Introduction

Public health is described as a tool and techniques for protecting the health of the population and implementing all measures for the safety of health of the local population. There are several public health issues such as drug addiction, aids and smoking. In this assignment the targeted public health issue is smoking as a lifestyle choice within the population of United Kingdom. Smoking has been assumed as a critical public health issue. It has been examined that smoking caused severe threats to the individual health as well as to the third world countries and developed countries (Rentería, et al., 2016). Amongst multiple significant reasons of deaths and medical ill-ness, smoking is also considered as the main cause. This assignment is conducted to underline the general evidence on how smoking can cause severe death and diseases. The main part of the assignment debates several smoking-related risk factors to public health and assesses risks. The other main aim of the assignment is to emphasis smoking as a major public health issue. Since Health promotion is essential to reduce chronic disease globally due to smoking. Smoking can be identified as an addictive disease. As nicotine is known to be a highly addictive and harmful substance.

Therefore, health promotion, disease prevention and health protection measures are utilized to address smoking issues. Additionally, multiple disadvantages of smoking habit have been discussed in accordance with the Joint Strategic Needs Assessment (JNSA) and the Clinical Commissioning (CCG) process. Moreover, 5 A’s approach along with Tannahills Health (1985) is elaborated to highlight the effective measures for smoking interventions. This assignment will discover the Public Health Outcomes Framework provided by Public Health England along with the effective discussion on how health expectancy would be increased through quitting smoking habit. Lastly, the WHO framework guidelines will be highlighted in order to reduce smoking habit globally.

Public Health

Public health can be elaborated as the techniques and methods of securing and maintaining the safety of health of communities through their proper education system, research and developments or policies relevant to disease preventions (Maziak, et al., 2017). Hence the definition of public health varies from person to person.  In the domain of public health, conducting a laboratory test or researching process are performed to improve the health of the Community. The successful execution of initiatives to increase the improvement of community health need deep insight into the complex and various procedures that develop healthy habit in societies. Health can be seen to depend on various factors including medical care, individual behaviour and genetics, social and economic conditions of the region for both individual and populations.

Public Health can also be considered as a complete science of improving the health of the public by promoting health precautions, healthy living standards, disease preventions, treating and preventing multiple infections (Fu, et al., 2018). Professionals of this respective field always work for the preventions of any health concerning issues. This work can be done through certain health promotions policies, adoption of educational programs and research and development procedures performed by the field professionals such as doctors and nurses. The main focus of these professionals is to treat the suffering ones, once they are diagnosed from any disease or infection. A major part of public health is promoting healthcare quality and accessibility. Additionally, public health deals in the promotion as well as protection of the health of the public (Xiao and Wang 2019).

Public Health awareness can be generated through performing scientific research to educate population regarding their health issues along with guiding the staff as well who are working for the provision of health measures such as vaccines for children, other measures to prevent adults from the disease. It the main responsibility of the public health to regulate certain effective safety standards in order to secure workers and establish programs related to the nutrition to assure that children have easy access to healthy food. Public health is also accountable to follow the disease, prevention of the injuries and highlight reasons behind suffering from poor health issues. The many aspects of public health include laws for promoting smoke-free indoor air and usage of seatbelts whilst driving.

Within the United Kingdom agenda, public health is considered as a continuous issue whereas all professionals of the domain will participate in it (Chertok and Archer 2015). Public Health emphasis on the well-being and healthy living habit of an individual and considered as the most efficient methodology of preventing health-related issues in the public. It identifies the root causes of the sickness, disease or illness. Additionally, it underlines all other factors including biological or social environment and provision of the services regarding health care. Public health completely depends on the skills, judgment and evidence. Moreover, public health promotes the involvement of the public who are members of the policymakers and actions of United Kingdom Public Health Association (UKPHA).

Smoking Habit as a Public Health Intervention

The main reason for selecting smoking habit is considered as a serious and essential public health issue. It has been examined that smoke is very harmful to the human tissues whilst smoking (Tanner, 2019). Furthermore, it has been observed that smoking tobacco not only affect an individual’s health but also accountable for creating an impact on the economy, society and environment as well (Tanner, 2019). Smoking habit are dangerous as it causes a severe effect on the entire body, smoking causes lungs diseases as well as it reduces the life expectancy and quality. It has been investigated that around 364,000 individuals admitted in the National Health Service (NHS) hospital of England on yearly basis due to diseases caused by smoking habit (Bauld et al., 2009)

Further, it has been critically examined that in the United Kingdom, 114,000 individuals die, amongst them, the majority are premature having an average age of 21 years. Approximately 42800 premature deaths are caused by Lung and coronary cancer that are caused by frequent smoking. Almost 29100 chronic obstructive heart diseases and 30600 coronary heart diseases result in deaths every year (Bauld et al., 2009).

It has been noticed that smoking is the root cause for more other diseases such as impotence, asthma, and gum diseases, infertility and psoriasis. Additionally, it has been justified by several types of research that non-smokers are also at risk due to the smoke emission from smokers. Such a process is also termed as passive smoking. Aronow, W. S. (1978).  It is further also termed as environmental tobacco smoke (ETS) and second-hand smoking (SHS).

Tannahills ladder of intervention

Health promotion strategies in this model are assumed as the primary tools to develop awareness in the public for smoking prevention (Ramsey, et al., 2018). Also, according to Tannahills model (1985) Public education is an integral part of the efforts to both prevent the initiation of smoking and encourage smoking cessation. Higher health promotion helps to make individuals aware of the dangerous effect of smoking. These health promotions also increase the power to quit smoking along with subsequent quitting amongst all other users. Health specialists may support and encourage all those smokers who want to quit by adding up their knowledge regarding smoking cessation techniques (Sorlí-Aguilar, et al., 2016).

Various health promotion techniques such as Tannahills promotion are being utilised for the purpose of smoking prevention. A positive impact on the deduction of smoking habit has been shown by an evaluation of the health promotion intervention studies. Presently it has been examined that the provision of effective smoking prevention to the population is very important. For youngsters there should be school-based prevention education Smoking prevention education programs must be arranged for the smoker. These prevention programs will emphasis on skills training strategies that are effective in minimising smoking.  Along with the prevention techniques, there must be health protection measure especially for those who indirectly effected by the smoke exhales by the smokers. The ladder of intervention framework, Nuffield Council Bioethics, can also be use, which commence with observing the situation/do nothing, give information, by giving out leaflets, advertisements, posters and campaigns, allowing  people to make their  own choices, to enable change in pattern of behaviours, a better choice option giving them options to choose from, incentives guides offering financial rewards for making a healthy behaviour, disincentives guide  which are shoves, such as discouraging people from smoking, through bans, restricting, their choice and removing choice totally such as restrictions on places where people can smoke.  Using this intervention have an ethical issue in place, of taking the autonomy power of an individual away from them but this is not so, the purpose is to encourage the society to live a healthy life through restrictive and  measures by saying it an illegal to smoke in the car while there is a minor present. putting age limit to those that wants to purchase cigarettes, changing the package to making it less inviting.  harmful choice of life, also providing a designated area for smoking, all these to discourage smoking habits and finally, eliminating choices through restrictions in places to smoke.

The Health and Social Care Act (2012)

The health and social care act oversee all the activities of public health UK. Local government has been empowered with the responsibility of funding and also the power in enhancing health as well as decrease inequalities in health of the public by the health and social care act.

Joint Strategic Needs Assessment (JSNA)

Joint Strategic Needs Assessment (JSNA) is a keystone of social care commissioning. JSNA ensure that organisations of heath concern and local administrations understand local populations and the challenges in handling health issues (Mazzonna and Salari 2018). A JSNA is based on an evaluation of present and forecasted health outcomes. Furthermore, it is accountable for what people want from their services. Additionally, JSNA is responsible for predicting potential or new requirements. A JSNA can be considered as a continuous procedure which recognises the big picture in regard to the wellbeing and health needs population of the region. JSNA has provided the assessment report regarding the smoking behaviours of an individual.

Clinical Commissioning Groups (CCGs)

All Clinical Commissioning (CCGs) were working for the National Health Service (NHS) statutory bodies from 1 April 2013. Clinical commissioning is accountable for commissioning most NHS services such as emergency care, mental health services, acute care and community services.

Smoking as a Disadvantaged

According to JSNA and CCG, smoking has been considered as a disadvantaged. There should effective preventions for reducing the smoking habit amongst the local communities within the United Kingdom. Smoking as a disadvantage has been evaluated due to certain reasons discussed below.

Heart Issues

It has been examined by Joint Strategic Needs Assessment (JSNA) And Clinical Commissioning Groups (CCG) that smoking habit effect the blood circulation within the human body as it changes the overall structure of vessels of the blood (Oikonomou, et al., 2019). This variation in a structure that is caused due to smoking build plaque in the vessels making them harder and narrow minimising the proper blood flow in the body. But according to JSNA it causes a general disease that leads to heart attacks and peripheral artery disease. This disease can be termed as atherosclerosis. Additionally, smoking cause high blood pressure as well due to inhaling to carbon monoxide from smoking. As per CCG smoking habit also increase the chances of blood clots in the blood that further cause severe strokes.

Functions of Lungs

According to the viewpoint of JSNA and CCG, lungs are mainly affected by the habit of smoking because inhaling chemical from smoke is directly linked with lungs. It has been examined that smoking cigarettes are the main reason behind the disease of chronic obstructive pulmonary (COP) (Porter and Greene, 2016). These diseases further create an effect on the functionality of the lungs. COPD contains emphysema and chronic bronchitis along with the variation in the structure of lung tissue. As per JSNA, smoking increases the attacks if the patient already suffers from asthma. In the contrary to JSNA’s statement CCG claims that, smoking effect the overall function of lungs, so the patients face breathing issues.

Problems within the Fertility

It has been examined that smoking also creates an effect on fertility within the human. According to JSNA, smoking lower down the chances of conception in either women or men (Porter and Greene, 2016). All those men, who smoke tend to have minimum sperm that will further lower down the ability of the sperm to fertilize. Smoking habit further reduce the ability of an ovary to produce eggs that are able for healthy fertilization. Although CCG general report it has been estimated that 20 to 30 percent of low-weight babies are born and 14% of premature births are caused due to smoking in pregnancy. Further, smoking in pregnancy will cause asthma in baby and it has been observed that in some cases babies have reduced the function of lungs if women smoke whilst pregnancy.

Initiative towards Cancer

It has been evaluated by JSNA, that 1 in 3 deaths are caused due to cancer occurred due to frequent smoking. On other hand, a report was provided by the CCG that highlights the relationship in between diseases and smoking habit (Porter and Greene, 2016). The report configures that 87% of lungs cancer death penalties are caused due to smoking habit. Smoking also initiates cancer in many other parts of the human body other than the lungs. Individuals who smoke, face a high risk of cancer of throat, stomach, mouth and oesophagus.

Smoking Effects Surroundings

It has been observed that smoking is a major reason for preventable deaths. CCG has estimated that many of the local population die from diseases related to smoking including all those individual who does not smoke but get affected indirectly (Porter and Greene, 2016). A blend of smoke from the burning of cigar or cigarette and smoke exhaled by the smoker is termed as second-hand smoke and it has been examined that low level of second-hand smoke is dangerous for human health. Second-hand smoke cause asthma attacks in young individuals, and a higher risk of infant deaths syndrome, ear infections and many other smoking diseases in the local population who do not smoke. More dangerous impacts of second-hand smoke involve lethal diseases.

Smoking can be considered as one of the most prevalent habit found in the local population. It has been examined that smoking intervention is generally inspired by the behavioural change theories such as the Transtheoretical model (Stockings, et al., 2016). Further, it has been observed that behavioural interventions required discussions, pieces of advice and other activities. These all align together to have successful attempts for the smoking interventions. Generally, it has been found that interventions involve behaviour changing methods highlighting the factors including motivation and self-efficacy. According to multiple studies, it has been evaluated that motivation is an essential component within the entire intervention process of smokers because it increases the eagerness of an individual to quit (Ferrante, et al., 2015).

These interventions further tend to increase skills and self-control to prevent smoking habit. It also involves the provision of suggestions on increasing social support. It has been observed that some behavioural change is complexed therefore interventions should be designed according to the need of an individual so that interventions should be more effective (Holmes, et al., 2016). No improvement has been examined in the effectiveness of behavioural change for the last 20 years. To fill this gap, the UK medical research has attempted behavioural changes techniques project. This will be helpful for smoking intervention and increase the effectiveness of behavioural change as well.

5 A’s Approach

This approach which consists of 5 A’s include ask, assess, and advice, assistance and arrange (Özdal, et al., 2017). ‘Ask’ asking queries is a fundamental step for motivating patients for further interview. Further, extract the required information from the individual which will directly lead to assess the provided information. Hence it is important to assess the status of the health for smoking interventions. Moreover, asking and assessing develops a collective relationship in which the complexity is recognised for the individual. The foremost step after asking and assessing is advising the individual on the harmful effects of the smoking and how it can be prevented. Patients must be recommended treatment including monitoring lifestyles and behavioural counselling.

Prior to the treatment process, it is essential to have an agreement regarding the treatment plan. All treatment plans must utilise effective principles of behavioural change including behaviour shaping. Right after an agreement to the plan professionals must assist patients. Hence, this 5 A’s approach tends to be more effective and this approach must be encouraged for smoking interventions. However, 5A’s approach is more widely implemented for behaviour change in the smoking intervention. Classical conditioning is referred to as a concept where a person learns to link two unrelated stimuli. Individual associate smoking with multiple events such as being stressful and such circumstances then develop cravings smoking behaviour. Another behaviour has been noticed that there is a fast release of dopamine when nicotine is inhaled. It develops feelings of pleasure or reinforces the behaviour which further drives the addiction.

Behavioural approaches to cessation focus on changing habit and patterns of smoking, replace smoking habit and emphasising the advantages of quitting. All such theories underlined the smoking patterns that can be minimised through the effective Transtheoretical model. Health Promotion Model (HPM) is used for research and practice. It emphasises on helping people to obtain well-being. There are four major assumptions of the health-promoting model for the effective intervention of smoking habit. These assumptions focus on controlling individual’s own behaviour through to have control over their smoking habit. The second assumption highlights the process through which they can regulate their behaviour through nicotine replacement therapy that is having chewing gum. According to health promotion model, the third assumption is to make improvements in their behaviour and their environment, and the last assumption of health promotion model is a self-initiated change of person and his entire characteristics to enhance his behaviour.

Public Health Outcomes Framework

The Public Health Outcomes Framework (PHOF) refers to a higher level of overview of Public Health outcomes at the local level that has been supported by a numerous set of indicators. The Public Health Outcomes Framework is utilised as a technique for local accountability whilst providing a means for progress in each local authority. The forecasters of the well-being of the population of United Kingdom highlighted by PHOF includes life expectancy, determinants of health, improvement in health, protection and preventing early deaths (Haluza, et al., 2015). With respect to life expectancy, it has been examined that early deaths due to lungs cancer are mainly caused due to smoking for 50 years.

Life Expectancy

It mainly emphasises on overarching health and healthy life expectancy. It has been observed that lifecycle of a smoker is ten years shorter as compared to non-smoker (Kezar and Maxey 2016). All those smokers who stop smoking by the age of 40 may live as long as those who do not smoke. Habitual smokers have a higher risk of dying than those who never smoked.

Health Determinants

The determinants of health include economic, social and environmental factors that impact the health and well-being of an individual. It has been observed that smoking tobacco not only affect the human health but also create a negative impact on the surrounding, such as it affects the environment due to the exhaling of carbon monoxide.

Health Improvement

The outcome in the domain of public health which highlights the methodologies of improving health is termed as health improvement. These health improvement methods are promoting smoking cessations, increase the awareness about health effects caused by direct smoking or smoke exposures.

Public Healthcare and Prevention

National Institute for Health and Clinical Excellence (NICE) have produced guidance on preventing the addiction of smoking amongst people. This prevention guideline emphasis on mass-media and strategies to prevent the smoking habit. The preventions that can be utilised for reducing smoking includes cessations awareness through media and educational programs. Public health can be secure through the implementation of smoke prevention laws.

WHO recognises numerous goals for the health system? WHO efforts to trigger not only the minimisation of disease, death and disability but also an enhancement in an individual’s response to their illnesses. It has been evaluated that smoking habit are accountable for almost six million death penalties every year (Palanisamy and Thirunavukarasu 2017). There are several effective measures to reduce the smoking habit. Hence the implementation of those measures varies with in the World Health Organisation (WHO). The smoking industry faces great lobbying of the tobacco industry which has impacted the measures to accomplish public health objectives. The WHO framework 2020 convention on tobacco control has been established. The main purpose of this framework is to control the increasing smoking habit and regulate the tobacco industry.

The framework majorly involves foreign investment, advertisement of the smoking tools, promotions and trade of smoking products. Therefore, it has been stated that FCTC is the first platform developed by WHO, which is accountable for assuring the provision of all health standards and control the smoking habit as well (Edelman, et al., 2017). The Framework Convention on Tobacco Control (FCTC) is sub-divided in 10 sections. FCTC is assumed as one of the essential conventions because it regulates tobacco control and public health policies both. The FCTC has indorsed smoke-free law to be adopted within the entire world. According to this law, smoking has been banned in all public areas such as restaurants, bars, sports stadiums, railway stations, shopping centres and cinema halls.

According to the analysis of who framework, unfortunately 9% of countries in the world are implementing the smoke-free rule whereas 65 countries are not following smoke-free laws. Within the UK, the government has introduced the first effective tobacco strategy termed as ‘Smoking Kills’ (Reisner, et al., 2015). This strategy was a milestone strategy within global smoking control. This strategy emphasis on the reducing effects of passive smoking, minimising marketing of smoking within the teenagers and helping smokers to quit this habit. According to the reports of WHO, smoking habit increases problems in breathing in teenage smokers with the rate of almost three times greater than those teenagers who do not smoke (Masters, et al., 2017).

Smoking during pregnancy can cause the risk of cervical and uterine cancer in females. According to WHO, the country should implement the smoke-free laws generated by FCTC, in order to control the rate of smoking within the population (Euro.who.int, 2019). The pregnant women and teenagers should be provided greater importance for planning the strategies to stop smoking. According to WHO, the rate of cigarettes must be increased to minimise the smoking addictions amongst the people (Euro.who.int, 2019). This particular tactic will minimise the difference in between socioeconomic groups in smoking. Further, the smokers who tend to stop smoking should be motivated and encouraged by the government in helping them to quit smoking. The direct smoking must be under controlled by adopting smoke-free law within the entire globe.

Conclusion

Tobacco smoking is considered as a significant factor to early deaths and widely contributes to the global burden of disease. Smoking is now considered as an essential public health issue that is affecting human health of the smokers. Smoking not only effects the smoker’s health but also harmful for those who do not smoke. Several health promotions such as aware of smoking cessations are highlighted to make individuals aware of cessation processes. It has been examined that smoking habit hold various disadvantages according to the observations of JSNA and CCG. These advantages include lungs cancers, heart diseases and environmental issues.

For the process of smoking intervention, 5 A’s approach has been developed. This approach is considered as an effective cessation. Public Health Outcomes Framework (PHOF) was developed which indicates two major outcomes focusing on the life expectancy and health determinants. Effective smoking prevention is discussed supporting these outcomes. Lastly, the World Health Organisation (WHO) 2020 framework also emphasise that smoking habit should be reduced for providing health to the population. Within the WHO, the law was introduced to stop smoking which was implemented by a few countries. For the effective prevention of smoking, this law should be enforced within an entire world.

References

• Aronow, W. S. (1978). Effect of passive smoking on angina pectoris. New England Journal of Medicine, 299(1), 21-24.
• Bauld, L., Bell, K., McCullough, L., Richardson, L. and Greaves, L. (2009). Journal of Public Health. [online] OXFORD ACADEMIC. retrieved from https://academic.oup.com/jpubhealth/article
• Chertok, I.R.A. and Archer, S.H., 2015. Evaluation of a midwife‐and nurse‐delivered 5 A’s prenatal smoking cessation program. Journal of midwifery & women’s health, 60(2), pp.175-181.
• Edelman, C.L., Mandle, C.L. and Kudzma, E.C., 2017. Health promotion throughout the life span-e-book. Elsevier Health Sciences.
• Euro.who.int. (2019). Health 2020: a European policy framework supporting action across government and society for health and well-being. [online] retrieved from http://www.euro.who.int/en/publications/abstracts/health-2020-a-european-policy-framework-supporting-action-across-government-and-society-for-health-and-well-being
• Ferrante, G., Simoni, M., Cibella, F., Ferrara, F., Liotta, G., Malizia, V., Corsello, G., Viegi, G. and La International Tobacco Control Four Country (ITC 4C) Survey. Tobacco control, 27(3), pp.310-318.
• Fu, D., Gratziou, C., Jiménez-Ruiz, C., Faure, M., Ward, B., Ravara, S., Prasad, V.M., Mauer-
• Haluza, D., Moshammer, H., Kundi, M. and Cervinka, R., 2015. Public (skin) health perspectives of gender differences in tanning habit and sun protective behaviour: A cross-sectional questionnaire survey. Wiener klinische Wochenschrift, 127(3-4), pp.124-131.
• Holmes, J., Angus, C., Meier, P. and Brennan, A., 2016. Potential Years of Life Lost (PYLL) due to alcohol consumption in the UK.
• Kezar, A. and Maxey, D., 2016. The Delphi technique: An untapped approach of participatory research. International journal of social research methodology, 19(2), pp.143-160.
• Masters, R., Anwar, E., Collins, B., Cookson, R. and Capewell, S., 2017. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health, 71(8), pp.827-834.
• Maziak, W., Taleb, Z.B., Jawad, M., Afifi, R., Nakkash, R., Akl, E.A., Ward, K.D., Salloum, D., Rentería, E., Jha, P., Forman, D. and Soerjomataram, I., 2016. The impact of cigarette smoking on life expectancy between 1980 and 2010: a global perspective. Tobacco control, 25(5), pp.551-557.
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Introduction

In recent years Evidence-based practice (EBP) has been advocating in nursing profession, however until now there still encounter many difficulties, conflict impact on evidence-based practice development. In this essay will be discussed the challenges and opportunities of future direction of evidence-based practice in nursing.

EBP is a decision making approach introduction in 1992. Sackett et al. (1996) state that EBP is a best evidence method of health care decision making which means to integrate sources from research findings, clinical expertise and consideration of client preferences, clinical setting and other external factors such as cost. (as cited in Hewitt-Taylor, 2002). EBP is a scientific and systematic process rather than traditional approach such as customs, rituals and authority from transmission to improve quality and efficiency of patient outcome (Shaneyfelt et al. 2006).

Challenges can be defined as barriers, difficulty during apply the evidence-based practice in nursing. Actually, there are many challenges of EBP development, in the article will try to divide into four types to discuss: Challenge of the nurse, Challenge of the clinical environment, Challenge of the research and Challenge of the organization. The part of opportunities is to analysis how to improve or diminish the gap between research evidence and clinical practice, and discuss the factors that help for the future direction of EBP in nursing.

Challenges

• 
  Challenge of the nurse,
  

Challenge of the nurse relate to the nurses’ beliefs or attitude to EBP, lack of understanding, knowledge and skills of EBP. A recent study (Oranta, Routasalo & Hupli, 2002) indicated nurses have divergence the value between research and practice; some nurses have conservative ideas that do not welcome change the nursing practice. The result reflect nurses have misunderstanding or negative attitude about evidence based care which may create wrong belief i.e. indifference or ignore the value of EBP. Nurse unawareness of research, are not familiar with EBP, and no sense improve the knowledge, not to mention to implement it in clinical care. (Hutchinson & Johnston, 2004; Wang, Jiang, Wang, Wang & Bai, 2013). Attitudes affect behavior, if nurse attitude remain unchanged, would increase degree of difficulty to carry out EBP in the future.

Lack of skills implementation of EBP also a big challenge facing by nursing (Majid et al. 2010; Hutchinson & Johnston, 2004). There are multiple components of EBP include asking suitable questions, selecting the best

pertinent

information, evaluating the evidence and integration of patient preference, research evidence etc in clinical decision making (Shaneyfelt et al. 2006). Nurse requests ability of integration and critical appraisal research skills i.e. information seeking, understand statistical terms, implementation to run through the EBP process. Provide education and training for EBP should be an important concern in the future for nurse.

• 
  Challenge of the research
  

Next challenge point related to research. Nurses always complain articles from journal are not readily available (Chau, Lopez & Thompson, 2008; Gale & Schaffer 2009; Wang et al. 2013). Actually findings from different research may not always have high level of reliability and validly, methodologies and presentation inadequacies or misconception may exist. Nurses probably feel confused and difficult to appraisal quality of findings, research reports are lengthy, include many academic, jargon terms and statistical analyses cause difficult to comprehension (Oranta, Routasalo & Hupli, 2002).

Furthermore, research finding usually not publishes fast enough and lack of guideline to implement in the clinical practice. Develop the research disseminate type to improve clinical utilization is a main direction in future, otherwise presentation of researches increase barrier to use finding in patient care, eventually obstruct EBP implementation.

• 
  Challenge of the clinical environment
  

Clinical environment seem to be a big challenge which absolute restrict nurse implementing EBP (Lee, 2003). Most studies (Hutchinson & Johnston, 2004; Gale & Schaffer 2009; Wang et al. 2013) stated that nurses have lack of time and heavy workload influences on utilization of research in practice setting. Take Hong Kong as an example, according to the survey conducted by Association of Hong Kong Nursing Staff at 2013, the average of nurse-patient ratio1:17 (normal: 1:4-6) in public hospitals, the bed occupancy rate is 92.9%. Nurses not only have daily heavy workload, also facing a serious shortage problem. Time and labour restrict and clinical safety concerns, nurse tend to use traditional practices and cannot keep frequently follow update journals during working (Hutchinson & Johnston, 2004). The working environment resistant changing tried and definitely threats EBP utilization in future.

• 
  Challenge of the organization
  

EBP is a complex and multifaceted process, cannot apply by individual, administrative support is very important. However lack of organization support is the common complaint by nurses. According to Chau et al. (2008) and Hutchinson & Johnston, (2004) the most important challenge of research utilization are lack of authority and no time to implement new ideas or involve research activity. These concerns related to the organization which include the setting barriers and limitations; e.g. time, resources, support and mentoring.

Besides, conservative attitude of organization such as lack of intention in changes or welcome new ideas must influences EBP utilization (Gale & Schaffer, 2009). It would limit the development of clinical practice to implement EBP and reduce the health care qualities.

In addition, nurse indicated that corporation with other professionals also a barrier of EBP implementation (Oranta, Routasalo & Hupli, 2002). Health care is a team working which involve many different professionals, such as physician, physiotherapist etc. during co-operation may cause differences of decision making. In traditional doctor has the most authority in clinical decision making, nurse advice may cause conflict or challenges by doctor. Therefore relationship between medical and nursing is also an organization related challenge of EBP utilization.

Although there are many challenges of EBP in clinical utilization, challenges creates opportunities, the following part would analysis how to overcome some barriers between research evidence and clinical practice, and talk about the factors that relate to the future direction of EBP in nursing.

Opportunities

Firstly, upgrading of nursing education curriculum improve nurses’ professional status and research knowledge. Nursing students learn of EBP show more potential of ability on clinical decision making (Brown et al. 2010). Although the nursing programme in universities already include research skills teaching to implement evidence-based practice, transferring finding into clinical practice still a big problem for novice nurses. The curriculum should be included how to connect the EBP to the utilization, not just focus the part of research skills training.

Besides, base on shortage of nurse, there are different kind of organizations provide nursing training such as nursing school, hospital nurse training courses, these courses more focus on clinical practice, but not include teaching EBP. At least the basic concept and skills of EBP should be educated in those courses which to improve knowledge of apply EBP into clinical practice.

Second, solidarity and cooperation is also an opportunity to future direction of EBP. No matter clusters, hospitals or ward in Hong Kong tend to working independently and lack of co-ordinate with other. To provide EBP should include cooperate and sharing. The hospitals or clusters can form some research groups from different hospitals or wards; include senior and junior nurses to conduct research-related work. This kind of workshop would improve the stuffs ability to identify the clinical issues, review researches, analysis, promote to implement research finding or conduct research etc. eventually improve the quality of nursing care.

Third relate to organization, the inferiors imitate the superiors; if the organization have positive attitude to motivate and reward EBP can raise the awareness to the staffs pay attention to EBP (Gale & Schaffer, 2009). To improve future develop of EBP, organizational should be modified the nurse ratios. Provide more time and facilities to encourage nurse for discussing and applying research finding in clinical (Lee, 2003).

Fourth, facing of decreasing birth rate, the elderly increasing inevitable, aging population already became a international problem, elderly care must pay more attention in nursing. Community services would be a big tendency and increase outreach services and day care services nursing care. Communities’ services for example community nurse and Nursing Clinic also help to relive the treatment cost, reduce stress and workload of front line nurse and bed occupancy rate. This situation closely relate to EBP because the role of nurses become more arduous and specialization, the case nurse provide professional health care services with integration, multifunction should have both evidence and knowledge to support the practice and patient outcome. The phenomenon provides opportunity to EBP to walk out the hospitals and integrate into the communities.

Fifth, in the future nurses implement EBP may not just focus on Western medicine, also include Chinese medicine. In current years, popularity of Chinese medicine increasing in Hong Kong, most elderly tend to use Chinese treatment such as acupuncture, qigong diet regimen. Chinese medicine research and the utilization on clinical should be part of concern in EBP when making decision. As favorable condition of geography and culture in Hong Kong, combine Chinese and Western medicine would be a tendency, as a nurse should have the knowledge integration and application in clinical care.

In conclude EBP utilization provide a more scientific method to the clinical decision making lead to improve and maintain health care quality, it is definitely the general direction in nursing future development. Base on the restrictive of policies and environment, working environment and organization seems to be two bigger challenges of EBP utilization. Although there are many challenges of EBP, different limitations from nursing and the external environment such as aging population, Chinese medication become more popularity etc provide some opportunities to indicate the future direction of EBP. Nursing profession need to sensitive to those factors, then appropriate to develop or improve, probably reduce the gap between clinical practice and EBP, also may provide a new direction for EBP in nursing utilization.

Healthcare practices and regard for healthcare practioners vary across and within cultures. (Book 11) Patients differ due to various aspects. These differences constitute of patient illness, personality, socioeconomic class or education, however the most endless variation is cultural. (Page 8) Race, religion, language, education, ethnicity and economic status are the essence of culture that has a significant influence on an individual’s health and wellbeing. (Page 21) Skills are crucial for ensuring that nursing care is culturally congruent; knowledge of cultures is important for facilitating communication with people (page 2).Nurses shall use effective, culturally competent, communication with patients that takes into consideration the individuals verbal and non verbal language, cultural values and context and unique healthcare needs and perceptions. (Page 9)

Culture refers to learned and transmitted values, beliefs, norms and life ways of an individual or group that guide their thinking, decisions, actions and fundamental ways of living. Culture consists of primary and secondary characteristics and dynamically constructs and shapes the communication patterns, health beliefs, health practices and relationships of people. (Book 11) Cultures are classified by variability and diversity. (Page 1) Culture tends to provide guidelines for body adornment including clothing, and for food consumption, education, music, art, housing and a variety of other conditions of living. Cultures educate standards of good and bad, value systems, an understanding of time and what constitutes health and illness. Culture plays a fundamental role in the manner in which meanings are interpreted. Not all cultures agree on what health is as there are wide variations in beliefs about the causes and treatment of illness. (book14). These beliefs shape how a group perceives the process of life, how they define health and maintain wellness, what they believe to be the cause of illness and how providers should care for the ill. (Book 8)

Diversity refers to the differences in race, ethnicity, national origin, religion, age, gender, sexual orientation ability/disability, social and economic status or class, education and related attributes of people in society. (Book 10) Cultural diversity comprises of a distinct range of people embedded in a collective belief and value system established by standards, customs and a way of life. (Page 6).This diversity is embodied in the uniqueness and profusion of the identities of the groups and societies making up human mankind. Cultural diversity enables an extensive range of opportunities for individuals and groups within society. It is one of the major factors of development, understood not purely in terms of economic growth, but also a means to achieve a more satisfactory intellectual, emotional, moral and spiritual existance. (Page 5) The way in which people live highlights evidence of diversity through an extensive range of domains and environments. A variation in land, climate and setting is compound diversity in social and cultural characteristics or the reflection of individuals in the diversity of contexts in which healthcare is delivered. (Page 21)

Care is the essence and central focus of nursing. Caring is essential for health and well being, healing, growth, survival and also for facing illness or death. Cultural beliefs and practices are continuously evolving, making it necessary for nurses to acknowledge various cultures. Culture care is a broad holistic perspective to guide for nursing care practices. (Page 7) Culture plays a significant role in patient care as individuals adhere to specific beliefs and ideals as a way of life and these carry over into the most basic aspect of health and illness. (Book 13) Nursing requires sophisticated assessment and analytic skills, the ability to plan, design, implement and evaluate nursing care for individuals, families, groups and communities representing various cultures. The patient’s concept of illness and its causes will help the nurse to assess and prioritise learning opportunities. An increase in patient compliance and cooperation is evident when treatment plans incorporate the patient’s cultural values and beliefs (page 23). Nursing interventions based on cultural knowledge help patients and families adjust more easily and assist nurses in working effectively and comfortably with all patients regardless of their cultural background. (Book 10) The perception and awareness of health breakdown and illness and the cause differs within culture; these individual perceptions affect the approach to healthcare and how patients respond to care that is provided. (Page 3) The relationship between culture and cognition is vital in nursing as nurses must deal with the varying preferred styles of interaction, thinking and learning in relation to both themselves and patients in their care. This cultural awareness maintains a high quality of care and positive health outcomes. (Page 2)

It is essential for nurses to obtain fundamental knowledge and skills in cultural competency. Obtaining cultural information and utilising this knowledge ensures cultural competence. In order for nurses to be culturally proficient they must understand both their and their patients’ perception of the world, while preventing stereotyping and exploitation of scientific knowledge. Nurses portray cultural competence in nursing practice as a continual development working towards achieving a set goal of effectively working with a range of culturally diverse people whilst displaying awareness of diversity during care, a strong understanding of theory and practical skills in nursing and a crucial level of respect for others from different cultures. (Page 5) Effective nursing practice and cultural competence consists of nurses constantly aiming to provide care within the cultural limitations of their patience. An understanding of cultural diversity is vital in all aspects of nursing as it is critical that nurses understand and recognise differences within an individual and not contribute to stereotyping. Culturally competent nurses recognise the harmful effects of ignorance, ethnocentrism, prejudice and bias on the health of their patients and patient populations. Nurses serve as patient advocates by providing a voice for their patients’ needs and concerns. They also ensure the autonomy of their patient populations and their right to safeguard their values, address their health and healthcare needs and to voice their concerns. (Page 14)

Today nurses are confronted with unprecedented cultural diversity as a result of the increasing level of multiculturalism. The continually increasing multicultural population poses a significant challenge to nurses providing individual and holistic care to their patients (page 4) Culture greatly influences how people view their health and the healthcare services they receive. Appreciation and respect for cultural values and beliefs help nurses to gain an understanding towards culturally determined behaviours (Page 22) and enhances family support and acceptance of nursing goals that have been developed (book 10). Nurses who understand and value the practice of culturally competent care are able to effect positive changes in healthcare practices for clients of designated cultures. Nurses have an obligation to advocate for the addition of their patients cultural beliefs and practices in all dimensions of their healthcare. (Page 8) Individuals are socialised through family into a particular culture; Nurses are socialised into the nursing profession through the training undertaken and the acceptance of values and behaviours as appropriate to the profession. In relation to health and care the professional culture of nursing provides the protocol or guide for determining the definition of health and associated values beliefs and practices (page 15) Nurses and healthcare providers must acquire the ability and knowledge to communicate and be aware of health behaviours influenced by culture. Embracing this ability and knowledge can eradicate barriers to the delivery of health care. (Page 31)

For the last five years, I have been working in the capacity of senior staff nurse in a rehabilitation unit for patients suffering from various forms of mental health conditions. When the ward manager offered me the opportunity to attend a course focusing on management skills, I had mixed feelings. I was pleased to realise that my manager had confidence in me to participate; However, I felt that this would be a challenge. At the same time, I was apprehensive; would I be able to fulfil her expectations? Especially as this course was designed for charge nurses who are expected to take a managerial role.

Boud et al (1985) wrote about reflection being a form of response of the learner to experience. Johns (2000) stated through the conflict contradiction, the commitment to realise desirable work and understanding why things are as they are, the practitioner is more empowered to take more appropriate action in the future. From a reflective perspective of my practice, I undertook this study because I wanted to develop my role and felt it would be a good opportunity for me to apply the knowledge gained into my clinical practice.

Effective resource management in the health care is paramount as without resources, there would be no health services. Various and appropriate resources are required to function and support the delivery of healthcare.

In a practice setting, there is the human resources and non human resources. Human resources are staff’s clinical knowledge, their skills and time. This refers to all categories of the workforce within the health care setting. It includes nursing, medical, management, domestic, Occupational therapist, administrators, patients, etc.. Therefore, this includes the skill mix of staff, recruitment and retention. Non human resources are buildings, medication, equipment methods and money.

Methods as resources include clinical procedures, policies and training.

For money, the resources include the cost of maintaining buildings, equipment, recruiting staff and their salaries and day today running of wards, etc.

These resources should be utilized effectively in order to achieve targets at minimal financial cost, in the minimum amount of time and to a high standard.

Learning about workforce planning gave me a greater understanding of assessing how many, and what type of staff required, identifying how these staffs will be supplied and deciding how a balance between demand and supply can be achieved. Workforce planning in the NHS is a challenging but an important process. More effective the workforce is ensuring better service for service users.

During our study lessons, we have had plenty of opportunities to participate in group work. Within an establishment / ward situation it is important to complete the decision making process as a team. Members should realise if they are to discuss an issue, find possible answers to an issue or make recommendations in order for implementation. There must be an open forum for discussion. Given the above, there is less chance members will waste time dealing with issues beyond their responsibility. Commitment to the decision is important as this will increase the commitment to implementation of the decision. Some of the advantages of group decision making are it allows attempts to persuade and influence others, which could result in achieving high quality results. Because of participants wider knowledge, experience and data collection it could produce more possible solutions. People are more committed to implement what has been discussed and planned if they are included in the discussion and the decision making process. Sharing ideas, opinions and options increase the understanding of the situation and commitment to the decision. In group discussions there is opportunity to learn from the other members. The advantage is there can be a tendency for more dominate member to take over and influence others. However, a few of the participants may attempt to appear superior and dominate the group. Especially when there are strong personalities among the group members. Respect differences of opinion (Brounstein,2003; Payne,2001). Also, group members may become more interested in winning rather than investing the best possible option. I have experienced advantages as well as disadvantages during our group work sessions. It felt warm and satisfying to be a part of a group which ensures that everyone has an opportunity to be heard respecting everyone’s idea and values. It was tense and uncomfortable when there are dominators and aggressors; they were interrupting others wanting only their ideas to be heard. There are numerous methods by which a group can interact, these be introduced to prevent the discussions being dominated.

I have also experienced differences in ideas, which led to feelings of a frustration and an unfriendly atmosphere. When you have a group that works well together as a team, negotiating will become more effective.

We should make sure that our negotiations are done in such a way that it flows. The aim is to find an outcome that’s acceptable to both parties. To achive this, we need skills such as: Listening, Questioning, reasoning and accepting. There are many ways to show that you are listening to someone. These involve two sets of skills. Non verbal, which relate to what you do and verbal relates to what you say. Non verbal methods include giving the person eye contact, nodding and not looking at your watch or yawning. Verbal ways include letting someone finish what they are saying, and thinking about what they have said rather than about what you are going to say next and responding to their comments.

In any negotiation situation, it is important that you should feel comfortable about questioning anything you are unsure of or not happy with.

There is no point in taking up a hard and fast position when you go into a negotiating situation. When this happens, both side retreat into their corners, and it becomes difficult to reason. You must be prepared to make some minor adjustments and compromises, as will your negotiating partner to reach a suitable outcome.

At the end of a successful negotiation, you should both feel satisfied that you have reached an acceptable decision. You should also both have had an opportunity to express your views, ask questions and work out a reasonable agreement. If one party cannot accept the position, the negotiation should continue.

I have also learnt and experienced how important it is to have bargaining skills when you are negotiating between two groups. During our negotiating exercise what we failed to do was to discuss between team members our strongest and weakest arguments and planning the sequences of our arguments. I believe the negotiation process can be summarised as a trading game. There is one way to play the game. That is to trade what we have with what we want.

Through this study course, I was expected to learn various topics such as finance/workforce scheduling, report writing/negotiating skills, Recruitment and selection, interview skills, etc. Each lesson I attended was crammed with information.

There were a number of skills I learned as part of my coursework, but in addition I learned a lot by going through the process. Reading relevant books and discussing these with my fellow classmates broaden my knowledge and interest in each topic. Looking at sample essays made me realise writing a report requires logical thinking and planning in order to organise one’s ideas carefully and express them accurately. This was a valuable exercise as we write reports daily in our work area.

I could use my new found knowledge and skills at work. The day after I learned about negotiating skills, a situation arose at work where the new information I learned assisted me in tackling the situation confidently.

The course also helped me to improve my supervision skills in leading the junior members of the team.

Many of the lesions stressed group work. This allowed me to work in a team setting confidently and expand my team building skills.

I highly value the skills and lessons I have learned from attending this course and would recommend the program to anyone who wants to expand their knowledge and skills.

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References

Boud D, Keogh R, Walker D (eds.) (1985) Reflection , turning experience into learning. London. Cogan Page.

Brounstein,2003;payne,2001 Nursing Management and Leadership. Ann Marriner Tomer

Johns C (2000) Becoming a reflective practitioner. Oxford: Blackwell