Professional Learning Portfolio. Kara Elkins. Ferris State University

PORTFOLIO 1 Professional Learning Portfolio Kara Elkins Ferris State University PORTFOLIO 2 Table of Contents I. Personal Information A. Backgro...
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Professional Learning Portfolio Kara Elkins Ferris State University

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Table of Contents I. Personal Information A. Background Summary II. BSN Program Outcomes A. Collaborative Leadership B. Theoretical Base for Practice C. Generalist Nursing Practice D. Scholarship for Practice E. Health Care Environment F. Professionalism III. Appendix A. Health Belief Survey B. Faculty Check Point Signatures

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Personal Information In this section of my portfolio, I will explain the many areas of nursing that I have done over the past seven years of my nursing career. I will also explain my career goals, and a summary of my professional accomplishments.

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Professional Background Summary I graduated in 2006 with an Associate’s Degree in Nursing from Grand Rapids Community College. After graduation, I was offered a job with Spectrum Health Hospital in a med/surg neurology specialized unit. There I cared for patients with strokes, seizure disorders, post head injuries, and many other ailments. I became NIH stroke certified, and became a charge nurse. I then realized that my passion was to care for critically ill patients. I took a job in the medical ICU at Spectrum and it was there that I found my passion for nursing. I became certified in many things such as, caring for patients with Intra-Arterial Balloon Pumps (IABP), and patients on continuous dialysis known as CVVH. I was ACLS certified and became a critical care nurse rounder in which I was a part of the code team, stroke team, chest pain team, and RAP (rapid response) team. I developed excellent critical thinking skills, and was able to help others learn as well. Due to changes in my family situation, I decided to take a job in an outpatient surgical center as a PACU nurse. Here I am learning many things as well. After I finish my BSN, my goal is to continue my education for my master’s degree specializing in anesthesia. Becoming a CRNA (certified registered nurse anesthetist) is something that I have always wanted to do.

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II. BSN Program Outcomes In these next sections I will provide several examples of assignments that I have completed during my education here at Ferris State University. These assignments will be categorized based on the outcome requirements of the BSN programs at Ferris. These requirements are Collaborative Leadership Theoretical Base for Practice Generalist Nursing Practice Scholarship for Practice Health Care Environment Professionalism

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A. Collaborative Leadership I have learned a lot during this program about collaborative leadership. I have learned about many leadership roles that I was not aware of, and I have learned about many things that these leaders do every day to help us give our patients quality care. The main thing I have learned in this area of professional development is how important collaborating with others on the health care team is to develop and implement plans for better work environments, and for providing the best evidence-based practice so that are patients are kept safe and given the highest quality of care possible. The first paper that I have included in this section is a role of nursing paper which discusses to roles of professional nurses in the area of childhood obesity. This paper talks about how these nurses are and have to be leaders in order to gain trust and implement plans to help this at risk group. The second paper is an analysis of a leader. In this paper I discuss the roles and collaboration of my charge nurse. I really learned a lot from this assignment. I never really understood everything that was involved in her job. She is so much more than a charge nurse. The third paper is a leadership strategy analysis. In this paper I discuss how I put together a quality improvement (QI) team to gather data and implement plans to decrease hospital-acquired MRSA in an ICU setting. This paper shows the collaboration of many different health care professionals and how they need to work together to help our patients.

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Role of Nursing in Childhood Obesity Prevention Kara Elkins Ferris State University

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Abstract The prevalence of childhood obesity rates in the nation, as well as the state of Michigan is rising, especially with elementary school age children. With this growing epidemic, our children are being put at great risk for long-term complications and diseases. Nurses can play a huge role in prevention, and can help save the lives of these children. In order for the prevention measures to be effective, the nurses need to be out in the community and in schools educating, along with nurses in pediatrician and family practice offices as more of a direct contact role, in a more personal setting with the child and parents.

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Role of Nursing in Childhood Obesity Prevention Childhood obesity has become a major epidemic in the nation, and the state of Michigan has some of the worst statistics. About 32% of children and adolescents, ages 2-19 years, are either overweight or obese (Schantz, 2011, par. 1). These rates are continuing to rise every year. These children are at high risk for developing diabetes, high blood pressure, asthma, self-esteem issues, depression, and many other diseases and complications (Schantz, 2011). We need to take action and help these children and their parents become educated on the risk factors, and help them to live a healthier lifestyle. Because most children ages 5-19 are attending elementary school or high school, school nurses play an important role in education and prevention of childhood obesity. Nurses in a doctor office setting also play important roles. Typically, in a doctor’s office, it is more private and the parents are generally with the children, which leaves a great opportunity to include parents in education as well. School Nurse (Leadership Nursing Role) School nurses have a direct contact role with the students as well, but they have a large leadership responsibility in their role as well. Seventy-five percent of schools have a school nurse on staff, either full or part time (Schantz, 2011). School nurses play a vital role in education of children and introduction of healthy habits. Nurses have many roles in schools. “Most of their work focuses on direct care for acute conditions, but they also perform health screenings such as vision, hearing, and blood pressure screening, in addition to screening for overweight and obese children” (Schantz, 2011). School nurses are able to build a rapport with the children in the schools by taking care of their health needs, and by building a trusting relationship with them, the children are more apt to take and follow their advice.

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School nurses are able to go through specific training to obtain the knowledge necessary to assist in obesity prevention. This education is known as S.C.O.P.E. (School Nurse Childhood Obesity Prevention Education). This program was “developed by the National Association of School Nurses (NASN) to provide strategies for school nurses to assist students, families and the school community to address the challenges of obesity and overweight children” (NASN, 2012, par. 1). This program works specifically with school nurses in providing them with the necessary tools to do proper screening for obesity complications such as hypertension, diabetes, along with the education on which methods of prevention are working the best against this issue. This program has specific objectives that pertain to adequate screening techniques, healthy food choices, physical education, and education for parents and students to help them maintain and understand why healthy choices are so important (NASN, 2012). Leadership Traits of the School Nurse The school nurse is the primary health care expert in the school setting, and must take the role very seriously if the health of the students is to be at its best. “School nurses can advocate for the school administration and supervisory personnel to change policies, follow health guidelines, increase nutrition education, as well as attend to issues related to vending machines, lunches, a la carte menus, physical activity, and other health issues in children” Schantz, 2011). Along with advocating for and developing new policies to promote healthy choices, school nurses can collaborate with groups such as parents, school board members, school staff, cafeteria personnel, and of course students to provide necessary education, and they can also collaborate and develop partnerships with politicians at all levels (national, state, and city) to help pass policies (Schantz, 2011). School nurses also lead meetings and in-services for school personnel

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and community members to provide education and for collaboration in the development of policies for the school. Communication is a trait that the school nurse needs to be an effective leader. They need to understand who to communicate with to make a difference, and how to communicate with students, parents, and other professionals regarding the sensitive issue of childhood obesity. They need to take a caring and compassionate approach, but one that does not take “no” for an answer because of the severity of the issue. ANA Standards of Professional Nursing The American Nurses Association (ANA) lists several standards for professional nursing leadership. Many of these need to be utilized in the school nursing role to allow for effective practice and prevention. This includes effective communication, proper education, ethical practice, collaboration with other groups, utilization of appropriate resources, and quality of practice. The role of a school nurse is very important, and if the nurse does not practice using these standards, their approach and plan to preventing childhood obesity will surely fail. These standards are important in practice to “reflect a desired and achievable level of performance against which actual performance can be compared. Their main purpose is to promote, guide and direct professional nursing practice” (Nursing Management, 2010). The school nurse can have a very large impact on the “hot issues” if they understand and have effective communication and persuasion skills. Family Practice Nurse (Direct Contact Nurse) The role of the family practice nurse/ pediatrics nurse is very important as well. These nurses work side by side and collaborate with doctors, physician assistants, and nurse practitioners to form better plans of care for each of the patients that are seen in the office.

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Children are supposed to see their physician for their well-child visit and physical every year, and then more often if there are issues concerning their health. This means that the time they are in the office is the best time for education on specific areas of concern. The nurse is the one who spends the most time with the patient and his or her parents, and therefore is a primary educator. The doctor’s office is a more personal and private setting for discussing issues such as childhood obesity. This can be a very sensitive issue for children and their parents because of embarrassment, low self-esteem, or even denial. The nurse must be compassionate, but also provide appropriate education to help them to understand why being overweight or obese is such a concern. The nurse should be aware of the factors that contribute to childhood overweight and obesity as well. “These are race and ethnicity, dietary habits, parental knowledge, and environmental influences such as age, illnesses or handicaps, and socio-economic status” (Berkowitz, 2009). There are not agencies that take on this particular role, but nursing students who are learning the different roles would be able to help out and reach out to the community with education for the children and families as part of their training. Leadership Traits of the Family Practice Nurse Many leadership traits are needed of the family practice nurse in order for there to be effective prevention of childhood obesity. The first and most important is again the need for good communication skills. “Other leadership traits include the need for advocacy for the patient and family, collaborative skills for working with doctors, PAs, NPs, dieticians and other members of the health community to help the patient form an appropriate plan of care, and also a sense of social marketing” (Berkowitz, 2009) . Social marketing is compared with understanding the target audience and assisting the parents or caregivers in developing a plan for changing

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behaviors. An example would be identifying the behavior that needs to be changed such as excessive video game playing, and then modifying a plan to the specifics of the child so that the change is desirable to the child as well. ANA Standards of Professional Nursing Along with the school nurse, the family practice nurse must also follow many of the ANA standards of professional nursing. They must have effective communication with patients, parents, and the ability to collaborate with other staff members such as NPs, PAs, and physicians. They must use evidence-based practice in order to be knowledgeable in the prevention measures that are working the best to prevent childhood obesity. They need to have proper education and statistics in order to convince the parents and the patients of the risks of overweight and obesity, and the consequences of not taking action and changing lifestyles. They must also be ethical in their practice in order to build a strong rapport with the families that are at risk. “These standards are and continue to be extremely important to nursing practice because they outline what the profession expects of its members and they promote, guide, and direct professional nursing practice” (Nursing Management, 2010).

Analysis Both the school nurse (leadership) and the family practice nurse (direct contact) need the same skills and standards of practice. The most important standards are effective communication and collaboration. These are important because both nursing roles are advocating for change in policy to prevent childhood obesity. These skills are a requirement for effective change. Though their roles seem similar, they are very different. The school nurse spends most of his/her time in the school setting with the students. This allows the nurse to build relationships

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with the students and get to know them throughout the school year. They spend a lot more time with the children, and therefore have more influence on them. Because of the trust, the students are more apt to listen and follow the guidelines of healthy living that the school nurse is promoting. The school nurse is usually the only health care person in the school. They do not work under direct supervision of a doctor or master’s degree nurse such as a NP. This is beneficial because they have more control over policy development since they are doing it mostly by themselves, with only the help of the school staff. The family practice nurse does not have as much time with the patients for relationship building and educating, but working side by side with the child’s physician helps the parents and patients to trust them. They are in a more private setting where sensitive subjects can be brought up and talked about easier, such as the issue of childhood obesity. The nurse must make sure that the conversation is private and only to be shared with the child’s physician. The family practice nurse also has more screening tools available to him/her as well. These tools include orders for lab draws, other testing for complications, and not having to refer back to the physician if there is a concern. Both nurses play very important roles in the prevention of overweight and obese children. Reflection I feel as though I have the qualities and standards for both roles. I am able to collaborate with others and work together for the betterment of the children, and I have good and effective communication skills. I feel as though I get along very well with children of all ages, and am able to talk to them in a way to build trust and a lasting relationship. The only weakness that I feel that I have is the courage to talk to parents and children about the sensitive subject of obesity. I feel as though it would be very hard to communicate and

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build relationships with patients and families who are in denial about the issue at hand and the risks associated with it. I think this is part of the challenge of the job though, and because it is so important to educate on prevention and healthy lifestyles, I would be up to the challenge and build enough courage and confidence to address the issue. If I had a choice of roles, I would definitely choose the role of school nurse because I would really enjoy working with the kids. I also like the thought of working more independently instead of under direct supervision of a physician.

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References Berkowitz, B., Borchard, M. (2009). Advocating for the Prevention of Children Obesity: A Call to Action for Nursing. Online Journal of Issues in Nursing, Vol. 14, No. 1. DOI 10.3921/14.1.02. NASN (2012, October 8). S.C.O.P.E.- School Nurse Childhood Obesity Prevention Education. Retrieved from https://www.nasn.org/ContinuingEducation/LiveContinuingEducationPrograms/SCOPE. Nursing Management (2010). Nursing Standards. Retrieved from http://currentnursing.com/nursing_management/nursing_standards.html. Schantz, S. (2001, June 20). The Role of School Nurses in Childhood Overweight and Obesity Intervention. Retrieved from: http://www.medscape.org/viewarticle/744434_transcript.

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Student Name: Kara Elkins_ Nursing’s Leadership Role in Population Based Issues Paper Rubric

Section

Guidelines

Possible

Points Earned

Points Content

Clearly identifies two nursing roles needed to carry out community project. Role of direct contact nurse 

Identifies possible agency for nursing role.

 

Identifies a leadership role a nurse might take in part of the proposal. Clearly explains what leadership characteristics would be needed to be effective in carrying out this role. Links to ANA Standards of Professional Practice.



Role of leader/manager nurse 

Identifies possible agency for nursing role.

 

Identifies a leadership role a nurse might take in part of the proposal. Clearly explains what leadership characteristics would be needed to be effective in carrying out this role. Links to ANA Standards of Professional Practice.

 Analysis 

How are the roles similar?



How are the roles different?



How could the leadership roles for both nurses explained above impact

the political arena related to your population based health concerns. What are the implications for the different skills needed? Reflection

10%

10

15%

15

15%

13

30%

25

30%

25

100%

88

(-30%)

-3

100%

85

  



Which of your skills might be most suited to each role? What role requirements would be a challenge for you? What might you do to be competent in either role?

Content Grade Writing

Total:

FINAL GRADE less Deductions: DEDUCTION OF UP TO 30 points (-30%) will be made for APA/writing/grammatical/punctuation errors.

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Analyzing a Leader Kara Elkins Ferris State University

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Analyzing a Leader Yoder-Wise defines leadership as “the use of personal traits to constructively and ethically influence patients, families, and staff through a process in which clinical and organizational outcomes are achieved through collective efforts” (2011). The Leader that I have chosen to interview is our permanent charge nurse. Her background consists of many things including ICU, labor and delivery, home health care, and PACU. Her main area of expertise is in an outpatient PACU setting, where she is currently the charge nurse. Bessie Davis has also worked as a lab/clinical coordinator at a university. She graduated with her BSN from Austin Peay State University, and is currently pursuing her MSN in administration/informatics from Ferris State University. Bessie’s current role at Midtowne Surgical Center is peri-op nurse, charge nurse, infection control officer, and educator. Andrea McBride has listed leadership characteristics in her article, “integrity, practical intelligence, communication skills, teamwork, an appreciation of diversity, problem solving, and systems thinking” (McBride, 2011). Bessie has every one of these characteristics, which is why she is a great leader. Job Duties Bessie’s current job duties are managing the flow of patients, surgeons, and surgeries throughout the day to maintain a smooth, working flow of the center. She also answers day-today questions and concerns from physicians, business office staff, peri-op staff, and OR staff, while acting as the liaison between all staff, the nurse mangers, and the physicians that are on the board for the surgical center. Bessie prepares the schedule for staff, and manages the peri-op staff on the unit. Bessie also acts as our educational liaison which includes the managing the orientation of new staff as well as yearly competencies and education for current staff. Bessie manages, trains, and coordinates all volunteers who come and volunteer at our facility, which

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includes training and scheduling. She also manages medication orders for the facility since we do not currently have a pyxis or pharmacy. By managing medication, she must check in all medication including narcotics, and she is also in charge of disposing expired medications on a monthly basis. Bessie does several things to help our staff and center run smoothly, but one of her main roles is infection control officer. Bessie has been sent to infection control conferences to relay information back to Midtowne to better keep up with the compliances of Medicare, and keep our patients safe and free from infection. She also tracks the infection rates for every patient, procedure, and surgeon that enters our facility. In this role Bessie also manages and tracks all of the monthly cleaning logs and assignments in reference to infection control, and reviews and rewrites policies and procedures to meet criteria for all licensing agencies. Bessie is always reviewing new products for infection control and monitors hand washing stations and staff for proper hand washing techniques. All staff including nurses in both peri-op and OR, along with business office staff (insurance personnel, billing, and schedulers) report to Bessie. Bessie reports to our clinical manager, Susan Tuesink, clinical director, Windy Korstange, and the physician board. She is responsible for handling all matters on the floor, and reports to our clinical manager with issues that need to be dealt with on a higher level. Collaboration Bessie collaborates with many staff of all levels on a daily basis. She coordinates with business office staff, OR staff, surgeons, anesthesiologists, CRNAs (certified registered nurse anesthetist), durable medical equipment (DME) companies, laundry services, surgeon’s office staff, scheduling, and upper management. Bessie is a very patient and confident person, who

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wants to do what is best for her staff and the patients that come through our facility. She is very accommodating, but is not afraid to make changes to better patient care or staff satisfaction. Bessie is frequently in meetings with upper management and physicians to bring her concerns as well as listening to them and what they need to help the facility run smoothly, and she always takes the time to listen to any complaints from nursing and business office staff. Legal or ethical issues One legal or ethical issue that Bessie is currently managing regards staffing issues. Our surgical center is in the process of opening a fourth OR and expanding to accommodate for an influx of patients. Over the last year, we have drastically increased the number of patients having surgery on a daily basis from an average of 12-16 patients a day to an average of 22-28 patients a day. This requires longer hours and more staff. We currently are understaffed by about two nurses, and we have another OR that is supposed to open in March which will again boost our daily numbers. Our nurses have to work more than 40 hours a week, and because we need all the help we can get out on the floor caring for the patients, we are getting behind on our pre-op assessment phone calls. This problem directly affects our staff and our patients. Our nurses are being burned out with all of the mandatory overtime, and the poor attitudes that sometimes follow with burnout can cause the patients anxiety. The patients also suffer when they are waiting in the discharge area for a longer length of time because their nurse is busy taking care of her many other patients and cannot get to them in a timely manner. Patients are being canceled on short notice, or not following all pre-op instructions such as stopping certain medications far enough ahead of time because we are not able to get to their pre op assessment until a day or two before they are to have surgery, instead of one week prior, which is preferred.

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Bessie is currently working with the other managers interviewing and hiring new nurses to fill the open positions, and in the mean time doing other things to help boost moral until the new nurses are off orientation. Bessie tries to switch up the areas that each nurse works in on a daily basis, such as one day a nurse will do pre-op, next day discharge, and another day PACU. This works well since everyone is trained to work in every area so that no one is burned out doing the same thing repeatedly. She also tries to coordinate fun team building activities, such as small trips on the weekends or even simply ordering lunch for everyone on a busy day. It is helpful to work in a smaller facility with less staff, so we have the ability to all get together more frequently. Bessie also helps on the floor when needed and makes sure that everyone gets a break for lunch. She is doing her best to remedy this situation, but does a lot for her staff to help with the effects of burn out. By keeping the staff happy, the patients are happy, and our surgeons are happy. Power and influence Yoder-Wise define power as “the ability to influence others in an effort to achieve goals” (2011, p. 176). When Bessie has an idea to better our flow or patient care, she always backs it up with research. Bessie is constantly researching different issues to find the best approach to better a situation. Her research may include patient or staff surveys on specific issues, or research from other hospitals or health care facilities to reconcile a problem we may be facing. Because of her work ethic and knowledge on many issues, she has a lot of power and influence on people for change. The surgeons that partially own surgical center always like to hear her ideas for change because she always brings research to back up her opinions. Our surgeons are very busy, so unless you have actual data, it is hard to get them to listen. Bessie is always prepared, and therefore is able to make the changes that are needed. With change for the better, patients are

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more satisfied, the staff has higher satisfaction rates, and things in the organization run more smoothly, which makes our surgeons and upper management happy. “One of the ways to improve patient care is to have the best nurses providing the best nursing care, and not just staff nurses. You need excellent nursing leadership. You need a medical staff supportive of excellence in nursing and willing to work with nurses as colleagues. You need an administration committed to supporting nurses and other clinical professionals” (Lewis, 2009). Bessie does her best every day to use her power for good and make this happen. Decision-making Making decisions and problem solving are a part of Bessie’s job every day. It is up to her (with the help of upper management) to make the surgical center run smoothly, as well as keep the staff and patients satisfied. They strive to keep the surgeon’s satisfied with the surgical center as well because without them, we would go out of business. Everyone works together to do the best we can for the patients. Upper management usually makes decisions, and then Bessie implements the change. Our management will usually take staff individually to talk about opinions and suggestions on many matters, to decide the best course of action, especially if the decision will result in significant change that will be felt by all staff. I feel as though the decision-making style that is used by Bessie and other management is democratic or participative meaning that they “use the opinions and suggestions of others to aid in the decision making process” (Yoder-Wise, 2011, p. 101). Bessie understands the importance in involving other staff in the implementation of change and decision- making. According to Yoder-Wise, “Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction” (2011, p. 101). In our interview, Bessie stated “it

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is much easier to get your staff to comply with change when they have helped to make the decision for change” (Davis, 2013). Even though we use this style of decision-making most often, the autocratic style has to be used as well for business decisions or times when more rapid decision-making is required. Many of the decisions that are being made have to do with the smooth running and service that we are giving to our patients, and what we can do to make it better and easier for them. We try to make the patient’s surgery experience the best it can be, and when we all work together to form a practice that keeps the satisfaction rates up, we know that we are helping our patients. Management and conflict resolution With every facility, there is conflict at one time or another. Bessie does a great job at confronting the issue before it gets out of hand. She will not tolerate intimidation between doctors and nurses, and because of this, nurses and doctors alike all get a long and respect each other and each other’s roles at the surgical center. Bessie does her best to work with the staff with scheduling as well. She splits the late shifts evenly, and makes sure that all nurses get enough variety in the areas assigned so nurses are not being burned out. Bessie supports her staff and provides staff with what is needed to feel comfortable in the work place. She is an excellent advocate for all staff, and everyone (nurse and physician alike) knows that they can go to her with problems and she will help them resolve them. She is a great listener and is fair. If there is a conflict between two staff members, she will be the mediator and not take sides. She is always honest with the staff, and does whatever she can to keep the doors of communication open. The organization benefits from her leadership style in that our staff remains content, and there is a lower turnover rate. We have nurses that are comfortable and good at their jobs, and that reflects to the patients, who most always are commenting on their “great care”.

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Bessie does a great job at Midtowne Surgery Center. She cares about her staff and the patients that come through the facility, and it definitely shows. I am very happy to be working with someone who has such a great work ethic and a genuinely caring attitude.

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References Davis, B. (2013, 02 09). Interview by K.A. Elkins [Personal Interview]. Analyzing a leader. Lewis, L (2009). Commitment of the Entire Organization. American Journal of Nursing. 109(11), p. 16. doi: 10.1097/01.NAJ.0000362011.76213.e7 McBride, A. (2011). Taking Leadership Seriously. American Journal of Nursing. 111(3), p. 11. doi:10.1097/10.1097/01.NAJ.0000395214.70390.fc Yoder-Wise, P. S. (2011). Leading and managing in nursing. (5th ed.). St. Louis: Mosby.

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Instructor Feedback Grade : 100.00 out of 100

Comments :

Excellent job on the assignment. You have clearly demonstrated your understanding of the assignment and have addressed all elements of the rubric. I appreciate your insight into the subject matter and excellent job on the research element of the assignment.

Keep up the great job!

Eppie

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Leadership Strategy Analysis Kara Elkins Ferris State University

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Abstract Hospital acquired MRSA (HA-MRSA) is a very serious problem in Michigan and the United States. High risk patients are given this “super bug” while in the hospital setting due to negligence on the part of the staff and other visitors that are constantly going in and out of the patient rooms. These patients are getting seriously ill from these bacteria and are forced to stay in the hospital longer to treat it, or worse dying from complications of it. This paper will discuss how the quality improvement team on an intensive care unit will discuss, collect data, and implement a plan to decrease the prevalence of HA-MRSA on this unit.

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Leadership Strategy Analysis The Quality Improvement (QI) process is a “continual analysis and evaluation of products and services to prevent errors and to achieve customer satisfaction” (Yoder-Wise, 2011, p. 395). The QI process consists of multiple steps to help the collaborative team plan, implement, and evaluate multiple changes, or problems in the healthcare setting to provide the safest and best quality care for our patients and their families. This process helps to develop plans that will decrease patient risk with issues like infection control, fall risk, and pressure ulcers, along with making the patient’s experience better in regards to wait times in the ER, doctor’s offices. This process helps with many other issues as well, so we can be sure that the comfort of the patient is at the top of our priority list as health care professionals. Clinical Need The issue in healthcare that I have found to be a large area of need deals with the increase incidence of hospital-acquired infections (HAI), and specifically hospital acquired (HA) MRSA, in the ICU setting. MRSA is a specific strain of Staphylococcus aureus that shows resistance to penicillin and other antibiotics related to it. According to a study done in 2006, “sepsis and pneumonia, two common conditions caused by HAIs specifically MRSA, killed 48,000 Americans, and cost the nation over 8 billion dollars to treat” (Paddock, 2010). “Patients who are admitted to the ICU are at an increased risk for developing complications from MRSA because of their underlying acute or chronic illness, as well as their decreased immunity related to their complex illness” (Jarnagin, 2010). MRSA spreads very easily and because roughly 2530% of the general population are carriers (meaning that they are asymptomatic and do not know that they carry the bacteria), we need to be extra cautious when caring for those at a high risk of infection (Jarnagin, 2010).

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“MRSA is a very resilient “super bug” and can live on a host or inanimate objects for an unknown period of time, and can be spread to another person or object by contact” (Jarnagin, 2010). The worst-case scenario is death, but there are many other reasons why we need to stop the spread of MRSA. MRSA infections can cause lengthened hospital stays and increased cost, and all of this is preventable. A report put out from the CDC in 2009 states that there are “nearly 90,000 life-threatening illnesses and 19,000 deaths associated with just MRSA yearly in the United States, and 85% of these cases were linked to the health care setting” (Jarnigan, 2010). This is a very scary, yet preventable problem, and something needs to be done to prevent the spread of HA-MRSA in the ICU setting. Interdisciplinary Team The team put together for the QI study relating to HA MRSA and the spread of infection would consist of 3 RNs (staff nurses), a nurse manager, an infection control officer, and a physician specializing in infectious disease. The staff RNs would be in charge of data collection regarding the patients on the unit. This would include keeping records of everyone on the unit who have a known MRSA infection and documenting everyone diagnosed with a MRSA infection during their admission. They would also be responsible for observing other staff and their behaviors while entering and exiting the contact precaution rooms. The nurse manager will be assisting the RNs in their tasks and helping to keep track of the records. They will also be responsible for the potential disciplinary action needed if there are staff that do not follow strict contact precautions while caring for the patients on the unit, as well as assisting with the implementation process. The infection control officer will help to change and update the policies and procedures regarding specific precautions and follow the HAI rates in the hospital and specifically in the ICU. The physician will head the

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group, identify specific areas of concern, and support the process with his /her knowledge and expertise. The team will collaborate and meet bi-weekly to share findings and documentation during the data collection phase of the QI process, and then work together to decide where the largest problem is so that they can develop a plan to decrease the spread of HA MRSA in the ICU. Data Collection After forming a QI team, they must collect data that measures the status of the issue that is under review, and use tools to find out the biggest areas that need to be addressed first to begin fixing the problem (Yoder-Wise, 2011, p. 397-98). Data collection can begin with sending out a survey to all staff including nurse aids, secretaries, nurses, PAs, and physicians, specific to the unit. This survey would be anonymous so that the data collected would be more truthful. This survey would discuss the practice of proper personal protection equipment (PPE), and how well does each individual “follow the rules”, or how well they question others if they see that they are not. The next step would be to observe the behaviors of staff upon entering the rooms of multiple patients at a distance to ensure that adequate data is being gathered. This would include observing if proper PPE are being used when entering a patient’s room who has known MRSA, proper hand washing (wash in wash out) upon entering and exiting every patient room is being done, and proper cleaning of equipment is being performed. This observation would also include making sure that the appropriate equipment is available in the rooms where contact precautions are being used, such as pens, computers, stethoscopes, and many others so that they are not being shared with the other rooms on the unit.

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During this time, HAI rates will be studied, and appropriate documentation of all patients including those who had MRSA before they were admitted, and those who were diagnosed with MRSA after admission (given at least 3 days post admission to be sure it is HA-MRSA) will be done. I feel that in this particular issue, a Pareto chart would be the most helpful in examining the data collected on the unit. “A Pareto chart helps the QI team determine priorities, and allows for the most significant problem to be addressed first” (Yoder-Wise, 2011, p.398). The vertical line of the chart would read number of errors recorded, and the horizontal line would be the types of precaution errors. There could be many different reasons for contamination and spread of MRSA to another patient on the unit. This could include people (staff or family) entering the room of a patient with MRSA and not using the correct PPE, not washing hands appropriately, or using a stethoscope or other item on a patient with MRSA and then using it on another patient without proper decontamination. There are many reasons for these behaviors and I believe the biggest are lack of staff and time, as well as lack of education on how serious this issue really is. By using the Pareto chart, the QI team can understand the area of most concern and start there in their planning. Establishing Outcomes The goal of the QI team would be to decrease the number of cases of HA MRSA on the specific ICU by 30% in 6 months. Implementation There are many possible ways to implement change regarding the unnecessary spread of HA-MRSA. One way is with staffing. If there is difficulty with increasing staff to patient ratios, then all MRSA positive patients can be placed together so that the nurse caring for them is only

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caring for MRSA patients in one shift and therefore eliminating any cross-contamination to other patients. Other ways to prevent the spread of HA-MRSA could include more education for hospital staff including volunteers, nutrition services, pastoral care, and others that may not understand the importance of infection prevention. If passive methods do not seem to be helping, then potential disciplinary action for those who are not following correct precautions needs to occur on a situational basis, whether it is just a meeting with the person and providing education, or if it continues something more serious such as a write up. This is patient safety and when we are not following proper precautions, we are potentially endangering our patients, and this is serious. The team will also make sure that the proper tools are in the rooms such as a disposable stethoscope, computers, and pens so that they are not being used in multiple rooms before being properly decontaminated. With family members, we need to give the appropriate education right away, and then be sure that they are following the proper precautions as well. If they refuse to follow precautions then they will be unable to enter the room. This should also include that no small children be allowed to enter the room, especially if they are being allowed to crawl on the floors. Some tips in preventing the spread of MRSA from Jarnigan’s article in American Nurse Today (2010) were to “always use good personal hygiene, always wear clean clothes to work, observing all precautions (standard, contact, or airborne) with all patients, strict hand washing, proper decontamination of equipment and other items in patient rooms, and avoiding artificial fingernails.” The biggest tip for prevention in most of the articles that have been researched on this topic has been proper hand washing and use of antibacterial hand sanitizer. Making hand sanitizer dispensers and hand washing stations easily accessible will assist employees so they do not have to travel far to wash when they are busy with multiple patients.

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Evaluation The way to measure improvement in this case is to calculate percentages. It is all about the numbers, such as the number of patients who enter the facility with a known MRSA infection versus the number of those who leave the unit with one. There are factors that will come into play in this situation that may prevent accuracy such as those who came in with a MRSA infection, but were not diagnosed until days after being admitted to the unit, or patients that were exposed on other units in the hospital before being transferred to the ICU. If proper documentation is done, than the numbers recorded should be very close to exact. There will be a HA-MRSA percentage recorded on the ICU unit before the change has been implemented, and then again, after 3 months, 6 months, 9 months, and one year, which will be helpful in detecting change and how well the implementation process has worked. If the percentages of HA-MRSA begin to decrease than the QI team will continue to monitor the rates and continue with the current plan. If the numbers do not change or increase, the QI team will go back to the data collection phase and begin the QI process over to develop other plans specific to decreasing the spread of HA-MRSA. The Center for Disease Control (CDC) is an excellent resource for the QI team and other units or hospitals that are dealing with a high incidence of HAIs or HA-MRSA. The CDC has been keeping a close watch on this topic in both the community setting and in the health care setting. They have noted that after setting their own guidelines for hand washing and proper contact precautions and isolation for hospitalized patients, the percentage of MRSA infections has gone down 28% from the years 2005-2008 (CDC 2011). They also state that the rate of community acquired MRSA has decreased by 17% (CDC, 2011). Although the prevalence of HA MRSA has decreased, the percentage is still high.

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By initiating these plans in the ICU, and following through to make sure everyone is compliant with them, the QI team will make tremendous progress in decreasing the overall HAMRSA infection rate on their unit.

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References CDC (2011). MRSA statistics. Retrieved from www.cdc.gov/mrsa/statistics. Jarnagin, T. (2010, June) MRSA: A growing threat in both community and healthcare settings. American Nurse Today. 5(6). Paddock, C. (2010, February). Hospital-Acquired Infections, MRSA, Killed 48,000 Americans in One Year. Medical News Today. Retrieved from www.medicalnewstoday.com/articles/180065.php. Yoder-Wise, P. (2011). Leading and Managing in Nursing. Elsevier.

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B. Theoretical Base for Practice Theory is a very important foundation for all nursing practice. Theories have been developed to explain many things from disease process, to management strategies. I have researched and learned about many theories throughout this program, as well as gained the knowledge to use them in my nursing career. This section includes examples of my work in nursing theory and how I have used theory to develop a foundation for my own nursing practice. The first example I have provided is a personal self-assessment of reasoning paper. This paper has not only given me the opportunity to research the large issue of barriers to healthcare that patients face outside of the hospital, but also has helped me to examine and relate it to a very important nursing theory, Dorthea Orem’s self-care theory. The next two examples I have provided are discussion posts that I have done based on a conceptual model that I have used throughout my practice, and my personal philosophy in nursing. Both of these examples required learning about specific models and theories of nursing that I have continued to reference throughout the program and my personal practice.

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Kara Elkins Self-Assessment of Reasoning Ferris State University

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Abstract In this paper I will describe content that has been most significant to me throughout this semester. I have chosen to write about the barriers to self-care that patients face out of the hospital setting. I have given myself a letter grade of B for this assignment related to the elements of reasoning and critical thinking. I will describe why I have chosen this in the following sections.

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Self-Assessment of Reasoning One problem that many patients face today is how to successfully administer self-care while considering the outside factors that can become significant barriers. Patients need our help and support as health care providers to notice which barriers affect them, and provide them with the correct resources. Significant Content The content that was most significant to me in this semester’s discussion came from week 4. In this week we discussed the barriers that many face related to self-care. These barriers include not having adequate finances, not having the level of education needed to understand medical regimens, or not having the support of family or friends. Thoughts and Feelings This issue makes me very upset. There are people who just can’t afford their meds, and some who don’t understand exactly what they need to be doing with medication regimens and diet restrictions, and they are continuously in and out of the hospital with all kinds of health problems or exacerbations which results in poor quality of life. Point of View or Assumptions I have worked in a medical ICU for 5 years and during this time have come across many patients who suffer from chronic illnesses such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes, etc. Many of the patients that are in and out of the ICU are ones who either choose not to take care of themselves, or ones that don’t have the means to appropriately care for themselves at home. I struggle with helping these patients find resources, and also with watching them deteriorate from their illness all because of lack of support or finances. Because of my experience in the ICU, I already had preconceived notions

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on this topic before the discussion or reading from this week, however, the discussion and reading did offer further incite on the topic. Analysis of Thinking This topic is extremely relevant to my practice. I constantly have patients coming in and out of the ICU setting with exacerbations of their chronic illnesses because they can’t afford medications, or they don’t have the family support at home to keep them on track with their medications, diets, and exercise routines. When a person doesn’t have the motivation themselves, family support is important. My opinion on this topic has been greatly influenced by the patients that I work with. We need to help these patients and provide them with the resources they need to help them have a good quality of life, otherwise they have nothing to live for or motivate them to life healthier lifestyles. I think the question that needs to be asked is how can we as health professionals better screen our patients for potential barriers for self-care? Coming up with an appropriate screening tool that is also effective is important. Patients don’t always want to tell us about their financial problems, and more often than not out of embarrassment our patients don’t tell us that they don’t understand something. We can usually tell how much family support they have by the amount of people coming to visit, but can’t always tell other barriers. We also need to be aware of different cultures and their standards or ways of dealing with chronic illnesses so as not to offend our patients, and equally as important to make sure that education and language barriers aren’t interfering with education. The model that is most used in this area of self-care is Dorthea Orem’s self-care model. Orem describes three types of self-care requisites in her model: universal, developmental, and health deviation requirements. Universal includes air to breathe, water, food, elimination, and the balance between activity and rest. Developmental includes maintenance of life processes that

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promote progression of maturation, and provision of care to prevent or overcome conditions that effect human development. Health deviation requirements include developing a system to maximize quality of life for those who suffer with chronic illness or other problems that effect development (Pender, 267-268). By using Orem’s self-care theory we can categorize our patients to better assist them with finding resources specific to their needs and illnesses. We aren’t always going to be able to help everyone, and that becomes the consequence for not having an appropriate assessment tool for patients, but there is a lot of information that can be learned to assist patients such as learning about Medicare and Medicaid programs and also learning about other drug programs offered by local pharmacies to assist in lowering costs. Other things to get to know are support groups in the area we can refer people to, or even exercise classes to get them moving. I have chosen to give myself the grade of B for this assignment. I feel that I have grasped the concept of critical thinking related to this class, but I also feel that I still have weaknesses in areas regarding the elements of reasoning. I still have biased opinions and find it difficult to truly listen to the opinions of others. This is something that I need to continue to work on. I feel like my critical thinking skill have improved over this semester and being a part of discussions has helped. I also feel that I have good problem-solving skills. Working in an ICU has helped me to learn how to problem-solve as well as helped me to develop my critical thinking skills.

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Sources Pender, N., Murdaugh, C., Parsons, M. (2011). Health Promotion in Nursing Practice. Upper Saddle River, New Jersey. Pearson Education.

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Conceptual Model I like Betty Neuman’s Systems Model for my professional practice. I like this model because in the ICU we deal a lot with environmental stressors and our patient’s reactions to them. This model helps to understand the different levels of resistance or defense in the patient, and also helps the nurse to prioritize and form goals to get rid of the stressor and get patients back to their baseline. This model also helps familiarize us to the different kinds of environmental stressors and where they may be coming from (the internal environment, the external environment, or the created environment). (Kearney-Nunnery 2008) This way the nurse can better understand how to get rid of the specific stressor for the patient, and which prevention modality is the best to use (primary, secondary, or tertiary.) (Kearney-Nunnery 2008)

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References Kearney-Nunnery, R. (2008). Advancing Your Career. Concepts of Professional Nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. (Original work published 1997)

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Personal Philosophy When asked what my personal philosophy of nursing was, I didn’t know what to say. Nursing is viewed in so many different ways by people. Some think it is just a job, but to others it is their life. In my opinion nursing has two sides. It is a science, but it is also about compassion and being an advocate for your patients. Nursing is defined as “activities, goals, and services.” (Kearney-Nunnery 2008) The responsibility of a nurse is very broad. We do everything from helping our patient’s with hygiene to teaching about medications and procedures. We are responsible for the whole patient: mind, body, and spirit. Our patients come from many different environments, which according to Kearney-Nunnery are the “physical, social, cultural, spiritual, and emotional climate or setting in which a person lives and interacts (2008), and we are to treat each individual, family, or community with the same respect. Our patients are people, not diseases, and everyone is deserving of the best care possible no matter what their background. It is the nurse’s responsibility to advocate for our patients and find resources to help them strive and stay healthy in their environments. When looking into the scientific aspect of nursing you will see that critical thinking and knowledge of anatomy, physiology, pharmacology, etc. is extremely important. As an ICU nurse we must stay “on our toes” with our patient’s condition. You have to be able to catch the small things so that you can notify the Dr. and fix the problem before the patient codes, or irreversible damage is done. Nurses can also become certified in their specific specialties such as CCRN in critical care, or CNRN in neuroscience etc. Our patients expect us to be knowledgeable in our specialty. They expect that we are capable to care for them and keep them safe. Keeping up with our knowledge base is extremely important, and that is why we are required to have continuing education credits.

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When looking at the compassionate side of nursing we see all of those little things that we do for our patients that may not be a prescribed remedy, but something that is essential for the “healing” process. This may include washing a patient’s hair, painting toe nails, shaving, or just taking time to sit with them and talk. Making a patient comfortable and building a rapport/ trust with your patient helps them to relax and not worry, which in turn helps the patient to heal. Like I said earlier we as nurses are responsible for the whole patient…MIND, BODY, and SPIRIT. Theory Many different nursing theories are used in the ICU setting. Maslow’s hierarchy of needs theory is a theory of great importance when caring for patients and their family members. It is important to know the needs of your patient, and where they are in the hierarchy. This way we know exactly what they need so they can reach the self-actualization level. We also use Florence Nightingale’s theory for environmental health. “Florence Nightingale worked on five components of environmental health (pure air, pure water, efficient drainage, cleanliness, and light.)” (Alligood 2010) Although these components are all important, the focus is primarily on cleanliness. In our practice we are always researching new ways to keep germs out, so our patients aren’t infected with nosocomial infections. This research is building off of Florence Nightingale’s original work. She was a very important person in nursing theory and practice.

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References Alligood M.R., and Tomey A.M. (2010). Nursing Theorists and Their Work (7th Ed.). Maryland Heights, MO: Mosby Elsevier. (Original work published 1986) Kearney-Nunnery, R. (2008). Advancing Your Career. Concepts of Professional Nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. (Original work published 1997)

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C. Generalist Nursing Practice I have learned so much about caring for different populations, and their different needs. I have learned a lot about my own practice and how I can make it better. In this section, I have provided examples of papers that show different health care needs of different populations. These examples show how I have developed and expanded my knowledge in the clinical area of nursing with many different at risk populations of patients. The first example is a paper written on childhood obesity, and what we as nurses working with the community can do to help this at risk population. The second example is a paper written based on evidence-based practice. This paper researches the different problems faced by patients in the ICU based on ventilator-assisted pneumonia (VAP). In this paper, I have researched different evidence-based ideas on how to lower the incidence and risk for patients on ventilators. The third paper that I have included is a health care disparities paper related to the incarcerated population. These examples identify the specific needs that the patients in all three of the categories need to have adequate health care. I have learned that many patients have different risks and different needs, and it is our job as nurses to be able to recognize them and care for them according to those needs.

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Childhood Obesity: How can we help our overweight kids? Janice Schmuckal and Kara Elkins Ferris State University

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Abstract Kids these days are spending the majority of their free time in front of the television or computer instead of outside. This is causing a huge rise in rates of childhood obesity all around the nation, which is also increasing the risk of cardiovascular disease and diabetes in our young population. There are state and federal laws that are hoping to mandate physical activities and healthier nutrition in our public schools, and many other programs to get involved in to help educate and teach our kids healthy habits. In the following pages there is an explanation of ways that are in place to help and ways that we as members of the community can help our kids with this growing problem.

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Childhood Obesity: How can we help our overweight kids? Everywhere we look it is easy to find information on the rise of obesity in the United States. Our kids are becoming more inactive and eating a much higher calorie, lower nutritional value diet. Activities that kept earlier generations up and moving, like playing outside, dancing, or sports are being replaced with a very sedentary lifestyle brought on by computers and technology. We need to encourage children to be physically active and for them to take us seriously we need to become active too. If we get out there and do it, so will our kids! In a prospective cohort study, information is gleaned on the impact of obesity in childhood having an effect on cardiovascular risk factors in adulthood. In the study, several measurements were used on the children to decide the high risk factors of the participants. The measurements used were BMI, waist circumference, fat mass, systolic and diastolic blood pressure, fasting glucose, insulin levels, triglycerides, LDL, HDL, and cholesterol levels. There were 7725 kids in the 9-10 year group, 7159 in the 11-12 year group, and 5509 participants in the 15-16 year group (Lawlor, 2010). The results of the study showed that childhood BMI will identify those at increased risk of cardiovascular disease later in life. This means that kids ages 9-12 that have higher adiposity levels have a higher cardiovascular risk factor by the time they reach age 15-16. High BMI, fat mass, and waist circumference are all associated with a higher risk for cardiovascular disease. The good news is that in this study it also showed that if the kids go from obesity in the 9-10 age to normal weight in the 15-16 age group, their cardiovascular risk improve. The kids that remain overweight during that period stay at a higher risk for cardiovascular disease (Lawlor, 2010).

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Physical Education in School Michigan law mandates that all students attending school in Michigan are required to participate in physical education program, however, our state does not require a certain amount of time per week the kids must be participating in the class. It is possible for a child to be exempt from gym class if a waiver from a doctor is obtained, like the children that have health problems such as exercise induced asthma. Michigan has provided our schools with the standard requirements that every district must adhere to, and that includes the same teacher to student ratio in a physical education class as in a regular class room of a given school (National Association for Sport and Physical Education, 2010). We have state requirements in place to assist in getting our kids moving, but the controversy remains whether it is the responsibility of the school to end the rising obesity in children or is it up to the parents to set the rules at home when a child’s weight is rising out of control. During the first three years of school children are very energetic and eager to learn skills in mobility and locomotion taught in P.E. class. They are taught to hop on one foot and then the other, skip and jump. These skills teach them spatial awareness and balance. They are taught to gallop, throw and catch a ball both over hand and underhand, kick a ball, and dribble a ball. At this age children usually have more motivation and energy than is required for the activities at hand. They are happy just to participate in physical activity. The benchmark skills are evaluated by Level 1 through Level 4 standards. Level 1 is an incomplete or inconsistent level of a skill meaning the child can do this skill some of the time, but is not very coordinated in doing it well. Level 2 is a complete mature skill performance meaning the child does the activity well and consistently. Level 3 is a mature form of the skill meaning the child can perform the skill in a controlled setting. Level 4 is an advanced skill performance meaning the child can perform the

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skill effortlessly. By the end of second grade the child is expected to perform mature manipulative skills of this caliber (Michigan Department of Education, 2007). At this age kids are on average very close to a normal weight and BMI, and are not being impacted by gross obesity in their physical education. During grade three through five these simple skills previously described become more mature and fine-tuned. The skills taught to this age group are to be able to hit a target or to channel their energy. Hitting a ball with a bat, playing basketball, and playing tennis are some examples of the skills taught to this age group. This age group must step up the pace to play against an opponent, and they are being taught to become more competitive. Running, jumping, and speed begin to come in to play for this age group. When a skill requires speed and agility, the slower, heavier kids are quickly filtered out by not being able to keep up with the light on their feet athletic kids. Obesity of children has impacted their physical activity at a very early age. The same standards are used for evaluation of these skills throughout school. By the end of fifth grade a child is using their skills in a complex environment. They are now able to use their skills in an organized sport, moving the way they need their body to move. This is the age group that begins the decline of an obese child not being able to keep up with their peers, giving them negative feedback and even less desire and motivation to be physically active. When a child enters the junior high level the patterns and lifestyle are in place for the child to either be physically active or headed toward obesity if not already there. Positive reinforcement and personal gratification will help teach a child to continue physical fitness as they age. Funding and cutbacks in our schools is a big part of how much the schools put into teaching the kids to be physically active. When we look at the cost of obesity and all the health issues it causes later in life, it only make sense to spend that money on prevention in the early

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years of school. These kids need to learn the importance of physical education, so that they can carry that knowledge with them as they grow older and are at a greater risk for developing diseases like diabetes and heart disease. Many kids in grades kindergarten through 3rd do not have the opportunity to participate in an organized sport for the benefit of exercise. During this time period kids rely on what they do in gym class and what they do on recess to get their exercise. It seems as though recess is the first thing threatened to be shortened or cut as schools are focusing more and more on test scores and academic achievement, but it really is important for our kids. Recess allows for kids to have active play time where they can run around and get their heart rates up. This physical activity at recess is very helpful in fighting childhood obesity. It will also benefit the child in school as healthy kids will have fewer absences from school (Frost, 2010). When a child is entering middle school they are at a very awkward period in their life. They are trying hard to fit in with their peers and their social life is of great importance to them. With computers and video games beckoning their attention, it is easy to understand that only a few minutes each day are being spent doing physical exercise. This is a crucial time in a child’s life to get them involved in sports and activities because it will help them develop a healthy body and healthy habits that will stick with them for a lifetime. Involvement in a sport at this age will provide many benefits such as improved cardiovascular health, weight management, and improved self-esteem. All of those benefits will improve how these kids feel about themselves. Some examples of sports this age group would enjoy are basketball, soccer, volleyball, and football. A child’s commitment to a team gives them a sense of belonging that will reinforce them wanting to continue the sport, and it will also teach them a good life lesson of responsibility and commitment to others (Frost, 2010).

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Nutrition in Schools Have you ever wondered what exactly your children are eating when they are at school? Many schools have vending machines full of candy and sugary drinks, but what is being served at lunch time? What choices do the kids really have? According to the Federal Register and nutrition standards for schools in the United States, schools are required to “provide at least minimum calorie and nutrient levels for protein, calcium, iron, vitamin A, and vitamin C” (Federal, 2011) which are the key nutrients that promote growth and development. They also must decrease the levels of sodium and cholesterol in the food they serve, and increase the amount of dietary fiber. Meals must also be limited to no more than 30% of total calories from fat and less than 10% of total calories from saturated fat (Federal, 2011). This plan is intended to provide students with meals that are nutritious and not full of fat and calories. This plan also hopes to provide several positive outcomes such as: increasing the availability of key food groups, improving students’ eating habits and providing them with nutritional education while updating the meal requirements in accordance with the latest nutritional science. (Federal, 2011) In the Dietary Guidelines for Americans, 2010 recommends less than 7% of total calories in saturated fat consumption and less than 1500mg of sodium consumption per day. (Federal, 2011) So what does this all of this mean for your school lunch menu? It means that nutritional factors are being monitored in the public schools across America, but as parents we still need to make sure our kids are getting the appropriate nutrition for their growing bodies. Activities There are many activities that obese children can do that will also provide them with support from other children in their position, and the education to lose weight in a healthy way. Examples of these activities are camps focused on overweight kids, after school programs, and

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support groups. One program available is called Wellspring. This organization has 11 locations around the United States and the UK. They offer camping opportunities, a year round boarding school, or just afterschool programs to help educate obese children. They provide the students with fitness programs, and nutritional education. They claim that their campers lose an average of 4 pounds a week, and also gain the knowledge to keep off the weight when they return to their normal lives at home (Wellspring, par.3). Wellspring also provides the parents with the education they need to make sure their child stays healthy at home. Some of the top activities to keep kids active are also inexpensive. Start with a game of tag. This will get the kids running around the yard and their heart rates up. Most kids only want to run for short bursts which is what is required of tag. Get children involved in gardening. This would require them to do some kneeling, digging, and raking. Having kid sized tools will help the child feel more coordinated with this activity. Biking, hiking, swimming, and walking a dog are also activities to get kids moving that are not very expensive. If you do not own a pet you could encourage your child to walk a neighbor’s dog. Most kids love animals and would enjoy talking a pet down the street. Both the dog and the child can benefit from the exercise. The place to start to help out these overweight kids is to educate both the kids and their parents. Education on what they can do to lose weight and keep it off, and also the importance of keeping the weight off like lowering their risk for life altering morbidities. Many people don’t truly understand the risk of being overweight, or even how or where to start to begin losing weight. They need our help, and it is our responsibility as health care professionals, educators, or just members of the community to get them the education and motivation they need to get started.

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References Federal Register ,Department of Agriculture (Jan 13, 2011). Nutrition Standards in the National School Lunch and School Breakfast [Vol 76 number 9]Retrieved from: http://www.fns.usda.gov/cnd/governance/regulations/2011-01-13.pdf. Frost, S. (2010, June 11). The Benefits of Recess in School for Children in Grades K-3. Retrieved March 16, 2011, from http://www.livestrong.com/article/ 146098-the-benefits-of-recess-in-school-for-children-in-grades-k-3/ Lawlor, D. A. (2010, November 25). Retrieved March 2, 2011, from BMJ 2010;341:c6224. 2010 National Association for Sport and Physical Education and the American Heart Association . (2011). Retrieved March 15, 2011, from National Association for Sport and Physical Education website: http://www.naspeinfo.org/shapeofthenation PHYSICAL EDUCATION. (2007, January). Retrieved March 16, 2011, from Michigan Department of Education website: http://www.michigan.gov/documents/mde/PE_Stnds.Bench_FINAL_2.14.07_186997_7. pdf Wellspring. (n.d) Retrieved from: http://www.wellspringweightloss.com/.

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Evidence Based Practice Proposal (EBPP) Kara Elkins Ferris State University

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Article annotation 1 Cutugno, C. (2007). Sedation in Mechanically Ventilated Patients. American Journal of Nursing, vol.107, issue 11, 72AA. doi: 10.1097/01.NAJ.0000298070.42596.0b

Christine Cutugno is an assistant professor at Hunter University School of Nursing. She has her PhD in nursing and is also CCRN certified. This article aims to show that even though the goal for ventilated patients is as little sedation as possible, these patients still require minimal sedation to reduce stress and anxiety due to invasive and life saving devices. Christine says that using a universal sedation assessment tool is extremely important so that the nurses and all Drs. are consistent in giving their patients sedation medication. She also points out the difference of judgment when it comes to assessing a patient between varying nurses, and this is another reason why using an easy, universal assessment tool is crucial. Article annotation 2 Pun, B.T, Dunn, J. (2007). The Sedation of Critically Ill Adults: Part 2: Management. American Journal of Nursing, vol. 107, issue 8, 40-49. doi: 10.1097/01.NAJ.0000282293.72946.1f Brenda Punn, MSN,RN,ACNP is a project manager at Vanderbuilt Univeristy Medical Center and is a member of its ICU Delirium and Cognitive Impairment Study Group. Jan Dunn MSN, RN is a research coordinator at Saint Thomas Hospital and also works for Hospira (manufacturer of certain sedation medications). This article shows that under sedation is just as harmful for ventilated patients as over sedation. They say that without having agreed upon sedation goals between Drs. and nurses there is a risk of complications regarding over or under sedation which could possibly impede recovery. The recommended medication for long term sedation is Propofol because of its short half-life. This drug allows daily awakening trials without much discomfort for the patient. Versed, Ativan, Haldol, and Fentanyl are recommended more for rapid sedation of extremely agitated patients. Picking the appropriate drug for patients is important along with trialing non-pharmacological techniques first such as low stimulation guidelines. This article is written by an employee of a drug manufacturing company and may be biased. Article annotation 3 Jackson, D.L. , Proudfoot, C.W , Cann, K.F., Walsh, T. (2010). A Systematic Review of the Impact of Sedation Practice in the ICU on Resource Use, Costs, and Patient Safety. Critical Care, vol.14, issue 2, 59. doi: 10.1186/cc8956 Timothy Walsh is a Professor of Anesthetics and Critical Care at Edinburgh University. Daniel Jackson is Head of Health Economics, EMEA at GE Healthcare. Clare Proudfoot is a Consultant at Heron Evidence Development Ltd, a health outcomes research consultancy. Kimberley Cann is a Health Outcomes Analyst at Heron Evidence Development Ltd. This article is a research experiment that shows that there is strong evidence supporting sedation improvement of ventilated patients and reduced length of ventilation and ICU stay. This article supports daily

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sedation breaks to perform spontaneous breathing trials (SBTs), crucial for weaning vent support. These authors also state that adequate sedation of these patients could not only benefit the patients with better control of pain and anxiety, but improve health care costs because of shortened hospital stays and lengths of time on life saving invasive devices. Their research determined the use of specific protocols was influential in giving the patients the amount of sedation needed without giving too little or too much. Evidence of Reasoning Proposal (EOP) The problem that I am hoping to address is the inconsistency of following sedation protocols, and sedation assessments between nurses and Drs.

Purpose: Appropriate sedation measures keep our patients at a lower risk for anxiety issues and in long term a lower risk for ICU psychosis. It also keeps our patients from experiencing the pain and discomfort of invasive life support devices such as mechanical ventilation by endotracheal tubes (ET tubes). Questions: Why do we use protocols with so much leeway on sedation goals? Why are Drs. shying away from sedating our ventilated patients even when they are extremely anxious? How can we help family members understand the importance of minimal stimulation for their loved one? Point of View: When taking care of these critically ill patients I see all kinds of unnecessary stimulation that results in extreme anxiety and increase in respiration and blood pressure for my patients. We have simple rules to minimize this stimulation such as 1-2 visitors in the room at a time, dim lights, lights out with no television or radio at night, and low volume on the monitors. I also see vented patients who are anxious and need to be restrained to prevent extubation or removal of important lines who aren’t sedated. Why do Drs. feel that these patients are ok without any type of anxiety medication even after we try non-pharmacological techniques first? These patients are suffering from unnecessary discomfort. Information: Many things contribute to anxiety and eventually ICU psychosis. Some of these things cannot be helped in the ICU setting, but some can. Things that can be fixed are adequate sedation, minimizing noise in the patient’s room, and limiting family noise. Family members are an important part of the healing process, but too much can be detrimental to the patient’s health. Mechanical ventilation and invasive lines and procedures are extremely painful, and restraining patients is very uncomfortable. We have a policy that all ventilated patients need to be restrained to prevent extubation, but where is the policy for appropriate sedation for these patients? Concepts and Ideas: We need to be using the types of sedation that even when used long term are easy to come off of such as Propofol or Precedex instead of the use of large doses of

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narcotics and benzodiazepines. This way it will be out of the patient’s system faster and shouldn’t decrease chance of getting off ventilator support. When the patient is admitted the family needs to know the rules of the ICU to keep their loved one safe, and we as staff need to enforce these rules consistently to protect the wellbeing of our patients. We need to develop a better assessment tool and protocol for when to sedate a patient, and it needs to be agreed upon by nurses and Drs. so that we all can stay consistent. Assumptions: There will always be those tough family members who will fight until they get what they want, and no one will stand up to them to enforce the rules, or the Drs. who will refuse to give the patient any sedation regardless of the patient’s anxiety level. Being a teaching hospital we constantly have new Interns and Residents caring for these patients, and not all of them have the same point of view in sedation techniques. Nothing will be perfect, we just need to strive to do our best for our patients. Implications and Consequences: I think we all know what the consequences will be. Worse case our patients could ultimately suffer from PTSD or ICU psychosis. This will lengthen the hospital stay or at the very least be a huge setback for the patient and their family with possibly years of symptoms related to their experience. Our patients could have anxiety attacks, blood pressures could spike resulting in other health problems, or their respirations could become rapid resulting in blood gasses that need to be normalized. Inference and Interpretation: We, as a unit, need to do something as a team to help our patients so they aren’t at an increased risk for these problems. We also need to collaborate with our physicians so that we are all on the same page regarding sedation for our patients. Our attending physicians need to teach our sedation protocols to all new Interns and Residents coming in to the program so that sedation can remain consistent regardless of new Drs. moving in and out of the unit.

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Health Care Disparities of the Incarcerated Kara Elkins Ferris State University

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Abstract The incarcerated population in this country suffers from many health care disparities and social determinants of health. This includes both those currently incarcerated and those who have previously been incarcerated. A change in policy is desperately needed to help this population receive the support that they need both inside and outside of their prison cell to be healthier and become a productive member of society. This paper will discuss the current problems that this population suffers from, and current policies that both help and discourage them. Keywords: social determinant, health care disparity, incarcerated, prisoner/inmate

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Health Care Disparities of the Incarcerated According to the FBI’s crime reporting program, in the year 2010, there were over 11 million adults arrested and placed in a correctional facility (Snyder, 2012, p. 1). In the state of California alone, there are 170,000 inmates in only 33 jails, and this is unfortunately, what every state is dealing with (Beam, 2009, p. 1). Because of the high number of those incarcerated, there is a lot of overcrowding in the facilities leading to even more social determinants of health and health care disparities for this population. Population and Health Care Disparity This underserved population does not just include those who are currently incarcerated here in the United States, but also those who have previously been incarcerated and are currently out in the community. According to public health experts, “inmates often have no access to medical care outside correctional facilities before entering, and are more often drug offenders, homeless, or mentally ill. They also come from a disproportionate number of racial and ethnic minorities, and typically have a higher rate of drug and alcohol abuse, lack of education, history of abuse, or participate in unsafe sexual practices” (Kelly, 2010, p.1). With the majority of the population entering correctional facilities being a part of this group, it gives everyone who is incarcerated a higher risk for contracting these diseases. The CDC defines health care disparities as “biological, socioeconomic, psychosocial, or behavioral factors that contribute to a person’s health” (CDC, 2011, p.1). Some of the health care disparities that this specific population faces are increased risk of communicable diseases such as TB, HIV, STIs, and hepatitis C, decreased social and financial support from family, lack of health insurance post incarceration, lack of education and job training, lack of timely health care

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while incarcerated, overcrowding, and poor health behaviors such as alcohol use, smoking, or drug use. (Harkness and DeMarco, 2012, p. 345).

Social Determinants The CDC defines social determinants of health as “economic and social conditions that influence the health of people and communities” (CDC, 2011, p. 1). The incarcerated population faces several social determinants. Low Income “After release from incarceration, inmates often face social injustices and economic problems” (Harkness and DeMarco, 2012, p. 345). Because most inmates usually come from a low economic community, they do not have much to begin with. After being released, if they do not have continued family support and are on their own, it makes it even harder to start over. They are less likely to receive higher paying jobs because of their record, and therefore, are less likely to be able to rent decent housing. They are also less likely to have health insurance because of the cost, and are less likely to see a doctor with any medical problems they may be experiencing until the problem becomes severe. Communities need to work hard to support this population in a way that will help prevent them from going back to their old ways and being arrested again. Discrimination Discrimination happens both inside and outside of correctional facilities. The currently incarcerated faces discrimination from other inmates, and most importantly from facility staff and guards. Depending on the crime that the individual inmate has done, the guard may not feel that they deserve the right of health care. Typically, when an inmate is not feeling well they will

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tell the guard that is on duty, and then based on the severity of the complaint, the guard will place them on a list to see the doctor or nurse. Because of overcrowding, and many inmates with complaints, it can take days to see the doctor (Beam, 2009, p.1). If the guard decides that it is not a valid complaint, or not serious, the inmate may be forced to wait for treatment. Discrimination also occurs for women in the correctional facilities. According to Braithwaite, Treadwell, and Arriola, there is little attention being given to the unique health concerns that women face (2005, p.1). Many times, they do not receive the important annual physicals needed to assist in disease prevention, “and prison officials often dismiss complaints in this area” (Braithwaite, Treadwell, Ariolla, 2005, p.1). Outside of the correctional facility discrimination takes place in the work place because of their previous incarceration, which can make it very difficult to find a job, and it also takes place in the community. It does not matter what the individual’s crime was, just the fact that they were incarcerated gives them a stigma that is not easily ignored by the community. Education According to Ann Kelly, prisoners are more likely to come from a background of poor education and low socioeconomic status (2010, p.1). Due to lack of education, it can be extremely difficult to find a decent paying job, which is why this population becomes involved in illegal activities. After incarceration, literacy and job training are two very important things that this population needs to get back on their feet in a legal way to prevent them from returning to old habits. When proper education is given, well-paying jobs can be obtained, and appropriate health care is provided. Education can be the key to break the “bad cycle” that contributed to the person’s arrest in the first place.

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Policies Those who are currently incarcerated have a legal right to some healthcare. This health care is paid for with taxes, and provides inmates with routine exams, blood work, counseling, and care for other ailments (Beam, 2009, p.1). This helps to prevent the spread of communicable diseases from inmate to inmate, and provide proper care to those who have a disease. This health care also helps to treat ailments before releasing inmates back into their communities, so that diseases are not able to spread outside of the correctional facility. Unfortunately, when patients have health complaints, because the decision maker in correctional facilities is often the director or warden, these complaints are not always handled appropriately or in a timely manner (Harkness and DeMarco, 2012, p. 345). This is a positive policy in that most inmates have not had health insurance previously, and can receive health care to assist them when they are released, but it is not always utilized for them, which can cause negative effects. Many places of employment, especially those that require caring for people (hospitals, schools, daycares, etc.) require background checks before hire. This puts inmates at a disadvantage for finding a decent job. Other jobs may not have specific policies regarding their previous incarceration, but most managers that are looking through resumes may develop an opinion of that person before giving them a chance. This then goes back to the fact that they are unable to find jobs after their release that pay enough to find a decent place to live and afford food and health insurance. Because of this, they will go back to making money illegally just so they can live, thus returning to the bad cycle again. Contributing Factors of Health Care Disparities Underlying Values and Beliefs

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Although this population has made some bad decisions in their lives, it does not mean that they cannot ever be forgiven for what they have done. The majority of inmates have been incarcerated for drug related offenses (Snyder, 2012, p.1), and not for major crimes such as murder or rape. It is unfair to pass judgments on this population and treat all of them as though they committed the worst crime imaginable. This population is serving their sentence, and it is only fair that after they have served their time we give them the benefit of the doubt. Yes, there will be some that will fall back into their old habits, and end up being arrested again, but there will be some who will work hard to get back on their feet and strive to become a productive member of society. The discrimination and hardships that this population faces has a direct impact on their future choices, and what they, as a person, will become. We as a society need to help those in this position, and assist them in turning their lives around. This will not only benefit the person individually, but also the community they live in. Values of Those in Power The way that inmates and those recently released from a correctional facility are treated, has everything to do with the attitudes and values of those in control of them. Inside the facility, the person in charge is usually the warden or director of the prison (Harkness and DeMarco, 2012, p.345). In order for the inmates to receive the health care that they need, this person needs to have the attitude that regardless of the fact that these men and women have made bad choices in their lives, they still deserve to be treated like human beings and given proper health care. Outside of the correctional facility, those in power are employers, and even the government. The attitudes and values of the employers need to be forgiving and open-minded to give this population a chance to start again. The government needs to have a helpful approach for the good of the communities to assist this population in becoming productive members.

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References Beam, C. (2009, May 25). Jailhouse Doc. Retrieved from www.slate.com/articles/news_and_politics/explainer/2009/03/jailhouse_doc.html Braithwaity, R., Treadwell, H., Ariolla, K. (2005). Health Disparities and Incarcerated Women: A Population Ignored. American Journal of Public Health, 95(10), 1679-1681. doi. 10.2105/AJPH.2005.065375. CDC. (2011, May 6). Social Determinants of Health. Retrieved from www.cdc.gov/socialdeterminants/FAQ.html Harkness, G., DeMarco, R. (2012). Community and Public Health Nursing, Evidence for Practice. Lippincott Williams and Wilkins. Kelly, A. (2011, July 1). Correctional Health Care is Community Health Care. Retrieved from http://knowledgecenter.csg.org Snyder, H. (2012, October). Arrest in the United States, 1990-2010. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/aus9010.pdf

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Student Name: Kara Elkins Section

Guidelines

Possible Points

Earned Points

Population and disparity defined



Clearly defines the population under consideration  Describes the health disparity(ies) experienced by this population.  Supports all data with reliable resources.

10%

10

Review of social determinants



What social determinants a r e relevant t o the identified disparity?  The connection between the social determinants and the disparity is clearly explained.  Support the data, explain the reasoning.

30%

30

Policies contributing to disparities



Identify policies that negatively or positively affect the disparities and the social determinants. Source the policies.  Make the connection between the policies and the outcomes on health.

30%

30

Contributing factors



30%

30

100% (-30%)

100 -5

100%

95

 

What underlying beliefs or values might contribute to the disparities? This is the tough critical thinking part. What values held by those in power might influence the health status of a particular population. Clarify your thinking.

Content Grade Writing

Total

FINAL GRADE less Deductions: DEDUCTION OF UP TO 30 points (-30%) will be made for APA/writing/grammatical/punctuation errors.

Kara, Great job. Very well written. You covered all required areas very well. A few APA errors noted. See comments in paper. This certainly is a population that can be discriminated against. Jo

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D. Scholarship for Practice Evidence-based practice (EBP) is what is helping the health care profession consistently give quality care to our patients, and research is what helps us get there. EBP helps to improve outcomes for patients, providers, and healthcare institutions (Burns and Grove, 2011, p. 468). “EBP also promotes the delivery of quality, cost-effective care, which is why many healthcare institutions are highly supportive of it” (Burns and Grove, 2011, p. 468). I have learned a lot about evidence-based practice throughout this program, and have learned a lot about how to research health care concerns in order to change specific issues for the better. The first example I have provided in this category is a group critique done on a mobility protocol for patients in the hospital setting. The second example is an evidence-based research paper done on catheter assisted urinary tract infections (CAUTI), and how we can decrease the prevalence in patients at risk, and shows that by reducing the prevalence we can reduce health care costs.

Reference Burns, N., Grove, S. (2011). Understanding Nursing Research, Building an Evidence- Based Practice. Elsevier.

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Nurse Driven Mobility Protocol Critique Sue Vansteel, Kara Elkins, Benjamin Kasper Ferris State University

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Abstract The critique of research by Padula, Hughes, Baumhover (2009) on: “The impact a nurse driven protocol on functional decline of hospitalized older adults” was conducted by a group of Ferris State nursing students. An analysis by the group determined that the overall study was weak. Despite the weakness noted “findings suggest that early and ongoing ambulating in the hallways may be an importune contributor to maintaining functional mobility” (Padula, Hughes, Baumhover 2009 p.330). Areas of weakness in the study were evident in the purpose and problem, which lacked clarity, conciseness. The literature revealed that it did not include opposing views. The Barthel Index (BI) and a Get up and Go test identify the individual ability to perform self care are subjective with an interrater agreement of r + 0.793 for BI score. Strengths include the hypothesis which state “independent variables was mobility protocol and dependent variables were functional status and length of stay” (Padula, Hughes, Baumhover 2009 p.325). The quasi research design was a “nonequivalent control group design” (Padula et al., 2009 p. 327). Which appears to be appropriate for the study. Institution may implement mobility protocols that are nurse driven despite the weakness of this study. However additional research in needed to validate the guidelines and outcomes of these protocols and studies. Keywords: functional decline, mobility, older hospitalized adults, protocols, critique

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Nurse Driven Mobility Protocol Critique Nursing research evolved from the days of Florence Nightingale which focused on a “healthy environment promoting patients’ physical and mental well-being” (Burns & Grove 2011, pg. 10) to the evidenced based clinical research of today (Burns & Grove 2011, pg. 10). Evidence based nursing research reports the strongest empirical findings that are significant to understanding health and illness experiences. Based on the relevance of the study clinical implication is estimated for therapeutic interventions in nursing practice. The purpose is to critique the quantitative research article: Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Older Adults, published in the Journal of Nursing Care Quality in October -December issue 2009. Using Groves and Burns (2011) text: Understanding nursing research: Building an evidence-based practice and the Niewiadomy’s guidelines provided by Hoisington to evaluate the strengths and weakness of the research. Padula, Hughes, Baumhover (2009) states “maintaining mobility in acutely and even critically ill people is a key component in achieving positive outcome” (p. 326). This study addressed the use of a mobility protocol that would be nurse driven to have an impact functional that is commonly seen in hospitalized older adults.

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Purpose Evidence Padula, Hughes & Baumhover (2009) states “the purpose of the study to determine the impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults (p. 326) Support According to Burns and Groves (2011) the purpose should contain clear and concise steps in-order to reach specified goals or outcomes. The process for identifying the purpose of a study according to Burns and Groves (2011) may include these elements “identify, describe, or explain a situation; predict a solution to a situation; or control a situation to produce positive outcome in practice” (p. 41). The purpose is a descriptive statement which includes a focus or concept to be studied (Burns and Groves 2011 p.148). In addition the variables are outlined such as population and relationships that may exist among the variables. Differences among the groups or variables need to be outlined in the purpose statement (Burns and Groves 2011 p.148). Analysis Padula et al. (2009) purpose statement is reflected in the title and restated in the abstract, as a goal in the first paragraph and after the literature review. The purpose statement describes the variables being hospitalized which includes older adults, mobility protocol (independent variable) and functional decline (dependent variable). This is a strong purpose statement. However, reduction in length of stay was discussed in the abstract as an outcome, and was noted in the area of research during the study but was not addressed in the purpose statement. The addition of LOS would have increased the strength of the purpose statement

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Problem Evidence The problem statement given by the authors in this article is: “Maintaining mobility is paramount in preserving independence in activities of daily living (ADL) for older adults, yet research has demonstrated that low mobility and bed rest are common during acute hospitalization” (Padula et al., 2009 p.325). Padula, Hughes, and Baumhover (2009) also state that “maintaining functional status forms the foundation for continued independence and health and encompasses behaviors necessary to actively engage in daily life,” (p. 325) which is why this study is so important. The author’s also state that “a stay in the hospital often results in complications that lead to functional decline in older adults, which occurs in 34% to 50% of hospitalized older adults, and impairment in functional status is a strong predictor of poor outcomes" (Padula et al., 2009, p. 325). Support According to Burns and Grove (2011) a research problem is “the area of concern where there is a gap in the knowledge base needed for nursing practice”(p. 146). With a research problem there needs to be a research problem statement, which is made to identify the “specific gap in the knowledge needed for practice” (Burns and Grove, 2011, p. 146). According to the Nieswiadomy critique guidelines, the problem statement must be clear, and the population should be included. The reader should be able to see how feasible the study will be as well as the significance of the study based on the problem statement (Hoisington, 2007). Analysis The problem statement in this article seems incomplete. The writers also placed the problem statement in a paragraph meshed together with the purpose of the research, which made

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it more difficult to distinguish. The problem statement is weak. The writers state a problem that is both ethical and feasible, but they are very broad. By just stating that bed rest is common during hospital stays may not be seen as a problem for readers who are not in the health care field. It would have been stronger with some examples of some solutions or specific problem areas, or by putting the problem statement in a section by itself and expanding on it. This way it would be better understood by every reader regardless of background. Padula et al. (2009) state the common problem during hospitalization is low mobility and bed rest (p. 325) and this is a problem because maintaining mobility in older adults is important. The point of this study seems feasible with the support of trained professionals a hospital setting to help mobilize the patients. Patient mobility is important in for positive patient outcomes.. Review of Literature Evidence A literature review section is not identified in this article. However, in the introduction section, this article has nineteen sources which were cited. There was minimal critique of the literature review cited in the article. The sources were paraphrased with no direct quotations. The reference section of this paper does contain all listed citations with source dates ranging from 1986 to 2008. Support According to Burns & Grove, “A review of literature provides you with the current theoretical and scientific knowledge about a particular problem, enabling you to synthesize what is known and not known” (Burns & Grove, 2011, p. 189). Nieswiadomy outlines a guideline for critiquing the literature review of a research article. The guideline includes the following questions to ask while doing a review of literature. The group of questions are as follows: is the

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literature review comprehensive and concise? Does the review flow logically from the purpose(s) of the study? Are all sources relevant to the study topic, are the sources critically appraised, are both classic and current sources included? Are paraphrases or direct quotes used most often, are both supporting and opposing theory and research presented? Are most of the references primary sources, can a determination be made if sources are primary or secondary? Are all sources that are cited in the article found on the reference list and do the references appear free of citation errors? Analysis The literature review by Padula et al. (2009) is a section that is untitled; however, the authors covered nineteen sources and gave many examples of studies in their introduction. The included sources and subsequent review of citation of these sources appear to be comprehensive supporting the authors study. Nevertheless, the author’s appear to be lacking information opposing their study. The literature review in this article is rather brief and it is not concise, to be concise, there needs to be a lot of information conveyed in a brief yet comprehensive section. “The purpose of the study was to determine the impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults” (Padula, Hughes, & Baumhover, 2009 p. 326). The literature does flow logically from the purpose; the review of literature was conducted on older adults. There was some information lacking in regards to the age population of the study participants in previous studies. The literature review which was done by the author’s flows nicely into the fact that little research was found specific to mobility and changes to mobility during hospitalization (Padula et al. 2009, p. 326, para. 3). While it appears that some possible sources have been excluded, all of the sources used in the literature review are relevant to the topic and based on functional decline in the hospitalized

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older adult population. It does not appear that the authors have critically appraised their sources and there is a lack of critique. According to Burns & Grove, “a critical appraisal of research involves careful examination of all aspects of a study to judge its strengths, limitations, meaning, and significance” (Burns & Grove, 2011, p. 28). It appears that the authors did include current and classic sources. However, due to lack of familiarity with this topic; appraisal of sources can be quite difficult. According to Burns & Grove, “Sources should be current up to the date the paper was accepted for publication” (Burns & Grove, 2011, p. 194). Current sources should be published within five years of the authors study. Based upon the five year criteria, there are many sources included in the study published within five years and many in the years previous to that. In a search on CINAHL using keywords of acute hospitalization functional decline forty related articles where found between the years 1998 -2009. Padula et al. (2009) did not use any direct quotations in their review of literature. It appears that paraphrases were used by the authors with the possibility of synthesis of sources being used. “Synthesis of sources involves compiling the findings from all of the selected studies and analyzing and interpreting those findings” (Burns & Grove, 2011, p. 220). The authors presented many supporting theories and research studies for their article. Conversely, there does not appear to be any opposing research present in the literature review. A search of CINAHL found articles demonstrating oppositional research. Academic Journal Exercise program implementation proves not feasible during acute care hospitalization. Full Text Available (includes abstract); Brown CJ; Peel C; Bamman MM; Allman RM; Journal of Rehabilitation Research & Development, 2006 Nov-Dec; 43 (7): 939-46

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(journal article - clinical trial, research, tables/charts) ISSN: 0748-7711 PMID: 17436179 Subjects: Frail Elderly; Home Physical Therapy; Therapeutic Exercise; Aged: 65+ years; Female; Male Database: CINAHL Theoretical/ Conceptual Model Evidence The author’s mention functional status, baseline functional status, mobility, activities of daily living, self-care, and cognitive function as components of various theories of nursing and conceptual frameworks. For the research study a Geriatric Friendly Environment through Evaluation and Specific Interventions for Successful Healing (GENESIS) program was utilized as a model of nursing care delivery for geriatric patients (Burns &Grove 2011). Incorporated into this mode of care is a nurse-driven mobility protocol. Features of the mobility protocol require the nurse to evaluate and eliminate barriers to ambulation. This includes addressing orders for bed rest, necessity of catheters, drains and intravenous therapy. Mobility of patient includes ambulation three to four times per day, up in chair for meals and bathroom or bedside commode encouraged. Support According to Burns and Grove (2011) “conceptual models are similar to theories but are more abstract than theories” (p.228). A conceptual model assists the researcher to provide details about the phenomena articulate any assumptions and reveal any philosophical positions (Burns & Grove 2011). To provide clarity and consistency for the direction of the research, it is important to identify the theory and theorist framework. An accurate understanding the concept and the

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theorist’s definition of the concept is often clarified in the study. Concepts may be an idea, word or object in which the meaning is defined by the theorist (Burns &Grove 2011). Concepts have more implication than a dictionary definition and need to be understood so they can be linked to the method of measurements and implementation in nursing practice (Burns & Grove 2011). Connecting the concept to the theory provides a foundation for how the findings will be used in a practice setting. Maps or models can be used to graphically display the correlation between a concept and a relationship statement (Burns & Grove 2011). When maps and models are utilized as a framework the theorist must include references as support (Burns & Grove 2011). Most important concepts in a theory or study framework are often expressed in a graphic manner and assist with identifying the gaps in the theory (Burns & Grove 2011) According to Burns & Grove (2011) frameworks are the guide by which a research study is developed. The framework provides a reasonable method for collecting and organizing data, information or problems being investigated. It is through this framework the researcher is able to examine the result of the study and link them to an existing body of knowledge. Research uses study frameworks to explain the theory that is being examined. Often the term conceptual framework or theoretical framework are used to identify the framework and may be used interchangeably in the context of a research study (Burns &Grove 2011). Some frameworks are not always clear and expressed in a manner which is difficult for the reader to locate. Burns and Grove (2011) describe these frameworks as rudimentary ideas that are explained through literature review or in the introduction. Often the ideas are not developed but rather implied from the readings. These are considered to be implicit frameworks (Burns & Grove, 2011, p. 239).

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Analysis Padula et al. (2009) do not clearly identify a theory or theorist within the context of the study. The review of the literature speaks to several previous studies which mention functional status, self-care, and mobility but they are not specifically identified as concepts. These words or ideas are found in the introduction but they lack definition, clarity and are not linked to a theory. The reader lumps together many components that tie into functional status to older adult health and quality of life, but these components also lack clarity or reference to a theory. An example would be the introduction of the article which states “Functional status, the ability to perform basic self-care activities, in a significant component of older adults’’ health status and quality of life” (Padula, Hughes & Baumhover, 2009, p.325). For clarity, a reference to Orem’s self-care theory would provide a specific framework in which to base the study. The study variables were identified as mobility protocol, functional status and length of stay (Padula, Hughes & Baumhover, 2009, p. 325) but explicit definitions and or framework were not defined. Padula et al. (2009) use the literature reviews as the method for making relationship statements that link mobility to functional status and length of stay. Several references are used to demonstrate that lack of mobility resulted in functional decline (Padula, Hughes & Baumhover 2009). Other references demonstrate that mobility and frequent ambulation improve functional outcomes for many patients (Padula, Hughes & Baumhover, 2009). It is therefore implied that there is a relationship between mobility and functional decline through various literature reviews. However, this relationship is vague because the definitions for mobility and functional status are not provided. Functional and cognitive status instruments are identified for their research.

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Without a specified conceptual framework, map or model identified there is a lack of context for the study. This makes the study weak but still feasible. Hypothesis and Research questions Evidence: In this study, two hypotheses were clearly stated. The first hypothesis given is “older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge”, and the second hypothesis given is “older adults who participate in a mobility protocol will have a reduced length of stay (LOS)” (Padula et al. 2009, p. 327). Both hypotheses identify the population, which in this case is older adults, and the dependent and independent variables. The independent variable in each of the hypotheses is the mobility protocol. The dependent variable in the first hypothesis is functional status, and in the second is length of stay (Padula et al. 2009, p. 327). Support According to Burns and Groves,( 2011) “a hypothesis is a formal statement of the expected relationship between two or more variables in a specified population” ( p.167 )A hypothesis is the researchers “educated guess” on what they believe will be the outcomes of the study. Hypotheses are valuable components of research because they influence the study design, sampling method, data collection and analysis process, and the interpretation of the findings by the author (Burns and Groves, 2011 p.167). A hypothesis guides the entire research process. A well-written hypothesis should include the variables that are to be measured, as well as the population that is to be studied, and the proposed outcomes (Burns and Groves, 2011, p. 167). There are a few different types of hypotheses that are used in research, and they are described in four different categories. 1) associative versus causal, 2) simple versus complex, 3)

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non-directional versus directional, and 4) null versus research (Burns and Groves, 2011, p.167). A hypothesis can be associative or causal based on the relationship among the variables being studied. “Associative hypotheses identify relationships among variables in a study but do not indicate that one variable causes an effect on another variable” (Burns and Groves, 2011, p. 167170). A causal hypothesis “proposes a cause-and-effect interaction between two or more variables” (Burns and Groves, 2011, p. 167-170). The difference between a simple and complex hypothesis is how many variables are being used in the study. A simple hypothesis has two variables, whereas a complex hypothesis has three or more variables being measured (Burns and Groves, 2011, p.172). Non-directional hypotheses state a relationship between the variables, but does not predict the exact nature of the relationship, and this is different than a directional hypothesis because in a directional hypothesis there is a relationship stated along with the nature of the relationship using terms such as positive, negative, increase, decrease, etc. (Burns and Groves, 2011, p.174). The last category of hypotheses is null verses research. “A null hypothesis is used for statistical testing and for interpreting statistical outcomes,” and “this type of hypothesis is used when a researcher believes there is no relationship between two variables and when information is inadequate to state a research hypothesis” (Burns and Groves, 2011, p.174). A research hypothesis actually states the relationships and provides adequate information (Burns and Groves, 2011, p175). Analysis Padula et al. (2009) clearly worded their hypotheses. The population, dependent and independent variables are clearly stated. This information helps to fully understand the author’s opinions the outcomes of the study. Both hypotheses stated are simple in that they compare two variables. They are also both research hypotheses in that there is a relationship stated in each.

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The first hypothesis which stated that “older adults participating in the mobility protocol will improve functional status, and in the second hypothesis they state that older adults participating in the mobility protocol will have reduced length of stay” (Padula et al. 2009, p. 327). Because of the use of the terms to describe the nature of the relationship, they are both considered directional hypotheses. This section of the research article is strong and the hypotheses directly relate to the purpose of the study. Research (Study) Design Evidence

In the research methods section of their study, researchers Padula, Hughes and Baumhover state what the research design for their study will be. “This study used a nonequivalent control group design” (Padula et al., 2009, p. 327). Support Burns & Grove define a research design as a blueprint for conducting a study (Burns & Grove, 2011). Research design comprises the type of data that will be collected and what resources will be used to obtain the data. The researcher must also decide if their goal is to determine causative factors, explore associations between variables or study historical data from previous research. A research design must be appropriate to test the hypothesis or answer the research questions. “Quasi-experimental design facilitates the search for knowledge and examination of causality in situations in which complete control is not possible” (Burns & Grove, 2011, p. 270). Quasi-experimental study designs vary widely, according to Burns & Grove, “the most frequently used design in social science research is the untreated comparison group design with pretest and posttest” (Burns & Grove, 2011, p. 271).

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Experimental designs are very similar to the quasi-experimental design with the exception of the control groups and the test groups which are randomized. Non experimental groups like descriptive and comparative designs are used to examine relationships between variables or examine a single unit in the context of real like environments (Burns & Grove, 2011, p. 262264). Nieswaidomy has set forth guidelines for critiquing quantitative research designs, they are as follows. Is the design clearly identified in the research paper and is the design appropriate to test the study hypothesis or answer the research question. If the study used an experimental design, was the most appropriate type of experimental design used and what means were used to control for threats to internal and external validity. Does the research design allow the researcher to draw cause-and-effect relationship between variables? If the design was non-experimental, would an experimental design have been more appropriate and what means were used to control for extraneous variables, such as subject characteristics if a non-experimental design was used (Hoisington, 2007). Analysis The research design is clearly stated in the research report. The researcher’s state that their research study is a “nonequivalent control group design” (Padula et al., 2009, p. 327). This type of research design is considered a form of quasi-experimental. Is the design appropriate to test the study hypothesis or answer the research questions? It appears that the research design that has been chosen will be appropriate for the study. The researchers used a convenience sample which can lead to internal validity problems. By using a convenience group, it is difficult to make certain that the control group and treatment groups begin at the same level. The researchers describe their use of a pretest and posttest called Barthel

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Index to measure the groups beginning, middle and ending statistics. With the use of a pretest the hope is that the researchers could tell if the groups were equal before the treatment was administered. It does appear that this research design is appropriate for this study. What means were used to control internal and external validity? Attempts to control validity were poorly made with this study; however, it does not appear that they were strong enough to prevent bias. According to Padula et al. (2009) criteria used to create groups were ability to understand English, no physical impairment to limit mobility, and cognitively intact. A research nurse screened potential patients and enrolled subjects. There was no discussion of the qualifications of the research nurse, which could lead to bias in which group a patient was placed (control or treatment) (p. 327). There was also mention of an advanced practice nurse employed on the control unit, with no mention of what, if anything was done to prevent internal validity concerns. There was no discussion on how the researchers controlled external validity such as the Hawthorne effect, reactive effects, and experimenter effect. Does the research design allow the researcher to draw a cause and effect relationship between the variables? Somewhat, the researchers were able to demonstrate by the use of Barthel scoring that there was a significant increase in the scores for the treatment group, in fact, according to Padula et al. (2009) the treatment group improved from baseline by +11.5 with the control group improving by 6.9 which was deemed ‘not significant’ by the researchers. The researchers also used an Up and Go test which showed scores which were of no significance to their study (p. 329). In summary, the research design which was selected seems to be appropriate to test the hypothesis and answer the research questions. The nonequivalent control group design which

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was chosen (pretest and posttest control group design) seems to be appropriate for this study. An area of weakness in this study was mainly the lack of controls for internal and external validity. The researchers did not discuss or identify how they could control internal and external validity. Sample and Sampling Methods Evidence For this study, “the researchers used a convenience sample of fifty adults (N=50) ages 60 and older, who were admitted with medical diagnoses to 1 of 2 nursing units” (Padula et al. 2009, p. 327). They took 25 patients from each unit being studied. Other criteria that was included when choosing the population for this study was a length of stay that was at least three days, English speaking, no prior physical impairment that would greatly limit mobilization, and those who were cognitively intact. Patients completed a Mini-Mental exam prior to the study and needed a score of 24 or more to qualify (Padula et al., 2009, p. 327). Before choosing the sample, a “research nurse screened 453 patients for eligibility, from those 84 subjects were enrolled, and from those patients 34 were withdrawn from the study for various reasons” (padula et al., 2009, p. 327). The study took place in a private hospital with 247 beds. Two nursing units in this hospital were a part of the study. The two units that were used were both “equal in size, cared for similar patient populations, and were characterized by similar nursing staff composition. They were both predominantly registered nurses and certified nursing assistants” (Padula et al., 2009, p 327). Support Sampling is defined by Burns and Grove (2011) as, “selecting a group of people, events, behaviors, or other elements with which to conduct a study” (p. 290). Padula et al. was very

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precise when choosing the population they would study. A criteria was established to screen the patients, and also made sure the population was accessible to them. An accessible population is very important for a research study, and is the portion of the target population (or entire set of individuals that meet the criteria of the study) that the researcher has reasonable access to (Burns and Grove, 2011, p. 290). Padula et al. used a convenience sample for their research study. Burns and Grove define a convenience sample as “a sample where subjects are included in the study merely because they happen to be in the right place at the right time” (Burns and Grove, 2011, p. 305). This way of sampling has been known as being a weak approach, only because there isn’t as much opportunity to control bias (Burns and Grove, 2011, p. 305). Researchers are not able to be as meticulous when choosing their subjects. On the positive side of using convenience sampling, “it is inexpensive, accessible, and usually less time consuming to obtain the samples” (Burns and Grove, 2011, p. 305). This type of sampling is very common in healthcare research. This is because the sampling frames that meet specific criteria are not always available and the researcher has to use what is available at the time or area where they are conducting their research study. The more criteria set when choosing the sample, the better the power and validity of the study. Power is “the capacity of the study to detect differences or relationships that actually exist in the population. The minimal acceptable level for power in a study is 80%” (Burns and Grove, 2011, p. 308). This means that the study has reasonable findings that can be used in the future. Analysis The sampling procedures that were used by the researchers in this study were very well thought out. They used a convenience sample, but had very specific criteria that gave the study

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the validity it needed. The researchers chose to use only medical patients in this study because then they were able to avoid potential limitations that are associated with post- surgical patients (Padula et al., 2009, p. 327). Along with this, there were several other criteria that made the sampling portion of the study very strong and valid. They had a very specific target population, and then took the initial 453 people and eventually narrowed them down to the final 84 patients that would take part in the study (Padula et al., 2009, p. 327). From the 84 patients chosen, 34 were withdrawn for many reasons which included discharge, transfer from the units being studied, having disqualifying procedures, or personal reasons (Padula et al., 2009, p.327). The researchers did an excellent job choosing their sample group. They clearly identified their target population, and had great criteria to narrow the population size. Because of the smaller location and sample of the study, a comparison study may need to be done in other hospitals with a similar population to prove the validity of this particular study. This study, however, will provide enough information to either prove or disprove the hypothesis that “older adults who participate in a mobility protocol will maintain or improve functional status from admission to discharge” (Padula et al., 2009, p. 327).

Data Collection Methods Evidence Data was collected by “an advanced practice nurse with expertise in gerontology and geriatrics was hired to collect data and was trained by the geriatric clinical nurse specialist and the principal investigator. Training included human subjects’ protection and achievement of high level proficiency with the protocol and data collection instrument (Padula et al. 2009 p 328)’ The data was collected at Miriam Hospital in Providence, Rhode Island. This facility has 247 beds and 2 nursing units were assigned to the study. These units were of “equal size, cared for

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similar patient populations and were characterized by similar nursing staff composition” (Padula et al. 2009 p. 327). Nurses on the treatment unit had been trained and supported a geriatric program called Geriatric Friendly Environment through Nursing Evaluation and Specific Intervention for Successful Healing (Genesis). Incorporated into this model is a nurse driven mobility protocol (Padula et al. 2009 p. 328). The control unit had not implemented the geriatric program and the nurses did not receive the training. The nurses did not float between theses two units. These data points focus on key elements that help to determine current heath status and future results of the mobility protocol. The data was collected to determine if the implementation of a mobility protocol would “maintain or improve an older patients functional status from admission to discharge” (Padula et al. 2009 p. 326). A demographic data collection sheet was developed specifically for this research. Eligible subjects for the study were screened by the research nurse and the data was collected within 48 hours of admission. A ratio-scale was used to measure the nursing staff characteristic by unit for the study period. The elements of this data included RN hours per patient day, unlicensed assistive personnel hours per patient day, total nursing hours per patient day, % total nursing hours by RN, and % total nursing hours by unlicensed assistive personnel. Key demographic data was collected on the eligible subject for the study. The level of measurement used for this information is a nominal-scale. Information obtained included “age; gender; primary diagnosis; use of assistive devices; fall risk assessment; presence of any restriction to mobility; use of occupational or physical therapy; LOS; first and number of times

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out of bed” ( Padula et al., 2009 p. 328). However, the fall risk assessment uses an ordinal-scale measurement. The modified Barthel Index, level of independence and the get up and go test are examples of ordinal-scale measurement. Each of the scales are described below. According to Padula et al. (2009) data was collected from the patients perception of their functional mobility 2 weeks before admission and at admission. The data was collected using a modified Barthel Index (BI). It measured 10 items with a 5 point rating scale to enhance the sensitivity (p 328). The level of dependence was measured using a numeric scale 0 (totally dependent) to 100 totally independent. A get up and go test with specific criteria measured the ability to stand, walk and return to sitting (Padula et al. 2009 p. 329). Data for this study was collect at “admission and at discharge on a 1 to 4 scale, 1 being able to rise in a single movement and to 4 being unable” (Padula et al. 2009, p. 329). Measurement of cognitive status was conducted routinely using a mini-mental state examination score. The rating of this test was not provided. Charts were reviewed to collect the data for ambulation, number of times in the chair and other activities. Support In 1946 Steven “organized the rules for assigning numbers to objects so that hierarchy in measurement was established”(Burns and Grove 2011 p.329). These levels describe as being nominal, ordinal, interval and ratio. Nominal-scale measurement is the lowest in which data is organized in categories of defined property but they cannot be ranked in any kind of order. There are several rules to this

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measurement in that there is no order to the categories, they are exclusive and exhaustive (Burns and Grove 2011 p. 329). Ordinal-Scale measurement are the level most used in nursing assessment. The data “are assigned to categories that can be ranked” (Burns and Grove 2011 p. 330) with rules governing how the data is ranked. These rules indicated an equal distance does not exist between the rankings and the categories must be exclusive and exhaustive (Burns and Grove 2011 p. 330). The third level is an interval-scale measurement in which there are “equal numerical distance between the intervals” (Burns and Grove, 2011 p. 329). According to Burns and Grove (2009) these scales follow the rules of mutually exclusive and exhaustive categories and ranking ordering are assumed to represent a continuum of value” (p. 330). The last and highest level of measurement is the ratio-scale. This measurement has categories that are mutually exclusive, exhaustive, order ranked, equally spaced intervals and a continuum of values (Burns and Grove 2011 p. 329). The type of test can pose a threat to internal validity. This is especially true with pretest and post test with the same questions. The threat comes from a subject already knowing the questions (Hoisington 2012 Cycle 3). External Validity may be threatened by the subject answering the in a manner that could sway results. Analysis. The author’s give a good description, comparison and reason for the selection of these two nursing units. The data collection was completed by hired trained professionals which decreases the possibility for error and strengthens the measurement process. However the author’s do not provide information if others were involved in data collection. A vast amount of data is collected at admission and discharge using the different assessment scaled. The article

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does not explain when other data is collected and how it is collected. In addition the author’s rely on information being documented in a chart. One cannot be sure if all elements of the data collectionwere documented in the chart. The researchers goal was to provide data that would demonstrate a nurse driven protocol would have an impact on a patient’s functional decline in a hospital setting. The modified BI tool to measure functional status is standard in the clinical and research setting with demonstrated inter-rater agreement. This strengthens the reliability of the results. The get up and go test also has been tested for reliability which also strengthen the validity. These were weak in that the test were subjective and based on patients or significant other perception. The threat to internal validity is high because the subjects were asked the same question at the start of the study and at discharge. Despite the weakness of the tool the results appear to be promising and may warrant a more in-depth follow up study. Instrument Evidence Padula et al. (2009) discussed four instruments which were used in their research. The instruments used are as follows, demographic data collection sheet, functional status via Barthel Index, Get Up and Go test, and Mini-Mental State Examination (MMSE) (Padula, Hughes, & Baumhover 2009, p. 328). The demographic data collection sheet falls under a nominal-scale measurement, no reliability or validity information was provided. The Barthel Index (BI) falls under an ordinal-scale measurement, the authors state that, “researchers have proposed the BI as the standard for clinical research purposes” (Padula et al., 2009, p. 328), and provided an interrater agreement of r = 0.793. The Get Up and Go test is also an ordinal-scale measurement, which accordng to the authors has been reported to be reliable and valid with a correlation rating

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of r = -0.78 in comparison to the BI (Padula et al., 2009). The MMSE also falls under ordinalscale, however, no reliability or validity measures were included by the authors. Support Reliability of an instrument is of great importance to a study. According to Burns & Grove, “reliability is concerned with the consistency of the measurement method” (Burns & Grove, 2011, p. 332). If an instrument is not reliable, researchers cannot know what it is really measuring or if it is really measuring what they want it to measure. Reliability testing measures the extent of random error in the measurement method (Burns & Grove, 2011, p. 333). There are three types of reliability testing, which according to Burns & Grove, are stability, equivalence, and homogeneity. Stability is described as a “concern with the consistency of repeated measures of the same attribute with the use of the same scale or instrument” (Burns & Grove, 2011, p. 333). Stability is also known as the test-retest reliability. Equivalence is also used as a form of reliability testing, according to Burns & Grove equivalence, “involves the comparison of two versions of the same paper-and-pencil instrument or of two observers measuring the same event” (Burns & Grove, 2011, p. 333). Also mentioned by Burns & Grove is interrater reliability which is a comparison of two observers of two judges in a study (Burns & Grove, 2011, p. 333). Homogeneity is the third form of reliability testing described by Burns & Grove, this type of testing is used primarily with paper-and-pencil instruments or scales which addresses the correlation of each question to the other questions within the instrument (Burns & Grove, 2011, p. 334). Validity of an instrument according to Burns & Grove is a, “determination of how well the instrument reflects the abstract concept being examined” (Burns & Grove, 2011, p. 334). An

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instrument may be valid for one study and that same instrument may not be valid for another. Researchers need to know if the instruments they are using are valid for what they are measuring, or their study may be in jeopardy. According to Burns & Grove, there are three types of validity, which are contrasting groups, convergence, and divergence (Burns & Grove, 2011, p. 335). Validity from contrasting groups can be determined by, “identifying groups that are expected (or known) to have contrasting scores on the instrument” (Burns & Grove, 2011, p. 335). Validity from convergence is determined, “when a relatively new instrument is compared with an existing instrument(s) that measure the same construct” (Burns & Grove, 2011, p. 335). According to Burns & Grove (2011), the instruments are used concurrently, and then the results are evaluated using correlational analysis. Measures which are positively correlated strengthen the validity of the instrument (Burns & Grove, 2011, p. 335). Lastly, validity from divergence can be measured, which is using an instrument of opposite effect than what is actually being measured. According to Burns & Grove, “correlational procedures are performed with the measures of the two concepts. If the divergent measure is negatively correlated with the other instrument, validity for each of the instruments is strengthened” (Burns & Grove, 2011, p. 335). Analysis Padula et al. (2009) provides clear descriptions of the instruments used for data collection performed in this study. The instruments are described; their purpose and function are included with how the data was collected. The authors created a demographic data collection sheet for this study; however, they did not include any form of reliability or validity for this tool. The function and purpose of the BI and Get Up and Go tests were described by the authors. The BI was listed as having an interrator score of r = 0.793 which according to Burns &

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Grove is a low score for reliability, an interrator score should be greater than 0.80 to avoid reliability concern (Burns & Grove, 2011, p. 333). The Get Up and Go test was reported to correlate to the BI with a score of r = -0.78. This score is negative due to the fact that the Get Up and Go test is a divergent test from the BI. This score also falls below the recommended score set forth by Burns & Grove of 0.80. The authors include excellent information on the instruments. However, they are deficient in explanation of the suitability of the tools used for their study. There are significant threats to internal validity of this study. The authors did not identify the possibility of skewed information, for example, the patients are being given the same test over and over again, and there is a possibility of repeated testing bias. Descriptive Analysis Evidence Padula et al. (2009) did not use many descriptive statistics in their research presentation. They have given two tables in their work, one that shows nursing staff characteristics by unit during the study period in hours between the treatment and control group, and another that shows Barthel scores (which reflect the subjects’ perception of functioning) preadmission, admission, and discharge between the treatment and control groups (p. 327 and 329). Support Burns and Grove (2011) defines descriptive statistics as “statistics that allow the researcher to organize the data in ways that give meaning and facilitate insight; such as frequency distributions and measures of central tendency and dispersion” (p. 536). Ways that this information can be given in a research article are in tables, charts, and graphs. There are

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many types of charts and graphs that can be used. The goal of descriptive statistics is to show the reader different examples of how the variables reflect and relate to each other (Burns and Grove, 2011, p. 389). Frequency distribution, a type of descriptive statistics, is “used to organize the data for examination. In this case tables are developed to display the values” (Burns and Groves, 2011, p. 384). Measures of control tendency, the average of the data, consist of the values for mode, median, mean, and midpoint (Burns and Groves, 2011, p. 385-387). Measures of dispersion, measures of individual differences of the members of the sample, include the variance, range, and standard deviation, which are usually shown in graphs (Burns and Groves, 2011, p. 388). “The purpose of this analysis is not to define causality, but to describe the difference in the variables and groups being studied” (Burns and Groves, 2011, p. 389). Analysis Padula et al. presented their data using limited descriptive statistics. As mentioned previously only two tables were used. The inclusion of additional graphs would have been more helpful to the reader and made it easier to understand their data and findings. This was a very weak section in their analysis. Inferential Statistics Evidence “Inferential statistics were used in this study to calculate the probability theory and the differences between the treatment and control group on the dependent variables” (Padula et al., 2009, p. 329). The majority of their probability testing gave results that were “nonsignificant”. The researchers calculated probability between the treatment and control groups on fall risk scores on admission. “The p score, or probability score, was documented as P=.07

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(about 7%), and the treatment group did have slightly lower scores than the control” (Padula et al., 2009, p. 329). Barthel scores were also calculated for probability. “Discharge scores improved for the treatment group from admission to discharge (P=.05), while the control group numbers were insignificant and actually had a slight increase by P=.006” (Padula et al., 2009, p. 329). “The treatment group did have a shorter length of stay on average than those in the control group with a probability score of P

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