Bland-Altman Agreement Analysis in Laboratory Research

September 9, 2024/in Uncategorized /by elias

Use of Bland-Altman agreement analysis in laboratory research: A survey of current reporting standards.

Introduction-

Advances in technology have led to development of new instruments and measurement devices in field of medicine. The clinicians and researchers often need to compare a newer method of measurement with an established one, to check for interchangeability. While assessing for interchangeability the emphasis should be on testing how well two methods agree with each other. Earlier Pearson’s product-moment correlation coefficient was used as a measure of agreement[R]. However the approach was inappropriate as this coefficient merely indicated association rather than agreement [R]. Hence Bland and Altman in their series of publications[R] stressed on quantification of bias. They provided a simpler and visually attractive plot for agreement analysis of continuous variables measured on the same scale.[R]

After its introduction to medical literature in 1983, the Bland-Altman’s (B-A) method [R] is one of most commonly used statistical method for agreement analysis. The method is extensively used in evaluating the agreement of laboratory analytes, physiological variables, newer instruments and other devices.

B-A method[R] advocates the construction of a scatter plot, where the absolute difference between the paired measurements is plotted on

y-axis

against the mean of two methods on

x-axis

. The SD of differences between paired measurements is then used to construct 95% limits of agreement (as ± 1.96 SD). The 95% of differences between paired measurements are expected to lie between these upper and lower LOA. The conclusions on agreement and interchangeability of two methods are then made based upon the width of these LOA in comparison to

a priori

defined clinical criteria[R]. The plot also enables the researcher to visually assess the bias, data scatter and the relationship between magnitude of difference and size of measurement. Often in biologic systems data scatter and the magnitude of differences increases proportionally to the size of the measurement (hetero-scedastic distribution). Bland and Altman recommended the logarithmic or percentage transformation of data in case of hetero-scedastic distribution and then constructing B-A plot with transformed data[R] instead of classical absolute difference plot.

Contrary to conventional statistical hypothesis testing, the output of B-A analysis consists of bias and LOA, both of which are estimates[R]. The estimates have inherent risk of sampling error and hence the authors suggested calculation of confidence interval (CI) of bias and LOA. The method also advocated the collection of data in replicates. Replicates are defined as two or more measurements on the same individual by the same method, taken in identical conditions. Replicates enable the comparison of the agreement between the two methods with the agreement each method has to itself (repeatability) [R] B-A also advocated for sample size calculations on in method comparison studies[R].

Despite its simplicity and frequent use in clinical laboratory research, the B-A method is not properly interpreted and reported in medical literature. Studies [R]conducted a decade ago highlighted poor reporting standards of B-A method, however there is paucity of current information on the same. Furthermore, uniform statistical reporting of results not only increases the generalizability of results, but also facilitates the inclusion of studies in systemic reviews and meta-analysis. Hence the aim of study was to review the current reporting standards of B-A method in laboratory research in medical literature.

Material and methods-

Three researchers (VC, RB, and SK) participated in this study. All researchers were qualified health professionals. VC and SK had previous experience of publishing laboratory research [R] with use of B- A agreement analysis.

Eligibility criteria-

Studies which tested agreement of laboratory analytes with continuous measurements, as per B-A methodology were included.

Literature search-

A thorough search of PUBMED, MEDLINE and GOOGLE SCHOLAR was conducted for studies published in years 2012 and 2013. The search strings used to search potential studies were “Agreement analysis” AND/OR “Bland Altman analysis” (MeSH) and “Laboratory analytes” and “clinical biochemistry” (MeSH). Included studies were evaluated according to Bland and Altman methodology on a predesigned checklist. The studies were evaluated for following 8 items: (1.) Measures of repeatability (2.) Representation and correct definition of LOA (3.) Correct representation of

x-axis

on BA plot (4.) Reporting of CI of LOA (5.) Comparison of limits of agreement with

a priori

defined clinical criteria (6.) Evaluation of pattern of relationship between difference (

y-axis

) and average (

x-axis

) (7.) Use of logarithmic or percentage conversion of data in case of heteroscedastic relationship between the difference and average (8.) Sample size calculations. Each item on the checklist was rated as ‘Yes’or ‘No’. We also recorded the data on use of other statistical methods for testing of agreement. However, we did not perform detailed evaluation of included studies for other statistical methods of agreement.

To ensure accurate data retrieval, each included study was evaluated twice by one author (VC) and data recorded on predesigned checklist. Opinion was taken from second author (SKK) in case of confusion arising during data extraction. We compared the results of our study with 3 similar surveys done earlier.

Results-

A total of 156 studies were screened for potential inclusion in the study. A total of 50 studies, were retrieved and included in the final study. The 38% of included studies were published in journals of various streams of internal medicine, while 30%, 26% and 6% were published in journals of laboratory medicine, emergency medicine, anaesthesia respectively. Results of survey and its comparison to three previous studies are as shown in

Table-1

.The other statistical methods used in addition to B-A plot in included studies were correlation coefficient (70%), Deming Regression(14%), Passing Bablok regression (14%), linear regression (24%), Lin’s Concordance (8%), Sensitivity specificity analysis (16%), Interclass correlation coefficient (6%), Grid error plot (10%), Critchley polar plots (2%).

Discussion-

Use of B-A for method comparison has increased in recent years with most of authors using it for analysing agreement. The original paper on agreement analysis by B-A[R] is among one of most cited statistical publication, with more than 34000 citations. Although claimed as a method which is simpler to perform and interpret, the method is often used and interpreted without proper understanding. Review by Berthelsen et al[R] in 2006 and earlier studies[R] demonstrated unsatisfactory reporting of B-A analyses, in anaesthesiology literature. Williamson et al[R] proposed a method of meta-analysis of method comparison studies, however authors also highlighted the problem of non-uniform reporting of studies. [R]

Twomey et al [R] suggested use of method hierarchy for selection of

x-axis

and advocated use of gold standard method as

x-axis

in B-A plot. However Bland and Altman statistically proved that use of any single method instead of average of two methods as

x-axis

is misguided and leads to misinterpretation[R]. Results of our study suggest that 94% of studies reported

x-axis

correctly, which is almost similar to results of earlier studies conducted by Mantha et al (94%) [R] and Dewitt et al (87%) [R]. although most method comparison computer softwares (analyse it, Graphpad Prism, EP evaluator) automatically select

x-axis

as mean of two methods, errors in selection of

x-axis

are still noticed.

The 95% LOA were correctly defined and drawn in 94 %( 47) of included studies. Further among 47 studies with correct definition of LOA, the 3 studies interpreted LOA wrongly concluding good agreement because 95 % of differences were present in-between upper and lower LOA. The 95 % LOA are in-fact drawn so as to contain 95% of differences between them. It is not LOA per se, but width of these LOA in comparison to

a priori

defined clinical criteria that conclusions regarding agreements can be made. The decision on acceptable differences between two methods is primarily clinical rather than statistical. Earlier studies by Dewitte et al [R]and Mantha et al[R] had shown that comparison with pre-defined clinical criteria was missing in >90% of studies. Total 74 % of authors in our study commented on agreement on basis of predefined clinical criteria which represents a significant improvement in reporting standards. The specifications for clinical acceptance criteria of laboratory analytes have been provided as by Ricos et al[R], CLSI[R], and West guard QC[R]. Alternatively a Delphi survey (expert opinion) can be done to determine acceptable limits before instituting study.

The CI limits of LOA were reported in only 6% of included studies in our study. The LOA are estimates and reporting LOA without CI is equivalent to reporting a sample mean without its CI. The CI limits [Ludbrook et al] represent the range within which a single, new, observation taken from the same population would be expected to lie. Although strongly recommended by B-A[R], and subsequently proved by a simulation study conducted by Hamilton et al[R], the statistical reporting of CI of LOA has remained poor (Mantha et al-2.6%) [R].

Although recommended by B-A method, the pattern of relationship between difference and wider concentration range is rarely evaluated[R]. Drawing difference plot with parallel LOA in datasets with heteroscedastic scatter makes LOA wider in lower concentration range and narrower in higher concentration range thus affecting validity of interpretation. [R] Bland and Altman [R]proposed logarithmic transformation of data with heteroscedasticy and then constructing difference plot against average of two methods using log transformed data. For meaningful understanding of LOA, they suggested back-transformation (antilog) of the log transformed data. Alternatively[R] plot of ratios of two methods or percent difference can be plotted against average of two methods for simpler interpretation. Transformation of data usually renders the scatter of differences as uniform (Homoscedastic). Twomey et al[R] recommended the drawing up of funnel shaped or V shaped LOA instead of classical parallel LOA in data sets with heteroscedastic scatter. Another option is breaking the data into smaller subsets and then analysing these subsets with absolute difference plot to make conclusions. [Twomey et al] We observed that only 28 % of studies made an attempt at evaluation of pattern of scatter. Rest of authors did not comment on pattern thus affecting the validity of results.

Another important problem noticed was lack of assessment of repeatability (38%), a practice that has not shown any substantial improvement

Table-1

. Conclusions drawn from studies without repeatability assessment are likely to be uncertain. Assessment of errors of the two methods (repeatability) enables the construction of the worst-case acceptable LOA. [R] With poor repeatability of one or both methods, the agreement between the two methods is bound to be unacceptable. [R]

Sample size calculations were done in only 15 studies. Lack of power and sample size analysis reduces validity of results. Different researchers have proposed sample size calculation for method comparison studies using Bayesian[R], regression[R], or concordance [R] approach. However Stockl et al[R] proposed an approach incorporating CI of LOA and predefined error limits in B-A plot. The approach is simple and allows for visual interpretation of appropriate sample size, as the classical B-A plot provides for agreement.

Despite a lot of research on B-A method in field of statistics, the uptake of the method in medical research has been slow. While efforts are on in statistical community for use of modifications of B-A plot in special situations like repeated measure studies[R] or using bar charts in B-A plots with limited value ranges[R], unfortunately reporting standards of classical B-A method among medical community are unacceptable. Guidelines “Reporting reliability and Agreement Studies (GRRAS)” were published as a guide to appropriate reporting of reliability and agreement studies. We found unsatisfactory reporting of B-A analysis in our study.

The Assessment Process Of Patients In Intensive Care

September 9, 2024/in Uncategorized /by elias

This essay will present a reflective account of communication skills in practice whist undertaking assessment and history taking of two Intensive Care patients with a similar condition. It will endeavour to explore all aspects of non verbal and verbal communication styles and reflect upon these areas using Gibbs reflective cycle (1988).

Scenario A –

Mrs James, 34, a passenger in a road traffic collision who was not wearing a seatbelt was thrown through the windscreen resulting in multiple facial wounds with extensive facial swelling which required her to be intubated and sedated. She currently has cervical spine immobilisation and is awaiting a secondary trauma CT. Mr James was also involved in the accident.

Scenario B –

Mr James, 37, husband of Mrs James, the driver of the car, was wearing his seat belt. He had minor superficial facial wounds, fractured ribs and a fractured right arm. He is alert and orientated but currently breathless and requiring high oxygen concentrations.

Patients who are admitted to Intensive Care are typically admitted due to serious ill health or trauma that may also have a potential to develop life threatening complications (Udwadia, 2005). These patients are usually unconscious, have limited movement and have sensation deprivation due to sedation and/or disease processes. These critical conditions rely upon modern technical support and invasive procedures for the purpose of monitoring and regulation of physiological functions. Having the ability to effectively communicate with patients, colleagues and their close relatives is a fundamental clinical skill in Intensive Care and central to a skilful nursing practice. Communication in Intensive Care is therefore of high importance to provide information and support to the critically ill patient in order to reduce their anxieties and stresses. Effective communication is the key to the collection of patient information, delivering quality of care and ensuring patient safety.

Gaining a patients history is one of the most important skills in medicine and is a foundation for both the diagnosis and patient – clinician relationship, and is increasingly being undertaken by nurses (Crumbie, 2006). Commonly a patient may be critically ill and therefore the ability to perform a timely assessment whilst being prepared to administer life saving treatment is crucial. Often the patient is transferred from a ward or department within the hospital where a comprehensive history has been taken with documentation of a full examination; investigations, working diagnosis and the appropriate treatment taken. However, the patient’s history may not have been collected on this admission if it was not appropriate to do so. Where available patients medical notes can provide essential information.

In relation to the scenarios where the patient is breathless or the patient had a reduced conscious level and requires sedation and intubation, effective communication is restricted and obtaining a comprehensive history would be inappropriate and almost certainly unsafe. The Nursing Midwifery Council promotes the importance of keeping clear and accurate records within the Code: Standards of Conduct, performance and ethics for nurses and midwives (NMC, 2008). Therefore if taking a patients history is unsafe to do so, this required to be documented.

Breathing is a fundamental life process that usually occurs without conscious thought and, for the healthy person is taken for granted (Booker, 2004). In Scenario A, Mrs James’s arrived on Intensive care and was intubated following her facial wounds and localised swelling. Facial trauma by its self is not a life threatening injury, although it has often been accompanied with other injuries such as traumatic brain injury and complications such as airway obstruction. This may have been caused by further swelling, bleeding or bone structure damage (Parks, 2003). Without an artificial airway and ventilatory support Mrs James would have struggled to breathe adequately and the potential to become in respiratory arrest. Within scenario B, Mr James had suffered multiple rib fractures causing difficulty in expansion of his lungs. Fractured ribs are amongst the most frequent of injuries sustained to the chest, accounting for over half of the thoracic injuries from non-penetrating trauma (Middleton, 2003). When ribs are fractured due to the nature and site of the injury there is potential for underlying organ contusions and damage. The consequence of having a flail chest is pain. Painful expansion of the chest would result in inadequate ventilation of the lungs resulting in hypoxia and retention of secretions and the inability to communicate effectively. These combined increase the risk of the patient developing a chest infection and possible respiratory failure and potential to require intubation (Middleton, 2003).

The key issue of Intensive Care is to provide patients and relatives with effective communication at all times to ensure that a holistic nursing approach is achieved.

Intensive care nurses care for patients predominantly with respiratory failure and over the years have taken on an extended role. They are expected to examine a patient and interpret their findings and results (Booker, 2004). In these situations patient requires supportive treatments as soon as possible. Intensive Care nurse should have the ability and competence to carry out a physical assessment and collect the patients’ history in a systemic, professional and sensitive approach. Effective communication skills are one of the many essential skills involved in this role.

As an Intensive Care nurse, introducing yourself to the patient as soon as possible would be the first step in the history and assessment taking process (Outlined in Appendix A). Whilst introducing yourself there is also the aim to gaining consent for the assessment where possible, in accordance with the Nursing and Midwifery Council’s Code of Professional Conduct (NMC, 2008). Conducting a comprehensive clinical history is usually more helpful in making a provisional diagnosis than the physical examination (Ford, 2005). Within Intensive Care the Airway, Breathing, Circulation, Disability, Exposure/Examination (ABCDE) assessment process is widely used. It is essential for survival that the oxygen is delivered to blood cells and the oxygen cannot reach the lungs without a patent airway. With poor circulation, oxygen does not get transported away from the lungs to the cells (Carr, 2005). The ABCDE approach is a simple approach that all team members use and allows for rapid assessment, continuity of care and the reduction of errors.

Communication reflects our social world and helps us to construct it (Weinmann & Giles et al 1988). Communication of information, messages, opinions, speech and thoughts are transferred by different forms. Basic communication is achieved by speaking, sign language, body language touch and eye contact, as technology has developed communication has been achieved by media, such as emails, telephone and mobile technology (Aarti, 2010). There are two main ways of communication: Verbal and non verbal.

Verbal communication is the simplest and quickest way of transferring information and interacting when face to face. It is usually a two way process where a message is sent, understood and feedback is given (Leigh, 2001). When effective communication is given, what the sender encodes is what the receiver decodes (Zastrow, 2001). Key verbal features of communication are made up of sounds, words, and language. Mr James was alert and orientated and had some ability to communicate; he was breathless due to painful fractured ribs which hindered his verbal communication. In order to help him to breath and communicate effectively, his pain must be controlled. Breathless patients may be only able to speak two or more words at a time, inhibiting conversation. The use of closed questions can allow breathless patients to communicate without exerting themselves. Closed questions such as “is it painful when you breathe in?” or “is your breathing feeling worse?” can be answered with non verbal communication such as a shake or nod of the head. Taking a patients history in this way can be time consuming and it is essential that the clinician do not make assumptions on behalf of the patient. Alternatively, encouraging patients to use other forms of communication can aid the process. Non verbal communication involves physical aspects such as written or visual of communication. Sign language and symbols are also included in non-verbal communication. Non verbal communication can be considered as gestures, body language, writing, drawing, physiological cues, using communication devices, mouthing words, head nods, and touch (Happ et al, 2000). Body language, posture and physical contact is a form of non verbal communication. Body language can convey vast amounts of information. Slouched posture, or folded arms and crossed legs can portray negative signals. Facial gestures and expressions and eye contact are all different cues of communication. Although Mr. James could verbally communicate, being short of breath and in pain meant that he also needed to use both verbal and non verbal communication styles.

A patient’s stay in Intensive Care can vary from days to months. Although this is a temporary situation and many patients will make a good recovery, the psychological impact may be longer lasting (MacAuley, 2010). When caring for the patient who may be unconscious or sedated and does not appear to be awake, according to Sisson (1990) hearing may be one of the last senses to fade when they become unconscious. Sedation is used in Intensive Care Units to enable patients to be tolerable of ventilation. It aims to allow comfort and synchrony between the patient and ventilator. Poor sedation can lead to ventilator asynchrony, patient stress and anxiety, and an increased risk of self extubation and hypoxia. (Ramsey et all, 2000). Over sedation can lead to ventilator associated pneumonias, cardiac instability and prolonged ventilation and Intensive Care delirium. Delirium is found to be a predictor of death in Intensive Care patients (Page, 2008). Every day a patient spends in delirium has been associated with a 20% increase risk of intensive care bed days and a 10% increased risk of morbidity. The single most profound risk factor for delirium in Intensive Care is sedation. Within this stage of sedation or delirium it is impossible to know what the patients have heard, understood or precessed. Ashworth (1980) recognised that nurses often failed to communicate with unconscious patients on the basis that they were unable to respond. Although, research (Lawrence, 1995) indicates that patients who are unconscious could hear and understand conversations around them and respond emotionally to verbal communication however could not respond physically. This emphasises the importance and the need for communication remains (Leigh, 2001). Neurological status would unavoidably have an effect on Mrs James’s capacity to communicate in a usual way. It is therefore important to provide Mrs James with all information necessary to reduce her stress and anxieties via the different forms of communication. For the unconscious patient, both verbal communication and non verbal communication are of importance, verbal communication and touch being the most appropriate. There are two forms of touch (Aarti, 2010), firstly a task orientated touch – when a patient is being moved, washed or having a dressing changed and secondly a caring touch – holding Mrs James hand to explain where she was and why she was there is an example of this. This would enhance communication when informing and reassuring Mrs James that her husband was alive and doing well. Nurses may initially find the process of talking to an unconscious patient embarrassing, pointless or of low importance as it is a one way conversation (Ashworth, 1980) however as previously mentioned researched shows patients have the ability to hear. Barriers to communication may be caused by physical inabilities from the patients however there are many types of other communication barriers. A barrier of communication is where there is a breakdown in the communication process. This could happen if the message was not encoded or decoded as it should have been. If a patient is under sedation, delirious or hard of hearing verbal communication could be misinterpreted. However there could also be barriers in the transfer of communication process (Kirby, 1997). The Intensive Care environment in itself can cause communication barriers. Intensive Care can be noisy environment with monitor and ventilator alarms and general movement of patients and staff, ensuring effective communication with explanations of the alarms at all times can alleviate any anxieties the patient and relatives may have. Other barriers can simply include language barriers, fatigue, stress, distractions and jargon. Communication aids can promote effective communication between patient and clinician. Pen and paper is the simplest form of non verbal communication for those with adequate strength. Weakness of patients can affect the movement of hands and arms making gestures and handwriting frustration and difficult. Patients may also be attached to monitors and infusions resulting in restricted movements which can lead to patients feeling trapped and disturbed (Ashworth, 1980). MacAulay (2010) mentions that Intensive Care nurses are highly skilled at anticipating the communication needs of patients who are trying to communicate but find the interpretation of their communication time consuming and difficult. The University of Dundee (ICU-Talk, 2010) conducted a three year multi disciplinary study research project to develop and evaluate a computer based communication aid specifically designed for Intensive Care patients. The trial is currently ongoing, however this may become a breakthrough in quick and effective patient – clinical and patient – relative communication in future care.

This assignment has explored communication within Intensive Care and reflected upon previous experiences. Communication involves both verbal and non verbal communication in order to communicate effectively in all situations. Researching this topic has highlighted areas in Intensive Care nursing which may be overlooked, for example ventilator alarms and general noise within a unit may feel like a normal environment for the clinians however for patients and relatives this may cause considerable amounts of concern. Simply giving explanations for such alarms will easily alleviate concerns and provide reassurance. From overall research (Alasad: 2005, Leigh: 2001, MacAuley, 2010: Craig, 2007) Intensive Care nurses believed communication with critically ill patients was an important part of their role however disappointedly some nurses perceived this as time consuming or of low importance when the conversation was one way (Ashworth, 1980). Further education within Intensive Care may be required to improve communication and highlight the importance of communication at all times. Communication is key to ensuring patients receive quality high standard care from a multidisciplinary team, where all members appreciate the skills and contribution that others offer to improve patients care.

The Malpractices Of Hand Hygiene In Nursing Staff

September 9, 2024/in Uncategorized /by elias

Hand washing practices are deteriorating day by day at public sector hospitals despite adequate knowledge. This study enlightens an approach to evaluate the knowledge and practice of standard hand hygiene in nursing staff to identify the causes of not adapting hand hygiene techniques during routine patient care work.

METHOD:

A cross sectional study was carried out from 15th May to 25th November 2010. A sample of 335 nursing staff was selected and was asked about their practices of hand hygiene through structured questionnaire at five major public sector hospitals of Karachi.

RESULTS:

The survey revealed that out of 335 nursing personnel, 71.6% were absolutely unaware of the fact that hand washing for 30 sec to 1 min can minimize the majority of infections, although 74.62% were aware of the fact that when hand washing is necessary to practice. Regarding practice, 35.5% use sanitizers while 47.2% use antiseptic or normal soap for washing hands, 67.8% practice hand washing before & after coming in contact with patients. Only 43.7% took some treatment after needle prick while others having more experience do not feel the necessity to take any treatment. Only 36.1% adopt sterile techniques after hand washing. Surveillance was below average (46.6%). The striking reasons found for poor practices were either lack of knowledge, facilities or intense patient flow. The survey also revealed that as the experience advances, the enthusiasm to work decreases.

CONCLUSION:

Hand hygiene knowledge and practice of nursing staff is part & parcel for minimizing infections. So, adequate hand washing facilities, adherence to practice and strict surveillance system for hand hygiene is essential to combat increasing incidence of infections.

INTRODUCTION:

Hand hygiene is considered to be the most effective measure to prevent microbial pathogens cross-transmission, healthcare-associated infections and the spread of anti-microbial resistance. The skin on our hands is our first defense against infection from pathogenic organisms. Hands are also the most likely way in which infections or microorganisms spread between people. So washing hands is simply the most effective method of preventing the transmission of infections.

The Centers for Disease Control and Prevention (CDC) and other healthcare-related organizations believe that cleaning hands before and after having contact with patients is one of the most important measures for preventing the spread of infections in healthcare settings.

Hand hygiene is a major component of standard precautions and one of the most effective methods to prevent transmission of pathogens associated with health care.(1) It is considered to be the primary measure to reduce the transmission of nosocomial infections.(2-5) Noncompliance with hand hygiene, however, remains a major problem in tertiary care public sector hospitals in Pakistan.

According to World Health Organization (WHO), the five moments you must remember to wash your hands after;

Before Patient contact

Before aseptic task

After body fluid exposure

After Patient contact

After contact with patient

Health Education is one of the cornerstones for improvement with hand hygiene practices. Health Care Worker education must be promoted at all levels of experience.(6,7) This study high-lights the lacking in practices of standard hand hygiene in nursing staff and their attitude to maintain proper hand hygiene with increasing experience.

METHODS:

Design & Setting: A cross sectional study was carried out in Karachi in various public sector hospitals i.e. Jinnah Post-graduate & Medical Centre (JPMC), National Institute of Child Health (NICH), Civil Hospital Karachi, Sindh Institute of Urology & Transplantation (SIUT) and National Institute of Cardiovascular Diseases (NICVD).

The study completed in six months from 15th May to 25th November 2010. The required permission was obtained from the administrators of various departments prior to study.

Nursing staff & Trainees working in the public sector Hospitals, departments of Medicine & Allied, Surgery & Allied, Gynecology & Obstetrics and Pediatrics were included.

A pilot study was carried out in Jinnah Post-graduate Medical Centre (JPMC) to test the applicability and consistency of the tools.

The sampling technique used is convenient sampling and a sample size of 335 has been taken by keeping a population result of 68.8% with 95% confidence interval (95% Cl) and 5% margin of error, rest could not be accessible due to non-willingness. P-value of less than 0.05 was considered as statistically significance.

The study protocol was approved by Research Supervisor, Community Medicine Department, Sindh Medical College (DUHS), and an informed consent was taken from the subjects who were personally interviewed through a structured questionnaire.

Nursing personnel working in these hospitals were evaluated according to the World Health Organization (WHO) protocol based on basic concepts of hand hygiene & its parameters.

Data Analysis: The significance of the data was determined by using Statistical Package of Social Sciences software (SPSS, Version 16.0). The results are expressed as frequencies and percentages, cross tabulations, pie charts and bar charts.

RESULTS:

Out of 335 individuals, 219 (65.37%) were females and 116 (34.62%) are males including 183 (54.6%) staff nurses & 152 (45.6%) trainees having ages between16 years to 50 years.

74.62% has sufficient knowledge about the benefits of hand washing while the facilities were available only to 34.3%. Regarding knowledge, 71.6% don’t even know that running water for 30 seconds to 1 minute can wash out most of the micro-organisms from their hands leaving only 28.4% with this piece of knowledge.

Regarding practice, 83.3% staff was daily getting exposed to body fluids (blood/urine/CSF/peritoneal fluid etc). 66% of the staff claimed that it is common that they do not practice hand washing due to heavy rush of patients.

Only 34% said that they properly practice hand washing in heavy rush of patients. 56.4% remembered that they had needle prick during their nursing practice atleast once & 43.6% couldn’t recall or didn’t have needle prick. Only 43.7% took some treatment for the needle prick while the rest were satisfied with washing hands with plain water.

78.2% were vaccinated & 72.2% were screened against HBV. 90.4% were having the provision to take sick leave. 35.5% use sanitizers while 47.2% use antiseptic or normal soap. About 90.4% and 83.9% of staff were available with disposable gloves & needles respectively. 85.7% staff has cutter boxes to dispose needles. Surveillance for nursing staff regarding hand hygiene was a mere 46.6%.

DISCUSSION:

Poor hand hygiene is the main source of infections amongst nursing staff as well as in patients. The study highlights the lack in practice of hand hygiene by nursing staff. World Health Organization has given reviewed results of different studies done worldwide about hand hygiene which showed that the adherence of health care workers to recommended hand hygiene procedure was unacceptably poor with the overall average of about 40 %.(8)

The present study showed that 74.62% nursing staff knew about the significance of hand washing but the basic knowledge was lacking. For instance, 71.6% of nursing staff was not aware of the fact that keeping hands under running water for 30 seconds can decontaminate hands to quite an extent. Regarding practice, 67.1 % washed their hands before and after attending the patient. But many of them didn’t use sterile technique s after washing hands. Reason behind malpractice were found to be heavy rush of patients in public sector hospital resulting in low staff to patient ratio and also lack of proper surveillance system. Another contributing factor was experience of the nursing staff as it was traced that as the experience increases, the enthusiasm to work properly decreases. Most of the nursing staff had experienced needle prick out of which less than half had taken some treatment. Figure 1 shows the number of subjects taking treatment after a needle prick compared to advancing experience.

Previously, many studies have been carried-out worldwide regarding hand hygiene amongst nursing staff. In our study it was found that 74.62% nursing staff had sufficient knowledge but only 66% were practicing it. It also showed that 34.3% had facilities available for hand washing. A very similar observational study was done locally at a major public sector hospital in Karachi, and it showed that 68.8% had sufficient knowledge about hand washing but 59% were practicing it, while 16.8% were provided with hand washing facilities.(9)

In our study a positive attitude was significantly higher among younger individuals who were working as trainee and about 67.1% decontaminate their hands before and after coming in contact with patients while compliance for invasive procedures was 92.8%. Fig 2 discusses the relationship of knowledge and practice of hand hygiene with experience.

Another study done in Italy showed that hand hygiene practice was significantly higher among the older personnel and in those with the high level of knowledge and 72.5% decontaminate hands before and after patient contact. High compliance is reported for invasive maneuvers (96.5%).(10) Regarding needle prick, our study revealed that only 43.7% took some treatment after needle prick. While a study done in the US showed that a large proportion of respondents did not take any treatment after needle prick.(11)

In our study, 71.6% of the staff did not even know that washing hands under running water for 30 seconds can wash out most of the micro-organisms but a study in Peru showed that mean duration for hand washing following patient contact is 14.5 seconds.(12)

According to our study, the surveillance system was found to be 46.6% while a study in Switzerland showed that compliance improved progressively from 48% in 1994 to 66% in 1997 after implementing proper surveillance program, because of same frequency of hand disinfection substantially increased during the study period and overall nosocomial infections decreased from 16.9% in 1994 to 9.9% in 1997. (13)

We also found that 35.5% of staff use sanitizer for hand washing and it was revealed in a study that adherence to hand washing increased significantly since the introduction of waterless hand sanitizers from 73% to 83% before and 80% to 90% after patient contact.(14)

The following are a number of recommendations for improving hand hygiene in nursing staff at government setup hospitals.

1. Informative sessions, trainings should be arranged regularly for nursing staff at government hospitals in order to constantly upgrade their knowledge regarding appropriate hand washing techniques as nurses with more knowledge decontaminate hands more appropriately.(15,16)

2. A system of proper surveillance should be installed in different wards in order to ensure the compliance to strict hand hygiene techniques.

3. Standard facilities – including wash basins, antiseptics scrubs etc – should be provided at all govt. hospitals to encourage adherence to proper techniques of hand washing.

4. Alcohol rubs should be provided at all wash basins as they are time saving as well as extremely effective.(17)

5. Patient should be made aware of their rights and be encouraged to interrogate the nursing staff regarding hand hygiene techniques adopted at the beginning of every procedure.

6. Different competitions could be arranged for paramedical staff in order to assess their knowledge regarding hand washing.

CONCLUSION:

Hand hygiene, knowledge and practice of nursing staff is part & parcel for minimizing infections among nursing staff as well as in patients they are attending. So, adequate hand washing facilities, adherence to practice and strict surveillance system for hand hygiene is essential to combat increasing incidence of infections. Nursing staff should be highly aware of the consequences of needle prick so proper treatment should be sorted in such a scenario. Upgrading knowledge regarding hand hygiene of nursing staff should be a part of routine.

Increasing experience was associated with decreased practice so a strict and proper surveillance system should be equally implied on every nursing personnel. Provision of health education through TV, print media, seminars & workshops are necessary too.

“THE HYGIENE WAS THE MOST IMPORTANT THING AS FAR AS KEEPING EVERY ONE HEALTHY.”

-CHRIS LANE-

ACKNOWLEDGEMENTS:

:Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name?Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name? The name and address? Is a medical record like a finger print? ( Use your own words and do not copy )

September 9, 2024/in Uncategorized /by elias

:Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name?Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name? The name and address? Is a medical record like a finger print? ( Use your own words and do not copy )

:Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name?

1. Discuss how much redaction is necessary to anonymize an electronic health record. Is it enough to redact the name? The name and address? Is a medical record like a finger print? ( Use your own words and do not copy )

Employee Satisfaction At Walmart

September 9, 2024/in Uncategorized /by elias

Employee Satisfaction At Walmart

Abstract

This study was conducted with the main objective of determining the level of employee satisfaction at Walmart. Given that the significance of employee satisfaction has been affirmed in literature, this research sought to determine whether employees at Walmart are satisfied or not. In addition, the study explored the perceptions of Walmart’s employees towards measures undertaken by the company to satisfy them. The study used a quantitative research design, wherein participants were selected randomly provided they were employees at the selected company (Walmart). Walmart was selected for this research because of the researcher’s inherent interest in the organization as well as the fact that the company has been consistently used as a case for worst employment relationships, particularly in the retail industry. The sample size for this research comprised of 50 Walmart employees, who were randomly selected. The primary data collection tool used in this study was the questionnaire, with responses being assessed using five-point likert scales. Evidence from the research suggests the following trends at Walmart:

Walmart’s employees not satisfied with their jobs; unsatisfied employees at Walmart are more likely to quit; employees at Walmart are more than moderately satisfied with workplace conditions and pays and promotions; employees at Walmart are not satisfied in terms of fair rewarding; and employees are moderately satisfied with employment evaluations, employee wellness programs, employee training and development, and perks and benefits. To this end, a number of recommendations were made for Walmart: (i) Walmart should expand its employee training and development opportunities, ensure that there is fair rewarding of employees, offer better pays as well as opportunities for promotion, and expand its employee wellness programs; (ii) Walmart should undertake an internal employee survey to determine which aspects need improvement; this will help in reducing the number of employees with intending to quit.

Employee Satisfaction at Walmart

Introduction

Background of the Study

The United States retail industry comprises of well-established distribution channels catering for diverse retail companies (Bustillo & Talley, 2011). Fishman (2006) stipulates that the retail service industry is the United States offers a competitive and open environment that cultivates innovation and strong business operations, which in turn, increases reliability and efficiency. Data from the US Commerce Department reports that, in 2011, the US retail industry reported total sales of $ 4.7 trillion from the 3.6 million establishments, which was an increase of 8% when compared to the previous year (Bustillo & Talley, 2011). In addition, Fishman (2006) reported that the retail industry provides employment to more than 42 million Americans. Data from the National Retail Federation points out that the 2012 retail industry sales were forecasted to increase by 3.4% relative to the 2011 sales. Walmart Stores Inc. is one of the major players in the United States retail industry. Walmart is a multinational retail corporation running several warehouse stores and discount department stores (Ingram, Lori, & Hayagreeva, 2010). The corporation third in terms of the largest public corporation globally and is consider the biggest private employer globally, providing employment to at least 2 million people across the globe. In addition, Walmart ranks third in terms of the largest retailers globally. The corporation was established in 1962 and later incorporated in 1969. At present, Walmart operates 8500 stores distributed in 15 countries, albeit under different names. For instance, in the United States, the company uses Walmart; in Mexico, the company operates as Walmex; in India, it operates as Best Price; in Japan, it operates as Seiyu; and in the UK, it operates as Asda (Ingram, Lori, & Hayagreeva, 2010). With the business environment adapting to new business concepts, methodologies and technologies, corporations are finding it extremely significant to make effective use of their most important asset: human resources. There is no doubt that human resources is linked to a company’s bottom line; simply stated, companies that make optimal use of their human resources perform better than companies that fail to get the best out of their employees. According to Armstrong (2003), organizations can only make the best use of their employees if they are satisfied. In this regard, employee satisfaction is a critical success factor in the contemporary business environment.

According to Ashar, Ghafoor, Munir, & Hafeez (2013), employee satisfaction describes the degree to which employees in an organization are happy and contented with regard to fulfilling their needs as well as desires at work. Several empirical studies have affirmed that employee satisfaction plays a pivotal role in influencing their goal attainment, motivation and positive employee morale. Studies have pointed out a number of variables that influence employee satisfaction, which include efforts aimed at employee empowerment, offering perks, offering compensation and benefits that are above the industry-average, recognition of employee’s efforts regularly, and positive management (Ashar, Ghafoor, Munir, & Hafeez, 2013; Chi & Gursoy, 2009; Armstrong, 2003). A number of studies have established a positive correlation between the level of employee satisfaction and the salaries and wages offered to employees.

According to Yee, Yeung, & Cheng (2008), no organization can realize its goals and objectives if does not have the right set of employees. As aforementioned, employees play a significant role in organizational success, especially in the contemporary business environment. Perhaps, this elucidates why firms are increasingly embarking on the allocation of extensive resources and efforts aimed at attracting and retain the top talent (Yazdani, Yaghoubi, & Giri, 2011). An empirical survey undertaken by Noe (2008) pointed out that most firms determine employee performance by using their amount of skills and knowledge; nevertheless, these firms underestimate the crucial role that employee satisfaction play in determining their performance. Studies by McDonald & Makin (2000) and Mauno, Kinnunen, & Ruokolainen (2007) have established a positive correlation between employee satisfaction and performance. In the light of this view, Lockwood (2004) recommends that, for an organization to make optimal use of its employees, it ought to devise the best strategies aimed at satisfying the needs and requirements of its workforce.

Employee satisfaction is positively related to customer satisfaction and service quality (Yee, Yeung, & Cheng, 2008; Noe, 2008; McDonald & Makin, 2000; Mauno, Kinnunen, & Ruokolainen, 2007), which are linked to profitability. According to Lee & Bruvold (2003), employee empowerment is one of the most effective strategies that firms can use to satisfy and retain their employees. Employee satisfaction is positively related to employee retention, which implies that satisfied employees are less likely to leave the organization in search for other opportunities elsewhere. Employee retention refers to the ability of an organization to retain its workforce. All organizations seek to lessen employee turnover, which translates to a reduced loss of talent and loss knowledge as well as a reduction in the recruitment and training costs (Lockwood, 2004; Lee & Bruvold, 2003). Lloyd (2002) articulates a number of measures that organizations can deploy to ensure high employee satisfaction and retention rates, which may include offering competitive benefits packages. Providing employees with financial incentives, offering employee with training and development opportunities, and ensuring that employees are aware of what is expected from them by the organization (LLoyd, 2002; Kim, 2002).

According to Karsh, Booske, & Sainfort (2005), employee satisfaction is an indicator of work behaviors, which may include organizational citizenship as well as withdrawal behaviors like turnover and absenteeism. In addition, employee satisfaction has been established to partially mediate the link between deviant work behaviors and personality variables (Karsh, Booske, & Sainfort, 2005; Iveta, 2012). Several studies have established a link between life satisfaction and employee satisfaction. Nevertheless, Fishman (2006) points out that these relationship is reciprocal, in the sense that an employee satisfied with his/her life is likely to be satisfied with work; similarly, an employee who is satisfied with his work is likely to be satisfied with his/her life. A significant finding for firms is that employee satisfaction is correlated to their productivity on the job. Emerson (2012) points out that this is crucial to businesses and researchers; this is because the notion that a direct relationship employee satisfaction and their performance exists is often mentioned in the media as well as in a number of non-academic management literature. However, a meta-analysis by Lee & Bruvold (2003) reported astoundingly low correlations existing between employee performance and job satisfaction. In addition, the meta-analysis pointed out that the relationship between employee performance and job satisfaction is often moderated by the level of job complexity in the sense that, for jobs that are highly complex, there is a higher correlation between employee performance and job satisfaction than for the case of jobs with low and moderate complexity (Brown & Lam, 2008). Moreover, a longitudinal study by Emerson (2012) pointed out that among the various work attitudes, employee satisfaction is considered a strong predictor for employee absenteeism, which suggests that devising measures to increase organizational commitment and employee satisfaction can be effective in reducing turnover and absenteeism. Studies have also pointed out that the intent to quit can have negative outcomes on employee performance, organizational citizenship behaviors and organizational deviance.

With regard to the retail industry, Armstrong (2003) asserts that Walmart is famed for having the worst employment relationships. Does this reputation translate to unsatisfied or satisfied employees at Walmart? Given that the significance of employee satisfaction has been affirmed in literature, this research seeks to determine whether employees at Walmart are satisfied or not.

Research Hypothesis

The primary objective of this study is to determine the level of employee satisfaction at Walmart. In order to achieve this objective, the following research hypotheses were used to guide the study:

H1: Employees at Walmart are not satisfied with their jobs

H2: Unsatisfied employees at Walmart are more likely to quit

H3: Employees at Walmart are not satisfied with the measures adopted by the company to satisfy and retain them (Employee evaluations, employee wellness programs, employee training and development, perks and benefits, pays and promotions, fair rewarding, and workplace conditions).

Research Methodology

Fisher (2007) asserts that the research methodology is a “general plan that outlines the steps required by the researcher to collect data in order to answer the research questions.” In any form of research, the research design can be either qualitative or quantitative, or a mix of both. This study used a quantitative research design, which entails the collection and analysis of quantifiable data using statistical techniques to determine the relationship between variables. It is evident that this study is confirmatory in nature, which poses the need to make use of quantitative research design. A confirmatory study is often recommended in situations where the research problem is clearly defined. In this regard, the study sought to confirm whether the reports of worst employment relationships at Walmart are true or not.

With regard to sampling, Fisher (2007) asserts that probabilistic sampling is recommended because it guarantees the validity of the study and lessens researcher bias. In this regard, this investigation used random sampling, wherein respondents were chosen randomly without any inclusion or exclusion criteria, provided that they were employees of Walmart. Walmart was selected for this research because of the researcher’s inherent interest in the organization as well as the fact that the company has been consistently used as a case for worst employment relationships, particularly in the retail industry. The sample size for this research comprised of 50 Walmart employees, who were randomly selected.

With regard to data collection, this study used primary data collected using questionnaires. A questionnaire is defined as “a self-administered instrument for asking questions” (Fisher, 2007, p. 125). The questionnaire for this study was designed to collect responses from Wal-Mart’s employees regarding their levels of job satisfaction, as well as their perceptions and attitudes towards the measures adopted by the company aimed at increasing their satisfaction. Prior to collecting data, the company was contacted and the researcher sought the permission of the company to use its staff in the study. In the questionnaire issued to respondents, the following information was observed:

Employee’s profile information: age, gender and years worked for Walmart;
Their levels of satisfaction with their jobs;
Their intention to quit or remain at the company;
Their perceptions and attitudes towards the measures adopted by the company to satisfy them.
Responses in the questionnaire were assessed using a five-point likert scale, with 1 indicating strongly dislike/dissatisfied and 5 indicating strongly like/satisfied. Data collected using the questionnaires were entered into SPSS version 20 for data analysis. The statistical tools used to analyze the quantitative data included measures of dispersion (standard deviation), measures of central tendency (mean) and the one-sample independent test.

Data/Findings

Respondents Characteristics

Age:

The table below shows the characteristics of the respondents basing on age:

Response Count Percent (%)
18-25 10 20
25-35 18 36
35-45 11 22
Above 45 11 22

Gender:

The table below shows the characteristics of the respondents basing on gender:

Response Count Percentage (%)
Male 27 54
Female 23 46

Years Worked at Walmart:

Years Worked At Walmart Response Count Percentage (%)
Less than 1 year 4 8
2-5 years 12 24
5-10 years 25 50
More than 10 years 9 18
Total 50 100

Level of Job Satisfaction

Level of Satisfaction Response Count Percentage
Not at all satisfied 7 14
Slightly satisfied 21 42
Moderately satisfied 9 18
Very satisfied 10 20
Extremely satisfied 3 6
Total 50 100

From the table above, it is evident that a significant percentage of employees at Walmart (42%) are satisfied with their jobs. A one-sample t-test was conducted to evaluate the significance of this finding with a test (hypothesized) value of 3, which moderately satisfied.

From the above one-sample t-test, the mean level of employee satisfaction at Walmart is M = 2.62, p< 0.05; this implies that difference between mean level of employee satisfaction and the hypothesized value of 3 is statistically significant. As a result, it can be concluded that employees at Walmart are not satisfied with their jobs; therefore, H1 is valid.

The Intention to Quit

One-way ANOVA was used to determine the link between the intention to quit and employee satisfaction at Walmart.

From the test, it is evident that those intending to quit had a mean satisfaction level of M = 2 while those with no intention to quit had a mean satisfaction level of M = 3.94, p

Level of Satisfaction and Attitudes towards Measures Adopted by Walmart to Satisfy Employees

This was measured using the ratings provided by employees with regards to their attitudes and perception of the various measures that Walmart uses to satisfy its employees. A one-sample test was conducted with a test value of 3, which indicates moderate satisfaction.

From the one samples t-test, employees at Walmart are more than moderately satisfied with workplace conditions and pays and promotions (p<0.05). However, employees are not satisfied with fair rewarding (M = 2.14, p<0.05). For the case of employment evaluations, employee wellness programs, employee training and development, employees at Walmart are moderately satisfied (P>0.05).

Conclusions and Limitations of Findings

The main objective of this study was to explore the level of employee satisfaction among Walmart employees as well as their attitudes and perceptions towards the measures adopted by Walmart to satisfy its employees. Evidence from the research suggests the following trends at Walmart:

Walmart’s employees not satisfied with their jobs;
Unsatisfied employees at Walmart are more likely to quit;
Employees at Walmart are more than moderately satisfied with workplace conditions and pays and promotions;
Employees at Walmart are not satisfied in terms of fair rewarding; and
Employees are moderately satisfied with employment evaluations, employee wellness programs, employee training and development, and perks and benefits.
From these findings, it can be concluded that H1, H2 and H3 are all valid.

Limitations of Findings

There are a number of methodological limitations associated with this research. The first limitation is associated with the use of questionnaire, which is the difficulty in ascertaining the truthfulness of information provided by respondents. There is the likelihood that the respondents may provide false information when responding to the questions in order to protect the name of the company. This has an impact on the validity of the findings. The second limitation stems from the sample size. A sample size of 50 is relatively small to make meaningful generalizations of the findings. In addition, the respondents were derived from one store, which implies that the findings cannot be generalized to include all Walmart employees distributed across the 15,000 stores worldwide. In addition, the scope of this study is only limited to the United States. There is no doubt that Walmart employees across the globe have diverse needs and requirements to be met, which implies that the findings from respondents gathered from the US may be different from the findings gathered from Walmart employees in other parts of the world.

Recommendations

Recommendations for Walmart

The findings from this research has highlighted significant insights regarding the level of employee satisfaction at Walmart as well as the employee’s perception of the measures that Walmart uses to ensure that its employees are satisfied. Three things are apparent, employees at Walmart are not satisfied with their jobs, unsatisfied employees are more likely to quit, and that employees are not satisfied with the measures used by Walmart to satisfy them. In this regard, the following are the recommendations for Walmart:

Walmart should expand its employee training and development opportunities, ensure that there is fair rewarding of employees, offer better pays as well as opportunities for promotion, and expand its employee wellness programs;
Walmart should undertake an internal employee survey to determine which aspects need improvement; this will help in reducing the number of employees with intending to quit.
Recommendations for Future Studies

It is apparent that this study is limited in its scope implying that these findings cannot be generalized. Perhaps, future studies should make use respondents from diverse organizations operating in diverse industries in order to enhance the generalizability of findings.

References

Armstrong, M. (2003). Human Resource Management Practice. New York: Prentice Hall.

Ashar, M., Ghafoor, M., Munir, E., & Hafeez, S. (2013). The Impact of Perceptions of Training on Employee Commitment and Turnover Intention: Evidence from Pakistan. International Journal of Human Resource Studies , 3 (1), 2162-3058.

Brown, S., & Lam, K. (2008). A meta-analysis of relationships linking eployee satisfaction to customer responses. Journal of Retailing , 84 (3), 243-255.

Bustillo, M., & Talley, K. (2011). For Wal-Mart, a Rare Online Success. The WallStreet Journal , p. B1.

Chi, C. G., & Gursoy, D. (2009). Employee satisfaction, customer satisfaction and financial performance: An empirical examination. International Journal of Hospitality Management , 28, 245-253.

Emerson, A. (2012, February 15). The Benefits of Employee Empowerment. Retrieved October 27, 2012, from CreditUnionTimes: https://www.cutimes.com/2012/02/15/the-benefits-of-employee-empowerment

Fisher, C. (2007). Researching and writing a dissertation. Edinburgh: Pearson Education Limited.

Fishman, C. (2006). The Wal-Mart Effect: How the World’s Most Powerful Company Really Works—and How It’s Transforming the American Economy. New York: Palgrave.

Ingram, P., Lori, Q. Y., & Hayagreeva, R. (2010). Trouble in Store: Probes, Protests, and Store Openings by Wal‐Mart, 1998–2007. American Journal of Sociology , 53-62.

Iveta, G. (2012). Human Resources Key Performance Indicators. Journal of Competitiveness , 4 (1), 117-128.

Karsh, B., Booske, B., & Sainfort, F. (2005). Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover. Ergonomics , 2 (3), 1260-1281.

Kim, S. (2002). Participative management and job satisfaction: lessons for management leadership. Public Administration Review , 62 (2), 1-23.

Lee, H., & Bruvold, N. (2003). Creating value for employees: investment in employee development. The International Journal of Human Resource Management , 2 (1), 981-1000.

LLoyd, C. (2002). Training and development deficiencies in ‘high skill’ sectors. Human Resource Management Journal , 12 (2), 64-81.

Lockwood, N. (2004). Maximizing human capital: Demonstrating HR value with performance indicators. Society for HUman Resource Management Quaterly .

Mauno, S., Kinnunen, U., & Ruokolainen, M. (2007). Job demands and resources as antecedents of work engagement: a longitudinal study. Journal of Vacation Behavior , 70 (1), 149-171.

McDonald, D., & Makin, P. (2000). The psychological contract, organisational commitment and job satisfaction of temporary staff . Leadership & Organization , 4 (2), 84-91.

Noe, R. (2008). Employee Training and Development. New York: Mc Graw Hill/Irwin.

Yazdani, B., Yaghoubi, N., & Giri, E. (2011). Factors affecting the Empowerment of Employees (An Empirical Study). European Journal of Social Sciences , 20 (2), 267-274.

Yee, R., Yeung, A., & Cheng, E. (2008). The impact of employee satisfaction on quality and profitability in high-contact service industries. Journal of Operations Management , 651-668.

Assignment: Racial Ethnic Disparities

September 9, 2024/in Uncategorized /by elias

ORDER NOW FOR AN ORIGINAL PLAGIARISM-FREE PAPER: Assignment: Racial Ethnic Disparities

Assignment: Racial Ethnic Disparities

Question 1

In the United States, research has documented socioeconomic and racial/ethnic disparities in residential exposures to _______________.

[removed]

air pollution

[removed]

hazardous waste sites

[removed]

industrial facilities

[removed]

all of the above

1 points

Question 2

In the context of ionizing radiation, the term relative biological effectiveness describes _______________, per unit of radiation energy absorbed by the body.

[removed]

the relative damage caused by different types of ionizing radiation

[removed]

the relative impact of acute versus chronic exposure to ionizing radiation

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the relative risk of birth defects caused by exposure early versus late in pregnancy

1 points

Question 3

Which of the following occupations is not particularly associated with high exposure to asbestos?

[removed]

Insulation Workers

[removed]

Oil Workers

[removed]

Shipbuilding Workers

1 points

Question 4

Which of the following diseases is a sentinel illness for asbestos exposure?

[removed]

Fibrosis

[removed]

Lung cancer

[removed]

Mesothelioma

1 points

Question 5

The half-life of a radioactive element is the time it takes for half the atoms in a sample to _______________.

[removed]

become non-radioactive

[removed]

lose an electron

[removed]

undergo radioactive decay

1 points

Question 6

Which of the following is not a syndrome associated with acute high-level exposure to ionizing radiation?

[removed]

Bone marrow syndrome

[removed]

Central nervous system syndrome

[removed]

Gastrointestinal syndrome

[removed]

Respiratory syndrome

1 points

Question 7

Occupational exposure to cotton dust causes _______________.

[removed]

byssinosis

[removed]

lacrimosis

[removed]

tinnitus

1 points

Question 8

Which of the following types of radiation is not ionizing?

[removed]

Beta radiation

[removed]

Gamma radiation

[removed]

Infrared radiation

1 points

Question 9

Which type of radiation is most penetrating, if a person is exposed from a source outside the body?

[removed]

Alpha radiation

[removed]

Beta radiation

[removed]

Gamma radiation

1 points

Question 10

Nanoparticles are in the same size range as __________________ particulates.

[removed]

fine

[removed]

respirable

[removed]

ultrafine

1 points

Question 11

Asbestos is a _______________ hazard.

[removed]

biological

[removed]

chemical

[removed]

physical

1 points

Question 12

Which of the following is not a documented health effect of noise in the workplace?

[removed]

Cognitive failures

[removed]

Coronary heart disease

[removed]

Decrease in immune system function

1 points

Question 13

Today, with asbestos exposures in the United States largely controlled, deaths from malignant melanoma in the country are _______________.

[removed]

declining

[removed]

holding steady

[removed]

rising

1 points

Question 14

Radioactive decay occurs when an atom of a radioactive isotope _______________.

[removed]

Absorbs a burst of energy

[removed]

Ejects part of its nucleus

[removed]

undergoes fusion of the particles in its nucleus

1 points

Question 15

In the United States, research on burdens of BPA, PFCs, and PBDEs in people’s bodies or in their microenvironments has shown:

[removed]

consistently higher burdens in lower-socioeconomic-status and/or minority populations.

[removed]

consistently lower burdens in lower-socioeconomic-status and/or minority populations.

[removed]

variation in demographic patterns in body burdens.

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Identify and discuss the theoretical basis for the conceptual “caring”.

September 9, 2024/in Uncategorized /by elias

Identify and discuss the theoretical basis for the conceptual “caring”.

This paper is a personal statement regarding ” CARING” In the nursing field. It should include a reference of nursing theorist ( JEAN WATSON) that relates to “caring” THEORY. Identify and discuss the teoretical basis for the conceptual “caring”. This paper should be APA style , 2-3 pages, 750-1000 words total. Here is what i got from the instructor to follow. According to South University’s BSN Nursing program, there are five conceptual frameworks of nursing: Communication, Professionalism, Holism, Caring and Critical Thinking. This paper will focus on one pillar in particular – Communication. (Wilkinson and Treas, 2011, p. 352). Elaborate More Furthermore, Wilkinson and Treas (2011), states that there are five components of communication: message (words or gestures), sender (person initiating message), channel (way in which the message is presented), receiver (person accepting message), and feedback (receiver’s response to message) (p. 353-354). Elaborate More In addition, there are two main types of communication: verbal and nonverbal. Verbal communication contains transmitted information via spoken language or written words (Wilikinson and Treas, 2011, p. 354). For example, verbal communication is often used when a nurse explains to the patient the importance of them taking their medications or explaining discharge instructions. According to Wilkinson and Treas (2011), the objective of the sender using verbal communication is so that the receiver may thoroughly understand the message (p. 354). This type of communication requires consciously selected words (Wilkinson and Treas, 2011, p.354). On the other hand, if a nurse taking care of a patient with consistently high blood pressure doesn’t effectively communicate to the patient the significance of taking their medications that help regulate their blood pressure, the patient may refuse the medication. Elaborate More In contrast, nonverbal communication mainly uses body language instead of words to convey a message (Wilkinson and Treas, 2011, p.356). For instance, a nurse is performing an assessment of a patient they believe are at risk of domestic violence, and as the nurse questions the patient, she says “everything is fine”, yet she’s twiddling her fingers and looking down at the floor. Elaborate More Furthermore, in order to have effective communication between the nurse and the patient, the nurse needs to build rapport with their patient by displaying a caring nature and taking the time to understand the patient’s needs. Elaborate More In conclusion, communication is a way in which a message is transferred from the sender to the receiver. Communication can be either verbal (conscious thought) or nonverbal (subconscious thought Elaborate More This is just a sample of information that I hope to receive from your paper. Of course the paragraphs are to be a lot longer. The paper should be 2-3 pages long. If you should have any questions please call or email me. Thanks

Saudi Arabia & Thailand: Comparative Nursing Paper

September 9, 2024/in Uncategorized /by elias

Saudi Arabia & Thailand: Comparative Nursing Paper

Introduction

The two nations that will be utilized for comparison in regards to nursing education are Saudi Arabia and Thailand. These nations are interesting to examine because they are both long histories, especially from the standpoint of such a young nation such as the United States. In addition, both nations have differing cultural influences, as well as, differing governmental approaches that are both quite interesting with regards to how they influence the nursing education, as well as, the nursing profession itself. Thailand and Saudi Arabia are two nations that have many differences, but share many similarities, nursing being one of those similarities.

Political History and Development of Nursing Education

Saudi Arabia

In the early Islamic times, women were known to join men near the battlefield so that they could help tend to the wounded. “These women were known as ‘Al Asiyat’ or ‘Al Awasi’, and each one of them was called ‘Asiyah’” (Almalki, FitGerald, & Clark, 2011). The first recognized female nurse was Kuaibah Bint Sa’ad Al-Aslamiyah. She lived at the same time as the Prophet Muhammad. She set up a tent near the mosque in Madinah and worked there with other women to treat the sick and injured. Following the death of Prophet Muhammad, there was nothing written about nurses until the 1950’s. There could be many reasons for this, including a cultural/religious aversion to sharing private information about one’s body. Nurses were likely viewed as healers, had no regulations directing their reporting methods or findings to any specific organization, and no doubt did not keep records because they knew their patients.

Thailand

The first nursing school in Thailand was opened in 1896 by Queen Sripatchariantra. “The tragedy of losing her infant child to cholera and the high maternal death rate motivated her to introduce modern nursing to Thailand” (Anders & Kunaviktihul, 1999). Her son Prince Mahidol attended medical school at Harvard University. He invited the Rockefeller Foundation to Thailand in order to offer their assistance to the Ministry of Public Health in order for Thailand’s medical facilities and care to become top notch.

The first nurses were the daughters of the noble class. These specific women are the only ones who had the required educational background to be accepted into the nursing schools. In the beginning, nursing schools had the female students focus solely on midwifery. At this point in time, it was culturally taboo in Thailand for females to care for male patients; therefore, a male nursing school was then opened in order to train men to be nurses so that men could receive nursing care without breaking the cultural taboo.

Government and Nursing Organizations Influencing Nursing Education

Saudi Arabia

“Health education in present-day Saudi Arabia started in Riyadh in 1958, when the Ministry of Health (MOH), in cooperation with the World Health Organization (WHO), initiated the first health institute for boys” (Almalki, FitGerald, & Clark, 2011). The government of Saudi Arabia is one that can be best described as authoritative; therefore nothing is done without the approval of the King. A few years after the male nursing school opened, a female school opened. This was something that was necessary. From an Islamic perspective, a male cannot care for a female, and a female cannot care for a male. The only way this is permissible are strict familial rules, for example a woman can physically care for her husband or son, but not her father. A man can care for his wife, but not his daughters.

“In 1967, the Department of Health Education and Training (DHET) was established by the MOH” (Almalki, FitGerald, & Clark, 2011). This means the Ministry of Health, which is a governmental organization has complete oversight of nursing education. The Ministry of Health answers to the King, which means the King himself, had direct oversight over nursing education from the early days of nursing education in Saudi Arabia. Of course, he would not directly run the oversight, but any abnormalities, concerns, or changes would have to go before the King.

Thailand

The royal family of Thailand is the ones who introduced nursing to Thailand, in the modern sense of nursing. The first nursing school was named after the Queen’s son who had passed away, which resulted in her desire for highly educated nurses to care for women and children. Her other son, who became a western-educated doctor, had an American foundation work with the government of Thailand in order to establish medical education and faculties, just like in the United States.

In 1975, the nursing practice act was passed and the Thai Nursing Council was formed. The Thai Nursing Council has 32 members, half of which are elected to their positions by their fellow nurses. “The other 16 members are appointed to the board by other agencies such as the Ministry of University Affairs and the Ministry of Public Health” (Anders & Kunaviktihul, 1999). This means that the government of Thailand not only has a great deal of oversight in regards to nursing and nursing education, they also have a great deal of sway with regards to the running of the council and the decisions they make. The council itself is not governmental, but the fact ministries appoint half the members, one can argue that the governments interests are amply represented.

Current System of Nursing Education

Saudi Arabia

Currently the nursing education programs and organizations were transferred from the MOH (Ministry of Health) to the Ministry of Higher Education (MOHE) (Almalki, FitGerald, & Clark, 2011). This has split all of nursing between two governmental agencies. While training and learning future nurses (as well as their programs and training) are looked after by the Ministry of Higher Education. Once they graduate, receive their licensing, and obtain work they are now under the watchful eye of the Ministry of Health. Either way, both Ministries answer to the King.

“In 2004, the Department of Nursing was once again upgraded to College status (in Saudi Arabia, colleges are the principal divisions of the university, and each college contains a number of departments)” (Almalki, FitGerald, & Clark, 2011). The disticinction of college status helps organize the gender specific schools, the curriculum, and the training. For example, one can train to be a specialized nurse, this specialization would require certain educational standards, the College status allows this specificity to occur for the students, as well as, the faculty, and members of the Ministry that oversees them.

Private nursing colleges must be accredited and licensed, which is overseen by the Saudi Committee for Health Specialists. Every nurse who completes their education is given a diploma or a certificate for completing training courses. Some are provided both, the certificates being minor achievements and the diploma being the major achievement. Recently, the Saudi Arabian government has been focusing on bettering the nursing education due to the shortage of nurses it is and has been facing.

Thailand

“The Thai Nursing Council regulates the accreditation and licensing of nursing schools” (Anders & Kunaviktihul, 1999). Students can attend a nursing school for a 2-year nursing degree. They also have the option of attending an additional 2-years in order to be determined a ‘professional’ nurse. A single 2-year degree results in a certificate, and the additional 2-year degree results in a diploma. Each degree is differentiated by the status one obtains upon completion of the educational coursework. In addition, in order to obtain the degree for the 4-year degree, one must has to pass a major test.

Much like the rest of the world, Thailand is experiencing a nursing shortage. It has incentivized students to attend nursing schools by offering very low tuition in combination with stipends for those students. While this has worked, and there is an average of seven students applying for every one open nursing school spot, not enough students have graduated yet to fill the needed nursing roles in the nation (Anders & Kunaviktihul, 1999). This will take time, but Thailand’s approach is working as applications to nursing schools have skyrocketed.

Post-Graduate (Masters/Doctoral) Education

Saudi Arabia

“The latest figures for the Saudi nursing workforce show 67% Diploma holders from health institutes; 30% Associate Degree holders from junior colleges; and 3% Bachelor’s Degree graduates from colleges and universities. In addition, there are 28 graduates with a Master’s Degree, and only seven graduates with a Doctoral Degree” (Almalki, FitGerald, & Clark, 2011)T Saudi government permits and is now encouraging nurses from Saudi Arabia to go abroad to further their education in nursing. There are current efforts underway in the Kingdom of Saudi Arabia to fortify the nursing education sector. They express desire to expand from nursing assistant to the PhD level.

Saudi Arabia is currently over dependent on expatriate nurses. There is a nursing shortage in Saudi Arabia, and expatriate nurses are presently the only way to fill the shortage. Bolstering the entire educational field of nursing and breaking down the cultural stigma of women working, women being educated, or women caring for people who are not their families must be addressed. Once the Saudi Arabian government addresses these issues they will be on the road to successfully addressing the nations nursing issues.

Thailand

Nurses in Thailand are expected to complete a four year degree. “The nursing curriculum is similar to those in the USA with the major courses being nursing fundamentals, adult health, geriatrics, psychiatric mental health, pediatrics, obstetrics and gynecology, and public health” (Anders & Kunaviktihul, 1999). There are programs for Master’s and Doctoral level nursing program, the issue in Thailand is there are not enough teachers for those roles. For example, there are only 101 professors for Doctoral level nursing education (Anders & Kunaviktihul, 1999).

Thailand is working to bolster their higher education level nursing programs. However, until it is ready to start educating people and getting them out into the workforce, other routes must be examined. Another route that is being examined and utilized is partnering with schools in the United States of America. Students from Thailand go abroad for one year, attend nursing school, and then return to Thailand to complete 2 more years of education. Doing this allows their students to obtain their education but return to Thailand to utilize their education for the betterment of Thailand and its people.

Conclusion: Reflections on Nursing Education

There were many similarities between Saudi Arabia and Thailand in regards to nursing. For example, both nursing programs were encouraged by the respective monarchies. One this that was very surprising is that they are still struggling with implementing higher education such as Master’s degrees and Doctoral degrees. The nursing shortages that both nations are combating are an issue many nations are fighting. The older generation is becoming older and sicker and the newer generation does not have enough people in it to care for all of them unless efforts are made to sway more people to join the nursing/medical profession.

Saudi Arabia allows children to begin studying to be nurses; the article stated that they allow the education to begin in Middle School. This was quite shocking, but sensible. In the United States many schools partner with a vocational training center in order to prepare students for their adult lives. This may be an answer to filling the nursing shortage from a global perspective, encourage schools to allow training to begin for certain professions. The offering of that choice could hold a massive influence over the future of the medical field.

References

Almalki, M., FitGerald, G., & Clark, M. (2011). The Nursing Profession in Saudi Arabia: An Overview.

International Nursing Review

, 58, 304-311.
Anders, R. L., & Kunaviktihul, W. (1999). Nursing in Thailand.

Nursing and Health Sciences

, 1, 235-239.

Risk Assessment for Elderly Falls

September 9, 2024/in Uncategorized /by elias

Q1: Part of your education includes experiences in different types of healthcare settings. How would your role in the primary care setting be different from your role in the acute care setting? Include in your discussion a definition of the philosophy of primary health care and the principles of wellness.

Healthcare is provided at three levels primary care, secondary or acute care and tertiary care , each provides a structure for how healthcare services are organised and delivered for example primary care tends to be delivered in a GP’S office’s and community clinics and tertiary care is more commonly provided in hospitals and rehab facilities ( Crisp J & Taylor C 1997).

in recent years the term primary healthcare has been used interchangeably with primary medical care and primary nursing care although they are not the same ( Wass,2000 ).

primary nursing care is focused on illness intervention. It is a pattern of care delivery in which a single nurse takes responsibility for a large group of clients, such is in an aged care facility.( Crisp J & Taylor C 2005).

where secondary and tertiary levels of care are provided in the hospital setting, in these settings, nurses work closely with all members of the health care team to plan , co ordinate and deliver care for people who are seriously ill. Nurses must constantly monitor and evaluate whether care is effective and how it can be improved, acute care nurses respond to clients needs expectations to form effective care partners.

The principles of wellness a classic definition of health is that adopted by the world health organization (WHO ) which states that health is a state of complete physical, mental and social well being and not merely the absence of disease and infirmity “(WHO 1974:1).?

Q2: Mr Alexopoulos, is 88 years old who has migrated from Greece and lives alone. He speaks very basic English only. In the past year he has fallen twice at home, once by tripping over a rug and once when he got up to go to the bathroom at night. He has become increasingly afraid of falling again and tends to restrict his activities in the home. He goes out only when accompanied by his son

.

QUESTION A. In the information provided, outline the data the nurse would use to complete a risk assessment for Mr Alexopoulos (include bio psychosocial and cultural health care considerations in relation to implementing primary

health care).

ANSWER . During the assessment the nurse obtains two types of data: subjective and objective. Subjective data are clients perceptions about their health problems only clients can provide that kind of information. For example the presence of pain or the meanings of an illness are subjective findings.

Although only clients can provide information about symptoms frequency, duration, location and intensity.

Subjective data may include feelings of anxiety physical discomfort or mental stress

Objective data are observations or measurements made by the data collector the nurse

(crisp et al 2005).

to conduct a comprehensive and patient focused assessment possible risks to the patients safety including enviromental as well as individual risk factors should be taken into consideration. When assessing a home for hazards and risks indiviual needs of the patient should be considered, a walk through the home with the patient should be done to assess the possible risks of the enviroment and to the patient, a discussion between the patient and nurse should take place to find out how the patient conducts his daily living activities this should give an indication of the patients immediate needs, getting a sense of how the patient conducts his daily routine helps the nurse to identify hazards that may not be obvious,(crisp 2013 p 278).

B. QUESTION What aspects of Mr Alexopoulos’ environment need to be assessed?

ANSWER The home environment needs to be assessed such as furniture placement , lighting, removing the rug as it is a trip/fall hazard incorporate multidisciplinary team members such as assisted living.

(crisp 2013 p 279).

C. QUESTION. Design interventions to ensure Mr Alexopoulos’ safety in his home.

ANSWER Assisted living, remove all trip and falls hazards with clients permission an ACAT assessment

D. QUESTION In terms of evaluation, what findings indicate that Mr Alexopoulos should not live alone in the house?

ANSWER due to the patients age and general health his two past falls,he can no longer care properly for himself

E QUESTION What allied health and community services referrals would you suggest to assist Mr Alexopoulos to maintain his independence?

ANSWER collaboration with other disciplines such as occupational therapy community nursing ,home care, meals on wheels, community transport physiotherapy may become an important part of the plan of care planning also involves an understanding of the patients needs and maintain his independence .the patient and nurse collaborate together to establish ways of maintaining the patients active involvement in the home.(crisp 2013 p 280).

Q 3 Choose

one

of the theories listed below and

explain how it would apply in these different healthcare settings: Aged Care; Palliative Care; Mental Health; Hospitals

3.Hildegard Peplaus theory (1952)is focused on the nurse and the interactive process with the patient so a relationship can be established between the two , according to Peplaus model the patient is an individual with specific needs and nursing is the interpersonal and therapeutic process. The nurses goal is to educate the patient and their family to help the patient reach personal development. The nurse develops a relationship with the patient so she can help the patient with resources needed for their care. This theory can also be applied to other healthcare settings such as aged care, pallitive care, mental health and hospitals for goals to be set in the above institutions the nurse must develop the same interpersonal relationship with the patient so effective care can be optimized for the patient. (Crisp 2013 p 49)

Q4: Many countries suffer health inequalities, including Australia – specifically within the ATSI community. In Western societies social issues continue to emerge as the gap between those with and those without economic resources grows.

In what ways do you think an individual’s financial status affects their ability to access health resources?

A. Socioeconomic factors: social and psychosocial factors can increase the risk for illness and influence the way a person defines and reacts to illness. One of the most powerful variables is economic status. Economic variables may affect a client’s level of health by increasing the risk of disease and influencing how or at what point the client enters the healthcare system. (Crisp et al 2013 p).

B. The most significant effects of economic status are more often experienced by those at the extreme lower end of the economic scale, racial (ATSI) and ethnic minorities are considered high risk groups for illness because of their economic status (Evans and stoddart, 1994;najman, 1993), (crisp et al 2001)

Q5: Discuss the following features of the Australian health care system: State vs Federal health care funding

A. The Australian Government is chiefly responsible for health service funding; control of health products, services and workforce; and national health policy leadership.

The states and territories are essentially responsible for the delivery and management of public health services (including public hospitals, community health and public dental care), and the standard of health care providers and private health facilities. Local governments fund and deliver some health services such as environmental health programs. (Australian bureau of statistics, 2012).

The Australian and state and territory governments fund and deliver a range of other health services including universal healthcare programs, community health services, health and medical research, Aboriginal and Torres Strait Islander health services, mental health services, health workforce and health base. (Australian bureau of statistics, 2012).

B. MEDICARE VS PRIVATE HEALTH INSURANCE, The face of the Australian public Health care system, Medicare, is run by the Federal Government. Medicare started in the

1970s under the Whitlam government as ‘Medibank’ and was renamed in 1984. The Medicare system allows free, universal hospital cover for eligible persons in public hospitals. (GCIT, 2014a) eligible persons means all Australian’s and the majority of people of low socioeconomic circumstance who may not be able to afford private healthcare

Private health care is also available in Australia under a ‘user pays’ system, whereby

Medicare will cover some costs, the private health company covers other costs and the patient pays the remainder or ‘gap payment’. Private health care insurers and providers receive the majority of their funds from charging their members. Private hospitals receive minimal to no funding from the government and are funded through the ‘user pay’ system of private health insurance. They receive the Medicare benefits identified for the treatment provided, but no more than that (even if the cost of the procedure to the hospital was $500 more). This is why there is a gap payment with private health. The private health system also benefits from a 30% private health rebate to all people who purchase private health insurance, which is paid for by the Federal Government. This rebate is aimed at encouraging more participation in the private health system, to take some of the pressure of the public health system. Private health insurance works alongside Medicare and can be used in both public and private hospitals. Patients have the right to elect to be admitted as a public patient even if they have private health insurance within public hospital facilities. (GCIT, 2014a)?

C. AGED CARE, Australia’s aged care system is structured around two main forms of care delivery, residential (accommodation and various levels of nursing and/or personal care) and community care (ranging from delivered meals, home help and transport to intensive coordinated care packages for people who otherwise would need residential care).

Residential services are mainly in the non-government sector, about half being operated by religious and charitable organizations.

Residential aged-care funding in Australia: that is day-to-day operations of facilities are governed by both Commonwealth and state government policies. (Australian Government, 2011)

D. The Pharmaceutical Benefits Scheme is an extension of Medicare and allows prescription medications to be purchased by Australians at differing rates, depending on their income. There’s a threshold and once this threshold is met, the pharmaceuticals can be purchased at a discounted rate. (GCIT, 2014a) ?

Q6: Access

DMF A4 nursing summary guide -2010

from the Nursing and Midwifery Board of Australia website:

(click on this link to be taken directly to the article – “Nursing practice decisions summary guide”)

http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-

Guidelines.aspx#professionalpracticeguidelines

Use this scope of practice decision-making summary to assist you to identify the issues outlined in the following case study:

This evening when you report for your shift on to your general medical ward, the charge nurse tells you that you need to assist on the orthopedic ward. You have not had any recent experience with orthopedic patients. When you arrive on the orthopedic ward, the charge nurse allocates you patients who require special techniques for getting out of bed and who need to do exercises using specialized equipment during the shift. You are not familiar with the techniques or the equipment. The charge nurse tells you that the patients can explain it to you.

6. A. according to DMF A4 summary guide Does the person who is to perform the activity have the knowledge, skill, authority and ability (capacity) to do so either autonomously or with education, support and supervision.

no I would not accept this assignment as I have had no recent experience with orthopedic patients and I should not have to rely on the patients to tell me how to transfer them or to use the equipment? ?

B. DMF A4 Select appropriate, competent person to perform the activity

C. ACTION

• Consult/seek advice (eg NUM, DON other health professional) OR

• Refer/collaborate OR

• Plan to enable integration/practice changes if appropriate (including developing/implementing policies, gaining qualifications as needed) ?

Within each nursing level, there are standards of practice and scopes of practice issued by the Australian Nursing and Midwifery Council. These guidelines and competencies are issued by the Nursing and Midwifery Board of Australia (NMBA). (GCIT, 2014a)

Ensuring that you practice within your scope and role, within your place of employment is essential. Furthermore, it should be made abundantly clear that all health care facilities will have policies and procedures that must be followed in order to undertake care provision or procedures. (GCIT, 2014a) ?

Q7: Identify 2 community health promotional strategies and evaluate their effectiveness.

Health promotion at a population and community level another main area of nursing intervention. (Crisp 2013 p 310) for example a health promotion strategy is get set for life The get set for life health promotion strategy was developed as a handbook / guide that provides realistic information to help parents and carers to interact with their child in developing and strengthen the value of establishing healthy life habits. The handbook also has useful resources for parents/carers to obtain further information regarding the health and development of their children. The aim of the Healthy Kids Check is to ensure all four-year-old children in Australia have a basic health check to see if they are healthy, fit and ready to learn when they start school. The Healthy Kids Check promotes early detection of lifestyle risk factors, delayed development and illness, and introduces a direction for healthy lifestyles and early intervention strategies (Australian Government, 2009.) The Healthy Kids Check can be undertaken by a doctor but not including a specialist or consultant physician, or a practice nurse on behalf of a GP. (Australian Government, 2009.).?

Another health promotion that is community based is active after school communities program this program was established by the Australian sports commission, the aim of the health promotion is to get kids moving and enjoying sport.

The Active After-school Communities (AASC) program, which is the largest Government initiative of its kind. The program is designed to engage non-active kids, or those not involved in mainstream sport. To start to participate in sport and enjoy playing sport A positive introduction to all varieties of sport to children may inspire a passion for sport and more importantly it can help develop mobility skills

Evaluation of the effectiveness of the program – “Since 2005, nearly 400 000 children have been given this introduction to sport and over half a million sessions have been delivered around the country”. “Currently, there are up to 150,000 children participating in the program, which is run in up to 3250 schools and after-school care locations in every state and territory in Australia”. (Australian Government, 2009.)

Q8: When you graduate, identify where you could find out about employment opportunities.

Outline the interview process and materials/Information required to apply for a position

8. To find jobs, the best information resources are newspapers (both print and online), the Internet, hospital internal vacancies and government websites. (GCIT, 2014a)

Once you have found a job you would like to apply for, you’ll need to create a resume. It can be a difficult task to list all of your attributes and education, without sounding ‘over the top’! A resume should include the sections that portray you at your best, outlining your experience in not only nursing, but other relevant areas of employment. Always ask for the position description before applying for a job. Also note that many organisations have specific selection criterion to be addressed when applying for a position, depending on the institution (e.g. state or private) and the job description. (GCIT, 2014a)

If your application appeals to the employer, the next step will probably be an interview. There are particular processes involved in a nursing job interview. A panel of selected nursing and non-nursing peers will review your application and ask you a series of questions related to both your experience and the role you’re applying for. (GCIT, 2014a)

This reflective essay is centred on pain assessment

September 9, 2024/in Uncategorized /by elias

For the purpose of the case study I intend to use Gibbs(1998) model of reflection as this model is clear, precise allowing for description, analysis and evaluation of the experience, then prompts the practitioner to formulate an action plan to improve their practice in future(Jasper, 2003).

Wilkinson (2007) identifies assessment as the first phase of the nursing process in which a nurse uses their knowledge and skills to express human caring. It is important to choose an organised and systematic approach when caring out an assessment that enhances your ability to discover all the information needed to fully understands someone’s heath status (Alfaro-Le Fevre,2004) .This can be achieved by obtaining your information form medical record and nursing charts by physical examination of the patient and also talking to patient and their families(Wilkinson,2007). The use of objective data is more helpful in collecting information when the patient is ventilated and sedated, as they are often in the critical care setting, and this can be done by examining the patients vital sign, blood pressure, heart rate, temperature and blood results (Bulman and Schutz 2004).

I have chosen pain assessment in post- operative ventilated patient. I have worked in ICU for 4 years during this time I have nursed many post- operative ventilator patients who were on continuous infusion of sedatives and analgesics. Many of them showed signs of inadequate pain relief and associated complications. Having undertaken this module I further educated myself in this field of nursing assessment I now know, or rather have an improved knowledge base and understanding of the different aspects of pain assessment tools and recognize the possibility that I have probably nursed many more patients who were demonstrating symptoms of inadequate analgesia and associated complications. Given an increased awareness and knowledge I have gained through teaching, research and current literature on this topic I now, also recognise the importance of this assessment practice in particular in relation to the ventilated, non- communicated patients in ICU.

According to International Association for the Study of Pain (IASP,1979) pain is described as unpleasant sensory and emotional experience associated with actual or potential tissue damage. Clinically pain is whatever the person says he or she is experiencing whenever he or she says it does (Mc Caffery 1979) .Appropriate pain assessment is crucial to pain management. Patient’s self- report is the gold standard of pain assessment. However pain tools that rely on verbal self-report may not be appropriate for using non- verbal ventilated sedated patients in ICU. Pain assessment tool used in our critical care setting is based on a numerical pain rating score from 0-4, a score of 0 being no pain at all and 4 being the worst pain ever experienced. There is also a visual analogue scale for patients who have difficulty communicating, they can indicate by looking at the chart and pointing at either the happy face that has no pain or a series of faces showing different stages of pain (appendix three). These tools were chosen by the specialised pain care nurses working for the trust. The tools are favoured as they provide nurses with a quick, easy assessment. They are used widely throughout the trust to provide continuity of pain assessment.Both of these tools have proved successful in practice and are supported by the literature as being reliable and accurate in practice. However they depend greatly on the patient being able to express themselves or communicate verbally with the practitioner .Using these methods of pain assessment is not accurate on sedated patients with altered conscious level. In nonverbal patients the use of behavioural or physiological indicators are strongly recommended for detection of pain (Jacobi et al 2006).

The patient in critical care may experience pain from many sources. Along with physical pain, psychological factors such as fear, anxiety and sleep disturbances may play a significant role in patients’ overall pain experience (Macintyre and Ready 2002). Urden et al (2010) states, pain can be acute or chronic, sensations are different in relation to its origin. Acute pain-duration is short corresponds to the healing process, ranges between 30 days to 6 months. Chronic pain lasts more than 3 to 6 months and can either or not associated with an illness. Somatic pain is well localised sharp, acute pain arising from skin, muscle, joints. Visceral pain refers to the deep, ill localized arising from an organ. Nociceptive pain occurs when inflammation stimulates pain receptors ( Urden et al 2010). Pain experienced in critical care patients are mostly acute and has multiple origins.

Mr. Smith a 45 year old gentleman admitted to ICU following Laparotomy for small bowel perforation and faecal peritonitis. Mr Smith was cardiovascularly unstable and was unable to be extubated immediately after surgery due to secondary sepsis. He was receiving an infusion of Propofol and Fentanyl to keep him comfortable and provide analgesia. His medical notes revealed his past medical history of previous Cholecystectomy for gall bladder stones and biliary obstruction. I was assigned to nurse him on his second day in ICU. During handover the previous staff member reported that Mr. Smith became very agitated and hypertensive soon after he was repositioned to his side. Mr. Smith was given a bolus dose of Propofol infusion and the rate of Infusion increased. Whilst doing the Patient assessment I noticed Mr Smith is restless and not compliant with the ventilator. Arterial Blood Gas (ABG) performed which showed Mr. Smith is hypo ventilating. Meanwhile Mr. Smith became more agitated with escalating non-compliance with ventilator and significant increase in his Mean Arterial Pressure (MAP) which was being monitored continuously by the arterial line and transducer. He was showing facial grimaces and moving his extremities restlessly. I tried to reassure him by talking to him, reorientating him to time, place and person, explaining to him that he is safe. Adam and Osbourne (2005) identifies that critically ill patients frequently require help with coping with many of the stresses like physical discomfort, isolation, fear of pain and death. By using strategies like communicate caring and understanding and provide information repeatedly and in sufficient detail for the patient etc. helps the patient to cope with the stress. But repeated reassurance and reorienting has not made any improvements in his current status.

Pain is an important problem in critical care and its detection is a priority. Pain assessment is vital to detect pain (Urden 2010). Pooler-Lunse and Price(1992) emphasises that critically ill patients who are unable to communicate effectively are at high risk of suffering from pain. Poorly controlled pain can stress the sympathetic nervous system leaving vulnerable patients at risk of complication and can compromise recovery and negatively affect both morbidity and mortality(Puntillo et al 2004, Dracup and Bryan- Brown 1995).Mr Smith was ventilated and due to the effect of sedatives his level of consciousness was altered. In critical care factors alter verbal communication is mechanical ventilation, administration of sedative agents and the patients change in level of consciousness (Hamill-Ruth R J, Marohn L 1999 ,Kwekkeboom K L, Herr K 2001,Shannon K, Bucknall T 2003). The consequences of untreated acute pain in critically ill patients include increases in catecholamine and stress hormone levels which are potential causes of tachycardia, hypertension, increased oxygen requirements and decreased tissue perfusion (Blakely and Page 2001, Hamill-Ruth and Marohn 1991). Mr Smith was increasingly hypertensive and tachycardia. Despite giving increased oxygenation Mr.Smith was hypo ventilating due to non- compliance to the ventilator.

Marshall and Soucy(2003) identifies agitation is a common problem in critically ill patients and has been shown to be associated with inadequate pain management. Agitation can have serious consequences with patience removing access lines compromising their oxygen needs by self extubating (Cohen et al 2002).

Following discussion with the nurse in charge of the shift it was apparent that Mr. Smith was showing behavioural signs of pain. There were no other obvious reasons as to why he had become compromised with his ventilation.When I approached the medical team concerning Mr.Smith’s increasing agitation and non- compliance to ventilation I was instructed to give a bolus of propofol and fentanyl and to increase the rate of propofol and fentanyl until Mr Smith was deemed medically manageable. I was decided to increase Mr.Smith’s ventilatory support. Following the treatment Mr Smith became much more stable, he became less tachypoenic was synchronising with the ventilator; his blood pressure was within acceptable limits and monitoring in sinus rhythm.

The clinician did not assess Mr Smith for signs of inadequate pain management. Unfortunately due to hypoventilation and non-compliance to mechanical ventilation, Mr Smith had to be remained on high levels of ventilation and increased levels of sedatives for the next few hours emphasising evidence by Pooler-Lunse and Price(1992), the physiological complications associated with pain including Pulmonary complications and increased cardiac workload as well as depression and anxiety and increased days of hospital stay(Desbians et al 1996).Upon further reflection I should have noted Mr Smith’s agitation associated with inadequate pain relief. Had I been knowledgeable in this field Mr.Smith’s agitation and physiological signs of restlessness and facial grimaces would have prompted me to carry out a detailed pain assessment. Had there been a behavioural pain assessment scale on the unit where I work that may have prompted me carry out the assessment and linked these signs as indicators of inadequate pain relief.

During my further assessment of Mr.Smith I had various thoughts and feelings which included feeling apprehensive and self-doubt regarding the decision to increase sedation and ventilator support. Whilst reviewing his past medication history I noticed that Mr Smith had been on regular analgesics which are co-codomol and paracetamol and there was no indication for their use in his notes. Fink R (2000) recognises that reviewing patient’s past pain experiences and how did he or she usually react to it can be of good value when assessing pain and can help to decide treatment options ,by questioning patients’ family or significant other can provide us the information about patient’s pain history. Later during the visiting hours Mrs Smith came to visit Mr Smith. I have given her a brief update of his condition including the changes made to his sedation and ventilation. Then I enquired to Mrs Smith about the indication of those analgesics he was on .She revealed that Mr.Smith developed back pain when he discharged to home after undergone cholecystectomy six months ago and he was prescribed those analgesics by his G.P(General Practitioner). She also mentioned that he had problems getting optimal pain relief post operatively even when he had cholecystectomy, and he would not tolerate lying on his sides. This co-related his agitation and restlessness happened when the night staff turned him to his side.

I notified these things to the ICU doctors and raised my concern that lack of adequate pain management could be the reason for Mr Smith’s earlier agitation. They also agreed on this possibility and advised to change fentanyl infusion to remifentanyl and to adjust the rate of the infusion to keep Mr Smith’s pain relief optimal. Remifentanyl is potent analgesics, so ensure the patient is pain free but prevents over sedating the patient, allows rapid arousal and recovery from sedation thus facilitates daily sedation holds and neurological assessment( Dhaba et al 2004). He was also prescribed regular paracetamol and Tramadol when required. It was then decided to reduce Mr.Smith’s sedation as he was haemodynamically stable, he was then able to respond and started following commands. Mr. Smith was now able to communicate if he had pain or not by squeezing my hand to command.

Invasive technology can restrict the reliance on many behavioural indicators of pain (Bucknall and Shannon 2003) on the other hand it is argued that invasive lines enables constant monitoring of blood pressure (B.P) and heart rate (H.R), two commonly utilised indicators of pain and thus help to assess pain (Bucknall and Shannon 2003) .Even though Mr Smith was hypertensive and tachycardic this was presumed to be due to agitation. In a contradicting statement Bucknall and Shannon(2003) points out that the sympathetic symptoms i.e. Increasing B.P and H.R are also been found to be unreliable. Pooler-Lunse and Price (1992) emphasises that the Para sympathetic stimulation can result in less observable signs with prolonged pain, but pain intensity remains unchanged. The American Society for Pain Management Nursing (ASPMN) recommendations cited in Herr k et al ( 2002) emphasises that vital signs can be affected by other distress conditions, homeostatic changes and medications there for they should not be considered as primary indicators of pain.With conflicting evidence it is difficult to make decisions that best support this assessment practice.

Anand K J S,Craig K (1996), Herr K et al (2006) states that behavioural indicators are strongly recommended for pain assessment in non- verbal patients , few tools have been developed and tested in critically ill patients. The Behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) are suggested and supported by experts for using uncommunicative critically ill patients (Li-D, Puntillo, Sessler 2008). BPS was tested and validated exclusively in ventilated, unconscious patients (Payen et al 2001,Young G 2006, Aissaoui Y et al 2005).The Behavioural Pain Scale (BPS) includes three behaviour’s 1) facial expression 2)movements of upper limbs3)compliance with the ventilator. Each behaviour is rated on a scale from 1 to 4 for a possible total score from 3 to 12. The BPS can be used quickly (2 to 5 minutes), most clinicians were satisfied with its ease of use (Payen et al 2001). The Critical Care Pain Observation Tool (CPOT) was tested in verbal and non- verbal critically ill adults (Gelinas C 2006,2007) its content validity supported by ICU experts including nurses and physicians (Gelinas C 2009). CPOT includes four behaviours 1) facial expression 2) body movements 3) compliance with the ventilator 4) muscle tension. Each behaviour is rated from 0 to 2 for a possible score of 0 to 8.Gelinas C and Hammond reports that feasibility and clinical utility of CPOT were positively evaluated by ICU nurses and agree it is easy to complete, simplicity to understand the usefulness for nursing practice.

My experience of using a behavioural pain scale tool is limited, however I feel that if practitioners were able to assess pain more accurately then they would be able to manage there patients pain more effectively.

Use of a behavioural pain score (BPS) evaluating facial expressions, limb movement and compliance with the ventilator has proved to be a valid reliable tool in practice. A recent study evaluating the reliability and use of the BPS consistently identified increases in pain scores after repositioning patients in the ICU. There were only small non- specific changes in the BPS after non painful intervention of eye care (Gelinas etal 2006).

I nursed Mr Smith again 5 days later. He had since been extubated and was alert and oriented. Even though he could not remember the events when he was ventilated and sedated, he learned from his wife what had happened. He was very thankful to me for investigating the possible reason for his agitated behaviour and prompting the doctors about this and thus provide him adequate pain relief.

Upon further reflection and evaluation of my assessment of Mr.Smith I feel there have been positive and negative aspects of the assessment. The positive aspects include- I have been able to gain further knowledge in various aspects and tools of pain assessment .By reviewing patients medical notes and gaining history from his wife I have linked his agitated behaviour and taken the possibility that these are signs of inadequate pain relief and I have managed to convince the medical team regarding this in order to act on it. Current research identifies multidisciplinary collaboration provides optimum care for the patient (Bucknall T, Shannon K 2003), this emphasises the need to perform regular, accurate pain assessment and care full documentation (Bucknall T, Shannon K 2003).

When considering the negative aspects of my assessment I feel I did not use a holistic approach instead I considered Mr.Smiths agitated behaviour as a physical problem, I was concentrated to treat the symptoms and not the patient. As described in Roper Tinney L(1989) assessment tools achieving patient centred nursing is important. I could not identify Mr.Smith’s behavioural indicators of pain primarily due to my lack of knowledge about this assessment tool as well as there was no unit assessment protocol which includes the behavioural assessment scale, Unfortunately this is not isolated, it is in fact a universal problem .Camp (1998) points out that like many speciality nurse critical care nurses and physicians recognises that there basics education was insufficient for caring for patients in pain.

Accurate detection of the critically ill patient’s pain is not an easy task for ICU nurses especially when the patient is unable to self-report because of mechanical ventilation or due to the effects of sedatives. Stanton (1991) argues that pain assessment and management may be significantly improved by enhancing nurses knowledge combined with improved communication of the problem. NMC(2008)emphasises that having appropriate knowledge, skills and attitude towards pain, pain assessment and its management is essential to provide optimum patient care.

Use of pain assessment tools is highly recommended by Kaiser(1992), identifies that an effective pain assessment tool as part of the documentation improves communication between patients and nurses as well as nurses and medical staff. Even though we had a pain assessment tool (0 to 4 numeric pain assessment scale) due its limitations on the use in non-communicative patients it was not contributing much in patient’s pain management. The previous practitioner documented the patient’s pain score is “Unable to assess “as the patient is sedated and ventilated. This highlights the inappropriate use of our pain tool currently being used in practice as a patient is unable to verbalise or communicate their pain if they are sedated and ventilated. Although todays guidelines strongly suggest that the use of a standardised behavioural pain scale to nurses who care for uncommunicative patients, further research is still needed to fully understand the behavioural and physiological responses of critically ill patients who are experiencing pain (Herr K et al 2008).

On reflection my underpinning knowledge and confidence in this area of assessment has developed tremendously. I feel that I have gained knowledge and insight into an important patient assessment, from an initial lack of sufficient knowledge I am now able to bring evidence based practice in the clinical area which will benefit the patient and my colleagues. By understanding the physiology, pain assessment tools and the complications of poorly managed pain, I will have the knowledge and skills to manage these patients. The use of sedatives and analgesics places a great deal of responsibility on critical care nurses and they must understand how the drugs work , complications of their use and how to monitor effectiveness staff must understand sedation does not equate analgesia (Ashley and Given 2003). The use of an appropriate pain assessment tool and management algorithm is essential for adequate pain management. Since undertaking this study, it is of interest to note that our practice development nurse and the specialist pain nurse for ICU ,have jointly developed a behavioural pain assessment scale similar to the BPS and CPOT scale, and staffs are encouraged to use it routinely.

I feel that my action plan and recommendations are to promote the use of the pain assessment tool by educating the nurses and emphasising the importance of this assessment to improve patient outcome. The need for education to train staff on how to use the tool would take both time and money. The NHS is already under extreme financial pressures and money for training is not readily available. However if an improvement in pain management was successful then patients stay may be shorter, thus having a beneficial effect. I am also aware of the importance of not relying solely on the assessment tools but the use of both good nursing assessment and assessment tools to improve optimal patient management, shortening the recovery time and reducing the likely hood of complications (Ashley and Given 2003). A sedated, ventilated, non-communicative patient is vulnerable and relies completely on those providing care for them but as to their family at this anxious time. Education and training will improve patient care and ultimately patient safety which is paramount. Therefore I will take the knowledge and information I have acquired back to my clinical area as I have a duty to provide a high standard of practise and care at all times (NMC 2008)

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METHODS:

RESULTS:

DISCUSSION:

CONCLUSION:

ACKNOWLEDGEMENTS:

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References

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