]
.
1-Explain how the topography of the United states can affect the wea.docxcuddietheresa
1-Explain how the topography of the United states can affect the weather.
2-
Explain why or why not the bodies of water that are in close proximity to the Commonwealth (P.A.) can affect our weather.
3-
Explain how sometimes it can we warmer in Alaska in December than here in PA?
4-
Explain how the temperature can range 30 degrees in Pittsburgh to 55 Philadelphia during the month of January.
5
Explain how the temperature can range from 75 degrees in Pittsburgh to 45 in Philadelphia during the month of May.
6-
Explain how Texas can sometimes be colder than PA during the winter.
7
.
Explain how Florida can sometimes be cooler than PA during the summer.
.
1. An exporter faced with exposure to a depreciating currency can.docxcuddietheresa
1.
An exporter faced with exposure to a depreciating currency can reduce transaction exposure with a strategy of: (Points : 1)
[removed] [removed] [removed] [removed]
.
1. According to the central limit theorem, a population which is .docxcuddietheresa
1.
According to the central limit theorem, a population which is skewed to begin with will still be skewed when it is re-formed as a distribution of sample means. (Points : 1)
.
1. Which of the following is not a class of essential nutrient.docxcuddietheresa
1. Which of the following is not a class of essential nutrient?
a. Dietary supplements
b. Carbohydrates
c. Lipids
d. Minerals
2. Which of the following statements about the nutrient composition of the American diet is true?
a. It contains too little protein
b. It contains too little carbohydrate
c. It contains too little fat
d. It contains too many calories
3. A kcalorie is a measure of
a. Heat energy
b. Fat in food
c. Nutrients in food
d. Sugar and fat in food
4. Which of the following nutrients can directly supply energy for human use?
a. Lipids and oils
b. Fiber
c. Vitamins
d. Minerals
5. Gram for gram, which provides the most energy?
a. Carbohydrates
b. Proteins
c. Alcohol
d. Fats
6. Which of the following yield greater than 4 kcalories per gram?
a. Plant fats
b. Plant carbohydrates
c. Plant proteins
d. Animal proteins
7. Which of the following contain no calories?
a. Alcohol
b. Proteins
c. Carbohydrates
d. Vitamins
8. Which one of the following is a carbohydrate?
a. apples
b. chicken
c. potatoes
d. both a and c
9. Which of the following is a protein?
a. apples
b. chicken
c. potatoes
d. both a and c
10. Which of the following is a lipid?
a. oils
b. fat
c. cholesterol
d. all the above
11. Fats:
a. Regulate body temperature b. protect organs
c. produce energy d. All of the Above
12. Water is _____ of a person's total body weight.
a. 40% b. 65%-75%
c. 10% - 20% d. None of the above
13. When looking at the ingredient label of a bottled spaghetti sauce, you see that olive oil is the second ingredient. This means that
a. Olive oil is the second ingredient by alphabetical listing
b. Olive oil is just one of the ingredients present in the sauce
c. Olive oil is the second ingredient by weight
d. Olive oil is the second ingredient by amount present in the sauce
14. How many kcalories are provided by a 2-oz brownie with icing? Its nutrient composition is 1g of protein, 5g of fat, and 15g of carbohydrates
a. 89
b. 109
c. 84
d. 159
15. Which of the following provides the most kcalories?
a. 5g carbohydrate
b. 3g fat
c. 4g protein
d. 2g alcohol
16. One-half of a mashed potato with milk contains 2g of protein, 1g of fat, and 14g of carbohydrate. What percentage of the total kcalorie content is provided by carbohydrates
a. 19%
b. 72%
c. 82%
d. 77%
17. True or False: A nutrition facts label can list 0 grams of fat even if the food does in fact contain some fat.
.
1. The process by which one group takes on the cultural and other .docxcuddietheresa
1. The process by which one group takes on the cultural and other traits of a larger group is called _______. (1 point)
assimilation
pluralism
culture
integration
2. Chinatown in San Francisco and Little Havana in Miami are examples of _______. (1 point)
assimilation
pluralism
culture
integration
3. The Salad Bowl analogy of U.S. society states that (1 point)
ethnic groups living in the United States retain unique features, but also contribute to American culture as a whole.
all ethnic groups’ cultures have melted overtime into one distinct culture.
ethnic groups are entirely separated in U.S. society and have no influence upon one another.
immigrants must abandon their traditions to be successful in U.S. society.
4. A form of government in which a king or queen acts as head of state while parliament makes legislation is called a ________. (1 point)
monarchy
democracy
democratic parliament
constitutional monarchy
5. Based on the text, what was the African diaspora? (1 point)
the transporting of Africans to the New World for slave labor
the dispersion of Africans during and after the trans-Atlantic slave trade
the multiculturalism of African American colonies in the New World
the assimilation of African culture into that of the United States
6. Which is the term for a completely structured language that develops from a blending of native languages and introduced languages? (1 point)
Pidgin
Creole
Esperanto
Dialect
7. Which movement was initiated in the 1960s by Quebecer Réne Lévesque? (1 point)
a movement to give indigenous people their own province
a movement to make French the official language of Canada
an initiative to put an end to all immigration into Canada
a movement to make Quebec an independent sovereignty
8. Which U.S. city is best known for celebrating the tradition of Mardi Gras? (1 point)
San Francisco
New York City
New Orleans
Miami
9. Which country is responsible for laying Canada’s cultural foundation? (1 point)
Great Britain
France
The United States
Germany
10. Which group makes up the largest segment of the Mexican population? (1 point)
Spanish
Indigenous peoples
Mestizos
Aztecs
.
1. Milestone InvestingCompare and contrast the interests of .docxcuddietheresa
1. Milestone Investing
Compare and contrast the interests of entrepreneurs and investors to the concept of milestone investing? Is there the potential for conflict of interest? How can conflict be resolved? Respond to two of your classmates’ postings.
2. NVCA
Explore the website of the National Venture Capital Association. Briefly review the membership list and the focus of the venture funding association. Discuss the economic importance of venture backed companies to the U.S. Economy. Provide examples. Respond to two of your classmates’ postings.
.
1. All dogs are warm-blooded. All warm-blooded creatures are mamm.docxcuddietheresa
1.
All dogs are warm-blooded. All warm-blooded creatures are mammals. Hence, all dogs are mammals.
True or False: The sentence, “Hence, all dogs are mammals,” is a premise in this argument. (Points : 1)
.
1-3 Final Project Milestone #1 ProposalThroughout this course.docxcuddietheresa
1-3 Final Project Milestone #1: Proposal
Throughout this course you will be asked to make wiki posts about a company in which you are a stakeholder. Before you can make your first post (due next week), you must submit a proposal to your instructor below.
This 1–2 page proposal must:
Identify the company you have selected
Give a brief synopsis of the company, summarizing its purpose and goals
State your rationale and reason for selecting this company
Describe your role as a stakeholder in this company
Describe at least three other stakeholders and their relationship to the company you have selected
Conclusion: what you hope to gain/understand as you research about this company
After the handshake is agreed upon, I will give the comany that I have chosen. Paper must be:
1-2 page APA.
Pass Turnitin
Received on or before the deadline.
.
1-Please explain Ethical Universalism. Should organizations be socia.docxcuddietheresa
1-Please explain Ethical Universalism. Should organizations be socially responsible to their stakeholders?
2
What factors go into putting together a Strong Management Team?
3-
Please discuss how Benchmarking by adopting Best Practices of other companies and enacting Continuous Improvement aids in Organizational Performance.
4-
How does an organization develop an High Performance Culture?
.
1-an explanation of why the Marbury v. Madison case is a landmar.docxcuddietheresa
1-an explanation of why the
Marbury v. Madison
case is a landmark decision. Then briefly describe the Supreme Court case you reviewed and explain the significance of the
Marbury v. Madison
decision on the outcomes of the case. Be specific.
Note: Put the name of the Supreme Court case you reviewed in the first line of your post. You will be asked to respond to a colleague who selected a different Supreme Court case than you did.
Powers of the Supreme Court
There are a number of Supreme Court cases that have significantly impacted law and public policy. As you progress through the course, you will review many of these cases. For this Discussion, you are asked to consider the significance of the
Marbury v. Madison
case.
In the presidential election of 1800, Thomas Jefferson defeated the incumbent president, John Adams, a Federalist. Before John Adams left office, he appointed judges and justices of the peace for the District of Columbia who also were Federalists. All of the appointments for the new judges and justices of the peace were approved in a mass Senate hearing. However, four of the justices of the peace did not receive their commissions before John Adams’ presidency was over. One of these justices of the peace, William Marbury, petitioned the Supreme Court to force James Madison, the new Secretary of State under Jefferson, to deliver his commission. Marbury cited the Judiciary Act of 1789 which gave the Supreme Court the power to take such an action. In the end, Chief Justice John Marshall of the Supreme Court declared that the Judiciary Act of 1789 was unconstitutional and then denied Marbury’s petition.
This decision was the first time in history that the Supreme Court deemed a legislative act to be unconstitutional. As a direct result of the case, the concept of judicial review was established and the checks and balances of the U.S. Government were further defined.
2-a brief explanation of the Supreme Court’s role in policy making. Then describe two strengths and two limitations of the Supreme Court’s role in policy making.
Role of the Supreme Court in Policy Making
While the U.S. Supreme Court is extremely powerful, theoretically, it is not able to create law or public policy in the way that Congress or the President does. However, the Supreme Court is able to review public policies or laws that are disputed and determine their constitutionality. Supreme Court justices must determine which cases or disputes to hear and then determine if the laws or policies in such cases are constitutional. If they rule that the laws or policies are unconstitutional, they make recommendations about how the laws or policies should be changed or adapted. In this way, the Supreme Court engages in policy making.
To prepare for this Discussion:
Review the Preface and Introduction in the course text,
Landmark Supreme Court Cases: The Most Influential Decisions of the Supreme Court of the United States.
Consider the history of the Supreme Court a.
1-Discuss research that supports the hypothesis that a person’s ac.docxcuddietheresa
1-Discuss research that supports the hypothesis that a person’s action in the environment affects depth perception.
2-Name and discuss two characteristics of optic flow.
3-What is optic ataxia? Describe the method, results, and implications of the research by Schindler on optic ataxia patients
4-Contrast the three types of dichromatism, in regard to rates, neutral points, color experience, and proposed physiological cause.
5-Name, define, and give an example (in words) of six pictorial depth cues.
Due Sunday by 5PM
.
1-Imagine you are a historian, and the only existing sources of evid.docxcuddietheresa
1-Imagine you are a historian, and the only existing sources of evidence
regarding the conquest are documents from Indigenous sources. What can we
conclude by analyzing the Florentine Codex, the Annals of Tlatelolco, as well
as the excerpts from Oaxaca and Yucatan that best describes the conquest
from the perspective of the Indigenous population?
2-In 1844, U. S. President James K. Polk ran on a Democratic platform that
supported manifest destiny. Manifest Destiny is the idea that Americans were
predestined to occupy the entire North American continent. The last act of
Polk's predecessor, John Tyler, had been to annex the Republic of Texas in
1845. Polk wanted to lay claim to California, New Mexico, and land near the
disputed southern border of Texas. Mexico, however, was not so eager to let
go of these territories. What ensued later is referred in the historical records as
the Mexican American War. Examine the causes that precipitated the
Mexican American War, as well as the end result of this conflict.
.
1-How does relative humidity affect the comfort of people Can you e.docxcuddietheresa
1-How does relative humidity affect the comfort of people? Can you explain the physiological reasons for this?
2-The diurnal (daily) relationship between temperature and humidity is such that the lowest humidity should occur in the afternoon hours. It is during these times, however, when it often seems to be most humid and uncomfortable. What could be the reason for this
perceived
inconsistency?
3- When dew forms on outdoor objects, can it be assumed that the atmosphere is saturated? If so, why is there often no fog accompanying the dew?
4-
Can you think of any agents or circumstances that may cause the mixing ratio in a room to change?
.
1-1) In general, what is the effect of one party being mistaken abou.docxcuddietheresa
1-1) In general, what is the effect of one party being mistaken about the subject matter of
a contract?
a. The mistaken party can rescind the contract.
b. Either party can rescind the contract, and the mistaken party can recover damages.
c. Neither party can rescind the contract or recover damages.
d. Either party can rescind the contract and/or recover damages.
e. Either party can rescind the contract.
2-5) In Wilson v. Western National Life Insurance Company, involving the party who lied
allegedly regarding prior drug abuse in order to obtain life insurance, what was
the holding of the court when the party later died from a drug overdose?
Unit 3 Examination
a. The life insurance company had to pay the proceeds because if the plaintiff’s medical
records had been consulted, the drug abuse would have been discovered.
b. The life insurance did not have to pay the proceeds only because the deceased’s wife
was unaware of the misrepresentation.
c. The life insurance had to pay the proceeds because the deceased’s wife actually paid
the premiums.
d. The life insurance company had to pay the proceeds because the plaintiff was not
using drugs during the time the application for insurance was made.
e. The life insurance company did not have to pay the proceeds because of the concealment
of the drug abuse.
3-8) Frank had a bicycle that he advertised for sale, honestly believing it to be a 1999
model even though it was actually a 1996 model. There were significant improvements
in the frame material, not readily apparent, made between 1996 and 1999 to
this model bicycle. The buyer believed Frank’s statement that it was a 1999 model,
and was excited to be getting a model incorporating the improvements. After discovering
that the bike was actually a 1996 model, the buyer could avoid the contract on
the basis of:
a. unilateral mistake.
b. fraud.
c. mutual mistake.
d. B and C.
e. none of the above.
Unit 3 Examination
Business Law
4-9) The owner of a gym tells Ruppert that if he joins the gym for a year and hires a personal
trainer, his body will be more attractive to women and his life will change forever.
Ruppert joins and hires a personal trainer, but otherwise his life remains the
same. The statements of the gym owner could be described as:
a. statements of fact.
b. statements of opinions.
c. predictions about the future.
d. both B and C.
e. A, B and C.
5-10) Which of the following is the false statement?
a. A legal right arising from a breach of contract may be assigned.
b. The same right can be assigned more than once.
c. You must get everyone’s consent to make a novation.
d. Purely mechanical duties are not delegable.
e. There is a guarantor in a delegation.
6-11) When there has been an assignment of rights under a contract, who has a duty to
notify the obligor of the assignment?
a. The assignor.
b. The assignee.
c. Both the assignor and the assignee.
d. Neither the assignor nor the assi.
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Delivering Value Through Evidence-Based PracticeMacias, Charles .docx
1. Delivering Value Through Evidence-Based Practice
Macias, Charles G; Loveless, Jennifer N; Jackson, Andrea N;
Srinivasan, Suresh. Clinical Pediatric Emergency Medicine;
Maryland Heights Vol. 18, Iss. 2, (2017): 89-97.
DOI:10.1016/j.cpem.2017.05.002
1. Full text
2. Full text - PDF
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Unwanted variation in care is a challenge to high-quality care
delivery in any healthcare system. Across the Emergency
Medical Services for Children (EMSC) continuum, there is wide
variation in care delivery for which best practices have
demonstrated opportunities to minimize that variation through
clinical standards (evidence-based pathways, protocols, and
guidelines for care). A model of development of clinical
standards is delineated and tools used in that process are
described. Implementation strategies for improving utilization
are also described with clinical decision support tools being a
promising strategy for accelerating uptake of guidelines.
2. Critical to implementing guidelines through improvement
science strategies is the ability to make iterative improvements
directed by data and analytics. The progression of sophistication
in a system's informatics and analytics capabilities is driven by
a maturity of data reporting to analytics that drives decision
support for implementing clinical standards. Integration of
financial data into the clinical standards processes and analytics
platforms is necessary to determine value of the work. Within
the EMSC continuum, a number of initiatives will drive national
clinical standards activities and are fueled by current pockets of
successful development and implementation activities within
organizations and systems.
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Health care organizations and our health care system as a whole
should be striving towards achieving high value. All
stakeholders in health care delivery systems benefit from
increased value including patients, providers, payers, and
suppliers who reap benefit from a stable and well-supported
system. As value is defined by outputs, measurement and
outcomes are critical to demonstrating increased value and
driving iterative improvement to achieve even greater value.
The relationship of outcomes relative to cost may define value,
and this has been popularized as a value equation where value is
equal to quality over cost (dollars spent).1,2
Quality itself has been defined as “the degree to which health
services for individuals and populations increase the likelihood
of desired health outcomes and are consistent with current
professional knowledge.”3 Professional knowledge implies
consideration for the best evidence to inform clinical decision-
making based on studies and scientific literature with a goal of
provision of the right care to the right child at the right time.
4. Evidence-based practice should not be construed to imply that
published or high quality scientific evidence is available to
inform all clinical questions, rather, that an evidence-based
model of care includes consideration for scientific evidence,
physician clinical expertise, patient and family values and
preferences, clinician preferences, and available resources
contextualized to the specific clinical care question for which a
recommendation will be derived.4
Variation and the emergency medical services for children
continuum
The Institute for Healthcare Improvement has suggested a triple
aim framework for optimizing health system performance: (1) a
better overall patient experience, (2) improving the health of a
population, and (3) delivering care at a better value.5
Application of the triple aim would be relevant for care
delivered across the pediatric emergency medicine (emergency
medical services for children or EMSC) care continuum.
Although thought of as beginning in prehospital or hospital
care, the EMSC continuum begins with an incident and involves
potentially multiple care venues and providers with ultimate
return of the patient to the community and their medical home
(Figure 1).
Health care has become increasingly complex, and variation in
care delivery has contributed to that complexity and potential
gaps in quality. The understanding that unwanted variation is
the enemy of quality has been attributed to W. Edwards
Deming, statistician, professor, and expert in quality
management,6 and can be applied to any type of care delivery,
including that within the EMSC continuum of care. Unwanted
variation in health care can contribute to waste, inefficiency and
ineffectiveness in providing diagnostic accuracy and therapeutic
reliability. Several studies across the pediatric emergency care
continuum have described wide variations in practice. In
prehospital care, Shah and colleagues described the prehospital
transport of 250 actively seizing children to 10 urban EDs in
which a wide variation in delivery of medication routes for
5. midazolam were noted with approximately half resulting in
dosing errors.7 Similar variation also has been noted in
utilization patterns for trauma specialty care for children with
moderate and severe injuries.8 Although variation in care
delivery for children treated in EDs has been well described,4
the association between this variation with cost and quality is
becoming increasingly highlighted. Data from the Pediatric
Health Information System, a comparative pediatric database
housed in the Children's Hospital Association, was used to
assess the management of 3 pediatric conditions treated in 21
hospital EDs (ie, gastroenteritis, asthma, and simple febrile
seizures). While wide variation in care was noted, higher costs
were not associated with better quality.9 ED based care also has
implications on the quality of care delivered in inpatient
settings. One study of children treated on inpatient units for
bronchiolitis noted variations in diagnostic testing and
management among 16 US hospitals that was unrelated to
patient demographics or severity of illness.10
Clinical standards in EMSC
Because unwanted variation can exist anywhere in the
continuum, a gap in quality can have the net effect of less than
optimal outcomes for the child. Aligning care with clinical
standards supported by systematic approaches to guideline
development will improve the probability that patient
populations will receive care based on the most current
professional knowledge. Clinical guidelines serve to synthesize
available evidence and bridge the gap between science and
clinical practice; not through rigid protocol adherence but by a
framework for care delivery, thus contributing to efficiency,
cost containment, and improved patient outcomes.11 Clinical
standards may refer to pathways, protocols, evidence-based
summaries, or full guidelines, and ideally are developed in a
patient-/family- centric manner in order to address care across
the continuum.
National attention for the need for evidence-based clinical
standards for prehospital care has been growing despite the
6. limited research on the direct benefits of existing prehospital
evidence-based guidelines (EBGs), mostly because of the wealth
of evidence to illustrate their contributions to improved
outcomes in other medical fields and other EMSC settings.12-14
One pediatric study used improvement science methodology to
improve adherence to national septic shock guidelines,
consequently demonstrating improvement in process and
outcome measures.15 A study of over 180,000 children with
gastroenteritis found that hospitals adhering to published
guidelines had 50% lower charges for ED or observation
patients without adverse effects on other outcomes.16
Guidelines for diagnosis and management of bronchiolitis both
in the ED and across the hospital continuum have been
associated with improved outcomes through decreases in
utilization of unnecessary testing and interventions, including
decreases in costs.17-21
Several organizations and systems have developed strategies for
minimizing unwanted variation in clinical care by utilizing
systematic approaches to development of evidence-based
clinical standards. Concurrently, they have described improved
processes and outcomes, many of which include reduced
costs.4,22-24 Thus, there is a plethora of experiential learning
from clinical standards work that is applicable to the EMSC
environment.
Developing clinical standards: One model
At Texas Children's Hospital/Baylor College of Medicine, the
Evidence-Based Outcomes Center has had a decade of
experience in the development and implementation of clinical
standards. The core elements of systematic clinical standards
development are described below and are applicable to any
venue of care.
Selection of a clinical topic can be determined by both
importance of outcomes (as defined by high prevalence, high
rate of morbidity and mortality, resource intensiveness, or wide
variation in care) and organizational readiness for improvement.
Internal data can help identify importance quantitatively,
7. especially when including cost of care for each disease process
being considered for clinical standards. Simply defined,
organizational readiness is the institutional member's
commitment to the complex change that might ensue from
development and implementation of the clinical standard;25
they must value the development process as well as the
potential in order to assure ongoing engagement for
development, implementation, and sustainability.
Guideline development teams should be created with a
multidisciplinary, “bottom up” approach to allow front line
content experts rather than authoritative leaders to voice all
opinions. Patient and family participation and feedback should
be incorporated into the guideline development process in order
to ensure that important clinical questions and outcomes to the
patients and their families are considered.
Determining the scope of the clinical standard, along with
patient inclusion criteria and exclusion criteria, is a prerequisite
to identifying the important clinical questions to be addressed.
Focused clinical questions should be brainstormed based on
areas of variation in care, new research availability, areas with
performance outcomes below benchmark, and/or identified
patient care concerns. Clinical questions should be presented in
Patient Intervention Comparison Outcome (PICO) format in
order to ensure searchable keywords and specific
recommendations (eg, in children with acute asthma in the ED
[P], do anticholinergic agents [I] versus standard albuterol care
[C] reduce admission rates [O]).26 Patient-centered outcomes
are preferred and should be rated on their degree of importance
to the patient. The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) methodology currently
utilizes 3 categories for outcome rating (critical, important but
not critical, and limited importance). Outcomes of limited
importance are not included in the development of the clinical
standard as they should not have an effect on decision-making
related to patient care.27
A systematic search for existing national guidelines and
8. pertinent clinical research for each question should be
completed using research databases, evidence-based practice
websites, and professional organization websites (eg, American
Academy of Pediatrics, Agency for Healthcare Research and
Quality National Guideline Clearinghouse, or specialty specific
professional societies pertinent to the guideline topic).
Existing guidelines and clinical research should be critically
appraised utilizing an established appraisal method (eg, Texas
Children's Hospital has implemented the use of Appraisal of
Guidelines for Research and Evaluation II [AGREE II] and28
GRADE methodologies for guidelines and clinical research,
respectively29). With the review of evidence for each PICO
question, unambiguous practice recommendations will be
developed that give guidance to clinicians on the care of the
patient. Remarks outlining the values and preferences of the
patients, families, and providers can be incorporated into
recommendations, especially when the desired effects of an
intervention are closely balanced with the undesired effects.28
Where evidence is lacking, consensus amongst the guideline
development team is needed with transparent statements to
reflect the paucity of evidence.
Assessments of existing guidelines utilizing tools should be
transparently demonstrated in the guideline. AGREE II is a 23-
item instrument encompassing 6 domains: scope and purpose,
stakeholder involvement, rigor of development, clarity of
presentation, applicability, and editorial independence. Each
item is ranked on a 7-point Likert scale and the item ratings are
used to formulate an overall rating of the guideline quality.29
Ultimately, the guideline is either adopted, adopted with
modifications (most common), or rejected. Other tools in
addition to the AGREE II tool, such as the Institute of Medicine
Standards for Developing Trustworthy Clinical Practice
Guidelines, also exist.30,31
For each PICO question, studies should be critically evaluated
as a body of evidence using an appraisal tool, such as
GRADE.32 GRADE is a widely adopted global tool that allows
9. for a seamless, transparent process of translating the evidence
into clinically useful practice recommendations. Each practice
recommendation is categorized as strong or weak and is
supported by high, moderate, low, or very low-quality evidence.
Limitations in study design and execution, inconsistency
between studies, indirectness between the PICO question and
the studies, imprecision of the studies, and publication bias can
lower the overall quality of evidence. Large estimates of
treatment effect, evidence of a dose-response gradient, and
plausible confounding that would increase confidence in an
estimate of effect can raise the quality of evidence. The strength
of the recommendation is “the extent to which we can be
confident that adherence to the recommendation will do more
than harm.” It is formulated by weighing the risks versus the
benefits of the intervention and by considering the
patient/family values and preferences, quality of evidence,
importance of the outcome, ease of implementation, costs, and
resources.
Implementation of clinical standards
Implementation of clinical standards, described here briefly as
the context in which guidelines are implemented, is broadly
variable and literature for successful uptake specific to the
EMSC continuum is limited. With rare exception, the entirety of
guidelines or components of the guideline may represent the
shared baseline by which a quality improvement (QI) initiative
is driven. Nonetheless, opportunities in utilizing improvement
methodologies such as the Model for Improvement with its
embedded Plan-Do-Study-Act (PDSA) cycles are used at Texas
Children's Hospital (TCH) as the method of choice, although
many other methods are also incorporated.33 Iterative
improvements are discovered during the planning phase and
multiple QI tools are utilized to understand the workflow,
leverage points, metrics, and analytics to manage change and
drive improvement in outcomes. The Agency for Healthcare
Research and Quality suggests that a QI implementation team be
comprised of individuals connected to or a part of hospital
10. leadership, clinical experts in the intervention or disease
process of focus, persons proficient in QI methodology, and
influential personnel from the areas most affected by the
change.34 Critical to understanding the financial impact and
value of clinical standards is the incorporation of finance team
members into our implementation teams.
Factors that influence implementation success of clinical
standards have been described and include the following:35-40
Characteristics of the guideline that improve uptake:
a low complexity guideline (ie, easy to understand and use)
the scientific nature of the guideline being evidence-based
rather than lacking a scientific basis
development by the target group and stakeholders who will use
it
Characteristics of the implementation strategies that improve
success:
multifaceted, intensive strategies involving system redesign
Characteristics of professionals that will decrease success:
lack of familiarity or limited familiarity
lack of agreement with the clinical standard
younger age or less experience of the professional
Characteristics of patients that decrease uptake by the user:
patients who perceive no need for guideline recommendations or
reject them
patients with comorbidities
Environmental characteristics that decrease success:
limited time and personnel resources
limited perceived support from peers or superiors
Clinical decision support
Clinical decision support (CDS) built within the electronic
medical record (EMR) is a powerful means to leverage
guideline uptake. CDS encompasses a variety of approaches to
provide clinicians, staff, patients, and other users with timely,
relevant information that can improve decision making, prevent
errors, and enhance health and health care.41 Qualitative
research has defined 3 categories of CDS: (1) Alerting CDS:
11. alerts and reminders that fire to deliver information and
interrupt workflow; (2) Workflow CDS: eases data entry,
documentation, and resource location, and (3) Cognitive CDS:
provides a patient management and planning overview.42 CDS
tools and interventions include computerized alerts and
reminders, order sets, patient data reports and dashboards,
documentation templates, diagnostic support, and clinical
workflow tools.41 CDS tools allow for dissemination of the
right information to the right people at the right time. At TCH,
we offer our clinicians a plethora of CDS tools, including
algorithms, evidence-based order sets, suggestion records,
interdisciplinary plans of care (IPOCs), best practice alerts
(BPAs), and navigators. Suggestion records use discrete
variables from the patient chart to promote the use of evidence-
based order sets by passively suggesting targeted order set use
to the ordering clinician on the order entry screen.
Interdisciplinary plans of care display goal-driven interventions
for the entire care team. Best practice alerts are pop-ups that
prompt a clinician to address an issue before continuing and can
be programmed with hard stops.
Algorithms or flowcharts provide a visual representation of the
practice recommendations. Evidence-based order sets allow for
timely application of evidence at the bedside. Orders that are
supported by evidence can be defaulted and orders that are not
supported by evidence are intentionally omitted or listed last on
order lists if minimal evidence supports their use. For example,
chest radiographs for bronchiolitis are not offered on ED- based
bronchiolitis order sets, and generic oral antibiotic choices are
listed first on options for community- acquired pneumonia order
sets and other ED- based infectious disease related order sets.
Order sets may have hyperlinks to resources (eg, clinical
standard, algorithm, or other pertinent internal or external
resources) to provide transparency to CDS. In addition, clinical
and information services governance structures at Texas
Children's Hospital prohibit consensus- or silo-based order set
builds if an existing evidence-based order set exists.
12. The implementation of evidence-based order sets, clinical
guidelines, and QI interventions driven by a CDS tool for early
recognition of severe sepsis and septic shock at our institution
led to an improvement in a number of quality metrics. The
trigger tool, designed as a hard stop alert, had an 81%
sensitivity and 99.9% negative predictive value.43 After
implementation of the protocol, measurement of impact
compared to baseline data revealed significant improvements in
time from triage to first bolus (decrease from a median of 56 to
22 minutes) and triage to first antibiotics (decrease from a
median of 130 to 38 minutes).44
Analytics
As with all quality improvement initiatives such as the sepsis
example above, measurement is critical to defining success.
This would include demonstration of clinical, operational, and
financial measures (including process and outcome measures for
those domains) for quantifying value in clinical standards work.
The science of informatics (data plus meaning), as it relates to
pediatrics, must target population health (including ED care
within a continuum) It must simultaneously address the rising
costs associated with implementation and maintenance of
computerized systems of care coordination, while at the same
time contribute towards excellence in patient care.45 Analytics
(data plus information) plays a key role in predictive
assessment, clinical decision support, and various patient
throughput measures.46 To illustrate this, an initiative to create
and implement clinical standards for asthma included EMSC
related activities comprised of prehospital and hospital based
interventions that included early steroid delivery;
standardization of scoring scales and pathways linking protocols
for care; standardization of first line, adjunct, and second line
therapies; standardization of asthma action plans; and control
medication for persistent asthma from any acute venue of care
including emergent care settings. One component of the bundle
driven by the ED is illustrated in Figure 2A, where efforts to
decrease orders for unnecessary chest radiographs was targeted.
13. Comprehensive guidelines for care were implemented with
education, CDS, dashboard dissemination, and enhanced
communication strategies that included components pertinent to
the ED. As this bundle of activities aligned with the asthma
guideline also included inpatient, critical care, and outpatient
activities, the resultant decreases in length of stay, reductions in
unnecessary test ordering, reductions in readmissions, and other
improvements in clinically relevant quality metrics led to a
decrease in cost of care for the population of thousands of
children with asthma treated in our enterprise and is
demonstrated in Figure 2B.
In order to support the analytics capabilities necessary to
demonstrate improvements from clinical standards, health care
systems must drive increasing sophistication in informatics and
analytics. To meet this demand, data systems must move from
simple data gathering and reporting, as can be done from a
patient EMR report at the bedside, to aggregating and analyzing
data in populations or themes (data analytics), to predicting
patients at risk (predictive analytics), or linking health
observation with health knowledge to influence clinical
decisions (prescriptive analytics or clinical decision support).47
(See Figure 3). Although many EMRs are developing analytics
platforms that embed some of these capabilities into their
existing workflows, robust analytics must still overcome gaps in
interoperability and the sharing of data between relevant health
care systems to track data related to the health of a population.
Guidelines developed along a patient- centric model ideally
would be able to track metrics across systems, such as EMSC
entities; however, current limitations in technology and culture
for data sharing provide restrictions for understanding the
complete value of clinical standards implemented across a
system. Nonetheless, demonstrations of improvements in value
likely understate the true impact across an entire health care
system. At Texas Children's Hospital, the integration of data
across multiple entities linked to our institution (eg, health plan
data, pediatric practice data, hospital data, and prehospital data)
14. can be housed in our Enterprise Data Warehouse (EDW) to
encompass the EMR, financial information and staffing data,
and other sources of data across its infrastructure. Future
integration of health information exchanges, government hosted
databases, and other big data sources will aid in providing
analytics support for identifying opportunities for driving,
assessing impact, and iterating quality improvement initiatives
driven by clinical standards.
When assessing the impact on quality of evidence-based
guidelines and other clinical standards products clinical
outcomes as illustrated above are important, but these may be
linked to financial outcomes to establish value. At Children's
Hospital of Pittsburgh, a hospital aim to integrate actionable
analytics into the broader framework of disease management
targeted an existing appendicitis guideline (preoperative and
postoperative phases) as its initial project. A self-service web-
based tool provided measurement to provide clinical leaders and
administrators analytics accessible in their offices or at the
point-of-care. These interventions for guideline-driven care
across the care continuum led to a 25% reduction in the median
length of stay of patients with appendicitis, and also a
significant decrease in the controllable (direct) cost per case.
This illustrates that collection, analysis, and timely
dissemination of accurate clinical and throughput data aligned
with clinical pathways changed behavior and improved care
outcomes.48 Across the Texas Children's Hospital continuum,
from ED to inpatient units to discharge, the total cost savings
across a subset of 21 diseases for which guidelines were
available in fiscal year 2016 was a net difference of $33.5
million in variable direct costs, or the costs directly attributable
to the additional burden of care for the patient calculated
relative to the personnel time and resources consumed.
Summary and future directions
Clinical standards drive value in health care by improving
quality of care: removing unwanted variation in a system drives
reductions in waste, minimizes error, and improves throughput.
15. Systematically developed guidelines can be implemented
effectively utilizing best evidence for leveraging known
enablers and eliminating barriers to adoption. Across the EMSC
continuum, wide variations in practice have demonstrated
opportunities for clinical standards to improve value. These
strategies may include system- based clinical decision support
and local analytics platforms to drive iterative improvement
centered on such a shared baseline of care.
Across the EMSC continuum, we anticipate a continued growth
in clinical standards activities and improvement science
initiatives to develop and implement them as stakeholders
demand greater transparency in data, and attribution models for
best practices illustrate new opportunities for spread. Efforts to
support prehospital clinical standards development and
implementation have been driven and supported by a number of
agencies such as the National Highway Traffic Safety
Administration, the Health Resources Services Administration
through the EMSC program, the Federal Interagency Committee
on EMS, and the National EMS Advisory Council. Strategies
included the creation of a prehospital guidelines consortium, the
development, promotion and implementation of prehospital
evidence-based guidelines, education and research on
prehospital evidence-based guidelines, and standardization of
evaluation methods for prehospital evidence-based
guidelines.41 The greatest potential for establishing value of
clinical standards in prehospital work will likely emerge from
standardization of evaluation strategies to link outcomes to
local, regional, state, and federal efforts at implementing
pediatric prehospital evidence-based guidelines.
The EMSC federal program has recently supported a conversion
of its coordinating center to one embedded in improvement
science (EMSC Innovation and Improvement Center), of which
its initiatives includes efforts to minimize unwanted variation in
care (www.EMSCImprovement.center). One such initiative
includes a partnership with the American Academy of Pediatrics
for development of national ED- based evidence-based
16. pathways. To date, these have included publically accessible
pathways for septic shock, bronchiolitis, and community
acquired pneumonia.49Hospital-based efforts are currently
limited by gaps in data sharing across institutions to evaluate
outcomes and costs related to implementation of these
pathways. However, local implementation of these and other
evidence-based clinical standards products will likely continue
to describe the value of clinical standards in pockets across the
EMSC continuum. The Pediatric Initiative for Clinical
Standards (PICS), now in its second year, is moving from its
development of hospital-based guidelines activities within this
consortium of children's hospitals to a phase of data collection
on quality metrics in order to demonstrate value in clinical
standards implementation that will include components of ED
based care.
Although limitations to big data sharing will continue to limit
the nation's ability to demonstrate the aggregate value in
clinical standards across the EMSC continuum, demonstrated
successes in defining value for components of the system will
fuel more comprehensive and widespread approaches to
development and implementation. Ultimately, these patient
centric approaches to clinical standards work will continue to
drive improved outcomes of care, a better patient experience,
and decreased costs of care--achieving the triple aim.
Acknowledgements
Travis L. Rodkey, Ph.D., Outcomes Analyst, Outcomes and
Impact Service, Texas Children's Hospital, Houston, TX.
References
1 M.E. Porter, N Engl J Med, Vol. 363, 2010, 2477-2481
2 M.E. Porter, E.O. Teisberg, Redefining health care: creating
value-based competition on results, 2006, Harvard Business
School Press, Boston, MA
3 K.N. Lohr, S.A. Schroeder, A strategy for quality assurance in
Medicare, N Engl J Med, Vol. 322, 1990, 707-712
4 C.E. Chumpitazi, P. Barrera, C.G. Macias, Diagnostic
accuracy and therapeutic reliability in pediatric emergency
17. medicine: the role of evidence-based guidelines, Clin Pediatr
Emerg Med, Vol. 12, 2011, 113-120
5 D.M. Berwick, T.W. Nolan, J. Whittington, The triple aim:
care, health, and cost, Health Aff, Vol. 27, 2008, 759-769
6 C.W. Kang, P.H. Kvam, Basic statistical tools for improving
quality, 2011, John Wiley & Sons, Hoboken, NJ
7 M.I. Shah, J.M. Carey, S.E. Rapp, Impact of high-fidelity
simulation on paramedic seizure management, Prehosp Emerg
Care, Vol. 20, 2016, 499-507
8 N.E. Wang, O. Saynina, K. Kuntz-Duriseti, Variability in
pediatric utilization of trauma facilities in California: 1999 to
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9 A.B. Kharbanda, M. Hall, S.S. Shah, Variation in resource
utilization across a national sample of pediatric emergency
departments, J Pediatr, Vol. 163, 2013, 230-236
10 C.G. Macias, J.M. Mansbach, E.S. Fisher, Variability in
inpatient management of children hospitalized with
bronchiolitis, Acad Pediatr, Vol. 15, 2015, 69-76
11 E.J. Andrews, H.P. Redmond, A review of clinical
guidelines, Br J Surg, Vol. 91, 2004, 956-964
12 J.L. Wright, Evidence-based guidelines for prehospital
practice: a process whose time has come, Prehosp Emerg Care,
Vol. 18, 2014, 1-2
13 M.R. Sayre, L.J. White, L.H. Brown, National EMS research
agenda, Prehosp Emerg Care, Vol. 6, 2002, 1-43
14 C. Martin-Gill, J.B. Gaither, B.L. Bigham, National
prehospital evidence-based guidelines strategy: a summary for
EMS stakeholders, Prehosp Emerg Care, Vol. 20, 2016, 175-183
15 R. Paul, E. Melendez, A. Stack, Improving adherence to
PALS septic shock guidelines, Pediatrics, Vol. 133, 2014,
e1358-e1366
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adherence to the standard of care of acute gastroenteritis,
Pediatrics, Vol. 124, 2011, e1081-e1087
17 A.T. Akenroye, M.N. Baskin, M. Samnaliev, Impact of a
bronchiolitis guideline on ED resource use and cost: a
18. segmented time-series analysis, Pediatrics, Vol. 133, 2014,
e227-e234
18 S.D. Wilson, B.B. Dahl, R.D. Wells, An evidence-based
clinical pathway for bronchiolitis safely reduces antibiotic
overuse, Am J Med Qual, Vol. 17, 2002, 195-199
19 M.A. Bryan, A.D. Desai, L. Wilson, Association of
bronchiolitis clinical pathway adherence with length of stay and
costs, Pediatrics, Vol. 139, 2017, e20163432
20 V. Mittal, C. Darnell, B. Walsh, Inpatient bronchiolitis
guideline implementation and resource utilization, Pediatrics,
Vol. 133, 2014, e730-e737
21 K. Parikh, M. Hall, S.J. Teach, Bronchiolitis management
before and after the AAP guidelines, Pediatrics, Vol. 133, 2014,
e1-e7
22 A.T. Akenroye, A.M. Stack, The development and evaluation
of an evidence-based guideline programme to improve care in a
paediatric emergency department, Emerg Med J, Vol. 33, 2016,
109-117
23 P. Kurtin, E. Stucky, Standardize to excellence: improving
the quality and safety of care with clinical pathways, Pediatr
Clin North Am, Vol. 56, 2009, 893-904
24 K.C. Lion, D.R. Wright, S. Spencer, Standardized clinical
pathways for hospitalized children and outcomes, Pediatrics,
Vol. 137, 2016, e20151202
25 B.J. Weiner, A theory of organizational readiness for change,
Implement Sci, Vol. 4, 2009, 67
26 G.H. Guyatt, D. Rennie, M.O. Meade, D.J. Cook, Users’
Guides to the Medical Literature: A Manual for Evidence-Based
Clinical Practice, 2nd ed., 2008, McGraw-Hill, New York City
27 G.H. Guyatt, A.D. Oxman, R. Kunz, GRADE guidelines: 2.
Framing the question and deciding on important outcomes, J
Clin Epidemiol, Vol. 64, 2011, 395-400
28 The AGREE Research Trust, Appraisal of guidelines for
research & evaluation II (AGREE II) Instrument, Available at:,
Accessed 4-29-17
29 J. Andrews, G. Guyatt, A. Oxman, GRADE guidelines: 14.
19. Going from evidence to recommendations: the significance and
presentation of recommendations, J Clin Epidemiol, Vol. 66,
2013, 719-725
30 S. Hollon, P. Areán, M. Craske, Development of clinical
practice guidelines, Annu Rev Clin Psychol, Vol. 10, Iss. 29,
2014, 213-241
31 National Academy of Sciences, Clinical practice guidelines
we can trust, Available at:, Accessed 4-29-17
32 The GRADE Working Group, GRADE, Available at:,
Accessed 4-29-17
33 G. Langley, R. Moen, K. Nolan, The improvement guide: a
practical approach to enhancing organizational performance,
2009, Jossey-Bass, San Francisco, CA
34 Agency of Healthcare Research and Quality, Preventing falls
in hospitals, Available at:, Accessed 4-29-17
35 A.L. Francke, M.C. Smit, A.J. de Veer, P. Mistiaen, Factors
influencing the implementation of clinical guidelines for health
care professionals: a systematic meta-review, BMC Med Inform
Decis Mak, Vol. 8, 2008, 38
36 M.S. Bauer, A review of quantitative studies of adherence to
mental health clinical practice guidelines, Harv Rev Psychiatry,
Vol. 10, 2002, 138-153
37 D.A. Davis, A. Taylor-Vaisey, Translating guidelines into
practice. A systematic review of theoretic concepts, practical
experience and research evidence in the adoption of clinical
practice guidelines, CMAJ, Vol. 157, 1997, 408-416
38 R. Tooher, P. Middleton, W. Babidge, J Wound Care, Vol.
12, 2003, 373-382
39 M.D. Cabana, C.S. Rand, N.R. Powe, JAMA, Vol. 282, 1999,
1458-1465
40 S.H. Simpson, T.J. Marrie, S.R. Majumdar, Respir Care Clin
N Am, Vol. 11, 2005, 1-13
41 American Medical Informatics Association, Clinical
Decision Support, Available at:, Accessed 4-27-2017
42 J.E. Richardson, J.S. Ash, D.F. Sittig, Multiple perspectives
on the meaning of clinical decision support, AMIA Annu Symp
20. Proc, Vol. 2010, 2010, 1427-1431
43 A.T. Cruz, E.A. Williams, J.M. Graf, Test characteristics of
an automated age- and temperature- adjusted tachycardia alert
in pediatric septic shock, Pediatr Emerg Care, Vol. 28, 2012,
889-894
44 A.T. Cruz, A.M. Perry, E.A. Williams, Implementation of
goal-directed therapy for children with suspected sepsis in the
emergency department, Pediatrics, Vol. 127, 2011, e758-e766
45 S. Suresh, The Intersection of Safety, Quality and
Informatics: Solving Problems in Pediatrics, Pediatr Clin North
Am, Vol. 63, 2016, xvii-xviii
46 S. Suresh, Big Data and Predictive Analytics: Application in
the Care of Children, Pediatr Clin North Am, Vol. 63, 2016,
357-366
47 C.G. Macias, K.A. Bartley, T.L. Rodkey, Creating a clinical
systems integration strategy to drive implementation, Curr Treat
Options Pediatr, Vol. 2, 2015, 1-13
48 S. Suresh, A. Buchert, G. Butler, Application of data-driven
observations and self-service analytics to improve meaningful
outcomes in appendicitis care. Poster presentation. Pediatric
Academic Societies Annual Meeting. San Francisco CA. May 9,
2017, Available at:
49 American Academy of Pediatrics Section on Emergency
Medicine, Publications, Available at:, Accessed 4-14-17
Word count: 4959
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Ulen i
Outline
Thesis: Recycling should be strictly enforced by the government
and people should be penalized for not following regulations.
Introduction.Most states do not enforce recyclingBenefits of
recyclingReduce wasteEnvironmental considerationsRecycling
in the homeNot using recycling
binsContaminationProgramsEducation
Make recycling easierUlen 5
Anthony Ulen
R. Sullivan
Composition 1301
5 October 2019
22. Government Regulations on Recycling
Recycling has many benefits, unfortunately, many states
do not force people to recycle. Some states, Alaska for
example, have zero systems in place to get people to recycle;
other states, however, do provide recycling bins or charge a
refundable fee on aluminum cans, this is not enough. States
have undermined the problems the US have been facing when it
comes to recycling for over 70 years. Since we can’t leave it to
just a few volunteer agencies that offer recycling benefits and
accessibility, then ultimately it should just be enforced by the
federal government. Unless States or the federal government
take action nothing will change, landfills will continue to grow
and the environment will worsen. Recycling should be strictly
enforced by the government and people should be penalized for
not following regulations. This would increase revenue and
create jobs that would ultimately boost the economy. But, in
order for these things to take place the US government would
have to regulate the several harmful single use plastic
companies that have been thriving on the sales of their products
for decades without being held accountable for the impact
they’re leaving on the economy and the planet.
In order to understand why recycling needs to be strictly
enforced by some form of the government you first need to
understand the benefits of recycling. Reducing waste has
several beneficial factors; like the ability to decrease the carbon
footprint that we’re leaving for our children and future
generations. Second those harmful single use goods like
aluminum cans or beverage plastics can end up being re-used, to
decrease the amount of waste in landfills polluting the soil and
potentially the under-ground water system; or in the oceans
where they are for sure devastating the very delicate eco-system
that drives life on our planet. “More plastic has been created the
past decade than the past 100 years.” (Susan Freinkel). By the
government enforcing recycling that number can be brought
down. Recycling can also increase jobs within our own country
which would inevitably increase our way of life by living in a
23. cleaner environment in which to raise a family, or boost the
American economy.
The problem is that even if recycling bins are provided there is
nothing stopping people from throwing away recyclable goods.
If there was a law that penalized people for putting cans or
plastics in the proper bin this would cause people to be more
aware of their actions. It sounds harsh but if people are not
going to help take care of their country with keeping it clean
and trash free then it may just be a necessary evil. This could
be enforced from spot checks on bins looking for recyclable
material and the owner would be ticketed for not complying.
Another issue is that recyclable material is contaminated.
Several items like single use plastic water bottles, fast food
straws and aluminum cans begin emitting potentially harmful
toxins when exposed to direct sunlight or water. This could
change by households cleaning off what they are putting in the
bin and making sure they are not cross contaminating; and use
the same type of fine penalty. In an article from the weekly
states; “It's estimated that about 25 percent of American
recyclables are contaminated with food waste and non-
recyclable materials, according to the National Waste &
Recycling Association trade group.” (The recycling crisis).
Once a recyclable good is contaminated it can no longer be
recycled and then turns to waste. Creating a new law could
have an impact on not contaminating recyclable goods.
In the home is where recycling starts, and many households do
not make a conscious effort to recycle. This problem is mostly
the lack of education. Americans feel that if they put all their
garbage; glass, plastics, bio-degradable items, anything they
want, into a plastic bag and take that plastic bag to the end of
their driveway into their trash bins and the trash is collected
and taken away then the problem disappears. This mindset is
what has created this enormous problem that we could’ve fixed
if only we were more educated on the subject. In a study by the
National Waste and Recycling Association said that ’’One third
of Americans are not sure what can be recycled.” (Allan
24. Gerlat). Very little information on the benefits of recycling are
available to the public. If the state or federal government
emplaced laws at the household level recycling would increase.
Recycling really could make an enormous difference but before
it can be enforced it must be made available. This is one way to
make the recycling crisis go away, is if state or federal
governments actually made programs available to those who
actually want to make a difference by recycling and creating a
beret and cleaner country in which to live in. A cleaner waste
free country has enormous benefits for the environment.
Education is going to have the best impact for people to change
their ways and government enforced programs is the only way
to make this work because what current systems that are in
place are not working.
Work Cited
Gerlat, Allan. “Americans Can Benefit from More Recycling
Education – Study.” Waste360, 22 Apr. 2014,
https://www.waste360.com/research-and-statistics/americans-
can-benefit-more-recycling-education-study.
Staff, The Week. “The Recycling Crisis.” Image, The Week, 30
Mar. 2019, https://theweek.com/articles/831864/recycling-
crisis.
Freinkel, Susan. Plastic: a Toxic Love Story. Houghton Mifflin
Harcourt (HMH), 2011.
25.
26. AU Did you use research material in this assignment? Research
is REQUIRED for this assignment.AU Do you have a Works
Cited page at the end of your essay with the title Works
Cited?AU Do you have three appropriate sources (see the
guidelines in this lesson) listed on the WC page?AU Are those
three sources cited in the paper using either paraphrases or
direct quotations?AU Did you define words, use a dictionary, or
use an encyclopedia? If so, those sources and information from
those sources must be removed. Most common words or words
used with their well-known definition do not need to be defined
in an essay. Dictionaries and encyclopedias are NOT
argumentative sources.AU Did you use MLA 8th edition to cite
your sources within the text and in the WC list?AU Have you
used parenthetical references within the text to show that you
are paraphrasing or quoting? AU Does the word/name in each
parenthetical reference match the first word/name in the
corresponding WC entry?AU Does the alphanumeric outline
appear in the same file as the essay itself (it should)? Is it the
first page in the document? (It should be.)AU Is the outline
page numbering different than your text pages? Outlines use
lowercase Roman numerals (i, ii, iii), while text pages use
Arabic numerals. AU Are your last name and page number in
the header (inside of the margin), NOT in the text? See the
examples online from Diana Hacker and youtube (for specific
instructions using your version of your word processing
program).AU Does your thesis appear in the outline AND in the
introduction? Is it the same thesis? They should be the same.AU
Is your thesis a single, concise sentence?AU Does the thesis
state the argument the essay will make?AU Is the file properly
named, as advised on Bb? (yourlastnameARGUEdraft)AU
REMOVE all FIRST and SECOND person pronouns (no you, I,
me, my, your, etc.). Remove all commands, too.AU Does the
method of organization suit the arguments you
are presenting?AU Does the essay refer to itself? (For example,
27. are you writing lines like, “In this essay I will . . .? If so,
remove them.)AU Have you checked MLA format for proper
margins (one inch all around--pre-formatted settings sometimes
use 1.5 inches on the side, so be sure to double check), heading
information, header placement, font, font size, outline structure,
etc.? Your grammar handbook has an example for you, as
does Bb. AU Did you run spellcheck? AU Does your conclusion
make a so what point? AU Did you begin the conclusion with
"in conclusion"? If so, remove that phrase.AU Have you met
the minimum word requirement? AU Have all contractions been
removed? (This is a formal essay.)AU Does the essay have
logical transitions throughout? AU Are all of your sentences in
each paragraph in the subject + verb sentence structure? If so,
review the grammar handbook's chapter on coordination and
subordination in order to avoid choppiness.
Ulen i
Outline
Thesis: Recycling should be strictly enforced by the government
and people should be penalized
for not following regulations.
I. Introduction.
A. Most states do not enforce recycling
II. Benefits of recycling
A. Reduce waste
28. B. Environmental considerations
III. Recycling in the home
A. Not using recycling bins
B. Contamination
IV. Programs
A. Education
B. Make recycling easier
Ulen 1
Anthony Ulen
R. Sullivan
Composition 1301
5 October 2019
Government Regulations on Recycling
Recycling has many benefits, unfortunately, many states do not
force people to recycle.
Some states, Alaska for example, have zero systems in place to
get people to recycle; other
states, however, do provide recycling bins or charge a
29. refundable fee on aluminum cans, this is
not enough. States have undermined the problems the US have
been facing when it comes to
recycling for over 70 years. Since we can’t leave it to just a
few volunteer agencies that offer
recycling benefits and accessibility, then ultimately it should
just be enforced by the federal
government. Unless States or the federal government take
action nothing will change, landfills
will continue to grow and the environment will worsen.
Recycling should be strictly enforced by
the government and people should be penalized for not
following regulations. This would
increase revenue and create jobs that would ultimately boost the
economy. But, in order for
these things to take place the US government would have to
regulate the several harmful single
use plastic companies that have been thriving on the sales of
their products for decades without
being held accountable for the impact they’re leaving on the
economy and the planet.
In order to understand why recycling needs to be strictly
enforced by some form of the
government you first need to understand the benefits of
30. recycling. Reducing waste has several
beneficial factors; like the ability to decrease the carbon
footprint that we’re leaving for our
children and future generations. Second those harmful single
use goods like aluminum cans or
beverage plastics can end up being re-used, to decrease the
amount of waste in landfills polluting
Commented [RS1]: Comma splice
Commented [RS2]: Comma splice
Commented [RS3]: This is not a first-person assignment.
Remove 1st person pronouns throughout.
Commented [RS4]: checklist
Commented [RS5]: unclear pronoun reference
Commented [RS6]: Is this the argument in each
paragraph? If not, then it is the so what point, the solution
for what should happen when the government actually
enforces its own rules.
Commented [RS7]: redundant. All of this says the same
basic thing.
Commented [RS8]: If the previous sentence is the thesis,
what is the purpose of this information? Leave the details
to the body paragraphs.
Commented [RS9]: Last time noted: NO essay this
semester will use second person.
31. Commented [RS10]: Does this topic address why the
government should enforce recycling rules?
Commented [RS11]: fragment
Ulen 2
the soil and potentially the under-ground water system; or in the
oceans where they are for sure
devastating the very delicate eco-system that drives life on our
planet. “More plastic has been
created the past decade than the past 100 years.” (Susan
Freinkel). By the government enforcing
recycling that number can be brought down. Recycling can also
increase jobs within our own
country which would inevitably increase our way of life by
living in a cleaner environment in
which to raise a family, or boost the American economy.
The problem is that even if recycling bins are provided there is
nothing stopping people
from throwing away recyclable goods. If there was a law that
penalized people for putting cans
or plastics in the proper bin this would cause people to be more
aware of their actions. It sounds
32. harsh but if people are not going to help take care of their
country with keeping it clean and trash
free then it may just be a necessary evil. This could be
enforced from spot checks on bins
looking for recyclable material and the owner would be ticketed
for not complying. Another
issue is that recyclable material is contaminated. Several items
like single use plastic water
bottles, fast food straws and aluminum cans begin emitting
potentially harmful toxins when
exposed to direct sunlight or water. This could change by
households cleaning off what they are
putting in the bin and making sure they are not cross
contaminating; and use the same type of
fine penalty. In an article from the weekly states; “It's
estimated that about 25 percent of
American recyclables are contaminated with food waste and
non-recyclable materials, according
to the National Waste & Recycling Association trade group.”
(The recycling crisis). Once a
recyclable good is contaminated it can no longer be recycled
and then turns to waste. Creating a
new law could have an impact on not contaminating recyclable
goods.
33. In the home is where recycling starts, and many households do
not make a conscious
effort to recycle. This problem is mostly the lack of education.
Americans feel that if they put all
Commented [RS12]: fragment
Commented [RS13]: Only the period at the end of the
sentence is used. Take this one out.
Commented [RS14]: Only last names are used in the
parenthetical reference because that is what starts the
corresponding entry.
Commented [RS15]: Quotations cannot stand alone like
this. They must be woven into the argument. Go back to Bb
and review the information there.
Commented [RS16]: Doesn’t this go off topic?
Commented [RS17]: Yes, this is a problem. How should
the government controlling recycling fix this?
Commented [RS18]: I’m not sure I follow this. How does
washing change the fact that the items themselves—straws,
cans, bottles—give off harmful toxins? If washing is the key,
the leftover food or products in those straws, cans, or
bottles are to blame.
Commented [RS19]: fragment
Commented [RS20]: Is this a title?
Commented [RS21]: Creates a fragment. Review how to
introduce quotations on Bb.
34. Commented [RS22]: Weekly Staff
Ulen 3
their garbage; glass, plastics, bio-degradable items, anything
they want, into a plastic bag and
take that plastic bag to the end of their driveway into their trash
bins and the trash is collected
and taken away then the problem disappears. This mindset is
what has created this enormous
problem that we could’ve fixed if only we were more educated
on the subject. In a study by the
National Waste and Recycling Association said that ’’One third
of Americans are not sure what
can be recycled.” (Allan Gerlat). Very little information on the
benefits of recycling are available
to the public. If the state or federal government emplaced laws
at the household level recycling
would increase.
Recycling really could make an enormous difference but before
it can be enforced it must
be made available. This is one way to make the recycling crisis
go away, is if state or federal
35. governments actually made programs available to those who
actually want to make a difference
by recycling and creating a beret and cleaner country in which
to live in. A cleaner waste free
country has enormous benefits for the environment. Education
is going to have the best impact
for people to change their ways and government enforced
programs is the only way to make this
work because what current systems that are in place are not
working.
Commented [RS23]: All of this is true and is related to
recycling, but is it related to your topic? Go back and look
at your thesis: Recycling should be strictly enforced by the
government and people should be penalized for not
following regulations. Does any portion of this mention
enforcement, the government, or penalties?
Commented [RS24]: Mixed construction
Commented [RS25]: hyphenate
36. Ulen 4
Work Cited
Gerlat, Allan. “Americans Can Benefit from More Recycling
Education – Study.” Waste360, 22 Apr. 2014,
https://www.waste360.com/research-and-statistics/americans-
can-benefit-more-recycling-education-
study.
Staff, The Week. “The Recycling Crisis.” Image, The Week, 30
Mar. 2019,
https://theweek.com/articles/831864/recycling-crisis.
Freinkel, Susan. Plastic: a Toxic Love Story. Houghton Mifflin
Harcourt (HMH), 2011.
Anthony,
All of the information here is inter-related and COULD support
the thesis. Right now, though, the
connection between each body paragraph and the thesis is not
entirely clear. Remember your
argument: Recycling should be enforced by the government.
When you take your topic sentences out
and list them, do they directly address that statement?
Recycling should be enforced by the government.
37. In order to understand why recycling needs to be strictly
enforced by some form of the
government you first need to understand the benefits of
recycling. [this says I am going to give
you information about the benefits of recycling. Yes, the first
part of the sentence mentions
wording from the thesis, but the emphasis is on the second part
of the sentence—giving
information.]
Recycling should be enforced by the government.
The problem is that even if recycling bins are provided there is
nothing stopping people from
throwing away recyclable goods.
Recycling should be enforced by the government.
In the home is where recycling starts, and many households do
not make a conscious effort to
recycle.
Do you see how the topic sentences do not indicate a direct
support of the thesis? Because they do not,
the paragraphs wander before coming back to the thesis. All of
this information could be brought back,
though, by rewriting topic sentences and working in the
connection throughout the body paragraphs
38. instead of waiting for one or two sentences at the end of the
paragraphs.
See the in-text details for additional details.
Commented [RS26]: Plural—more than one source listed
here.
Commented [RS27]: Use the appropriate font. Entries
should be alphabetized and should use hanging indent.
Commented [RS28]: Week Staff. “The Recycling Crisis.”
Commented [RS29]: ???
Commented [RS30]: This is the name of the page sponsor
Ulen 5
1. AU Did you use research material in this assignment?
Research is REQUIRED for this assignment.
2. AU Do you have a Works Cited page at the end of your essay
with the title Works Cited?
3. AU Do you have three appropriate sources (see the guidelines
in this lesson) listed on the WC page?
4. AU Are those three sources cited in the paper using either
paraphrases or direct quotations?
5. AU Did you define words, use a dictionary, or use an
encyclopedia? If so, those sources and information
from those sources must be removed. Most common words or
39. words used with their well-known definition do not
need to be defined in an essay. Dictionaries and encyclopedias
are NOT argumentative sources.
6. AU Did you use MLA 8th edition to cite your sources within
the text and in the WC list?
7. AU Have you used parenthetical references within the text to
show that you are paraphrasing or quoting?
8. AU Does the word/name in each parenthetical reference
match the first word/name in the corresponding WC
entry?
9. AU Does the alphanumeric outline appear in the same file as
the essay itself (it should)? Is it the
first page in the document? (It should be.)
10. AU Is the outline page numbering different than your text
pages? Outlines use lowercase Roman
numerals (i, ii, iii), while text pages use Arabic numerals.
11. AU Are your last name and page number in the header
(inside of the margin), NOT in the
text? See the examples online from Diana Hacker and youtube
(for specific instructions using your
version of your word processing program).
12. AU Does your thesis appear in the outline AND in the
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41. Critical Thinking and Caring in Nursing Students
Arli, Senay Karadag, PhD; Bakan, Ayse Berivan, PhD; Ozturk,
Senay, PhD; Erisik, Ela; Yildirim, Zubeyde. International
Journal of Caring Sciences; Nicosia Vol. 10, Iss. 1, (Jan/Apr
2017): 471-478.
1. Full text
2. Full text - PDF
3. Abstract/Details
Abstract
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The literature shows us the nursing students can improve this
ability in undergraduate clinical education and they should learn
how to think critically for giving better care. This study
identifies the relationship between disposition toward critical
thinking and caring behaviour of nursing students. This cross-
sectional study used a convenience sample that comprised 167
undergraduate nursing students enrolled in a four-year nursing
course in Eastern Turkey. The data was obtained through a
sociodemographic characteristics form, the Caring Nurse-
Patient Interaction Scale (CNPI-Long Scale) and the California
42. Critical Thinking Disposition Inventory (CCTDI). We
determined that there was a positive relationship between
overall critical thinking dispositions and caring behaviours (r =
0.470, p < 0.01). The simple linear regression analysis result
was analysed and it was observed that 22% of the Caring Nurse
Patient Interactions were predicted by critical thinking
disposition (R^sup 2^ = 0.221, p < 0.01). The findings indicate
that caring behaviours relate to critical thinking disposition.We
suggest critical thinking which promote the development of the
intellectual capacities of student nurses as independent critical
thinkers so that critical thinking should be in all nursing
curriculum. Therefore, quality client care will be better.
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Headnote
Abstract
Background: The literature shows us the nursing students can
improve this ability in undergraduate clinical education and
they should learn how to think critically for giving better care.
Objective: This study identifies the relationship between
disposition toward critical thinking and caring behaviour of
nursing students.
Methodology: This cross-sectional study used a convenience
sample that comprised 167 undergraduate nursing students
enrolled in a four-year nursing course in Eastern Turkey. The
data was obtained through a sociodemographic characteristics
form, the Caring Nurse-Patient Interaction Scale (CNPI-Long
Scale) and the California Critical Thinking Disposition
Inventory (CCTDI).
Results: We determined that there was a positive relationship
between overall critical thinking dispositions and caring
behaviours (r = 0.470, p < 0.01). The simple linear regression
44. analysis result was analysed and it was observed that 22% of the
Caring Nurse Patient Interactions were predicted by critical
thinking disposition (R^sup 2^ = 0.221, p < 0.01).
Conclusions: The findings indicate that caring behaviours relate
to critical thinking disposition.We suggest critical thinking
which promote the development of the intellectual capacities of
student nurses as independent critical thinkers so that critical
thinking should be in all nursing curriculum. Therefore, quality
client care will be better.
Keywords: Critical Thinking Disposition, Caring Behaviour,
Nursing Students
Introduction
Critical thinking skills are now an expected outcome of nursing
education programmes. The American Association of Colleges
of Nursing (1998), the National League for Nursing (1992), and
the National League for Nursing Accrediting Commission
(2002) identified critical thinking as an essential component of
baccalaureate nursing education. Schools of nursing are
required to produce outcome assessments of students'
competence in critical thinking as accreditation criteria. As
nursing is a practice profession, it is important for the faculty to
know the cognitive process characteristics of expert nurses, lead
by example and impart critical thinking in clinical settings. The
current healthcare environment reflects societal patterns of
constant change and complexity. The rapid growth of
knowledge and technology related to health and illness requires
nurses who are able to solve problems and make crucial
decisions in clinical situations. Nurse educators must address
the challenge of preparing nurses who can think critically
(Twibell et al., 2005).
Background
Nursing is an aid-oriented profession and its main role is
caring. Nursing is a profession that requires complex
behavioural practices. The responsibilities of practitioners
include physical, psychological, mental and spiritual care for a
variety of clients. A nurse affects the patient and is affected
45. them through positive communication and planned nursing
initiatives (Tutuk et al., 2002; Ozcan, 2006).
Watson (2005) advocated patient-nurse interaction-based
nursing care, and developed Caring Theory from a humanistic
and holistic point of view. It is essential to improve knowledge
regarding caring, which is the basis for nursing (Watson, 1990;
Ozer et al., 2006; Yurtsever and Altiok, 2006; Yildirim and
Tasci 2013). According to Watson, a nurse must develop and
sustain a helping-trusting, authentic caring relationship with
their patient in order to promote healing and health. Moreover,
in Watson's theory, the nurse-patient caring relationship
protects, enhances and preserves the patient's dignity, humanity
and wholeness. Therefore, Watson's theory-focusing mainly on
the nurse-patient relationship as a variable central to nursing-
serves as a guide for developing a scale that captures the core of
nursing practice. Watson suggests ten carative factors for nurses
engaging in caring. The guidelines do not attempt to describe
specific clinical activities, but simply highlight essential
elements at the core of caring nursing practice. They identify
the elements of humanism in nursing care in therapeutic
relationships and clinical activities. The ten carative factors are
as follows: (1) humanistic-altruistic value system; (2) faith-
hope; (3) sensitivity to self and others; (4) helping-trusting,
human care relationship; (5) expressing positive and negative
feelings; (6) creative problem-solving caring processes;
(7)transpersonal teaching-learning; (8) supportive, protective
and/or corrective mental, physical, societal and spiritual
environment; (9) human needs assistance; and (10)
existentialphenomenological-spiritual forces (Watson, 1988;
Cossette et al., 2005).
It is well-known that occupational knowledge, experience,
critical thinking skills and critical thinking processes are very
important in the nursing profession. That is why, while
managing the caring process, nurses are obliged to assess the
problems of the patient and decide on the method of caring
according to the data obtained. Most of the time, nurses must
46. assess a number of options concurrently and make quick
decisions. Sometimes the right decision made by the nurse plays
a vital role in a patient's life. This is why critical thinking is
crucial in nursing (Ozdelikara et al., 2012).
In this modern healthcare environment, with its complex
technology and patient interventions, nurses require critical
thinking skills. Therefore, many studies have emphasised the
need for critical thinking (Cho, 2005; Zygmont and Schaefer,
2006; Hoffman, 2008; Vacek, 2009; Wood and Toronto, 2012).
Critical thinking ensures that the nurse reflects the basic
nursing training they have received, their occupational
experiences and research results which they had assessed
logically, when caring for patients. A lack of critical thinking
skills can negatively affect the quality, sufficiency and
efficiency of service and the professionalism, autonomy and
authority in profession. The more effective the nurses are in
critical thinking, the better their services become in increasing
quality of life and protecting and improving public health. That
is why it is highly important to provide students with an insight
into critical thinking (Ozturk and Ulusoy, 2008).
Consequently, nursing can be defined as the science and art of
caring, whereas caring can be defined as an interpersonal
process/interaction. Moreover, in this modern healthcare
environment-with its complex technology and patient
interventions-nurses require critical thinking skills. Therefore,
many studies have emphasised the need for critical thinking;
however, there is a gap in our understanding of the dimensions
of critical thinking as related to certain behaviours, especially
caring, which is the core of nursing. This study thus analyses
the relationship between critical thinking disposition and caring
behaviour of nursing students, and it sought to answer the
following question: 'What is the relationship between caring
behaviour and disposition toward critical thinking?'
Methods
Design
This study was a cross-sectional study.
47. Participants and sampling methods
The participants were a convenience sample of nursing students
from a four-year nursing course in Eastern Turkey. The final
sample comprised 167 nursing students (95 males and 72
females). The sample age range was from 18 to 28 years (M =
22.28). The participants of the research were in the first, third
and fourth years of the Nursing Department of the Health
School: we had no second-year students because the university
did not admit any students for one year because of a shortage of
lecturers. Moreover, all the students were practicing in clinics
from their first year so had clinical experience. All participants
reported having no education on critical thinking.
Data collection
Data collection for this study took place at a university in
Turkey. The data was collected between May and June of 2015.
A convenience sample of nursing students was invited to
participate in the study to be held in a classroom, and the
students were asked to sign on a consent form. The students
completed the questionnaire, which was written in Turkish.
Instruments
Socio-Demographic Characteristics Form
The Socio-Demographic Characteristics Form was developed by
the authors. Demographic data collected included a participant's
year of study, age and gender.
The Caring Nurse-Patient Interaction Scale (CNPI-70)
The Caring Nurse-Patient Interaction Scale (CNPI-Long Scale)
was developed by Cosette in 2005 to assess attitudes and
behaviours which were related to the Watson's Care Theory. The
scale comprised 70 items in 10 subscales: humanism, hope,
sensitivity, helping relationship, expression of feelings,
problem solving, teaching, environment, needs and spirituality.
The scale has the dimensions of importance, competence and
feasibility. The lowest score that can be obtained in the three
dimensions of the scale is 70 and the highest is 350.
The students rated their addressing perceptions about how
realistic attitudes or behaviours on a scale of 1 to 5, with 1
48. being 'not at all' and 5 being 'extremely'. The Turkish version
validity and reliability were conducted by Atar and Asti (Atar
and Asti, 2012). The Turkish version of the scale was used in
this study and permission was obtained from the scale's authors.
For internal consistency, the scale's item-total correlations were
0.56-0.81 and Cronbach's alphas were 0.99, 0.98 and 0.99,
respectively, for the three dimensions.
When participants' scores increased on the scale, their nurse-
patient interaction value related to attitudes and behaviours
increased positively (Cossette et al., 2006).
Cossette, along with Pepin, Cote' and De Courval, also
developed a shorter version of the scale (CNP-Short Scale) in
2008; however, they suggested using the 70-item long version
for evaluating nursing students' attitudes and behaviours related
to caring nurse-patient interaction (Cossette et al., 2008).
Two things led them to abridge their original scale into a more
concise version (CNPI-Short Scale). First, many of their
subscales were moderately to highly correlated: this is an
empirical reflection of the theoretical nonindependence of the
carative factors. Secondly, the lengthy 70-item questionnaire
was problematic in the clinical research setting, particularly
with severely ill patients. This shortened scale was based on
three a priori caring domains that were synthesised from the
original ten carative factors (Cossette et al., 2006).
The California Critical Thinking Disposition Inventory (CCTDI)
This inventory was developed based on the results of the Delphi
Report, in which critical thinking and disposition toward it were
conceptualised by a group of critical thinking experts (Facione,
1990). The original CCTDI includes 75 items loaded on seven
constructs: inquisitiveness, open-mindedness, systematicity,
analyticity, truth-seeking, critical thinking selfconfidence and
maturity.
Kokdemir (2003) carried out an adaptation study to transform
this inventory into a Turkish version because of cultural
concerns. After all items were translated into Turkish by eight
experts-six psychologists, a simultaneous translator and
49. Kokdemir himself-it was given out to 913 students in the
Faculty of Economic and Administrative Sciences.
First, item-total score correlations were estimated and 19 items
whose correlation was under 0.20 were eliminated from the
scale. Factor analysis was performed on the reduced scale.
Kokdemir's study revealed that five items had factor loadings
lower than 0.32 and that items under the constructs of open-
mindedness and maturity were loaded on one construct. Finally,
51 items with six constructs were kept in the scale. Reliability
of the whole scale was found to be 0.88. Reliability coefficients
of each subscale ranged from 0.61 to 0.78 (Kokdemir, 2003).
Statistical analysis
The SPSS Statistics Packet Program was used in the data
analysis for the descriptive statistics such as one-way ANOVA,
Pearson correlation and simple linear regression analysis. The
significance level was set at p < 0.05 for all statistical tests.
Ethical consideration
Ethical approval was obtained from a university in Turkey,
where the study took place. The Ethics Approval Number is
11002.
Results
Participants and Descriptive statistics
Socio-demographic characteristics of the nursing students were
determined. From 167 students participating in the study, 56.9%
were males and 50.9% out of those were in their fourth year of
study. When the Nurse-Patient Interaction Scale average was
analysed in accordance with factors such as gender and year of
study, no significant difference was found.
The Total Scores of the California Critical Thinking Disposition
Inventory and the Caring Nurse-Patient Interaction Scale
The critical thinking disposition scale average of the group was
254.39 ± 26.69 and the Caring Nurse-Patient Interaction Scale
average was 283.36 ± 41.27.
However, a significant decrease was found in the critical
thinking scale average when the year of study decreased. The
difference was found to be caused by freshmen and seniors with
50. the help of a Post Hoc Tukey HSD test (Table 2).
The Simple Linear Regression Result in Terms of Predictive
Factors of the Caring Nurse-Patient Interaction
When analysed in accordance with a Pearson correlation, a
positive link was found between critical thinking disposition
scale results and the Caring Nurse-Patient Interaction Scale
results (R = 0.470, p < 0.01). The simple linear regression
analysis result was analysed and it was observed that 22% of the
caring nurse-patient interactions were predicted by critical
thinking disposition (R2 = 0.221, p < 0.01) (Table 3).
Discussion
Information and experiences provided in a clinical atmosphere
play an essential role along with the theoretical information
when providing critical thinking insight to nurses. Clinical
practice is a training process that provides the student with an
opportunity to put theory into use and become a professional.
Clinical skills play a key role in nursing training. At the same
time, clinical skills allow students to interact with the patient,
giving them the opportunity to improve and utilise their
occupational know-how and skills regarding nursing, make
correct decisions, solve problems, improve their ability to
understand themselves and think critically (Eskimez et al.,
2005).
Critical thinking allows a nurse to utilise their basic nursing
training and occupational experience and provides an
opportunity to assess the search results logically and reflect
them in patient care. Lack of critical thinking skills can
negatively affect quality, sufficiency and efficiency in service;
it also affects professionalism, autonomy and authority in
profession. The more effective the nurse is in critical thinking,
the better their services become in increasing quality of life,
protecting and improving public health. Thus, it is highly
important to provide students with insights into critical thinking
(Ozturk and Ulusoy, 2008).
Some studies revealed that university students in Turkey have a
relatively low capacity of critical thinking (Dil and Oz, 2005;
51. Ozturk and Ulusoy, 2008; Bulut et al., 2009; Beser and Kissal,
2009; Akkus et al., 2010). In this study, the average score of the
nursing students for the critical thinking disposition scale was
254.39 ± 26.69. According to the results of CCTDI, scores less
than 240 are low, between 240 and 300 are average and above
300 are accepted to reflect a high critical thinking capacity (Dil
and Oz, 2005). This scale showed that our group had an average
level of critical thinking skills. According to Colucciello,
'critical thinking dispositions are essential for the development
of higher-order critical thinking and learning'. As such, these
students need more training in critical thinking (Colucciello,
1999).
A number of studies have shown that the more training the
students receive the higher their critical thinking capacity
becomes (Shin, 1998; Adams et al., 1999; Gunes and Kocaman,
2005; Dil and Oz, 2005; Ozturk and Ulusoy, 2008). As the
number of years of study increases, the knowledge capacity
increases, resulting in a higher capacity of critical thinking
(McGovern and Valiga, 1997). However, in this study a
significant decrease was found in the critical thinking capacity
average when the number of years of study was lower. With the
help of a Post Hoc Tukey HSD test, this decrease was identified
between freshmen and seniors (Table 2). This result is
considered to be obtained because of factors such as the lack of
trained staff in the analysis/synthesis and interpretation fields,
tendency of the students to avoid critical thinking as they gain
experience, insufficiency of practice fields in quality and event
or the lack of training in their schedule regarding critical
thinking. According to the study carried out by Akkus, Kaplan
and Kaçar in 2010, third year students have a lower average
score on the critical thinking disposition scale. However,
because they face many events that require problem solving,
independent decision-making and multidimensional thinking,
the capacity of critical thinking of nursing students is expected
to increase as they participate in the higher classes (Bulut and
Ertem, 2009; Akkus, 2010).
52. The Caring Nurse-Patient Interaction Scale average of nursing
students in this study was found to be 283.36 ± 41.27 (Table 2).
In the three dimensions of the scale, the highest score that can
be obtained is 350 and the lowest is 70. As the score increases,
the behaviours and attitudes of students regarding caring nurse-
patient interaction improves. In this study, a moderately
positive improvement was observed in the behaviours and
attitudes of students regarding caring nurse-patient interaction.
Thus, students with greater caring behaviours reported more
positive critical thinking dispositions (Pai and Eng, 2013).
These results support the view of Watson (1990) that caring is
at the core of nursing practice, and they are consistent with the
research that demonstrates the important role of caring in
critical thinking (Zimmerman and Phillips, 2000; Pai and Eng,
2013). This implies that caring motivates students to listen to
and consider patient demands, which provides a foundation for
critical thinking and the provision of high-quality care. This
finding is also supported by the perspective of Redding, who
described caring as involving the integration of internal and
external sources of information and taking valid action through
holistic critical thinking (Redding, 2001).
In improving the clinical decision-making skills of health care
professionals, critical thinking allows better and independent
decision-making regarding patients. Critical thinking efficiency,
attitudes necessary for critical thinking and critical thinking
standards, fundamental occupational knowledge and experience
are important in the decision-making process. Critical thinking
skills are affected by occupational training and clinical
experience (Hicks et al., 2003; Ay, 2011).
Implications for nursing practice and education
In nursing, critical thinking for clinical decisionmaking is the
ability to think in a systematic and logical manner with
openness to question and reflect on the reasoning process used
to ensure safe nursing practice and quality care (Paul and
Heaslip, 1997). Critical thinking when developed in the
practitioner includes adherence to intellectual standards,
53. proficiency in using reasoning, a commitment to develop and
maintain intellectual traits of the mind and habits of thought
and the competent use of thinking skills and abilities for sound
clinical judgments and safe decision-making. We suggest
critical thinking which promote the development of the
intellectual capacities of student nurses as independent critical
thinkers so that critical thinking should be in all nursing
curriculum. Therefore, quality client care will be better.
Conclusions
It is essential to examine the factors that improve critical
thinking skills and select the methods that encourage students to
search and think. Moreover, clinical practices positively affect
critical thinking. Clinical practice fields should be amended to
improve caring nurse-patient interaction; thus, the efficiency
and productivity of practices should be ensured. These types of
studies should be carried out for nurses and nursing students in
larger groups. Consequently, future research should use a
random sample or wider geographic region to obtain
participants and utilise a longitudinal design.
Acknowledgements We thank our nursing students for
participating in the study.
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AuthorAffiliation
Senay Karadag Arli, PhD
57. Assist Prof. Department of Nursing, Agri Ibrahim Cecen
University School of Health, Turkey
Ayse Berivan Bakan, PhD
Assist Prof. Department of Nursing, Agri Ibrahim Cecen
University School of Health, Turkey
Senay Ozturk, PhD
Assist Prof. Department of Nursing, Agri Ibrahim Cecen
University School of Health, Turkey
Ela Erisik
Department of Nursing, Agri Ibrahim Cecen University School
of Health, Turkey
Zubeyde Yildirim
Department of Nursing, Agri Ibrahim Cecen University School
of Health, Turkey
Corespondence: Assist Prof. Dr. Senay Karadag Arli
Department of Nursing, Agri Ibrahim Cecen University School
of Health, Turkey email: [email protected]
Word count: 3947
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Copyright Professor Despina Sapountzi - Krepia Publisher of
the International Journal of Caring Sciences Jan/Apr 2017
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