"Financial Management" Please respond to the following:
· Explain the three methods for calculating credit card interest and your reason for going with a particular method.
· Provide an example of how you can use the power of compounding interest to pay for a future expense.
· Discuss which practical application covered in the chapter you think you will use within the next year and how you think studying this topic will help you make wise financial choices in the future.
ICU Nurses' Oral-Care Practices and the Current Best Evidence
Author: Ganz, Freda DeKeyser, RN, PhD; Fink, Naomi Farkash, RN, MHA; Raanan, Ofra, RN, MA; Asher, Miriam, RN, BA; Bruttin, Madeline, RN, MA; Nun, Maureen Ben, RN, BSN; Benbinishty, Julie, RN, BA
ProQuest document link
Abstract:
The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics.
A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics.
The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care.
While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all ICU nurses to introduce and use evidence-based, oral-care protocols.
Practicing ICU nurses in this survey were often not adhering to the latest evidence-based practice and therefore need to be educated and encouraged to do so in o ...
150 words 1 reference within 5 years, in text citations a must and m.docxtangyechloe
150 words 1 reference within 5 years, in text citations a must and must match the reference. This is a response.
Numerous factors have created significant challenges in the work environments of contemporary nurses. New advances in biomedical science, the growing need for improved disease prevention and management, integration of new clinical care technologies, cultural diversity and shifts in care delivery have all contributed to the rapidly increasing need for well-educated, experienced nurses (Holloway & Galvin, 2016). Collaboration within multidisciplinary teams fosters opportunities to address clinical problems and issues using various perspectives and expertise. Also, nurses can use research to shape health policy in patient care. Incorporating relevant research findings into clinical practice and evaluating effectiveness, helps close the gap between research and practice (Grove, Burns & Gray 2014).
Research uses investigation, exploration, and discovery to understand the philosophy of science. The use of clinically relevant research can develop, refine, and extend nursing knowledge and strengthen their skills by utilizing evidence- base practices to provide patients with the best outcomes, provide safe nursing interventions and use accurate and precise nursing assessment measures (
Parahoo
, 2014).
Evidence--based practices (EBP) has impacted nursing practice, education, and science. Three primary goals of the Magnet Recognition Program
are supported
by research, evidence-based practice and quality improvement.
Evidence-based practice is guided by research findings, quality improvement, and expert opinion to identify methods of improvement (
Parahoo
, 2014). EBP uses the best evidence stemming from research and applies it to the clinical decision-making. EBP typically comes from systematic review, meta-analysis, or established evidence-based clinical practices. Other evidence comes from randomized controlled trials, quantitative studies, qualitative studies, and expert opinion and analyses. EBP integrates current trends, identifies assessment, diagnostic strategies and therapeutic interventions that reflect current evidence including data and research literature to the individualization of care with the inclusion of patient preferences (Grove, Burns & Gray, 2014).
...
150 words 1 reference within 5 years, in text citations a must and m.docxtangyechloe
150 words 1 reference within 5 years, in text citations a must and must match the reference. This is a response.
Numerous factors have created significant challenges in the work environments of contemporary nurses. New advances in biomedical science, the growing need for improved disease prevention and management, integration of new clinical care technologies, cultural diversity and shifts in care delivery have all contributed to the rapidly increasing need for well-educated, experienced nurses (Holloway & Galvin, 2016). Collaboration within multidisciplinary teams fosters opportunities to address clinical problems and issues using various perspectives and expertise. Also, nurses can use research to shape health policy in patient care. Incorporating relevant research findings into clinical practice and evaluating effectiveness, helps close the gap between research and practice (Grove, Burns & Gray 2014).
Research uses investigation, exploration, and discovery to understand the philosophy of science. The use of clinically relevant research can develop, refine, and extend nursing knowledge and strengthen their skills by utilizing evidence- base practices to provide patients with the best outcomes, provide safe nursing interventions and use accurate and precise nursing assessment measures (
Parahoo
, 2014).
Evidence--based practices (EBP) has impacted nursing practice, education, and science. Three primary goals of the Magnet Recognition Program
are supported
by research, evidence-based practice and quality improvement.
Evidence-based practice is guided by research findings, quality improvement, and expert opinion to identify methods of improvement (
Parahoo
, 2014). EBP uses the best evidence stemming from research and applies it to the clinical decision-making. EBP typically comes from systematic review, meta-analysis, or established evidence-based clinical practices. Other evidence comes from randomized controlled trials, quantitative studies, qualitative studies, and expert opinion and analyses. EBP integrates current trends, identifies assessment, diagnostic strategies and therapeutic interventions that reflect current evidence including data and research literature to the individualization of care with the inclusion of patient preferences (Grove, Burns & Gray, 2014).
...
Knowledge and Practice of Documentation among Nurses in Ahmadu Bello Universi...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Original ArticleThe Establishment of Evidence-BasedPract.docxgerardkortney
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes,.
INFLUENCE OF HEALTH SERVICE PROVIDER COMPETENCY ON UTILIZATION OF UNIVERSAL H...Premier Publishers
Health workers competency is very critical in realization of quality health care which is a major pillar of Universal Health Coverage. This study assessed the influence of healthcare provider competency on Universal Health Coverage utilization in Seme Sub County, Kisumu County. The study targeted community households and health facility managers. The health facilities were stratified according to their tiers and randomly sampled. The catchment population was stratified by locations and a proportionate sampling technique applied in each stratum giving a computed sample of 377 participants. The descriptive statistics were summarized using tables and charts, while logistic regression was used to determine relationship between variables. The results revealed that quite a number of health service providers are not competent enough in their departments of operation and there is no periodic training on new guidelines. This study further revealed a statistical effect on competency of health service provider on UHC (OR=2.29, 95%CI=1.02-5.15, p<0.05). Healthcare service provider competency levels have direct significant influence on utilization of UHC services by community members.
6410 Application 3 Becoming a Leader in the Translation of Evide.docxtroutmanboris
6410 Application 3: Becoming a Leader in the Translation of Evidence to Practice
Note: Have an APA Level 1 header for each area noted below in blue (a level 1 header is centered, bolded, using upper and lower case letters—see APA manual area 3.03) Follow APA format and include a minimum of 5 scholarly references less than 5 years old.
Include a BRIEF Introduction and Summary in addition to the headers below. DO NOT EXCEED THREE PAGES AND MUST CITE OFTEN THROUGHOUT THE PAPER.
Grading Area
Points Possible
Points Earned
Potential areas for earning points:
Header: Efforts to Increase Finance and Economic Knowledge
How you would continue to increase your knowledge and awareness of financial, economic, and other concerns related to new practice approaches
2
Header: Use of Evidence to Improve Practice
How translating evidence would enable you to affect or strengthen health care delivery and nursing practice
2
Header: Advocating for EBP Policy Change
How you would advocate for the use of new evidence-based practice approaches through the policy arena
2
Potential areas for losing points:
Grammar, Spelling, and APA errors
Up to 2 pt. deduction
Went Over Page Limit (2-3 pages max)
Up to 2 pt. deduction
Improper credit & citation issue
(See Turnitin Report)
1-6 pt. deduction
Late Submission
20% deduction (1.2 pts) per day late (per syllabus)
6 Total Points Possible
Total Points Earned
P.S. Under the first header on “Effort to Increase Finance and Economic Knowledge, please refer to the attached week 6 discussion you did for me, except you did not include specific numbers and statistics. Below is the critique made by the professor on that area. Please read through the critique and try to incorporate it in this portion of this paper.
Dear student: Thank you for your contribution to this week’s discussion. You brought forward potential costs associated with increased mobilization of ICU patients….namely the need for more nurse time. Do you have some hard numbers you can provide on the potential cost of this? Do you have any local or national information on the cost of not mobilizing the patients (longer stays, increased infection, readmission)? Calculating approximate cost associated with the practice change versus the cost of not changing is important. This will help stakeholders see the value in the investment.
DISCUSSION PAPER
Evidence-based practice models for organizational change: overview
and practical applications
Marjorie A. Schaffer, Kristin E. Sandau & Lee Diedrick
Accepted for publication 19 July 2012
Correspondence to M.A. Schaffer:
e-mail: [email protected]
Marjorie A. Schaffer PhD RN
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Kristin E. Sandau PhD RN CNE
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Lee Diedrick MAN RN C-NIC
Clinical Educator
Children’s Hospitals and Clinics of
Minnesota, St. Paul, Minnesota, USA
S C H A F F E R M . A . , S A N D A U K ..
Original ArticleThe Establishment of Evidence-BasedPract.docxhoney690131
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes,.
Original ArticleThe Establishment of Evidence-BasedPract.docxvannagoforth
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes, ...
Cost and benefit analysisWe are doing group presentation.docxvoversbyobersby
Cost and benefit analysis
We are doing group presentation tomorrow but we are struggling to make the
presentation sldies. We need presentation slides.
Could you guys help me? Maximum slides we have to make are 11 pages.
Below are structure of prejesentation we should do.
<>
In your analysis, make sure you take the followings into consideration:
•
the alternative projects ,
•
the groups who benefit and suffer from project,
•
list the physical impact of alternatives,
•
predict monetary value of those impacts (benefit and cost) over the life of project in terms of their present value,
•
conclude which of the alternative project should be selected.
-----------------
Addendum: PT slides
•
1 intro slide that discusses the motivation behind the project and CBA
•
Information about which groups have standing, and how they either benefit or lose from the considered policies
•
Numbers, sources
•
Conclusion
•
1-2 slides on other key information you would need to conduct a thorough analysis
•
1-2 slides at the end with a list of sources
Addendum: PT slides
Do Not Include:
•
Typos and spelling/grammar mistakes.
•
Basic definitions of CBA terms.
•
Too many pictures.
•
Unsubstantiated claims (unless you explicitly states that you had made the judgement call because there was insufficient data)
.
Cosmetics as endocrine disruptors are they a health risk.docxvoversbyobersby
Cosmetics as endocrine disruptors: are they a health risk?
Polyxeni Nicolopoulou-Stamati1 & Luc Hens2 & Annie J. Sasco3
Published online: 29 January 2016
# Springer Science+Business Media New York 2016
Abstract Exposure to chemicals from different sources in
everyday life is widespread; one such source is the wide range
of products listed under the title Bcosmetics^, including the
different types of popular and widely-advertised sunscreens.
Women are encouraged through advertising to buy into the
myth of everlasting youth, and one of the most alarming con-
sequences is in utero exposure to chemicals. The main route of
exposure is the skin, but the main endpoint of exposure is
endocrine disruption. This is due to many substances in cos-
metics and sunscreens that have endocrine active properties
which affect reproductive health but which also have other
endpoints, such as cancer. Reducing the exposure to endocrine
disruptors is framed not only in the context of the reduction of
health risks, but is also significant against the background and
rise of ethical consumerism, and the responsibility of the cos-
metics industry in this respect. Although some plants show
endocrine-disrupting activity, the use of well-selected natural
products might reduce the use of synthetic chemicals.
Instruments dealing with this problem include life-cycle
analysis, eco-design, and green labels; in combination with
the committed use of environmental management systems,
they contribute to Bcorporate social responsibility .̂
Keywords Endocrine active substances . Endocrine
disruptors . Cosmetics . Sunscreens
1 Introduction
Women and men all over the world use large amount of cos-
metic products in pursuit of everlasting youth, ignoring the
probable health risks. The commercial category of Bcosmetic
products^ entails substances or mixtures of substances that are
designed mainly for external use, for instance to improve the
appearance; clean; perfume; and sometimes protect as in the
case of sunscreens [1]. Many cosmetic products such as oils
and lipsticks contain UV filters, even though they are not
marketed under the term Bsunscreens^ or Bsun lotions^.
Cosmetic products contain active substances, preservatives
and also the so-called Bfragrances^ or Bperfumes^, the exact
composition of which remains a secret under the trade secret
standards [2].
Increasing scientific concern exists about the nature and the
safety of the ingredients used by the cosmetics industry re-
garding their endocrine-disrupting effects. Although numer-
ous studies have proved the endocrine-disrupting potential of
many ingredients, such as parabens, phthalates and UV filters,
and also their ability to cause reproductive impairments [3–6],
these substances are still extensively used and characterized as
Bsafe^. The main justification is the fact that manufacturers
keep the concentrations of the suspected chemical substances
low in accordance with the relevant legislation. However, the
possib.
More Related Content
Similar to Financial Management Please respond to the following· Explain.docx
Knowledge and Practice of Documentation among Nurses in Ahmadu Bello Universi...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Original ArticleThe Establishment of Evidence-BasedPract.docxgerardkortney
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes,.
INFLUENCE OF HEALTH SERVICE PROVIDER COMPETENCY ON UTILIZATION OF UNIVERSAL H...Premier Publishers
Health workers competency is very critical in realization of quality health care which is a major pillar of Universal Health Coverage. This study assessed the influence of healthcare provider competency on Universal Health Coverage utilization in Seme Sub County, Kisumu County. The study targeted community households and health facility managers. The health facilities were stratified according to their tiers and randomly sampled. The catchment population was stratified by locations and a proportionate sampling technique applied in each stratum giving a computed sample of 377 participants. The descriptive statistics were summarized using tables and charts, while logistic regression was used to determine relationship between variables. The results revealed that quite a number of health service providers are not competent enough in their departments of operation and there is no periodic training on new guidelines. This study further revealed a statistical effect on competency of health service provider on UHC (OR=2.29, 95%CI=1.02-5.15, p<0.05). Healthcare service provider competency levels have direct significant influence on utilization of UHC services by community members.
6410 Application 3 Becoming a Leader in the Translation of Evide.docxtroutmanboris
6410 Application 3: Becoming a Leader in the Translation of Evidence to Practice
Note: Have an APA Level 1 header for each area noted below in blue (a level 1 header is centered, bolded, using upper and lower case letters—see APA manual area 3.03) Follow APA format and include a minimum of 5 scholarly references less than 5 years old.
Include a BRIEF Introduction and Summary in addition to the headers below. DO NOT EXCEED THREE PAGES AND MUST CITE OFTEN THROUGHOUT THE PAPER.
Grading Area
Points Possible
Points Earned
Potential areas for earning points:
Header: Efforts to Increase Finance and Economic Knowledge
How you would continue to increase your knowledge and awareness of financial, economic, and other concerns related to new practice approaches
2
Header: Use of Evidence to Improve Practice
How translating evidence would enable you to affect or strengthen health care delivery and nursing practice
2
Header: Advocating for EBP Policy Change
How you would advocate for the use of new evidence-based practice approaches through the policy arena
2
Potential areas for losing points:
Grammar, Spelling, and APA errors
Up to 2 pt. deduction
Went Over Page Limit (2-3 pages max)
Up to 2 pt. deduction
Improper credit & citation issue
(See Turnitin Report)
1-6 pt. deduction
Late Submission
20% deduction (1.2 pts) per day late (per syllabus)
6 Total Points Possible
Total Points Earned
P.S. Under the first header on “Effort to Increase Finance and Economic Knowledge, please refer to the attached week 6 discussion you did for me, except you did not include specific numbers and statistics. Below is the critique made by the professor on that area. Please read through the critique and try to incorporate it in this portion of this paper.
Dear student: Thank you for your contribution to this week’s discussion. You brought forward potential costs associated with increased mobilization of ICU patients….namely the need for more nurse time. Do you have some hard numbers you can provide on the potential cost of this? Do you have any local or national information on the cost of not mobilizing the patients (longer stays, increased infection, readmission)? Calculating approximate cost associated with the practice change versus the cost of not changing is important. This will help stakeholders see the value in the investment.
DISCUSSION PAPER
Evidence-based practice models for organizational change: overview
and practical applications
Marjorie A. Schaffer, Kristin E. Sandau & Lee Diedrick
Accepted for publication 19 July 2012
Correspondence to M.A. Schaffer:
e-mail: [email protected]
Marjorie A. Schaffer PhD RN
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Kristin E. Sandau PhD RN CNE
Professor of Nursing
Bethel University, St. Paul, Minnesota, USA
Lee Diedrick MAN RN C-NIC
Clinical Educator
Children’s Hospitals and Clinics of
Minnesota, St. Paul, Minnesota, USA
S C H A F F E R M . A . , S A N D A U K ..
Original ArticleThe Establishment of Evidence-BasedPract.docxhoney690131
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes,.
Original ArticleThe Establishment of Evidence-BasedPract.docxvannagoforth
Original Article
The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN
Keywords
evidence-based
practice,
competencies,
healthcare quality
ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.
Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.
Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.
Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.
Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion
processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.
BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that
yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).
Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes, ...
Cost and benefit analysisWe are doing group presentation.docxvoversbyobersby
Cost and benefit analysis
We are doing group presentation tomorrow but we are struggling to make the
presentation sldies. We need presentation slides.
Could you guys help me? Maximum slides we have to make are 11 pages.
Below are structure of prejesentation we should do.
<>
In your analysis, make sure you take the followings into consideration:
•
the alternative projects ,
•
the groups who benefit and suffer from project,
•
list the physical impact of alternatives,
•
predict monetary value of those impacts (benefit and cost) over the life of project in terms of their present value,
•
conclude which of the alternative project should be selected.
-----------------
Addendum: PT slides
•
1 intro slide that discusses the motivation behind the project and CBA
•
Information about which groups have standing, and how they either benefit or lose from the considered policies
•
Numbers, sources
•
Conclusion
•
1-2 slides on other key information you would need to conduct a thorough analysis
•
1-2 slides at the end with a list of sources
Addendum: PT slides
Do Not Include:
•
Typos and spelling/grammar mistakes.
•
Basic definitions of CBA terms.
•
Too many pictures.
•
Unsubstantiated claims (unless you explicitly states that you had made the judgement call because there was insufficient data)
.
Cosmetics as endocrine disruptors are they a health risk.docxvoversbyobersby
Cosmetics as endocrine disruptors: are they a health risk?
Polyxeni Nicolopoulou-Stamati1 & Luc Hens2 & Annie J. Sasco3
Published online: 29 January 2016
# Springer Science+Business Media New York 2016
Abstract Exposure to chemicals from different sources in
everyday life is widespread; one such source is the wide range
of products listed under the title Bcosmetics^, including the
different types of popular and widely-advertised sunscreens.
Women are encouraged through advertising to buy into the
myth of everlasting youth, and one of the most alarming con-
sequences is in utero exposure to chemicals. The main route of
exposure is the skin, but the main endpoint of exposure is
endocrine disruption. This is due to many substances in cos-
metics and sunscreens that have endocrine active properties
which affect reproductive health but which also have other
endpoints, such as cancer. Reducing the exposure to endocrine
disruptors is framed not only in the context of the reduction of
health risks, but is also significant against the background and
rise of ethical consumerism, and the responsibility of the cos-
metics industry in this respect. Although some plants show
endocrine-disrupting activity, the use of well-selected natural
products might reduce the use of synthetic chemicals.
Instruments dealing with this problem include life-cycle
analysis, eco-design, and green labels; in combination with
the committed use of environmental management systems,
they contribute to Bcorporate social responsibility .̂
Keywords Endocrine active substances . Endocrine
disruptors . Cosmetics . Sunscreens
1 Introduction
Women and men all over the world use large amount of cos-
metic products in pursuit of everlasting youth, ignoring the
probable health risks. The commercial category of Bcosmetic
products^ entails substances or mixtures of substances that are
designed mainly for external use, for instance to improve the
appearance; clean; perfume; and sometimes protect as in the
case of sunscreens [1]. Many cosmetic products such as oils
and lipsticks contain UV filters, even though they are not
marketed under the term Bsunscreens^ or Bsun lotions^.
Cosmetic products contain active substances, preservatives
and also the so-called Bfragrances^ or Bperfumes^, the exact
composition of which remains a secret under the trade secret
standards [2].
Increasing scientific concern exists about the nature and the
safety of the ingredients used by the cosmetics industry re-
garding their endocrine-disrupting effects. Although numer-
ous studies have proved the endocrine-disrupting potential of
many ingredients, such as parabens, phthalates and UV filters,
and also their ability to cause reproductive impairments [3–6],
these substances are still extensively used and characterized as
Bsafe^. The main justification is the fact that manufacturers
keep the concentrations of the suspected chemical substances
low in accordance with the relevant legislation. However, the
possib.
COSC2737 Assignment 2 IT Infrastructure in the Cloud. .docxvoversbyobersby
COSC2737 Assignment 2: IT Infrastructure in the Cloud.
In this assignment, you will combine 3 different cloud services to build an application of your choice.
Typically, this might include a web-facing component. The focus of the assignment is not this content, but
the infrastructure behind it – the “wiring”, if you will.
As part of the assignment, you will create a presentation video. If this is done well, you will be able to add
these to a portfolio of work that you can demonstrate at job interviews, etc….
NB. This assignment is focused on Amazon products, primarily because that is what we teach in ITIS,
but, you are also allowed to use Google or Microsoft products, or a combination – but only with prior
permission from the Course Coordinator. And we may not be able to help you if problems between
vendor products arises.
For this assignment, you will provide a simple working cloud implementation, and submit the contents in a
ZIP file to Canvas, along with a presentation video, a report, and an initial PDF “pitch” document submitted
some weeks earlier than the deadline.
Note that the web content itself is not evaluated, only how it is set up. So you can use material from
anywhere (as long as you cite it on the web pages).
List of Amazon Services: https://aws.amazon.com/products/
List of Amazon services available to AWS Educate: https://s3.amazonaws.com/awseducate-starter-account-
services/AWS_Educate_Starter_Accounts_and_AWS_Services.pdf also available on Canvas.
Submission Details
1. Build a cloud infrastructure using at least 3 components from the AWS list of products above:
1. This could be a server and storage, or compute, or whatever.
2. One of the components counted could be the use of Alexa services for query.
2. The topic of the website is up to you, but must have a least (say) 5 different pages, and must ideally
be some form of B2B flavour.
3. Submission will be the following:
1. Pitch Document – An initial “pitch” where you describe your proposal in a few paragraphs
(not more than a page)
1. This will be due in week 11
2. Worth 5%, and will provide feedback from your tutor.
2. Report – A PDF report containing the following sections
1. Rationale
- The rationale behind this website or cloud construction. More or less a copy
of the pitch in its final form.
2. Cost Estimates
- both development, fixed and cloud running and how these running cost
scales for LOW (1-1000 transactions/day), MEDIUM (1000-1,000,000), and
HIGH (above 1,000,000+ transactions per day) – hese costs all to be
itemised and justified
- Imagine you are a professional quoting for the job
3. An installation manual that
- contains instructions to recreate the website(s)
- A marker should be able to rebuild it him/herself from this
4. There is no limit on report size, but a guide is about 10-15 pages including figures,
screen dumps, etc.
.
https://aws.amazon.com/prod.
Cortes and the Aztecs Respond in writing to the following questi.docxvoversbyobersby
Cortes and the Aztecs
Respond in writing to the following questions after reading Cortés' letter on page 260 and watching the two videos above.
1. What aspects of Aztec life and culture favorably impressed Cortés? Of what was he critical?
2. With their belief in a pantheon of deities, how might an Aztec have reacted upon visiting a Christian house of worship such as Chartres Cathedral?
3. What is the Colombian Exchange? List the consequences of the exchange.
Make sure to:
· Write a short essay or paragraph of at least 100 words. Do not go over 250 words.
· Use concrete examples/details and avoid generalities.
· Address all questions.
· Use proper grammar and punctuation.
· If you researched your topic and are using information from what you learned, remember to cite your sources.
· Do not plagiarize. Your work will be checked by turnitin.com.
.
Correlation and RegressionForecasting is a critical job for mana.docxvoversbyobersby
Correlation and Regression
Forecasting is a critical job for managers. Correlation and regression are two statistical methods used by managers for forecasting.
Correlation allows you to quantify how closely two variables are related. The correlation values or correlation coefficients have a range between -1.0 and +1.0. The closer the value is to the absolute value of 1, the stronger the correlation. The negative or positive sign indicates if the variables have a negative or positive correlation. A positive correlation exists when both variables increase or decrease. A negative correlation exists when one variable increases while the other variable decreases. If the two variables are independent and have no relationship, then the correlation is 0.
Be careful not to confuse correlation and causality. For instance, you can be reasonably sure that higher distribution and lower prices both cause higher sales; however, there are many things in this world that are correlated mathematically but are not at all related.
Regression is a statistical technique that lets you construct an equation to describe the relationship between the movements of two variables. On a scatter plot, the regression equation would calculate the best-fit line through the points. Regression allows you to forecast and simulate different scenarios by ascertaining the relationship between causes and effects. The causes are known as independent variables or drivers. The effects are known as dependent variables or what is being forecast.
You need to have a sufficient amount of history for the dependent variable and all the independent variables that you might think are useful in predicting the dependent variable to build a regression model. The minimum number of observations required is generally between 20 and 30. A key concept for regression is that it uses the past to predict the future. It assumes that relationships between historical dependent and independent variables will hold true for present of future dependent and independent variables.
There is an extension to the regression model, known as the multiple regression model. Adding another independent variable to a regression model turns it into a multiple regression model. The equation can become quite complex when more than two independent variables are added to the model, but these equations are rarely calculated by hand. Most commercial spreadsheet, accounting, and statistics software include these in their function library.
Counselor Dispositional Expectations
Dispositions are the values, commitments, and professional ethics that influence behaviors toward others, and, if sincerely held, dispositions lead to actions and patterns of professional conduct. The Grand Canyon University Counseling Program’s dispositions adhere to the University’s mission statement, as well as to the established counseling profession codes of ethics.
The Grand Canyon University Counseling Program have adopted the following disposition.
Correlation and Regression StudyBackground During this week .docxvoversbyobersby
Correlation and Regression Study
Background
During this week you will identify a research question created in Week 1 for which correlation or regression would be the best statistical approach to take. If you do not have a research question that indicates correlation or regression, review the research questions posted by your peers last week and select one that is ideal for correlation or regression.
Discussion Assignment Requirements
Initial Posting – In your initial posting for this assignment, include the following:
•Identify an appropriate research question that would require the use of correlation and regression to answer.
•Describe why this question is appropriate for a correlational study.
•Identify the two variables in this study and each of their attributes: discrete or continuous, quantitative or categorical, and scale of measurement (nominal, ordinal, interval, or ratio).
•Do the variables fit the qualifications of a correlational study? Explain.
•What type of correlation would you expect to find for this study (i.e., positive or negative)? Explain.
•What predictions might you be interested in making with these variables if the correlation is found to be significant?
Article Critique: Correlation & Regression
The readings for this week focus on the concepts of correlation and regression. In this discussion we will apply those concepts to the review and critique of Wagenheim & Anderson (2008). For information on how to critique a research article, see the Coughlan et al. (2007) from your resources in Week 1 and UIS (n.d.) from your resources in Week 2.
In the body of your posting, include an overview of the following topics:
•Research question – State the research question for the study.
•Methods and study design – Describe the basic methods used, including the variables, sampling methods, data collection, etc.
•Data analysis – Summarize the statistical tests conducted, the results obtained from each test, and the conclusions regarding the research question.
•Critique – Critique the results of the study, paying specific attention to the appropriateness of the analyses conducted, any biases or assumptions that were made, practical significance of the results, and recommendations for improving upon the study (methods or analyses).
•Summary – Provide a brief summary of the study's findings in 2-3 sentences. Do not use any numbers or statistical terms, but provide a review that would make sense to someone who has not studied research methods or statistics.
Be sure to put information in your own words and to cite appropriately. Respond substantively to at least two of your classmates’ postings. Specifically, focus on their critique of the results and discussion of the analysis. Do you agree with their assessment? What questions did the study leave you with? How might you have done this study differently? What do you see as the limitations of the study as compared to your classmates?
Z, T, or Chi-Square Test Study
Background
During th.
Correlate your job responsibilities with the Disaster recovery c.docxvoversbyobersby
Correlate your job responsibilities with the Disaster recovery course outcomes listed above. Should be Minimum 200 words
Disaster Recovery Course Out-come
• Recognize the need for disaster recovery plans within organizations.
• Develop a complete and accurate disaster recovery plan.
• Assess risks that may impact an organization
• Identify data storage and recovery sites.
• Develop plans, procedures and relationships.
• Develop procedures for special circumstances.
• Test the disaster recovery plan.
• Continue to assess needs, threats, and solutions after testing the disaster recovery
plan.
Job Responsibility:
· Responsible in delivering the complete
Project Plan with total supporting data which included the status Reports, Issues Log, Performance Testing Matrix, detailed Testing Reports, Fine tuning Recommendation reports to both Executive Management & Senior Management
· Responsible to provide Technical and Functional Support to the users, tester and Business System Analysts
· Managing and Preparation of the Test Plan and Test strategy for the various projects
· Liaison with the onsite and offshore teams for testing status and issue resolution
· Tested the data mapping, fixing errors
· Tested staging table for EDI 210 Invoice, Balance Due Invoice, EDI 810 Invoice inbound, 850 Inbound Purchase order
· Tested Web service using SoapUI
· Involved in User acceptance testing (UAT)
· Written standard test scripts for Oracle Financial, Procure to Pay, SOA, web services
· Involved in standard Functionality testing in Phase I Phase II for 3 Instance
· Documented and communicated test results to the test Management and Business Management Team
· Worked closely with Developers team for different issues
· Experience with test automation tools like JIRA
· Worked on the testing of SaaS, Web services, XML and web application.
.
Correctional CounselingRobert HanserScott Mire20111 The .docxvoversbyobersby
Correctional Counseling
Robert Hanser
Scott Mire
2011
1 The Role of the Correctional Counselor
CHAPTER OBJECTIVES
After reading this chapter, you will be able to:
· 1. Identify the functions and parameters of the counseling process.
· 2. Discuss the competing interests between security and counseling in the correctional counseling process.
· 3. Know common terms and concerns associated with custodial corrections.
· 4. Understand the role of the counselor as facilitator.
· 5. Identify the various personal characteristics associated with effective counselors.
· 6. Be aware of the impact that burnout can have on a counselor’s professional performance.
· 7. Identify the various means of training and supervision associated with counseling.
PART ONE: A BRIEF INTRODUCTION TO COUNSELING AND CORRECTIONS
There are many myths concerning the concept of counseling. Although the image of the counseling field has changed dramatically over the past two or three decades, much of society still views counseling and therapy as a mystic process reserved for those who lack the ability to handle life issues effectively. While the concept of counseling is often misunderstood, the problem is exacerbated when attempting to introduce the idea of correctional counseling. Therefore, the primary goal of this chapter is to provide a working definition of correctional counseling that includes descriptions of how and when it is carried out. In order to understand the concept of correctional counseling, however, the two words that derive the concept must first be defined: “corrections” and “counseling.” In addition, a concerted effort is made to identify the myriad of legal and ethical issues that pertain to counselors working with offenders.
It is very difficult to identify a single starting point for the counseling profession. In essence, there were various movements occurring simultaneously that later evolved into what we now describe as counseling. One of the earliest connections to the origins of counseling took place in Europe during the Middle Ages (Brown & Srebalus, 2003). The primary objective was assisting individuals with career choices. This type of counseling service is usually described by the concept of “guidance.” In the late 1800s Wilhelm Wundt and G. Stanley Hall created two of the first known psychological laboratories aimed at studying and treating individuals with psychological and emotional problems (Brown & Srebalus, 2003). Around the same time (1890), Sigmund Freud began treating mental patients with his patented technique of psychoanalysis. As a result, the origins of counseling can be traced to two different but simultaneous movements: (1) guidance and (2) psychotherapy.
Guidance
Guidance has been used as a concept to describe the process of helping individuals identify and choose what they value most (Gladding, 1996). Guidance can occur in any instance where one individual, usually more experienced, helps another to identify choices that best refle.
Correlate health and safety issues at workplace with ideals. Y.docxvoversbyobersby
Correlate health and safety issues at workplace with ideals.
Your response should be at least 200 words in length. You are required to use at least your textbook as source material for your response. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations.
Hartman, L., DesJardins, J., & MacDonald, C. (2014). 1.
Business ethics: decision making for personal integrity and social responsibility
(3rd ed., pp. 276-283). New York: McGraw-Hill.
No Wiki, Dictionary.com or Plagiarism
.
Correctional Program ShowcaseSubmitted BY Intensive moti.docxvoversbyobersby
Correctional Program Showcase
Submitted BY
Intensive motivational program of alternative correctional treatment (IMPACT)
IMPACT- Two phase program
Mission: to engage and rehabilitate the offenders with sentence of seven years
Goals: To engage the offenders into correction program for their betterment
To help the offenders to live a life with worth with out committing a crime.
Intensive motivational program of alternative correctional treatment (IMPACT) is a program that is based on the two phases, it is continuation shock incarcerations that initially started in the 1987. The mission of the program is to engage the offenders who are sentenced for 7 years into correctional program. Goals of the program is to engage the offender voluntarily in the two phase program and they can quite if they are not willing to continue the program. The offenders ahs to pass through the phases and complete the instructions of the drill instructors. The target population is based on the offender who do not mix in to normal general population. IMPACT is among the top three programs of the state to correct and rehabilitate the offenders (Mackenzie & Shaw, 2006).
2
Intensive motivational program of alternative correctional treatment (IMPACT)
Population : Offenders with sentence of seven years
Effectiveness:
Increased the prosocial behavior in offenders
Decreased the aggression and anxiety
Improvements have been seen in the offenders that lead them towards rehabilitation.
The program is effective for the offenders by send in to the offenders into military boot camps. Offenders who were engage in the IMPACT program were reported as having the high prosocial behaviors anxiety and aggression have been lowered in the offenders who have completed the program. Offender with change are promoted to the next phase of rehabilitation (Mackenzie & Shaw, 2006). It was designed because authorities are aware of that emotional instability is a main reason behind the offenses. Thus this program helped to provide emotional stability and also help in rehabilitation process.
3
Reentry Program
Reentry program is basically developed as a correctional program which is covering different aspects.
Educational paradigm
Health sector
Rehabilitation sector
Job skills and Employment Readiness program
Reentry programs is an effort made by the Louisiana corrections. The mission of the program is to provide the services regarding education, job and employment skills, substance abuse treatment and rehabilitation services are offered by the programs to education the offenders and help them rehabilitate in the society. Reentry program was designed to motivate those offenders who came again after relapse of drugs or crime. This program focus on all areas of life of offenders because it not only provided basic education but also provide job skills to make them productive member of society. Some profit and not for profit organizations help to design and to make it effective by financ.
Corrections in America - please type the answers separateDiscu.docxvoversbyobersby
Corrections in America - please type the answers separate
Discussion Board #2A : Research and discuss the differences between State and Federal Prison Systems. Who goes to Prison in each of these systems? What about Women Offenders? What about Juvenile Offenders?
iscussion Board #2B concerns Racial Issues within Prison Systems. Research and discuss if there is racial disparity as to who is sent to jail/prison. Are all groups sentenced equally? Why is there an issue with fair sentencing? Who is to blame?
.
Correction to be made for my code of ethical plan Inclusion of.docxvoversbyobersby
Correction to be made for my code of ethical plan: Inclusion of a letter from leadership to the reader of the Code of Ethics. This sets the tone and lets the reader know why the Board of Directors and management consider the code of Ethics important.
2. Accetable and unacceptable behavior on the part of employees.
3. Resources for more information and what to do if unethical behavior is seen such as contact information for an Ethics Compliance Officer or if someone needs to report unethical conduct. This includes reporting procedures.
4. Ethics training and awarness program for your company.
5. Consequences of unethical /or illegal behavior
6. The legal regulations of conducting business overseas.
7. The ethical code of conduct for employees and vendors
8. Distingushing between right and wrong in business dealings when the action is legal
9. Identifying the issues surrounding the motivation behind unethical or illegal business operations when the consequences are properly documented.
10. Anything else that you deem important support your ethical code of conduct plan.
11. Your ethical code of conduct plan should demonstrate your understanding of the concepts and ideas covered throughout the course.
1,250--1,500 words and references.
.
Correct the following paragraph. Insert or delete hyphens as nee.docxvoversbyobersby
Correct the following paragraph.
Insert or delete hyphens as needed in the following paragraph:
1
Attending College in New York City can be pretty scary, especially for a small-town girl from Des Moines, Iowa.
2
Since I am studying nursing, I decided to join Scorpions for Smiles, a student-volunteer-group that visits children who spend a-lot of time in the hospital wards for recovery or treatment purposes.
3
It's a great feeling knowing that a sick or hurting child is benefiting from my time and up-beat attitude.
4
The last time I visited, I brought coloring supplies so that Amy, the eight year old patient I usually spend time with, and I could draw pictures for her family.
5
Amy is a very well known patient; she is always playing practical jokes on the nurses and doctors!
6
When I went visited with my student group this past week, Amy wasn't there because she had an X-ray scheduled.
7
I left her a note with some crayons so that she could color after the procedure.
8
Next week is her birth-day.
9
. I won't be visiting that day, but when I do, I'll bring two plain t shirts to decorate with paints and markers.
10
The corner store near my dorm has cake-mix for only ninety nine cents!
11
. I'll bring a cake for Amy and-the-rest of her friends, too!
Step 2
Save and submit your assignment.
.
Correctional AdministratorsPrisons and jails are both clas.docxvoversbyobersby
Correctional Administrators
Prisons and jails are both classified as correctional facilities, however their missions and day-to-day operations can vary significantly. The types of offenders being held and the reasons they are incarcerated are notably different between a state or federal prison and a county jail.
In your initial response,
A)
Compare and contrast the role of a correctional administrator at a prison vs. a jail.
B)
Be sure to highlight the missions of both and how those missions impact the way day-to-day operations are managed by a correctional administrator.
Assignment Instructions:
1) Based on research, and
2) Using professional, scholarly sources, and
3) Submitted in APA 6th ed style, and
4) A minimum of 350 words, excluding the references list.
.
Corporations are making the assumption that everyone uses a sm.docxvoversbyobersby
Corporations are making the assumption that everyone uses a smartphone. How does this perpetuate the negative outcomes created by the “Digital Divide”?
Your rough draft is your work-in-progress version of your final paper (which is due on Sunday). The purpose of the rough draft assignment is to allow me to understand where your team is at, and to be able to provide feedback that you can use for refining your paper.
Your paper should have the following characteristics:
Be in APA format
Have the following sections:
Title page
Abstract (from Friday's assignment - revised according to the feedback that was given (if any).
Rough draft, this should address:
Introduction
Background/Literature Review
Relevant Theory Exploration
Findings/Examples
Lessons Learned
Future Research
References (non-annotated)
Appendix:
.
Corporation M, a calendar year corporation that began doing business.docxvoversbyobersby
Corporation M, a calendar year corporation that began doing business on January 1, 20X1, had accumulated earnings and profits of $30,000 as of January 1, 20X8. On July 2, 20X8, M distributed $22,000 cash to Mrs. C, M's sole shareholder. M had a $20,000 deficit in earnings and profits for 20X8. Mrs. C had an adjusted basis of $14,000 in her stock before the distribution. What is the amount of Mrs. C's basis in the stock after the distribution?
.
CORPORATE TRAINING 1
Running head: APA IS EASY
Paper Title
Student’s Name, Class
University of the Cumberlands
Note the
header &
the page
number.
Also this
the header
is l/2 inch
from the
top (p. 306)
Double spaced,
upper/lower case and
centered on the page.
See pg 41, APA, 6th
edition
Ask your facilitator if
they desire the date/their
name on title page.
APA doesn’t require it.
Running
head is
typically
optional –
ask your
instructor –
used
primarily if
publishing
CORPORATE TRAINING 2
Corporate Training
Today, managers need well-trained employees and are finding they do not exist.
Corporations are, therefore, providing additional training for their employees. One such training
program that is being added to corporate learning environments is an awareness of emotional
intelligence. Business managers are learning that successful managers need high Emotional
Quotient (EQ) or Emotional Intelligence (EI) to work effectively. Emotional intelligence is the
ability to accurately perceive emotions in self and others, to identify different emotional
responses, and to use emotional information to make intelligent decisions (Goleman, 2000). A
leading expert on EQ finds that “people good at managing relationships tend also to be self-
aware, self-regulating, and empathetic” (Goleman, 2000, p. 33). Emotional intelligence is
especially important “at the highest levels of the company, where differences in technical skills
are of little importance. In other words, the higher the rank of the person, the more emotional
intelligence capabilities are needed for decision making effectiveness” (Goleman, 1986, p. 94).
Emotional intelligence is crucial to a successful business career and for effective group
performance (Goleman, 1986). The core competencies required for emotional intelligence are
“the perception of emotions in one’s self and others, the understanding of these emotions, and
the management of emotions” (Feldman, 2001, ¶ 4). Success in the modern workplace requires
teamwork and collaboration. Emotional Intelligence training is essential since most modern
Title of
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CORPORATE TRAINING 3
companies rely on teams of employees working together, rather tha.
Corporate TAX homework problems. Need help with solving. email is .docxvoversbyobersby
Corporate TAX homework problems. Need help with solving. email is
[email protected]
Notes
Ch1 corporations
Complete the problems as presented in this document. You may create a new document and/or spreadsheet as needed. Any memo should be no more than 3 pages in length. Please state any assumptions used if problems are not clear.
Problem 1
Your client, a physician, recently purchased a yacht on which he flies a pennant with a medical emblem on it. He recently informed you that he purchased the yacht and flies the pennant to advertise his occupation and thus attract new patients. He has asked you if he may deduct as ordinary and necessary business expenses the costs of insuring and maintaining the yacht. In search of an answer, consult RIA’s CHECKPOINT TAX available on-line through the SNHU Shapiro Library. Explain the steps taken to find your answer.
Problem 2
Stacey Small has a small salon that she has run for a few years as a sole proprietorship. The proprietorship uses the cash method of accounting and the calendar year as its tax year. Stacey needs additional capital for expansion and knows two people who might be interested in investing. One would like to practice hairdressing in the salon. The other would only invest.
Stacey wants to know the tax consequences of incorporating the business. Her business assets include a building, equipment, accounts receivable and cash. Liabilities include a mortgage on the building and a few accounts payable, which are deductible when paid.
Write a memo to Stacey explaining the tax consequences of the incorporation. As part of your memo examine the possibility of having the corporation issue common and preferred stock and debt for the shareholders’ property and money.
Problem 3
Five years ago, Lacey, Kaylee, and Doug organized a software corporation, DLK, which develops and sells Online Meetings software for businesses. DLK is a C corporation. Each individual contributed $10,000 to the company in exchange for 1,000 shares of DLK stock (for a total of 3,000 shares). The corporation also borrowed $250,000 from ACME Venture Capital to finance operating costs and capital expenditures.
Because of intense competition, DLK struggled for the first few years of operation and the corporation sustained chronic losses. This year, Lacey, DLK’s president, decided to seek additional funds to finance DLK’s working capital.
CME declined to extend additional funds because of the money already invested in DLK. High Tech Venture Capital Inc. proposed to lend DLK $100,000, but at a 10% premium over the prime rate. (Other software manufacturers in the same market can borrow at a 3% premium.) First Round Capital proposed to invest $50,000 of equity capital into DLK, but on the condition that the investment firm be granted the right to elect five members to DLK’s board of directors. Discouraged by the “high cost” of external borrowing, Lacey decides to approach Kaylee and Doug.
Lac.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
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A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Financial Management Please respond to the following· Explain.docx
1. "Financial Management" Please respond to the following:
· Explain the three methods for calculating credit card interest
and your reason for going with a particular method.
· Provide an example of how you can use the power of
compounding interest to pay for a future expense.
· Discuss which practical application covered in the chapter you
think you will use within the next year and how you think
studying this topic will help you make wise financial choices in
the future.
ICU Nurses' Oral-Care Practices and the Current Best Evidence
Author: Ganz, Freda DeKeyser, RN, PhD; Fink, Naomi Farkash,
RN, MHA; Raanan, Ofra, RN, MA; Asher, Miriam, RN, BA;
Bruttin, Madeline, RN, MA; Nun, Maureen Ben, RN, BSN;
Benbinishty, Julie, RN, BA
ProQuest document link
Abstract:
The purpose of this study was to describe the oral-care practices
of ICU nurses, to compare those practices with current
evidence-based practice, and to determine if the use of
evidence-based practice was associated with personal
demographic or professional characteristics.
A national survey of oral-care practices of ICU nurses was
conducted using a convenience sample of 218 practicing ICU
nurses in 2004-05. The survey instrument included questions
about demographic and professional characteristics and a
checklist of oral-care practices. Nurses rated their perceived
level of priority concerning oral care on a scale from 0 to 100.
A score was computed representing the sum of 14 items related
to equipment, solutions, assessments, and techniques associated
with the current best evidence. This score was then statistically
analyzed using ANOVA to determine differences of EBP based
on demographic and professional characteristics.
2. The most commonly used equipment was gauze pads (84%),
followed by tongue depressors (55%), and toothbrushes (34%).
Chlorhexidine was the most common solution used (75%). Less
than half (44%) reported brushing their patients' teeth. The
majority performed an oral assessment before beginning oral
care (71%); however, none could describe what assessment tool
was used. Only 57% of nurses reported documenting their oral
care. Nurses rated oral care of intubated patients with a priority
of 67+/-27.1. Wide variations were noted within and between
units in terms of which techniques, equipment, and solutions
were used. No significant relationships were found between the
use of an evidence-based protocol and demographic and
professional characteristics or with the priority given to oral
care.
While nurses ranked oral care a high priority, many did not
implement the latest evidence into their current practice. The
level of research utilization was not related to personal or
professional characteristics. Therefore attempts should be made
to encourage all ICU nurses to introduce and use evidence-
based, oral-care protocols.
Practicing ICU nurses in this survey were often not adhering to
the latest evidence-based practice and therefore need to be
educated and encouraged to do so in order to improve patient
care.
Links:Check for Full Text
Full text:
Headnote
Abstract
Purpose: The purpose of this study was to describe the oral-care
practices of ICU nurses, to compare those practices with current
evidence-based practice, and to determine if the use of
evidence-based practice was associated with personal
demographic or professional characteristics.
Design: A national survey of oral-care practices of ICU nurses
was conducted using a convenience sample of 218 practicing
ICU nurses in 2004-05. The survey instrument included
3. questions about demographic and professional characteristics
and a checklist of oral-care practices. Nurses rated their
perceived level of priority concerning oral care on a scale from
0 to 100. A score was computed representing the sum of 14
items related to equipment, solutions, assessments, and
techniques associated with the current best evidence. This score
was then statistically analyzed using ANOVA to determine
differences of EBP based on demographic and professional
characteristics.
Findings: The most commonly used equipment was gauze pads
(84%), followed by tongue depressors (55%), and toothbrushes
(34%). Chlorhexidine was the most common solution used
(75%). Less than half (44%) reported brushing their patients'
teeth. The majority performed an oral assessment before
beginning oral care (71%); however, none could describe what
assessment tool was used. Only 57% of nurses reported
documenting their oral care. Nurses rated oral care of intubated
patients with a priority of 67±27.1. Wide variations were noted
within and between units in terms of which techniques,
equipment, and solutions were used. No significant
relationships were found between the use of an evidence-based
protocol and demographic and professional characteristics or
with the priority given to oral care.
Conclusions: While nurses ranked oral care a high priority,
many did not implement the latest evidence into their current
practice. The level of research utilization was not related to
personal or professional characteristics. Therefore attempts
should be made to encourage all ICU nurses to introduce and
use evidence-based, oral-care protocols.
Clinical Relevance: Practicing ICU nurses in this survey were
often not adhering to the latest evidence-based practice and
therefore need to be educated and encouraged to do so in order
to improve patient care.
Key words
Oral care, intubated patient, evidence-based nursing practice
Some members of the Israeli Cardiology and Critical Care
4. Nursing Society took the initiative to organize a work group
dedicated to promoting critical care nursing research and
evidence-based practice. The group first heard lectures about
evidence-based practice and how it can clinically affect patient
care and how to critically review the literature. Following these
lectures, the group conducted lengthy discussions about the
purpose of the group and what projects could be realistically
completed. Members of the group came to the conclusion that
they wanted to conduct a national project related to a clinical
area that is exclusive to nursing, could apply to all types of
intensive care units, had some evidence in the literature, and
could affect patient outcomes.
At the time of the beginning of the project (late 2003 to early
2004), several studies were published that found that poor oral
hygiene might be associated with an increased risk for
pneumonia with its concomitant increased morbidity and
mortality. One specific article caught the attention of the group
(Grap, Munro, Ashitani, & Bryant, 2003). These authors
reported that intensive care unit (ICU) nurses' oral care
practices were not documented nor were they in accordance
with the most recent evidence. Oral care of intubated patients
was then chosen as the topic for the project. Members of the
group also believed that no consistent practices related to oral
care existed, even within the same unit, and that most nurses
had little or no knowledge of the current best evidence-based
practice. Because the primary purpose of the group was to
promote evidence-based practice, members were interested in
determining what factors could be associated with the use of
evidence in practice so that future interventions could be
directed toward those groups to improve clinical practice and
patient care. Therefore the purpose of the project was three
fold: (a) to describe oral-care practices of ICU nurses, (b) to
compare those practices to the current evidence, and (c) to
determine whether personal demographic or professional
characteristics were related to evidence-based, oral-care
practice.
5. Background
Ventilator-associated pneumonia (VAP) is considered to be the
most common nosocomial infection (Vincent, 2004) and has
been found to be a major cause of morbidity and mortality in
ICUs (Bercault & Boulain, 2001; Elward, Warren, & Fraser,
2002; Relio et al., 2002). In a review of VAP literature, Chastre
and Fagon (2002) concluded that VAP is a complication in 8%-
28% of patients receiving mechanical ventilation and causes a
high mortality rate of 24%-50%.
Several reports of studies have been published that indicated
that oral decontamination might be associated with decreased
risk for VAP (Bergmanns et al., 2001; Hubmayr, 2002; van
Nieuwenhoven et al., 2004). Therefore, nurses could directly
affect the level of VAP by providing effective oral care to
decrease this contamination.
Some investigators have shown that nurses based their oral-care
practices on tradition, used many different techniques and
products for oral care, and had no uniform method of oral
assessment (Binkley, Furr, Carrico, & McCurren, 2004;
Bowsher, Boyle, & Griffiths, 1999; Curzio & McCowan, 2000;
Evans, 2001; Furr, Binkley, McCurren & Carrico, 2004; Grap et
al., 2003; Jones, Newton & Bower, 2004; McNeill, 2000; Munro
& Grap, 2004; Munro & Grap, 2004; Stiefel, Damron, Sowers &
Velez, 2000; White, 2000). Grap et al. (2003) concluded that
ICU nurses' oral-care practices were not documented nor were
they in accordance with the most recent evidence. Similar
results were found in several later studies conducted in the
United States (Binkley et al., 2004; Cutler & Davis, 2005;
Hanneman & Gusick, 2005) and in a survey of 59 European ICU
nurses (Relio et al., 2007); but not by Jones et al. (2004) who
found that UK nurses did perform appropriate oral care
methods.
When our evidence-based nurse (EBN) group was trying to
decide which protocol to recommend, we found no consensus in
the literature about what was the best evidence related to oral
care. In a recent systematic review, Berry, Davidson, Masters,
6. & Rolls (2007) concluded that scarce evidence exists related to
oral care practices of intubated ICU patients. The Centers for
Disease Control and Prevention (CDC) staff have developed
guidelines for preventing VAP (R). These guidelines include
hand washing; education of healthcare workers about
nosocomial pneumonia and its prevention; wearing of gloves;
sub-glottic suctioning; head of bed elevation; and use of
Chlorhexidine for cardiac-surgery patients.
The last element of the CDC guideline for preventing VAP is
the development of a comprehensive oralhygiene program;
however, details are lacking about what the program should
include. Another relevant set of guidelines from the CDC and
the American Association of Critical Care nurses is the
"ventilator bundle," that includes steps to reduce the incidence
of VAP for mechanically ventilated patients. This bundle
includes elevating the head of the bed, continuous subglottal
suctioning, changing ventilator circuit no more than every 48
hours, and hand washing before and after contact with each
patient. This protocol does not even mention oral care
(Tolentino-DelosReyes, Ruppert, Shyang-Yun, & Shiao, 2007).
Therefore, even though, in principle, oral care is considered of
great importance to intubated and ventilated patients, its place
in many guidelines related to these patients is unclear.
Many studies have been conducted in order to determine what
barriers are associated with a lack of evidencebased practice
(EBP). Most of these studies have used the Barriers
questionnaire developed by Funk and colleagues (1991), which
groups these barriers into four basic categories: qualities of the
research; presentation and accessibility of the research; setting
or organizational barriers and limitations; and nurses' research
values, skills, and awareness. Few researchers have investigated
whether individual characteristics of nurses may be related to
such perceptions.
In many other countries around the world, there is access to
nursing research (for example access to the Internet), but the
culture of nursing research is not well developed. Ricart and
7. colleagues (2003) comment that variability in following
evidence-based guidelines may be because of differences in
training or cultural aspects of the country. In a recent article,
Rassin (2008) found that nursing research was rated last in a list
of 20 professional values among Israeli hospital nurses.
This result is not surprising given the fact that nursing research
capacity and exposure is relatively low in Israel (Ehrenfeld,
Itzhaki, & Baumann, 2007; Glazer & DeKeyser, 2000). Most
research is conducted by nurses obtaining an advanced degree
and no national mechanisms are in place for designated funding
for nursing research or for promoting EBP.
Because no information was available about the current state of
evidence-based oral care practice in Israel, the group decided to
conduct a survey describing current oral-care practices of ICU
nurses with intubated patients and to determine whether
evidence-based practices were related to personal demographic
or professional characteristics.
Methods
Sample
A convenience sample of 218 practicing ICU nurses was
obtained in 2004-2005. Members of the EBN group recruited
nurses from their own ICUs, with some also recruiting nurses
from other units within the same organization. Nurses in the
survey worked in 12 different ICUs, 5 in general-respiratory
ICUs, 3 in cardiovascular-surgical ICUs, 2 in neurosurgical
ICUs and 2 in cardiac care ICUs.
Instrument
The survey included two major sections. The first section
contained questions about demographic and professional
characteristics including age, gender, nursing education, years
of ICU experience, postbasic ICU certification, type of ICU,
work full or part time, and shifts worked.
The second section contained a checklist which included a
listing of the current oral-care practices including type of
equipment used, solutions used, technique, and the type and
timing of oral assessment. Nurses were asked to check off all
8. responses that applied to their practice. Some of the items on
the checklist were based on current best evidence, for example
the use of Chlorhexidine or toothpaste; however, other items
listed were not recommended, such as bicarbonate or lemon
water. Nurses were also asked their perceived level of priority
of oral care on a scale from 0 to 100. This question had a visual
analogue format in which descriptors were placed at each end
(highest priority= 100; lowest priority=0) on a 10-cm line.
Nurses were asked to mark an X on the place that corresponded
with the level of priority they gave to oral care.
The survey instrument was based on the literature and
constructed by a committee of experienced ICU nurses. Content
validity of the tool was improved by including questions
suggested by members of the EBN task force and consultants.
The survey was also sent for review to an instructor of dental
hygiene and to other ICU nurses for obtaining content validity.
Reviewers were asked to suggest additional items or remove
those which were listed. The final survey questionnaire was a
conglomeration of the items suggested by the EBP group and
those of the reviewers. The use of Cronbach's alpha for this tool
was not deemed appropriate because the questionnaire is a
checklist.
Data Collection
Each member of the EBN group obtained both ethical and
institutional approval to collect the data. Then group members
explained the study to nurses in a staff meeting, obtained
informed consent from participants, and distributed the
questionnaires on an individual basis. Nurses were asked to
return the questionnaires to an envelope placed in a convenient
location on each unit.
Data Analysis
Descriptive statistics, including measures of central tendency
and dispersion and frequency data were used to describe the
sample as well as responses to the oralcare practices survey.
Not all participants completed all of the items - and these were
not included in missing-data analyses.
9. An EBP score was also determined, which was defined as the
number of items on the checklist that were checked off by the
nurse and considered to be necessary for proper oral care
according to the literature. Supplies listed included a
toothbrush, suction and suction catheter, toothpaste,
Chlorhexidine, and petroleum jelly (6 items). Technique items
included care of the upper and lower mouth, tongue, and
brushing of the patient's teeth (4 items). Assessment questions
were about doing an assessment upon admission to the unit and
at each shift (2 items). Use of an assessment tool and results of
the assessment and oral care were to be charted accordingly (2
items) - for a total of 14 items.
Each nurse obtained a score corresponding to the total number
of evidence-based items checked off (from ?? 4). A higher score
shows higher use of evidence-based practices. This total score
was then correlated with demographic and professional
characteristics to determine if such characteristics were
associated with oral-care EBP. Data were collected on
questionnaires that were delivered to one of the researchers,
who then coded the data into an SPSS data file (Version 12).
This score was then analyzed to determine whether a difference
in EBP scores existed based on personal demographic or
professional characteristics using ANOVA. Interval level
independent variables were categorized as follows: age (years):
20-29, 30-39, 40-49, 50+; years of clinical experience (as RN,
as an ICU nurse, and in this particular ICU): 0-5, 6-9, 10-14,
15-20, 20+; percentage of time worked: <50%, 50-75%, 75-
99%, 100%). All other variables were categorical (gender,
education, type of ICU).
Results
The majority of the sample was female (?= 172, 82%) with an
average age of 37.4+8.6 years. Nurses were mostly registered
nurses with a baccalaureate degree who had completed a
postbasic certification course (see Table 1). According to the
latest available statistics of the Nursing Division of the Israel
Ministry of Health (Nursing Division, Ministry of Health,
10. 2007), 76% of nurses in Israel are registered nurses; 25% have a
baccalaureate degree or higher; and 41% have completed some
form of postbasic certification. One tenth of nurses were male
and 39% of all nurses were age 30-44 years. Nurses in this
sample were better educated than the general population of
Israeli nurses but otherwise seemed to be similar.
The most commonly used supplies were gauze pads (n=182,
84%), followed by tongue depressors (n=118, 55%), and
toothbrushes (n=73, 34%). Often nurses attach gauze pads to a
tongue depressor to use for oral care - a practice that substitutes
for the use of sponges or swabs attached to a stick sometimes
done in other countries. Chlorhexidine was the most commonly
used solution (n=161, 75%) followed by petroleum jelly (n=87,
40%), and toothpaste (n=72, 33%). Almost all nurses performed
oral care (n=198, 91%); however, less than half (n=96, 44%)
brushed their patients' teeth. Only 57% (n=120) of nurses
reported documenting oral care. On a scale of 0-100, nurses
rated oral care for intubated patients with a priority of 67+27.1,
where 44% (n=96) rated it on a priority of 90%-100%. The
mean EBP score was 9/14 or 68%. All participants stated that no
known written oral-care protocol existed on their unit (see
Table 2).
No significant relationship was found between the use of
evidence-based practices and demographic or professional
characteristics or with the priority given to oral care.
Discussion
While nurses ranked oral care as a high priority, many did not
implement the latest evidence into their current practice. The
level of evidence-based practice was not related to personal
demographic or professional factors.
Perceived level of priority of oral care practices has been
measured differently in different studies but for the most part
many studies have shown that critical care nurses rate oral care
with a moderate to high priority, including the nurses in this
study (Binkley et al., 2004; Grap et al., 2003; Jones et al., 2004;
Relio et al., 2007).
11. As in previous studies (Binkley et al., 2004; Grap et al., 2003;
Relio et al., 2007; Ricart et al., 2003), the level of EBP has
been questionable. Many nurses in this sample did not
implement the latest evidence in their practice. The American
Association of Critical Care Nurses produced a "practice alert"
based on the current best evidence, describing recommended
oral care in the critically ill (American Association of Critical
Care Nurses [AACN], 2007).
AACN recommendations included developing an oralcare
hygiene program which includes brushing patients' teeth, gums,
and tongue at least twice a day, using a soft pediatric or adult
toothbrush, moisturizing oral mucosa and lips every 2-4 hours,
and in precardiac surgery patients - using oral Chlorhexidine
gluconate (0.12%) rinse twice a day. All of the nurses in our
study stated that no organized protocols or programs related to
oral hygiene existed on their units. Most did not brush their
patients' teeth. It is not known what type of toothbrush was used
among those that did brush their patients' teeth. However,
almost all of the respondents (8491%) claimed to clean their
patients' tongue and upper and lower mouth. Petroleum jelly, a
substance used to moisturize the lips, was used by many of the
respondents; however, the frequency of use was not reported.
The majority of nurses on all of the units reported using
Chlorhexidine, a substance that has received scientific support
for use in a very limited population-precardiac surgery patients.
This solution was not recommended for other patient
populations.
A wide range of practices was found in this study among nurses
working within the same unit and between units, partially
because of the fact that no known written oral-care protocols
existed. Several authors have commented on the importance of
using written protocols in guiding oral care (Cason, Tyner,
Saunders, & Broome, 2007; Cutler & Davis, 2005; Steifel et al.,
2000).
None of the individual nurse characteristics in this study were
found to be related to evidence-based practice or priority of oral
12. care. The only characteristics found in the literature to be
related to evidence-based practice were educational level,
nursing position, and experience. Several investigators have
found that the higher the level of academic nursing education,
the more positive the attitude toward nursing research and EBP
(Bonner & Sando, 2008; Bucknall, Copnell, Shannon, &
McKinley, 2001; Fink, Thompson, & Bonnes, 2005; Furr et al.,
2004; Hannes et al., 2007; Kajermo et al., 2008); however, Oh
(2008) and Roxburg (2006) found the opposite results. In a
recent study of Israeli hospital nurse values (Rassin, 2008), the
findings were that nurses with a baccalaureate degree valued
nursing research more than any other type of nurse, including
those with a master's degree. The authors did not explain this
result but the finding is in keeping with a discrepancy in the
literature.
The literature is also ambiguous regarding the influence of
nursing position on attitudes toward research and EBP. While
several authors (Bonner & Sando, 2008; Egerod & Hansen,
2005; Oh, 2008) found that higher level positions were
associated with more positive attitudes, Bucknall et al. (2001)
found the opposite result. Oh (2008) determined that level of
nursing experience was associated with more positive attitudes,
while Furr et al. (2004) found the opposite. In these studies, the
researchers defined attitudes toward EBP differently and the
studies were conducted using different designs and in different
cultures therefore conflicting findings are not too surprising.
However, many of the studies using the barrier scale found that
one of the greatest barriers to evidence-based practice was the
nurses' assessment of her lack of skills related to use of
research. Perhaps increased education, experience, and a higher
position may be related to increased feelings of competence
related to research.
Based on the results of this study, where no oral care protocols
were reported and where there were no differences between
nurses based on personal or professional characteristics related
to the use of EBP, it is recommended that standardized, written,
13. evidence-based protocols related to the oral assessment and care
be introduced into all ICUs admitting intubated patients. Nurses
at all levels should be informed and encouraged in its use.
Further research could include investigating other barriers
related to EBP in this area and in this culture, as well as what
other factors are associated with the introduction and use of
evidence-based protocols.
Conclusions
While nurses ranked oral care as a high priority, levels of EBP
were found to be relatively low. Demographic and professional
characteristics were not found to be associated with the use of
EBP. Therefore, all nurses, regardless of personal
characteristics, should be involved in educational programs
related to oral care and evidence-based practice and should be
encouraged to introduce and utilize written protocols based on
the latest evidence in an attempt to decrease VAP on their units.
Acknowledgements
This study was supported by the Israeli Cardiology and Critical
Care Nursing Society.
Clinical Resource
* Practice Alert of the American Association of Critical Care
Nurses: http://www.aacn.org/WD/ practice/docs/oraLcare Jn
_the.critically.ill.pdf
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AuthorAffiliation
Freda DeKeyser Ganz, RN1 PhD1, Naomi Farkash Fink, RN,
MHA2, Ofra Raanan, RN, MA3, Miriam Asher, RN, BA4,
Madeline Bruttin, RN, MA5, Maureen Ben Nun, RN, BSN6, &
Julie Benbinishty, RN, BA7
1 Pi, Head, Master's Program, Hadassah-Hebrew University
School of Nursing, Jerusalem, Israel
2 Nursing Research Coordinator, Rabin Medical Center, Petach
Tikva, Israel
3 Instructor, Sheba-Tel Hashomer Medical Center, Tel
Hashomer, Israel
4 Rabin Medical Center, Petach Tikva, Israel
5 Instructor, Recanati School of Health Professions, Ben Gurion
University, Beer Sheva, Israel
6 Kaplan Medical Center, Rehovot, Israel
7 Instructor, Hadassah Hebrew University School of Nursing,
Jerusalem, Israel
AuthorAffiliation
Correspondence
DeKeyser Ganz, Hadassah-Hebrew University
School of Nursing, Kiryat Hadassah, P.O. Box
12000, Jerusalem. E-mail:
[email protected]
Accepted: December 1 , 2008.
dol: 10.1111/j.1547-5069.2009.01264.x
20. Correspondence
Edward Roddy
Academic Rheumatology
Clinical Sciences Building
Nottingham City Hospital
Hucknall Road
NG5 1PB
UK
E-mail:
[email protected]
Keywords:
clinical guidelines,
evidence-based medicine, strength of
recommendation
Accepted for publication:
27 April 2005
Evidence-based clinical guidelines: a new system to better
determine
true strength of recommendation
Edward Roddy MRCP (Specialist Registrar in Rheumatology),
21. 1
Weiya Zhang PhD (Senior Lecturer in
Musculoskeletal Epidemiology),
1
Michael Doherty MA MD FRCP (Professor of Rheumatology),
1
Nigel K. Arden MD MSc MRCP (Senior Lecturer in
Rheumatology),
2
Julie Barlow PhD (Professor of Health
Psychology),
3
Fraser Birrell MA PhD MRCP (Senior Lecturer in
Rheumatology),
22. 4
Alison Carr PhD (Special Lecturer
in Musculoskeletal Epidemiology),
1
Kuntal Chakravarty FRCP (Consultant Rheumatologist),
5
John Dickson FRCP MRCGP (Community Specialist in
Rheumatology),
6
Elaine Hay MD FRCP (Professor of
Community Rheumatology),
7
Gillian Hosie FRCP (General Practitioner),
8
23. Michael Hurley PhD (Reader in
Physiotherapy & ARC Research Fellow),
9
Kelsey M. Jordan MRCP (Rheumatology Research Fellow),
2
Christopher McCarthy PhD (Research Physiotherapist),
10
Marion McMurdo MD FRCP (Professor of Ageing and
Health),
11
Simon Mockett MPhil (Senior Lecturer),
12
Sheila O’Reilly MD MRCP (Consultant Rheumatologist),
24. 13
George Peat PhD MCSP (Research Fellow),
7
Adrian Pendleton MD MRCP (Specialist Registrar in
Rheumatology),
14
Selwyn Richards MA MSc FRCP (Consultant Rheumatologist)
15
1
Academic Rheumatology, Clinical Sciences Building,
Nottingham City Hospital, Hucknall Road, Nottingham, UK
2
MRC Epidemiology Resource Centre, Southampton General
25. Hospital, Tremona Road, Southampton, Hampshire, UK
3
Interdisciplinary Research Centre in Health, School of Health
and Social Sciences, Coventry University, Priory St,
Coventry, UK
4
Musculoskeletal Research Group, University of Newcastle upon
Tyne, UK
5
Haroldwood Hospital, Gubbins Lane, Romford, Essex, UK
6
Langbaurgh PCT, Langbaurgh House, Bow Street, Guisborough,
Cleveland, UK
7
Primary Care Sciences Research Centre, Keele University,
Staffordshire, UK
26. 8
Primary Care Rheumatology Society, Northallerton, North
Yorkshire, UK
9
King’s College London, Rehabilitation Research Unit, Dulwich
Hospital, East Dulwich Grove, London, UK
10
The Centre for Rehabilitation Science, University of
Manchester, Oxford Road, Manchester, UK
11
Department of Medicine, University of Dundee, Ninewells
Hospital, Dundee, UK
12
Division of Physiotherapy Education, School of Community
Health Sciences, University of Nottingham, Nottingham City
Hospital, Hucknall Road, Nottingham, UK
27. 13
Derbyshire Royal Infirmary, London Road, Derby, UK
14
Craigavon Area Hospital, 68 Lurgan Road, Portadown, Co
Armagh, UK
15
Poole Hospital, Longfleet Road, Poole, UK
Abstract
Rationale, aims and objectives
Clinical practice guidelines often grade the
‘strength’ of their recommendations according to the robustness
of the sup-
porting research evidence. The existing methodology does not
allow the
strength of recommendation (SOR) to be upgraded for
recommendations
for which randomized controlled trials are impractical or
unethical. The pur-
28. pose of this study was to develop a new method of determining
SOR, incor-
porating both research evidence and expert opinion.
Methods
A Delphi
technique was employed to produce 10 recommendations for the
role of
exercise therapy in the management of osteoarthritis of the hip
or knee. The
SOR for each recommendation was determined by the
traditional method,
closely linked to the category of research evidence found on a
systematic
literature search, and on a visual analogue scale (VAS).
Recommendations
were grouped A-D according to the traditional SOR allocated
and the
mean VAS calculated. Difference across the groups was
assessed by one-
E. Roddy
et al.
348
30. ANOVA
. However, certain recom-
mendations which, for practical reasons, could not assessed in
randomized
controlled trials and therefore could not be recommended
strongly by the
traditional methodology, were allocated a strong
recommendation by VAS.
Conclusions
This new system of grading strength of SOR is less con-
strained than the traditional methodology and offers the
advantage of
allowing SOR for procedures which cannot be assessed in RCTs
for prac-
tical or ethical reasons to be upgraded according to expert
opinion.
Introduction
Clinical guidelines have been defined as ‘systemati-
cally developed statements to assist practitioner
and patient decisions about appropriate health care
for specific clinical conditions’ (Field & Lohr 1990).
Guidelines that employ an evidence-based format
currently grade each recommendation in two ways:
first, by classifying the ‘category of evidence’ and,
second, by giving a ‘strength of recommendation’.
Although several methods of producing such grades
31. are described, in most of these, including the method
most commonly used by clinical guidelines in rheu-
matology (Pendleton
et al
. 2000; Jordan
et al
. 2003;
Dougados
et al
. 2004; Zhang
et al
. 2004; Roddy
et al
.
2005), the latter is strongly dependent on the former
(Shekelle
32. et al
. 1999) (Table 1). That is, the strength
of recommendation (SOR) primarily reflects the
robustness of the research evidence, with evidence
from randomized controlled trials (RCTs) and
systematic reviews automatically conferring the
strongest recommendation. However, although this
traditional method allows a downgrading of the SOR
for reasons including side effects or inconsistent
studies, it does not allow an upgrading of recommen-
dations in situations where RCTs are impractical or
unethical, e.g. total joint replacement, but effective-
ness is not in doubt. Furthermore, the practice of
evidence-based medicine requires the integration of
clinical expertise with the best available evidence
from systematic research (Sackett
et al
. 1996). Dur-
ing the development of recent recommendations for
the role of exercise in the management of osteo-
arthritis (OA) of the hip or knee (Roddy
et al
. 2005),
33. we found that the SOR allocated by this method was
often discordant with the consensus opinion of the
Table 1 Traditional hierarchy for category of evidence and
strength of recommendation (Shekelle
et al
. 1999)
Categories of evidence
1A. meta-analysis of RCT
1B. at least one RCT
2A. at least one CT without randomization
2B. at least one type of quasi-experimental study
3. descriptive studies (comparative, correlation, case-control)
4. expert committee reports/opinions and/or clinical opinion of
respected authorities
Strength of recommendation
A. Directly based on category 1 evidence
B. Directly based on category 2 evidence or extrapolated
recommendation from category 1 evidence
C. Directly based on category 3 evidence or extrapolated
recommendation from category 1 or 2 evidence
D. Directly based on category 4 evidence or extrapolated
recommendation from category 1, 2 or 3 evidence
35. Methods
A multi-disciplinary panel employed a Delphi tech-
nique to produce 10 recommendations relating to
the role of exercise in the management of OA of
the hip or knee (Roddy
et al
. 2005). Following a
literature search and summary analysis of results,
the evidence for each recommendation was
assessed. The category of evidence and SOR was
assigned for each according to the method previ-
ously described (Shekelle
et al
. 1999). In addition,
each participant was asked to indicate how strongly
they rated each recommendation, based not just on
research evidence but also on all aspects relating
to their knowledge and clinical opinion. This was
recorded using a 10-cm visual analogue scale (VAS)
anchored with two descriptors labelled ‘not recom-
mended at all’ at the far left (0 cm) and ‘fully rec-
ommended’ at the far right (10 cm). The mean VAS
and standard deviation for each recommendation
were calculated. The recommendations were then
36. grouped according to their original SOR (A-D) and
the mean VAS and 95% confidence interval calcu-
lated for each group. A one-way
ANOVA
variance
analysis was performed to assess the difference
between the groups.
Results
The recommendations and the categories of evi-
dence, SOR and VAS for each, are shown in Table 2.
Figure 1 shows the mean VAS and 95% confidence
interval for recommendation groups A, C and D in
addition to one recommendation which was contra-
dicted by the research evidence and could not there-
fore be graded according to the traditional method
(‘not recommended’). No recommendations were
allocated a grade B SOR. The one-way
ANOVA
vari-
ance analysis identified a significant difference across
the groups (
P
37. <
0.001) and significant linearity
(
P
<
0.001).
Discussion
There was similarity between the SOR produced by
this method and the traditional methodology (Shek-
elle
et al
. 1999). The mean VAS for each recommen-
dation group (A, C, D) increased with the traditional
SOR, and therefore the category of evidence, and the
38. lowest mean was seen for the recommendation which
could not be recommended by the research evidence
ie was based solely on expert opinion.
This new system has the advantage of allowing the
SOR to be upgraded or downgraded based on ex-
pert opinion relating to global aspects of health
care delivery, such as generalizability, safety, cost-
effectiveness and patient preference, and common
sense. It therefore gives an additional dimension and
weighting to guideline recommendations other than
just the support from research evidence alone. In the
traditional system, the term ‘strength of recommen-
dation’ is almost a misnomer as it directly relates
to the category of evidence and provides little extra
information beyond that afforded by the ‘category of
evidence’. This is an important limitation of currently
practised evidence-based guideline methodology
that was overlooked in a recent critique of the meth-
odology of OA guidelines (Pencharz
et al
. 2002).
During the development of guidelines there are
many situations for which the existing SOR method-
ology (Shekelle
et al
. 1999) is not ideal. Interventions
39. for which placebo-controlled trials are impractical or
unethical (e.g. total joint replacement) cannot score
highly on the existing hierarchy and yet clearly may
Figure 1 Comparison of mean VAS (95% confidence
intervals) and traditional strength of recommendation.
VAS, visual analogue scale; NR, not recommended.
0
1
2
3
4
5
6
7
8
9
A C D NR
Strength of recommendation (Traditional method)
M
ea
n
V
A
S
(
cm
41. the recommendation for such interventions to be
upgraded beyond that afforded by the category of
research evidence. Furthermore, when recommenda-
tions are not easily assessed in the setting of a clinical
trial yet have clear face validity, as with our third and
fourth recommendations (Table 2), the panel may
feel a much stronger recommendation is warranted
than that permitted by the current research-linked
method. For example, the mean VAS for both prop-
ositions 4 and 5B (Table 2) was 7.7, yet the SOR
according to the traditional methodology were D and
1B respectively. This reflects that although proposi-
tion 4 would be impractical to assess in the setting of
a RCT, it was highly supported by the expert panel
Table 2 Evidence-based recommendations for the role of
exercise in the management of osteoarthritis of the hip or
knee: category of evidence, strength of recommendation
(Shekelle
et al
. 1999) and visual analogue score (VAS)
Recommendation
Category of
Evidence (1–4)
Strength of
Recommendation (A-D)
42. Strength of
recommendation
(VAS) – Mean
(SD) cms
1. Both strengthening and aerobic exercise can
reduce pain and improve function and health
status in patients with knee and hip OA.
Knee 1B
Hip 4
A
C (extrapolated from knee OA)
8.9 (1.1)
6.3 (2.1)
2. There are few contra-indications to the
prescription of strengthening or aerobic
exercise to patients with hip or knee OA.
4 C (extrapolated from adverse
event data)
8.0 (1.5)
3. Prescription of both general (aerobic
fitness training) and local (strengthening)
exercises is an essential, core aspect of
management for every patient with hip or
knee OA.
43. 4 D 7.1 (2.5)
4. Exercise therapy for OA of the hip or knee
should be individualized and patient-centred
taking into account factors such as age,
co-morbidity and overall mobility.
4 D 7.7 (1.9)
5. To be effective, exercise programmes
should include advice
and education to promote a positive lifestyle
change with an increase in physical activity.
4
1B
D
A
6.1 (2.6)
7.7 (1.4)
6. Group exercise and home exercise are equally
effective and patient preference should be
considered.
1A
4
A
D
45. 2006 Blackwell Publishing Ltd,
Journal of Evaluation in Clinical Practice
,
12
, 3, 347–352
351
whereas robust evidence from RCTs exists to sup-
port proposition 5B. Finally, the traditional hierarchy
does not accommodate the scenario where research
evidence contradicts a recommendation, as with our
ninth recommendation (Table 2).
Other guideline methodology groups have
attempted to overcome these limitations and reduce
the dependence of the SOR on the category of
research evidence. However, the grading systems,
produced by American College of Cardiology/
American Heart Association (ACC/AHA) Task
Force (ACA/AHA 2004), the US Preventive Services
Task Force (2003), the National Institute for Clinical
Excellence (NICE) (NICE 2004) and the New
Zealand Guidelines Group (New Zealand Guide-
46. lines Group 2004), derive the SOR primarily from
the category of research evidence. The ACC/AHA
guidelines state that any combination of classification
of recommendation and level of evidence is possible
and that a recommendation can be strongly sup-
ported even if it is based entirely on expert opinion
and no research studies have ever been conducted on
the recommendation (ACA/AHA 2004). However,
this system does not provide for the incorporation of
factors such as cost-effectiveness and safety, and the
descriptive and quantitative criteria for assigning the
classification and evidence ratings weight research
evidence and clinical expertise equally, which may
not be appropriate for some modalities, e.g. total
joint replacement. The guideline development
methods of NICE state that when the evidence is
very strong, this should translate directly into a rec-
ommendation, yet when the literature search finds no
evidence to answer the clinical question, the guide-
line development group should consider using con-
sensus methods to identify current best practice,
suggesting that consensus methods are only needed
when there is no robust evidence (NICE 2004).
Furthermore, NICE produces guidance on the role of
individual treatments rather than disease-orientated
recommendations on global treatment strategies. The
recently published GRADE collaboration (Atkins
et al
. 2004), although highlighting the difficulties in
producing clinical guidelines and grading strength of
recommendation, has not produced a simple, practi-
cal solution. The VAS, on the other hand, has the
47. advantage of being simple to apply and allows all
facets to be incorporated, e.g. category of research
evidence, safety, cost-effectiveness, generalizability
and expert opinion.
A limitation of the VAS-SOR methodology is that
as the basis for the VAS is not based on explicit
criteria, it cannot be examined and assessed readily
by external groups. However, we recommend that
the VAS method should be used alongside the tra-
ditional method of determining the category of
research evidence supporting each recommendation.
Any discrepancy between the category of evidence
and SOR would therefore be highlighted and should
then be justified in the ensuing discussion. A further
limitation is that this method has only been used
in the setting of recommendations for exercise in
osteoarthritis by a single group of experts, so evi-
dence of its generalizability to other fields and other
groups is required.
Other possible methods for grading SOR include
the development of an ordinal scale. A numerical
scale, however, is commonly used to assess self-
reported pain and disability in clinical trials, and
applying this principle to SOR seemed preferable.
Although the numerical scale scores themselves do
not have intrinsic comparability between different
sets of guidelines, there is at least scope for grading
or even ranking of different recommendations within
each set of guidelines. Other groups that prefer
verbal scales may wish to develop an ordinal scale
with descriptors to help guide practice in a clinical
setting.
48. Our guideline development group concludes that,
in comparison to existing traditional methodology,
this new system of grading SOR is less constrained
and offers the advantage of allowing the SOR for
procedures which cannot be assessed in RCTs to be
upgraded according to expert opinion consistent with
the principles of evidence-based medicine (Sackett
et al
. 1996). We would encourage other groups that
develop management recommendations or guide-
lines to try this approach, so that its clinical applica-
bility and usefulness can be determined more widely.
Acknowledgements
We are grateful for an educational grant from
MOVE (http://www.move.uk.net) and are also
indebted to the Arthritis Research Campaign, UK
for financial support (ICAC grant D0593; WZ Senior
http://www.move.uk.net
E. Roddy
et al.
50. whose mission is to provide exercise opportunities
for older people. Profits go to ageing research.
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