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Using Epidemiology to Evaluate Health Services Paper Using Epidemiology to Evaluate Health Services Paper Permalink: https://nursingpaperessays.com/ using-epidemiolo…h-services-paper / D-From Gordis TO ASSIGNMENTS (NOT DISCUSSION): Gordis-Review all problems and answers in Ch 16, 17, 18. No problems to submit. Gordis assignment — instead of problems, Post to Assignments (NOT Discussion).(1) From Gordis Ch. 17, 18, & 19 (each), on review of each of these 3 chapters, post and discuss any 1 epidemiology concept in each listed chapter that you better understand see highlighted concepts in each chapter (2) Include your possible use of your example (from each chapter) in the future practice (Primary Care at a community health clinic).(3) Offer any concepts you plan to further explore. Using Epidemiology to Evaluate Health Services Paper Post as: CH 17-post & discuss any 1 epi concept in that chapter with 1 future application of either concept.CH 18-post & discuss any 1 epi concept in that chapter with 1 future application of either concept.CH 19-post & discuss any 1 epi concept in that chapter with 1 future application of either concept. Gordis CHAPTER 17 Using Epidemiology to Evaluate Health Services Keywords measures of process and outcome; efficacy, effectiveness, and efficiency; outcomes research; avoidable mortality; Healthy People 2020 health indicators LEARNING OBJECTIVES To distinguish measures of process from measures of outcome, and to discuss some commonly used measures of outcome in health services research. To define efficacy, effectiveness, and efficiency in the context of health services. To compare and contrast epidemiologic studies of disease etiology with epidemiologic studies evaluating health services. To discuss outcomes research in the context of ecologic data, and to present some potential biases in epidemiologic studies that emerge when evaluating health services using group-level data. To describe some possible study designs that can be used to evaluate health services using individual-level data, including randomized and nonrandomized designs. Perhaps the earliest example of an evaluation is the description of creation given in the book of Genesis 1:1–4, which is shown in the original Hebrew in Fig. 17.1. Translated, with the addition of a few subheadings, it reads as follows BASELINE DATA In the beginning God created the heaven and the earth. And the earth was unformed and void and darkness was on the face of the deep. IMPLEMENTATION OF THE PROGRAM And God said, “Let there be light.” And there was light. EVALUATION OF THE PROGRAM And God saw the light, that it was good. FURTHER PROGRAM ACTIVITIES And God divided the light from the darkness. This excerpt includes all of the basic components of the process of evaluation: baseline data, implementation of the program, evaluation of the program, and implementation of new program activities on the basis of the results of the evaluation. However, two problems arise in this description. First, we are not given the precise criteria that were used to determine whether or how the program was “good”; we are told only that God saw that it was good (which, in hindsight, may be sufficient). Second, this evaluation exemplifies a frequently observed problem: the program director is assessing his own program. Both conscious and subconscious biases can arise in evaluation. Furthermore, even if the program director administers the program superbly, he or she may not necessarily have the specific skills that are needed to conduct a methodologically rigorous evaluation of the program. Dr. Wade Hampton Frost, a leader in epidemiology in the early part of the 20th century, addressed the use of epidemiology in the evaluation of public health programs in a presentation to the American Public Health Association in 1925. 1 He wrote, in part, as follows: The health officer occupies the position of an agent to whom the public entrusts certain of its resources in public money and cooperation, to be so invested that they may yield the best returns in health; and in discharging the responsibilities of this position he is expected to follow the same general principles of procedure as would be a fiscal agent under like circumstances. … Since his capital comes entirely from the public, it is reasonable to expect that he will be prepared to explain to the public his reasons for making each investment, and to give them some estimate of the returns which he expects. Nor can he consider it unreasonable if the public should wish to have an accounting from time to time, to know what returns are actually being received and how they check with the advance estimates which he has given them. Certainly any fiscal agent would expect to have his judgment thus checked and to gain or lose his clients’ confidence in proportion as his estimates were verified or not. However, as to such accounting, the health officer finds himself in a difficult and possibly embarrassing position, for while he may give a fairly exact statement of how much money and effort he has put into each of his several activities, he can rarely if ever give an equally exact or simple accounting of the returns from these investments considered separately and individually. This, to be sure, is not altogether his fault. It is due primarily to the character of the dividends from public health endeavor, and the manner in which they are distributed. They are not received in separate installments of a uniform currency, each docketed as to its source and recorded as received; but come irregularly from day to day, distributed to unidentified individuals throughout the community, who are not individually conscious of having received them. They are positive benefits in added life and improved health, but the only record ordinarily kept in morbidity and mortality statistics is the partial and negative record of death and of illness from certain clearly defined types of disease, chiefly the more acute communicable diseases, which constitute only a fraction of the total morbidity. 1 Using Epidemiology to Evaluate Health Services Paper Dr. Charles V. Chapin commented on Frost’s presentation: Dr. Frost’s earnest demand that the procedures of preventive medicine be placed on a firm scientific basis is well timed. Indeed, it would have been opportune at any time during the past 40 years and, it is to be feared, will be equally needed for 40 years to come. 2 Chapin clearly underestimated the number of years; the need remains as critical today, some 90+ years later, as it was in 1925. Studies of Process and Outcome Avedis Donabedian is widely regarded as the author of the seminal work on creating a framework of examining health services in relation to the quality of care. He identified three important factors simultaneously at play: (1) structure, (2) process, and (3) outcome. Structure relates to the physical locations where care is provided, the personnel, equipment, and financing. We will restrict our discussion here to the remaining two components, process and outcome. Studies of Process At the outset, we should distinguish between process and outcome studies. Process means that we decide what constitutes the components of good care, services, or preventive actions. Such a decision may first be made by an expert panel. We can then assess a clinic or health care provider, by reviewing relevant records or by direct observation, and determine to what extent the care provided meets established and accepted criteria. For example, in primary care we can determine what percentage of patients have had their blood pressure measured. The problem with such process measures is that they do not indicate whether the patient is better off; for example, monitoring blood pressure does not ensure that the patient’s blood pressure is under control or that the patient will consistently take antihypertensive medications if they are prescribed. Second, because process assessments are often based on expert opinion, the criteria used in process evaluations may change over time as expert opinion changes. For example, in the 1940s, the accepted standard of care for premature infants required that such infants be placed in 100% oxygen. Incubators were monitored to be sure that such levels were maintained. However, when research demonstrated that high oxygen concentration played a major role in producing retrolental fibroplasia—a form of blindness in children who had been born prematurely—high concentrations of oxygen were subsequently deemed unacceptable. Studies of Outcome Given the limitations of process studies, the remainder of this chapter focuses on outcome measures. Outcome denotes whether or not a patient (or a community at large) benefits from the medical care provided. Health outcomes are frequently considered the domain of epidemiology. Although such measures have traditionally been mortality and morbidity, interest in outcomes research in recent years has expanded the measures of interest to include patient satisfaction, quality of life, degree of dependence and disability, and similar measures. Efficacy, Effectiveness, and Efficiency Three terms that are often encountered in the literature dealing with evaluation of health services are efficacy, effectiveness, and efficiency. These terms are often used in association with the findings from randomized trials. Efficacy Does the agent or intervention “work” under ideal “laboratory” conditions? We test a new drug in a group of patients who have agreed to be hospitalized and who are observed as they take their therapy. Or a vaccine is tested in a group of consenting subjects. Thus, efficacy is a measure in a situation in which all conditions are controlled to maximize the effect of the agent. Generally, “ideal” conditions are those that occur in testing a new agent of intervention using a randomized trial. Effectiveness If we administer the agent in a “real-life” situation, is it effective? For example, when a vaccine is tested in a community, many individuals may not come in to be vaccinated. Or, an oral medication may have such an undesirable taste that no one will take it (so that it will prove ineffective), despite the fact that under controlled conditions, when compliance was ensured, the drug was shown to be efficacious. Efficiency If an agent is shown to be effective, what is the cost–benefit ratio? Is it possible to achieve our goals in a less expensive and better way? Cost includes not only money, but also discomfort, pain, absenteeism, disability, and social stigma. If a health care measure has not been demonstrated to be effective, there is little point looking at efficiency, for if it is not effective, the least expensive alternative is not to use it at all. At times, of course, political and societal pressures may drive a program even if it is not effective (an often-cited example is DARE—Drug Abuse Resistance Education, which has never been shown to have an impact on adolescent and young adult drug use). However, this chapter will focus only on the science of evaluation and specifically on the issue of effectiveness in evaluating health services. Measures of Outcome If efficacy of a measure has been demonstrated—that is, if the methods of prevention and intervention that are of interest have been shown to work—we can then turn to evaluating effectiveness. What guidelines should we use in selecting an appropriate outcome measure to serve as an index of effectiveness? First, the measure must be clearly quantifiable; that is, we must be able to express its effect in quantitative terms. Second, the measure of outcome should be relatively easy to define and diagnose. If the measure is to be used in a population study, we would certainly not want to depend on an invasive procedure for assessing any benefits. Third, the measure selected should lend itself to standardization for study purposes. Fourth, the population served (and the comparison population) must be at risk for the same condition for which an intervention is being evaluated. For example, it would obviously make little sense to test the effectiveness of a sickle cell screening program in a white population in North America (as sickle cell disease primarily affects African Americans). The type of health outcome end point that we select clearly should depend on the question that we are asking. Although this may seem self-evident, it is not always immediately apparent. Box 17.1 shows possible end points in evaluating the effectiveness of a vaccine program. Whatever outcome we select should be explicitly stated so that others reading the report of our findings will be able to make their own judgments regarding the appropriateness of the measure selected and the quality of the data. Whether the measure we have selected is indeed an appropriate one depends on clinical and public health aspects of the disease or health condition in question. Box 17.1 Some Possible End Points for Measuring the Success of a Vaccine Program Number (or proportion) of people immunized Number (or proportion) of people at (high) risk who are immunized Number (or proportion) of people immunized who show serologic response Number (or proportion) of people immunized and later exposed in whom clinical disease does not develop Number (or proportion) of people immunized and later exposed in whom clinical or subclinical disease does not develop Box 17.2 shows possible choices of measures for assessing the effectiveness of a throat culture program in children. Measures of volume of services provided, numbers of cultures taken, and number of clinic visits have been traditionally used because they are relatively easy to count and are helpful in justifying requests for budgetary increases for the program in the following year. However, such measures are all process measures and tell us nothing about the effectiveness of an intervention. We therefore move to other possibilities listed in this box. Again, the most appropriate measures should depend on the question being asked. The question must be specific. It is not enough just to ask how good the program is. Box 17.2 Some Possible End Points for Measuring Success of a Throat Culture Program Number of cultures taken (symptomatic or asymptomatic) Number (or proportion) of cultures positive for streptococcal infection Number (or proportion) of persons with positive cultures for whom medical care is obtained Number (or proportion) of persons with positive cultures for whom proper treatment is prescribed and taken Number (or proportion) of positive cultures followed by a relapse Number (or proportion) of positive cultures followed by rheumatic fever Comparing Epidemiologic Studies of Disease Etiology and Epidemiologic Research Evaluating Effectiveness of Health Services In classic epidemiologic studies of disease etiology, we examine the possible relationship between a putative cause (the independent variable or “exposure”) and an adverse health effect or effects (the dependent variable or “outcome”). In doing so, we take into account other factors, including health care, that may modify the relationship or confound it (Fig. 17.2A). In health services research, we focus on the health service as the independent variable (the “exposure”), with a reduction in adverse health effects as the anticipated outcome (dependent variable) if the modality of care is effective. In this situation, environmental and other factors that may influence the relationship are also taken into account (see Fig. 17.2B). Thus, both etiologic epidemiologic research and health services research address the possible relationship between an independent variable and a dependent variable, and the influence of other factors on the relationship. Therefore, it is not surprising that many of the study designs discussed are common to both epidemiologic and health services research, as are the methodologic problems and potential biases that may characterize these types of studies. Using Epidemiology to Evaluate Health Services Paper FIG. 17.2 (A) Classic epidemiologic research into etiology, taking into account the possible influence of other factors, including health care. (B) Classic health services research into effectiveness, taking into account the possible influence of environmental and other factors. Evaluation Using Group Data Regularly available data, such as mortality data and hospitalization data, are often used in evaluation studies. Such data can be obtained from different sources, and such sources may differ in important ways. For example, Fig. 17.3 shows the changes in the estimated proportion of the US population with influenza-like illness (ILI) over time—trends—using three different data sources: sentinel surveillance sites overseen by the Centers for Disease Control and Prevention (CDC), Google Flu Trends, and Flu Near You. 3 FIG. 17.3 Estimated proportion of US population with influenza-like illness January 2011–13. CDC, Centers for Disease Control and Prevention. (From Butler D. When Google got flu wrong. Nature. 2013;494:155–156.) Although the trends are fairly similar in this time period, we can see that Google Flu Trends estimated a higher proportion of the US population with ILI toward the end of 2012, nearly twice as high as the CDC estimates. This is potentially attributed to the varying methodology of data collection of each data source. The CDC generates its data from over 2,700 health care centers that capture over 30 million patient visits each year. Google Flu Trends uses data mining and modeling methodology generated from the flu-related search terms entered in Google’s search engine. Flu Near You uses data entered by internet users volunteering information, not necessarily physicians, to report on a weekly basis whether they, or their family members, have ILI symptoms. It is possible that not all individuals who develop ILI symptoms will seek medical care, and hence are not captured by the CDC data, but they may perform a Google search for ways to alleviate ILI symptoms, for example. Since Flu Near You solely depends on voluntary self-report of ILI symptoms it might well underestimate prevalence. In a recent flu season, New York State Governor Andrew M. Cuomo declared a Public Health Emergency in response to a severe flu season. It was suggested that this might have prompted numerous searches on Google by individuals who are not actually suffering from ILI symptoms, which in turn could have triggered the spike that we see in the figure. Outcomes Research The term outcomes research has been increasingly used to denote studies comparing the effects of two or more health care interventions or modalities—such as treatments, forms of health care organization, or type and extent of insurance coverage and provider reimbursement—on health or economic outcomes. The health end points may include morbidity and mortality as well as measures of quality of life, functional status, and patient perceptions of their health status, including symptom recognition and patient-reported satisfaction. Economic measures may reflect direct or indirect costs, and can include hospitalization rates, rehospitalization for the same condition within 30 days of discharge, outpatient and emergency room visits, lost days of work, child care, and days of restricted activity. Consequently, epidemiology is one of several disciplines needed in outcomes research. Outcomes research often uses data from large data sets that were derived from large populations. Although in recent years some of the large data sets have been developed from cohorts that were originally set up for different research purposes, many of the data sets used were often originally initiated for administrative or fiscal purposes, rather than for any research goals. Often several large data sets, each having information on different variables, may be combined or linked (resulting in “meta-data”) in order to have sufficient sample size to explore a question of interest. With the advent of the electronic medical record (EMR), patient care data are increasingly available to the epidemiology and health services research communities. The purpose of the EMR is to provide health care providers all of the information pertaining to individual patients—findings from office visits, utilization of preventive services, prescribed medications, procedures, radiologic findings, laboratory test results—continuously over time (i.e., prospectively). However, the purpose of the EMR is not to serve as a research base but to direct patient care. Harnessing the EMR to evaluate health services research questions has great promise, but to date it has proven difficult to use and the methods to maximize its potential are still being developed and tested in the field. The advantages of using large data sets (sometimes referred to as “big data”) are that the data refer to real-world populations, and the issue of “representativeness” or “generalizability” is minimized. In addition, since the data sets exist at the time the research is initiated, analysis can generally be completed and results generated relatively rapidly. Moreover, given the large data sets used, sample size is not usually a problem except when smaller subgroups are examined. Given these considerations, the costs of using existing data sets are generally lower than the costs of primary data collection. The disadvantages are that, since the data were often initially gathered for fiscal patient care and administrative purposes, they may not be well suited for research purposes and for answering the specific research question addressed in the study. Even when the data were originally gathered for research, our knowledge of the area may now be more complete and new research questions may have arisen that were not even conceived of when the original data collection was initiated. In general, data may be incomplete. Data on the independent and dependent variables may be very limited. Data may be missing on clinical details including disease severity and on the details of interventions, and diagnostic coding may be inconsistent across facilities and within facilities over time. Data relating to possible confounders may be inadequate or absent since the research now being conducted was often not even possible when the data were originally generated. Because certain variables that today are considered relevant and important were not included in the original data set, investigators may at times create surrogate variables for the missing variables, using certain variables that are included in the data set but that may not directly reflect the variable of interest. However, such surrogate variables vary in the extent to which they are an adequate measure of the missing variable of interest. For all these reasons, the validity of the conclusions reached may therefore be in doubt. Using Epidemiology to Evaluate Health Services Paper Another important problem that may arise with large data sets is that because the necessary variables may be absent in the available data set, the investigator may consciously or subconsciously change from the question he or she had originally wanted to address to a question that is of less interest, but for which the variables that are needed for conducting the study are present in the data set. Thus, rather than the investigator deciding what research question should be addressed, the data set itself may end up determining what questions are asked in the study. Finally, using large data sets, investigators become progressively more removed from the individuals being studied. Over the years, direct interviews and reviews of patient records have tended to be replaced by large computerized databases. Using these sources of data, many personal characteristics of the subjects are never explored and their relevance to the questions being asked is virtually never assessed. One area in which existing sources of data are often used in evaluation studies is prenatal care. The problems discussed earlier are exemplified in the use of birth certificates. These documents are often used because they are easily accessible and provide certain medical care data, such as the trimester in which prenatal care was begun. However, birth certificates for women with high-risk pregnancies have missing data more often than those for women with low-risk pregnancies. The quality of the data provided on birth certificates also may differ regionally and internationally, and may complicate any comparisons that are made. An example of outcomes research using large data sets is a study by Ikuta et?al. of Medicare beneficiaries in the United States. 4 Since Medicare health coverage is provided to virtually all elderly (ages 65 years and older) individuals in the United States, it is assumed that if a study population is limited to those who have Medicare coverage, financial obstacles to care and other variables such as age, gender, or racial/ethnic subpopulations are held constant among different groups. However, wide disparities still remain between blacks and whites in utilizing many Medicare services. The authors studied the national trends in the use of pulmonary artery catheterization (PAC) among Medicare beneficiaries during the period 1999–2013. 4 PAC is a procedure by which a tube is inserted in one of the large veins in the body, and then threaded through the heart to be ultimately placed in the pulmonary artery. This procedure used to be indicated as part of routine management of heart failure and sepsis-related acute respiratory distress syndrome, among many others. However, given the rising evidence that PAC did not improve patient outcomes, the clinical practice guidelines of the American College of Cardiology and the Society of Critical Care Medicine now recommends against the routine use of PAC. The authors studied inpatient claims data from the Centers for Medicare and Medicaid Services from 1999 to 2013 and estimated the rate of use of a PAC per 1,000 admissions, 30-day mortality, and length of stay. They found a statistically significant 67.8% relative reduction in PAC use (6.28 per 1,000 admissions in 1999 to 2.02 per 1,000 admissions in 2013), in addition to year-to-year reductions in in-hospital mortality, 30-day mortality, and length of stay. However, the findings also showed that such rates varied substantially by gender (Fig. 17.4), race (Fig. 17.5), and age (Fig. 17.6). These results showed the added benefits in restricting the use of PAC in some patients. In the meantime, the authors admitted the limitations in the use of administrative data sets and the inability to generalize to younger and uninsured individuals. FIG. 17.4 Pulmonary artery catheter use rate per 1,000 admissions by gender between 1999 and 2013. (Modified from Ikuta K, Wang Y, Robinson A, et?al. National trends in use and outcomes of pulmonary artery catheters among medicare beneficiaries, 1999–2013. JAMA Cardiol. 2017;2:908–913.) FIG. 17.5 Pulmonary artery catheter use rate per 1,000 admissions by race between 1999 and 2013. (Modified from Ikuta K, Wang Y, Robinson A, et?al. National trends in use and outcomes of pulmonary artery catheters among medicare beneficiaries, 1999–2013. JAMA Cardiol. 2017;2:908–913.) FIG. 17.6 Pulmonary artery catheter use rate per 1,000 admissions by age groups between 1999 and 2013. (Modified from Ikuta K, Wang Y, Robinson A, et?al. National trends in use and outcomes of pulmonary artery catheters among medicare beneficiaries, 1999–2013. JAMA Cardiol. 2017;2:908–913.) Potential Biases in Evaluating Health Services Using Group Data Studies evaluating health services using group data are susceptible to many of the biases that characterize etiologic studies, as discussed in Chapter 15. In addition, certain biases are particularly relevant for specific research areas and topics, and may be important depending on the specific epidemiologic design selected. For example, studies of the relationship of prenatal care to birth outcomes are prone to several important potential biases. In such studies, the question often addressed is whether prenatal care, as measured by the absolute number of prenatal visits, reduces the risk of prematurity and low birth weight. Several potential biases may be introduced into this type of analysis. For example, other things being equal, a woman who delivers prematurely will have fewer prenatal visits (i.e., the pregnancy was shorter so that there was less time in which it was possible for her to “be at risk” for prenatal visits). The result would be an artefactual relationship between fewer prenatal visits and prematurity, only because the gestation was shorter. However, bias can also operate in the other direction. A woman who begins prenatal care in the last trimester of pregnancy will likely not have an early premature delivery, as she has already carried the pregnancy into the last trimester. This would lead to an observed association of fewer prenatal visits with a reduced likelihood of early premature delivery. In addition, women who have had medical complications or a poor pregnancy outcome in a prior pregnancy may be so anxious that they come for more prenatal visits (where problems with the fetus may be detected early), and they may also be at greater risk for a poor outcome. Thus, the potential biases can run in one or both directions. If such women are at a risk that is not amenable to prevention, an apparent association of more prenatal visits with an adverse outcome may be observed. Finally, prenatal outcome studies based on prenatal care are often biased by self-selection; that is, the women who choose to begin prenatal care early in pregnancy are often better educated and from a higher socioeconomic status with more positive attitudes toward health care. Thus, a population of women, who to begin with are at lower risk for adverse birth outcomes, select themselves for earlier prenatal care. The result is a potential for an apparent association of early prenatal care with lower risk of adverse pregnancy outcome, even if the care itself is without any true health benefit. Two Indices Used in Ecologic Studies of Health Services One index in evaluating health services that uses ecologic studies is avoidable mortality. Avoidable mortality analyses assume that the rate of “avoidable deaths” should vary inversely with the availability, accessibility, and quality of medical care in different geographic regions. The UK Office for National Statistics defines avoidable mortality as: Avoidable deaths are all those defined as preventable, amenable, or both, where each death is counted only once. Where a cause of death falls within both the preventable and amenable definition, all deaths from that cause are counted in both categories when they are presented separately. 5 Conditions include tuberculosis, hepatitis C, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), selected malignant neoplasms, substance use disorders, cardiovascular and respiratory diseases, unintentional and intentional injuries, among others. Ideally, avoidable mortality would serve as a measure of the accessibility, adequacy, and effectiveness of care in an area. Deaths from HIV/AIDS will be less frequent in communities with ample, friendly, and convenient HIV testing and counseling and high-quality AIDS service organizations, often found in urban areas. In rural areas, such services may be less accessible, and diagnoses may only be made when a patient presents with an AIDS-defining illness. Thus, patients are more likely to have a higher mortality rate in areas with poorer service coverage, which they would not have experienced had they lived in an urban environment. Changes over time could be plotted and comparisons made with other areas. Unfortunately, the necessary data for such an analysis are often lacking for many of the conditions suggested for avoidable mortality analyses. Moreover, data on confounders may not be available and the resulting inferences may therefore be open to question. A second approach is to use health indicators. With this approach, certain sentinel conditions are assumed to reflect the general level of health care, and changes in the incidence of these conditions are plotted over time and compared with data for other populations. The changes and differences that are found are then related to changes in the health service sector

NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay Please use the two articles below and cite from these only, I have also attached a secondary source that is a book pdf on the files too from 2017, you may cite from here too as long as everything is in the correct APA format. NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay My last sentence in the introduction was my purpose statement, mentioning the three main points I’ll be writing about. You make three headers from those points, and in each header I should have one paragraph of 6-7 sentences(including the citations.) Along with this body text, I will also need a conclusion (1 paragraph) and a reference page. The three paragraphs from the body text and the conclusion should not be more than 3 pages long. The reference page will be another page. I have included the guide/rubric for this class (start on page 20 to see the main points that need to be made on the paper.) Please do not make my writing style sound too formal, I am supposed to sound like a first-time writer, and I wish for my professors to not be suspicious if I sound too professional. No plagiarism of any kind , they’re very strict with that. Main sources: Hand hygiene management among nurses Effectiveness of hand hygiene in child care. Secondary source: Hand hygiene 2017 book _entry_level_activities_ WEEK 1 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 Welcome and Orientation · Course orientation · Canvas · Time management Review : Getting Started on Canvas Home Page, and review and print out the Syllabus and Activities & Assignment Note: Each week begins on Monday at 12:01 AM/EST and ends on Sunday at 11:59 PM/EST *** Note: For all written activities, discussion postings, and assignments, students may use the articles posted in the class only in addition to the required peer-reviewed scholarly journals and references . *** Classroom Activities will be completed in the classroom. Students must be present in class and participate in the activities to receive points. NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay Week 1 Content · Go to Modules on the Course Menu, click, and scroll down to Week 1 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Introduction to APA Manual Review of the Canvas Learning System · Course messages (versus NSU email) · Pre-Course instructions, Syllabus, A&A, My Grades, Calendar · Student Success Session (SSS) Weekly Webinar: A free service for students. View the SSS Introduction Power Point located in Week 1. The sessions take place in Weeks 2-6 on Thursday’s from 4:00 PM to 5:00 PM/EST HIPAA Environmental Health and Safety Education Services (EHSES) Class 2 Stress Reduction/Time Management · Review of Stress Management/Coping Strategies · Time Management Week 1 Content · Go to Modules on the Course Menu, click, and scroll down to Week 1 content In-Class Activity 1 (3 points): · One of the major challenges of an entry level baccalaureate of science nursing (BSN) student is the organizational skills needed to be successful. This in class activity is to help each student develop a time management schedule and personal calendar. Student Success Seminar · Click on the Student Success Seminar (SSS) button in the course menu · Click on the first link to register, use NSU email address and password only · Register once for all sessions. Once registered, look for an email sent to the NSU email with confirmation and information to on how to join the SSS. In the email, click on the save to calendar. WEEK 2 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 APA, Online Library, and Internet Basics · Begin mechanics of Microsoft Word · APA concepts and formatting: APA style · Library access and databases · Role of RN as adult learner Readings: American Psychological Association (APA) Manual (7 th ed.) · See weekly reading list in Course Documents · Please complete before coming to class Week 2 Content · Go to Modules on the Course Menu, click, and scroll down to Week 2 content NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: NSU Writing Center Representative NSU Librarian · Introduction to the 7 th edition APA manual · Marking APA manual · Defining APA format · Introduction and discussion of the mechanics of Microsoft Word · APA formatting · Writing clearly and concisely · Use of first person, editorial we · Examples of what can be used instead of ‘I’ · Wikipedia: Not a reputable Internet site as it can be altered Class 2 APA, Online Library, and Internet Basics · Begin mechanics of Microsoft Word · APA concepts and formatting: APA style · Library access and databases · Role of RN as adult learner Week 2 Content · Go to Modules on the Course Menu, click, and scroll down to Week 2 content In-Class Lecture/Discussion/Activity 2 (3 points) In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: · Go to the NSU homepage; go to Libraries · Click on Health Professions. · This leads to the homepage of the Health Professions Division (HPD) Library · Click on the Nursing icon (Band-Aid) · Click on Entry Level · Discussion of topics for scholarly paper/parts of the scholarly paper · Topic Choices o Hand Hygiene, Medication Errors, Patient Safety o Adult Learning, Obtaining a BSN, Stress and Anxiety in Nursing School o How to be successful in Nursing School Homework Activity: Library (3 points): · Review the instructional rubric (directions) for Assignment 2 (Introduction and Purpose Statement) · Go to the Health Profession Division (HPD) online library · Locate two (2) articles related to the topic that address the instructions in Assignment 2. These articles will be used to develop the paper · Save the articles as a PDF to computer or flash drive · Submit the Assignment before class in Week 3 · Bring the two peer-reviewed scholarly articles to class in Week 3 (preferably as a hard copy) Student Success Seminar Starts This Week WEEK 3 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 APA and Microsoft Word · Continue mechanics of Microsoft Word and APA style · Title page development · Topic selection Week 3 Content · Go to Modules on the Course Menu, click, and scroll down to Week 3 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Continue to mark the APA Manual Setting up an APA document Title page Submitting the Assignment Instructor feedback in My Grades · Identify a topic of interest (in-class). Notify Faculty of choice. Go to the Health Profession Division (HPD) on-line library, find two (2) articles related to your chosen topic. Save the articles as a PDF to computer or flash drive. In-Class Activity 3 (3 points): o The instructor will assign groups in class Each group will complete the APA Table Each group will use the APA Manual to complete this in-class activity In Class APA Collaborative Activity 1 (5 points): · The instructor will assign groups/shared pairs in class Each group will discuss and collaborate the responses to the activity providing page numbers from the APA manual to support the answer Class 2 APA and Microsoft Word · Continue mechanics of Microsoft Word and APA style · Title page development · Topic selection Week 3 Content · Go to Modules on the Course Menu, click, and scroll down to Week 3 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Continue to mark the APA Manual Setting up an APA document Title page Submitting the Assignment Instructor feedback in My Grades Assignment 1: Title Page and Page 2 (8 points): Create a title page and Page 2 using APA format Follow the instructions for Setting Up an APA Document in Word located in Week 3/Microsoft® Word folder Scroll to the bottom of this grid and follow the instructional rubric (directions) and grading rubric for the assignment Submit the Assignment by the posted due date WEEK 4 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Introduction and purpose statement development · APA level one headings · Plagiarism Week 4 Content · Go to Modules on the Course Menu, click, and scroll down to Week 4 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paraphrasing, direct quotes, in-text citations and parenthetical citations Assignment 1: Title Page and Page 2 instructor feedback Continue to mark the APA Manual Introductory paragraph and purpose statement Utilizing the instructional rubric (directions) located at end of the grid Avoiding plagiarism NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay In-Class Activity 4: Plagiarism (3 points): Determining if articles are evidence-based and citing information properly from sources to avoid student plagiarism are two important components of successful scholarly writing. One of the major reasons for properly citing information from sources following APA guidelines in scholarly papers is to avoid student plagiarism when writing scholarly papers. All scholarly papers must be grounded in evidence-based practice. Using evidence-based sources validates the information presented and strengthens the scholarly paper. After completing the assigned reading in the APA manual on plagiarism discuss the following: · Define plagiarism · Discuss the different types of plagiarism · Discuss the consequences of plagiarism · Discuss ways to avoid plagiarism Class 2 Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Introduction and purpose statement development · APA level one headings · Plagiarism Week 4 Content · Go to Modules on the Course Menu, click, and scroll down to Week 4 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paraphrasing, direct quotes, in-text citations and parenthetical citations Assignment 1: Title Page and Page 2 instructor feedback Continue to mark the APA Manual Introductory paragraph and purpose statement Utilizing the instructional rubric (directions) located at end of the grid Avoiding plagiarism In-Class APA Collaborative Activity 2 (5 points): · The instructor will assign groups/shared pairs in class · Each group will discuss and collaborate the responses to the activity providing page numbers from the APA manual to support the answer Assignment 2: introduction and Purpose Statement (15 points): Each student will develop the introduction paragraph and purpose statement · Rename the paper submitted in Assignment 1 · Students will add Assignment 2 to Assignment 1 becoming one document · Follow the assignment instructions and rubric at the end of this grid · Submit the Assignment by the posted due date WEEK 5 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 APA, Microsoft Word, and Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Body of text · In-text citation: Paraphrasing and direct quote · Reference page Week 5 Content · Go to Modules on the Course Menu, click, and scroll down to Week 5 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paragraph development for Assignment 3 Level of heading, citations, personal communication, and references Abbreviations, body of paper, reference page Faculty review Turnitin Direct submission and how to read the Similarity Report Instructor lead APA Exercises Paraphrasing, direct quotes, in-text citations and parenthetical citations Developing the body of text and levels of heading utilizing the instructional rubric (directions) References Assignment 2: Introduction and Purpose Statement feedback NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay In Class Activity 5: APA Format Exercise (3 Points ): · Evaluation of Scholarly Papers for APA Basics and Mastery · Students given sample papers to review in groups · Students present findings of errors to class (5 minutes each) · Begin presentations; time permitting Class 2 APA, Microsoft Word, and Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Body of text · In-text citation: Paraphrasing and direct quote · Reference page Week 5 Content · Go to Modules on the Course Menu, click, and scroll down to Week 5 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paragraph development for Assignment 3 Level of heading, citations, personal communication, and references Abbreviations, body of paper, reference page Faculty review Turnitin Direct submission and how to read the Similarity Report In Class APA Collaborative Activity 3 (5 points) · The instructor will assign groups/shared pairs in class · Each group will discuss and collaborate the responses to the activity providing page numbers from the APA manual to support the answer Assignment 3: Body of Text, In-text Citations, Level 1 Heading, and Reference Page (15 points): Students will add the body of text, in-text citations, level one headings, and a reference page to Assignment 2 document (the title page, introduction, and purpose statement) · Include level one headings, two direct quotes, two paraphrases, and a personal communication in the body of the paper · Review all previous submissions and make any corrections (Assignment 1 and Assignment 2) · Review the instructions and grading rubric that follow this grid · Submit the Assignment by the posted due date WEEK 6 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Plagiarism exercise · Conclusion Week 6 Content · Go to Modules on the Course Menu, click, and scroll down to Week 6 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: · Review of APA style: in-text citations, parenthetical citations, direct quotes, paraphrasing, journal and website reference, and personal communication · Assignment 3 feedback: Body of Text, In-text Citations, Level 1 Heading, and References · Plagiarism · Review Assignment 4: Adding the Conclusion In-Class Activity 6: HPD Library Exercise (3 points) · Go to the HPD Online Library · Find one article related to student plagiarism in college setting · Find one article related to transitioning entry level nursing student · Save article as a PDF Class 2 Scholarly Writing · Continue mechanics of Microsoft Word and APA style · Plagiarism exercise · Conclusion Keep bullets consistent throughout document Week 6 Content · Go to Modules on the Course Menu, click, and scroll down to Week 6 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: · Review of APA style: in-text citations, parenthetical citations, direct quotes, paraphrasing, journal and website reference, and personal communication · Assignment 3 feedback: Body of Text, In-text Citations, Level 1 Heading, and References · Plagiarism In Class APA Collaborative Activity 4 (5 points): · The instructor will assign groups/shared pairs in class · Each group will discuss and collaborate the responses to the activity providing page numbers from the APA manual to support the answer Assignment 4: Adding the Conclusion (8 points): · Make ongoing corrections from previous submissions (Assignments 1-3) · Rename the document and add the conclusion to the prior assignments · Review the instructions and grading rubric at the end of this document · Submit the Assignment by the posted due date WEEK 7 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 Putting It All Together · Continue mechanics of Microsoft Word and APA style · Using Turnitin Direct Week 7 Content · Go to Modules on the Course Menu, click, and scroll down to Week 7 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paraphrasing practice exercise Review Turnitin Direct submission and Similarity Report Introduction to course and instructor evaluations Instructors will discuss the importance of completing the evaluation following each course, how to access them, and answer any questions as the students complete the evaluation Assignment 4: Adding the Conclusion instructor feedback In-Class Activity 7 – Plagiarism (3 points): · Students will work in groups to locate one review peer-reviewed, current article on plagiarism · Discuss and summarize the article and present three (3) suggestions to prevent plagiarism · Prepare a three-minute skit to presentation to the class demonstrating the group’s three suggestions to prevent plagiarism. Be creative using any props! · Additionally, include if the article is from a peer-reviewed source · Identify how it was determined to be peer-reviewed · Intended message the author is trying to convey to the reader and/or the audience · If source greater than 5 years out of date? NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay Class 2 Putting It All Together · Continue mechanics of Microsoft Word and APA style · Using Turnitin Direct Week 7 Content · Go to Modules on the Course Menu, click, and scroll down to Week 7 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: Paraphrasing practice exercise Review Turnitin Direct submission and Similarity Report Introduction to course and instructor evaluations Instructors will discuss the importance of completing the evaluation following each course, how to access them, and answer any questions as the students complete the evaluation Assignment 4: Adding the Conclusion instructor feedback Assignment 5: Final Paper (10 points): · Complete corrections on previous assignments (Assignment 1-4) · Rename the document · Submit the paper to Turnitin Direct before submitting the Assignment · Make any revisions necessary based on the results from the Turnitin Direct Originality Report · Submit to the Assignment by the posted due date WEEK 8 TOPICAL OUTLINE ACTIVITIES AND ASSIGNMENTS Class 1 Course Wrap Up · Course reflection · Final papers due · End of course evaluations Complete the course and instructor evaluations! Thank you Week 8 Content · Go to Modules on the Course Menu, click, and scroll down to Week 8 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: · Assignment feedback for final paper · Muddiest point · Course evaluations · Preparation for NUR 3160 Online Course Evaluations · Please complete both course and instructor · Link sent in the NSU Email Class 2 Course Wrap Up · Course reflection · Final papers due · End of course evaluations Week 8 Content · Go to Modules on the Course Menu, click, and scroll down to Week 8 content In-Class Lecture/Discussion/Activity In-class activities will be facilitated by the instructor and may include small groups, shared pairs, individual work, groups discussions, and individual/group presentations. Prior to class, read the weekly content and be prepared to discuss the following: · Assignment feedback for final paper · Muddiest point · Course evaluations · Preparation for NUR 3160 In-Class Faculty led Discussion: · Discuss how the new knowledge and skills can assist in academic success · Discuss any changes made as a student since beginning this academic journey · Reflect on your Calendar and Study habits, and future application in 2 nd semester Online Course Evaluations · Please complete both course and instructor · Link sent in the NSU Email In-Class Activity (7 x 3 points each/21 points total) In Class Activities will be completed in the classroom. Students must be present in class and actively participate in the activities in order to receive points. NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay In-Class Activities Grading Tool (3 points) Class Activity 3 points 0 points Participated/submitted class activity. Did not participate/submit activity and/or did not attend class Total Homework Activity (3 points) After reviewing the instructional rubric (directions) for Assignment 2, go to the Health Profession Division (HPD) online library. Locate two (2) articles related to the chosen topic that address the instructions in Assignment 2. Save the articles as a PDF to computer or flash drive. Bring the two peer-reviewed scholarly articles (preferably as a hard copy) to class beginning in Week 4. These articles will be used in developing the paper. Submit the Assignment by posted due date. Homework Activity 3 points 0 points Two articles related to topic brought to class for participation in the weekly activity and submitted the Assignment No articles brought to class and/or no submission of the Assignment Total In-Class APA Collaborative Activity (4 x 5 points/20 points total) The instructor will assign groups/ in class. Each group will discuss and collaborate on the responses to the activity providing page numbers from the APA manual to support the answers. Students must be present in class and participate in the activities in order to receive points. Assignment 1: Title Page and Page Two (8 points) This assignment will demonstrate the understanding of the mechanics of how to set up a paper in Word. This will include creating the title page, margins, font, line spacing, and running head on page one, running head on page two, pagination, indentations, Saved As, and the understanding of how to submit papers as an Assignment. This is a great start to creating a scholarly paper! Assignment Criteria/Instructional Rubric (directions): NovaSU NUR 3002 Week 8 Hand Hygiene Effects in Hospitals and Children Essay For this first assignment, the student will create a title page and page two of the document Open a blank Word document. Choose the area within the student’s computer to save the paper. Save the paper to where ever it is convenient: Flash drive, My Documents. To save the paper: Click on the File in the upper left corner of the screen, click on Save As. Name the paper: Last Name Assignment 1 NUR 3002 Click on Save in the lower right-hand corner. Create a title page following the step-by-step instructions found in the APA Help Documents: Setting Up an APA 7th Edition Document in Word. Select a title for the paper. The title should be reflective of the intent of the assignment. The title summarizes the main idea of the assignment and is no longer than 12 words. Please review page 31 in APA manual. On Page 1: The title of the paper will appear in two places on the title page. It should be centered in the upper half of the title page and in the running head on Page 1. On Page 2: The title of the paper will appear in two places on Page 2. It should be centered beneath the running head (not in bold) and in the running head on Page 2. Submit the Assignment on or before the posted due date. Assignment 1: Title Page and Page Two Grading Rubric (8 points) 8 points 5 points 2 points 0 points Title Page The title page contains all the required elements and formatting is correct in APA style. The title page contains all the required elements, but formatting is incorrect in APA style. The title page is missing two to five of the required elements and/or formatting is not in correct in APA style. The assignment not submitted Total Points Assignment 2: Introduction and Purpose Statement (15 Points) When writing a scholarly paper, it is important to inform the reader of the topic of the paper. The introductory paragraph establishes this in a scholarly paper. The introduction will draw the reader into the paper, making them want to read further. Each student will choose a topic from the list below for the development of the final paper (list located in Week 3). For this assignment, the introduction to the paper should contain a minimum of three well-stated, complete sentences relating to the general topic of the paper. The introduction should conclude with a purpose statement. The purpose statement tells the reader what the paper is going to address as well as assists the writer in the organization of the paper. To develop a purpose statement, the student will use the instructional rubric (directions located below). The instructional rubric (directions) provide the instructions and key points addressed in each assignment. These directions will drive the content of the paper and development of the headings in the paper (see page 47 in the APA manual). The level headings will keep the student focused and on target when developing the paragraphs that are required within the scholarly paper. This assures that the student addresses all areas in the assignment criteria. The instructional rubric (directions) will guide the research for the chosen topic when looking for scholarly articles in the library. Select one topic Hand Hygiene, Medication Errors, Patient Safety Adult Learning, Obtaining a BSN, Stress and Anxiety in Nursing School How to be successful in Nursing School Assignment Criteria/Instructional Rubric: Discuss the importance of the chosen topic in healthcare Discuss how the chosen topic can improve the delivery of quality patient care Discuss how the chosen topic can be incorporated into patient education. Develop an introductory paragraph, which will include the purpose statement. This will be the first paragraph of the paper on page 2 of the document. The introduction must include cohesive, well-developed sentences. The Introduction ends with a purpose statement. The assignment should include the title page, with the Introduction starting on page two. Make any corrections to Assignment 1. Rename Assignment 1 to Assignment 2 (include your last name) and add this assignment to the initial submission. Submit the Assignment by the posted due date. Assignment 2: Introduction and Purpose Statement Grading Rubric (15 points) Points 5 points 4 points 2 points 0 points Introduction Introduction is well stated, with three well-defined sentences Introduction is reasonably well stated, but does not contain three well-defined sentences Introduction is not well stated or does not contain three well-defined sentences The assignment was not submitted Points 5 points 4 points 2 points 0 points Purpose Statement The purpose statement is clearly defined and reflects the assignment criteria The purpose statement does not reflect assignment criteria. The assignment does not contain a purpose statement. The assignment was not submitted Points 5 points 4 points 2 points 0 points APA Format The paper is written in APA format with all the required elements The paper demonstrates APA elements learned but errors noted The paper does not reflect the required APA elements learned The assignment was not submitted Total Points Assignment 3: Body of Text, In-Text Citations, Level 1 Heading, and Reference Page (15 Points) For this assignment, students are going to continue to add to the paper with a focus on the body of the paper. This paper should have the correct title page, introductory paragraph, and purpose statement. In this assignment, the body of text and a reference page are added. The body must contain three (3) fully developed paragraphs addressing the purpose of the paper (the student developed the purpose statement in Assignment 2 from the instructions/directions). Students will need to review the information from scholarly peer-reviewed articles obtained from the HPD library when developing the scholarly paper. A paragraph for this assignment is three to four sentences. Each paragraph should be well thought-out, follow a logical development, and be separated by a level one heading. A level one heading is centered, in upper and lowercase letters, and in bold (page 47 in your APA manual). The body of the paper must include two direct quotes, one personal communication (optional), one in-text (in the sentence) paraphrase, and one parenthetical (at the end of the sentence) paraphrase. Cite each according to the correct APA format. A re

Nursing

Assignment: Nurse Burnout Issue in Healthcare ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Nurse Burnout Issue in Healthcare Attached is a copy of my PIP (so it can be fixed like you did the other PIP one). I have also attached her copy so you can see how it flows and how mine needs to look. I have also attached additional resources and copies of PIPs from other universities to try and help and make mine look better. Please let me know if there are any questions so we can work on this project together. PLEASE! Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper attachment_1 attachment_2 attachment_3 Why Nurse Burnout is a Real Issue in Healthcare and What Organizations Can Do about It. Assignment: Nurse Burnout Issue in Healthcare Jesus G Rebolledo The University of Texas at Rio Grande Valley NURS 7302 LET Dr. Lilia A. Fuentes 07/24/2019 Introduction Nursing is a field that allows no margin for error. For nurses to provide services that guarantee high-quality and patient safety, it is essential that they are at their best physical, psychological, and physiological state. Unfortunately, nurses are susceptible to physical, mental, and emotional strain that arises from working for long hours and their inability to handle these pressures. This results in nurse burnout, which is defined as the physical, emotional, and psychological stress or strain that affects nurses, and which leads to dulled emotions, detachment, and low levels of motivation in one’s work (Van Bogaert, Peremans. Van Heusden, Verspuy … Franck, 2017). This is a problem that affects both nurses and patients. In nursing practice, the relationship and interaction between nurses and patients are vital as it has a major influence on the quality and relevance of services that these nurses offer. In this regard, research has shown that nurse burnout negatively affects the satisfaction of both the nurses and the patient often leads to poor health outcomes and high chances of errors (Hall, Johnson, Watt, Tsipa & O’Connor, 2016). Thus, it is important that every healthcare facility strives to resolve any cases of nurse burnout as a way of raising its quality of services and improving the welfare of the patient. Nurses encounter many risks of burnout than most other professions. Watching the patients suffer, striving to ensure the recovery of all patients, having busy schedules, putting others ahead of oneself, and having to work for extended hours, among others, not only expose nurses to physical strain and stress, but they also expose them to high risks of emotional and mental stress (Ribeiro, Filho, Valenti, Ferreira, de Abreu … Ferreira, 2016). In the past, many healthcare organizations did not clearly understand the concept, diagnosis, effects, and measures to address the problem of nurse burnout. Despite increased research and awareness of the problem, Van Bogaert et al. (2016) reports that many facilities still fail to mitigate the problem. In return, this negatively affects service delivery and the welfare of the patients and the nurses alike. However, ongoing research and increased attention in this field present healthcare providers with a solution and an opportunity to design projects or programs that can address this problem. The purpose of this practice intervention project (PIP) is to help healthcare organizations understand nursing burnout, explore the significance, its characteristics, and identify this condition to help prevent this phenomenon. With the use of Maslach Burnout Inventory (MBI) self-assessment survey healthcare organizations can implement this tool to increase awareness of who is at risk. The application of this survey will not only empower organizations to learn to recognize and become aware but also rethink its structure and examine recommendations to lessen employee exhaustion, depersonalization, and aid in personal achievement development. Significance of the ProblemPatient safety and quality of care have always been guiding factors in nursing practice and other healthcare fields. Unfortunately, these values have been ignored in the past, and they have never been accorded the attention that they deserve. In 1999, a study report by the Institute of Medicine (IOM) that was corroborated by many other studies showed that the healthcare industry lacked the necessary measures to address the problem of patient safety. In its report, IOM attributed between 44,000 and 98,000 annual deaths to preventable medical errors (Makary & Daniel, 2016). Surprisingly, this number exceeded many of the leading causes of death at the time despite medical errors not being recognized as a major cause of death or an inhibitor of patient safety and quality care. As such, healthcare providers were tasked with formulating measures that could uphold these two values in their practice through the prevention of unnecessary medical errors. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Nurse burnout is one of the key inhibitors of quality services and patient safety as it directly inhibits the attachment between nurses and the patients while also raising the chances of errors. As Ribeiro et al. (2016), the emotional health of nurses is important as it enhances communication among themselves and between themselves, physicians, and patients. In this case, detachment results in poor relations that may negatively affect the welfare of the patients. This is more so the case in vital sections of healthcare, such as primary care that requires personal engagement and interaction between nurses and patients. Burnouts impair communication and collaboration among healthcare providers. In this regard, nursing practice is a field that demands critical concentration and collaboration among different parties. Any breakdown in communication can lead to errors that could be costly for a healthcare provider. Studies have shown that, besides the close to 98,000 patients who die due to preventable medical errors, between $73.5 and $98 billion are directly associated with these errors each year (Makary & Daniel, 2016). The relevance of nurse burnout in medical errors is too high as it is ranked as a key cause of these errors. For instance, a recent study reported that addressing nursing and physician burnouts could reduce medical errors by 50% (Panagiotis, Geraghty, Zhou, Hodkinson … Riley, 2019). Addressing burnout among nurses and other healthcare professionals should thus be prioritized in all healthcare settings as it could be a key solution to the reduction of healthcare costs and medical errors as well as improvement of patient safety, quality of care, healthcare outcomes, patient experiences, and satisfaction of the nurses and other professionals. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Burnout is one of the most prevalent problems among nurses and other healthcare professionals. As reported earlier, there are numerous risks that nurses encounter in their profession that exposes them to burnout. As such, many of them may experience this problem at any one time if healthcare professionals do not adequately monitor their practices and implement sufficient controls. A recent study showed extremely high Maslach Burnout Inventory (MBI) scores of nurse burnout among 10.1% of the nurses in Sao Paulo and a high propensity among 55.4% of all the nurses (Ribeiro, Filho, Valenti, Ferreira … Ferreira, 2014). The same study also cited this problem as one of the reasons that most of the nurses in these regions are childless women past 35 years. While presenting their solutions to the problems, the authors insisted that the prevention of nurse burnout should be prioritized as it is more effective than other forms of management. These assertions are consistent with a report by Hall et al. (2016) that termed nurse burnout as one that can easily turn into a permanent problem if inadequately unaddressed. With the emergence of reliable tools to test nurse burnout rates and potential solutions, healthcare organizations should work collaboratively with the nurses as one of the ways to address nurse burnout and create an improvement at both personal and organizational level. There are several studies that have broken down this topic into the distinct forms of burnout. In this case, emotional exhaustion has been found to vary from 28% to 31% depersonalization at 15% to 21% and low personal accomplishment at from 31% to 39% (Monsalve-Reyes, San Luis-Costas, Gómez-Urquiza, Albendín-García … Cañadas-De la Fuente, 2018; Pradas-Hernández, Ariza, Gómez-Urquiza, Albendín-García, De la Fuente & Cañadas-De la Fuente, 2018). From these two studies, it is clear that nurse burnout has an effect on both patient experience and the ability of nurses. This is in the sense that a nurse will have poor performance while the patients will experience poor quality health that is also of low safety standards. As such, addressing nurse burnouts could serve as a key solution to both personal and professional problems in nursing practice, which could eventually improve the healthcare sector from all areas. Assignment: Nurse Burnout Issue in Healthcare Nurse burnout is a significant issue among nurses because it leads to detachments and dulled emotions among nurses. Also, organizations must take nurse burnout with seriousness because it undermines motivation among the nurses, leading to a sense of hopelessness among the nurse staff. Burnout cascades to the patients and thus healthcare organizations must prioritize the quality of healthcare provided to the patients (Jennings, 2016). A high rate of burnout among nurses will thus lead to negative reviewed and feedback from patients to the low patient satisfaction with the quality of healthcare they receive. Therefore, nursing burnout is an issue that must worry about all stakeholders in the healthcare sector. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Quality Measures Every program should have a set of measures that should help in evaluating its effectiveness. In this practice intervention project, the focus is on early peer education as a solution for nurse burnout. As has been identified in the section above, this is a problem of great significance in nursing practice, and that should be prioritized by all healthcare providers aiming at improving the satisfaction of their staff, improving the quality of their services, enhancing patient safety, and improving the general outcomes of care. However, every program that an organization implements should be closely monitored against a set of goals and objectives to ensure that it yields the desired results. The performance and quality measures should provide a clear view of the improvements that have been achieved and its impact on various elements of patient care. One of the most important quality measures is the National Academy of Medicine (NAM). This is a non-profit agency that was widely known as the Institute of Medicine (IOM) before it was renamed to NAM. This agency is an important source of data regarding nurse burnout programs and particularly in relation to patient safety and the occurrence of preventable medical errors. As mentioned earlier, research has shown that when addressing the physical, emotional, and mental exhaustion known as burnout, this could reduce medical errors by 50%. “To Err is Human,” which is a popular report published by IOM attributed a maximum of 98,000 annual deaths to preventable medical errors (Makary & Daniel, 2016). Data from the agency regarding the prevalence of medical errors could thus be an important quality measure for peer education as a solution for nurse burnout. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper The project will be guided by three critical quality measures of the MBI tool alongside other measures like the prevalence of preventable errors, patient satisfaction, absenteeism, productivity, and changes in the cost of care, among others. The three core MBI measures are emotional exhaustion, personal accomplishment, and depersonalization. As explained by Loera, Converso and Viotti (2014), emotional exhaustion is measured through a series of nine items from the MBI scale that test the emotional outcomes from one’s work. The peer education program’s outcomes will be measured in the changes in the MBI scores of a nurse before and after its implementation. On the other hand, depersonalization will be measured through a series of items along the MBI scale that tests the impersonal response of a nurse towards the patients. The scores of the nurses are expected to decline if the program is successful. Regarding the third measure, the personal accomplishment of a nurse is important as it measures how competent nurses consider themselves. According to Heeb and Haberey-Knuessi (2014), this is particularly important as it also helps to understand the perception that nurses have on their job, which could then be used to improve their experience and satisfaction in their work. This measure will thus be used for improvement in areas outside the burnout boundaries. Nurse burnout is the mental physical and emotional state that nurses experience after chronic overwork and a sustained lack of support and job fulfillment at their workplace. The symptoms of nurse burnout include emotional and physical exhaustion having a low sense of personal accomplishment at work, and cynic related to their work. Untreated burnout may advance into clinical depression manifesting itself as unaddressed symptoms. The Center for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the American Nurses Association (ANA) would also be important quality measures. These agencies track health outcomes and clinicians’ welfare data. They also fund several research studies related to nurse burnout and its impact on health outcomes. Data from these sources could be used together with results from the evaluation of nurse burnout through the MBI scale. Evaluation results that show nurse burnout rate that is higher than that recorded by the above agencies would be an indication that an intervention program has failed. Additionally, related outcomes including the prevalence of preventable health outcomes will also be analyzed against data provided by these agencies. They are thus some of the most important quality measures in the sector. Among the major ways through which nurse burnout may be addressed by first of all studying and understanding the stressors that cause the burnout. Depending on whether the cause of the nurse burnout is emotional, physical, or environmental stress, the burnout should be addressed by solving the exhaustion among the nurses (Cañadas-De la Fuente, Vargas, San, 2015). Once these symptoms of exhaustion are identified and addressed before the nurse becomes overwhelmed, the nurse should be advised to take remedial and break form the nurse activities to relieve self from such stressors. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Recognizing the warning signs would thus enable various agencies to initiate necessary intervention measures to prevent the situation by facilitating the evaluation of nurse burnout through the MBI scale (Jennings, 2016). Prioritizing authentic leadership will help in measuring the strain of burnout, thus identifying the areas of stress that need attention. Giving the nurses a positive wellness program will help the nurses to confide in professionals who can help them overcome the burnout (Erickson & Grove, 2007). Nurses should also give priority to their health and pay attention to control their health. Managing stressful emotion and protecting one’s passion would also help nurses overcome burnout. Resilience, self-care, recognizing triggers and stressors, as well as creating a strong relationship with co-workers also help overcome burnout. Most nurses experience nurse burnout due to work-related issues going by the findings of the Center for Medicare and Medicaid Services (CMS). Regularly, nurses work in an environment where they deal with life and death, thereby facing an emotional strain of losing their patients. CMS (nd) also notes that the nurses may experience burnout as a result of the emotional distress of helping the grieving family members to overcome the pain of losing their loved one. Also, CMS (nd) notes that nurses in the emergency and critical care department are the most affected group because they get overwhelmed with the stressful environment which makes them susceptible to these burnout symptoms. The Center for Disease Control and Prevention (CDC) argue that nurses may suffer burnout as a result of the long shifts that last for more than 12 hours leading to stress and exhaustion. While these causes of nurse burnout are work-related, CDC (nd) also notes that the individual personality of the nurses may also be a major contributing factor to burnout. The collaborative work environment of nurses makes nurses lack independence when it comes to clinical decision-making (Erickson & Grove, 2007). Also, the nurses are always under constant pressure to meet the expectation of the patients and their families, thus making them susceptible to mental exhaustion. If a nurse gets into the professional with a sole aim of providing help to patients and their families, the chances of experiencing nurse burnout are very high because they tend to get personal with their success or failure at work. The American Nurses Association (ANA) argues that nurse burnout may arise out of the relationship that nurses such as those in the oncology department form with patients. The time that nurses spend with patients as they battle chronic conditions leads to an emotional attachment which makes the nurses develop an acute feeling of loss in case the patients pass away (Holdren Paul, David & Coustasse, 215). The greater sense of urgency with which nurses in the emergency departments are required to attend to the patients also exposes the nurses to more risks of experiencing burnout. The nurses also experience burnout as a result of the pressure they face regularly and the exceptionally large volume of patients that these nurses, especially those in the emergency department handle (Rushton, Batcheller, Schroeder & Donohue, 2015). Also, the shortage of nurses in the market has contributed to the overwhelming of nurses as they attend to patients, thereby leading to stressful situations that develop into burnout. Description of the ProgramThe planned resolution is to implement education and awareness on the pediatric floor within a nursing organization to detect and obtain information on the prevalence of nurse burnout. Nurse burnout is a global phenomenon that has led to turnover, job dissatisfaction, poor quality of work and essentially decreased patient outcomes. A survey conducted in 2017 by Kronos, Inc uncovered that 93 percent of nurses reported feeling mentally and or physically tired at the end of the workday, 90 percent had considered leaving the hospital they worked at to find something more balanced, 37 percent of nurses reported that they worried about how their fatigue could increase the chance of making mistakes and 11 percent actually admitted to making mistakes as well as 28 percent who admitted to calling in sick just to get some time to rest. Understanding these statistics represents the dire need of an education program to be implemented in the United States as well as in different countries within organizations to identify employees who are potentially at risk for burnout, and employees who are indeed burned out. Early identification of burn out can help the nurse individually as well as organizationally. Individually because the nurse is able to seek and obtain help and organizationally because of the cost of an organization losing nurses to burnout. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper With the implementation of a strong education and awareness program the need for an appropriate scale to measure and analyze is required. The MIB is a tool that will be administered to nurses to self-assess and provide information as to whether they may be at risk for burn out, which is essential in this education program. The Maslach Burnout Inventory (MBI) is a vital tool in covering three major components which include exhaustion, depersonalization and personal achievement and should be placed in organizations where ever nurses work. Using the Maslach Burnout Inventory (MBI) self-assessment survey, healthcare organization increase awareness of the nurses who are at risk of experiencing burnout. However, the healthcare organizations must, first of all, identify the nurses in the departments with a high probability of experiencing disengagement due to work overload and longer working hours such as the emergency department, the critical care, and chronic care nurses (Rushton, Batcheller, Schroede, & Donohue, 2015). Healthcare organization can rely on this tool to encourage the nurses to conduct a self-assessment survey, thereby identifying the risk factors that make the nurses susceptible to burnout. From the outcome of the survey of each nurse (Maslach, 2017). A healthcare organization will come up with appropriate intervention measures that address the unique risk factors identified by each nurse to achieve an effective outcome. Assignment: Nurse Burnout Issue in Healthcare The Maslach Burnout Inventory (MBI) self-assessment survey also enables healthcare organization to recognize and become aware of the specific issues of concern among nurses which require immediate attention. Also, the outcome of the self-assessment survey enables healthcare organization to rethink about their structure and examine recommendations that may promote a reduction in disengagement, exhaustion, and depersonalization (Bocéréan, Dupret & Feltrin, 2019). Above all, the survey tool provided a clue on the issues that the organization may address to motivate the nurses to focus on personal achievement development as opposed to caring for others during their professional engagement with patients. There is a current gap in knowledge present on the topic of nurse burnout and any tools and or resources to minimize this occurrence. There are no resources in place that provide nurses with primary intervention techniques to stress and or education on the effects of nurse burn out. Stress is present in the everyday functions of nurses and effective ways of managing this stress is not addressed. Negative effects of stress on nurses there for leads to poor quality of care provided, dissatisfaction within the nurse and the patient and increase in potential medical errors. If organizations implement the use of the MIB, information on nurse burnout risk can help to guide organizations to what areas are more effected and begin to use this education program to make improvements and changes. Having a solid team who is thoroughly educated on this nurse burn out education program will help to increase the movement and awareness of the issue. If there are different stakeholders involved in this program it can create a more positive outcome not only on the pediatric floor, but within the organization as a whole. The stakeholders involved in this program include registered nurses, licensed practical nurses, nurse practitioners and nurse managers. In order to decrease stress during the day the nurses will be given 15 minute sessions on ways to decrease stress such as…..encourage work life balance, encourage peer support, furnish resources for self care and mental health, ( The section in blue is something that I wrote and had a thought in mind but was not sure in regards to how to help the nurses and the organization resolve the issue of burnout. I believe there has to be something else that I do besides the actual education program and tool such as like interventions and such) Burnout among nurses has become a major concern for many healthcare organizations, given that it also affects the efficiency of healthcare service delivery to the patients. Patients are also adversely affected by the nurse burnouts because nurses fail to offer quality healthcare that leads to quality patient outcome. However, the Maslach Burnout Inventory (MBI) self-assessment survey enables healthcare organizations to detect signs and symptoms of nurse burnout early enough and then implement the appropriate intervention measures to mitigate the adverse effects of the nurse burnout. Coincidentally, new ideas may not be easily introduced for this tool as a way of lessening nursing burnout. This practice intervention project (PIP) evaluates how health care organizations can implement the tool to prevent burnout. Theoretical Framework There are several nursing theories that can help in improving one’s understanding of nurse burnout and peer education program as a solution of the problem. One of these is the theory of Nursing as Caring was developed by Anne Boykin and Savina Schoenhofer. This theory is founded on the framework that every human is naturally caring and that they have the potential to support other people in a caring way (Alligood, 2014). From this theory, one can consider nurses as people whose services are aimed at achieving beneficence. This theory is important in understanding the various forms of nurse burnout, and particularly the concept of detachment, and their impact on the welfare of a nurse. According to Salvagioni, Melanda, Mesas, González, Gabani and Andrade (2017), nurses have to be attached to their patients to understand their problems better and to work with them collaboratively towards developing a more appropriate intervention. When a nurse is physically or mentally detached from the patient and other healthcare professionals, the element of caring may become lost, and this could impair the quality of services and patient safety as well. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper This practice intervention project has suggested nurse burnout education and particularly with a focus on peer education. This theory is supported by several theories, including the theories of social learning, reasoned action, diffusion of innovation, participatory education, and differential association theory, among others. In social learning theory, Abdi and Simbar (2013) argue that human behavior and social situations can elicit behavioral change and particularly if an individual develops the right interpretation of the system and the values. This theory promotes social learning, learning in groups, or learning with a high level of flexibility as a way of enhancing the values that a nurse develops from the training process. As such, organizations should encourage peer education as much as possible as this theory supports their success over other instruction-based learning. Assignment: Nurse Burnout Issue in Healthcare Nurses are likely to have people whom they look up to for guidance and mentorship. This is a concept that is supported by the theory of reasoned action. According to Hackman and Knowlden (2014), this theory asserts that nurses can easily learn from influential people they trust, and whose ideologies and values have been proven to succeed. When designing peer education programs, healthcare organizations need to allow nurses to learn amongst themselves while availing role models or successful people from within or outside the organization. This theory is founded on similar analogies to the theory of diffusion learning that considers opinion leaders or influential people as ones who are capable of influencing the behavior of others by sharing values that have helped them to excel (Mohammadi, Poursaberi & Salahshoor, 2018). In this regard, peer education allows nurses to share their experiences, including their challenges, things that have worked, and those that have failed. For nurses who are known to succeed, and particularly nursing leaders or those who receive occasional promotion, it is likely to influence new nurses and those experiencing challenges in realizing their problems, potential solutions, and implementing solutions to their problems. Peer education is widely considered as an empowerment process. Rather than offering instructions and dictating things that nurses should do to improve themselves, organizations ought to allow them to share among themselves and develop one another. According to this theory, nurses who feel powerless can easily regain control through participatory learning and particularly since it allows them to accept themselves and to have a better understanding of their problems. This theory’s assertions are reinforced by communication of innovations theory that perceives nurses as capable of realizing their competence and developing more appropriate and personalized solutions to their problems. As such, organizations should only provide influential or successful people as moderators of the training programs and allow the nurses the much-needed flexibility and freedom. Such a program has better chances of success as the nurses can also learn from one another without the limitation of risks of burnout and potential solutions that can be provided by a single individual as is the case with instruction-based learning. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Literature ReviewNurses are expected to be at their optimum physiological, physical, emotional, and mental status during service delivery. According to Makary and Daniel (2016), nursing practice is one of the most critical professions that allow no room for error while at the same time requiring nurses to always be in their optimum status for the best outcomes. Unfortunately, nurses experience several problems that face employees in every other sector. Demotivation, stress, burnout, depression, fatigue, depression, and low levels of satisfaction are common among nurses (Iglesias & Vallejo, 2013; Vermeir, Blot, Degroote, Vandijck … Vogelaers, 2018). Unlike most other professions, however, nursing practice tends to be more demanding and particularly due to the relationship that nurses share with the patients. It is for this reason that problems related to emotions, including stress, depression, and burnout, tend to be more common among nurses than in other areas (Van Bogaert et al., 2017). Nursing burnout is defined as the physical, emotional, and psychological exhaustion that nurses experience in the course of service delivery (Van Bogaert et al., 2017). While it is common for the three forms of exhaustion to manifest themselves at the same time, it is also possible for one or two to affect the nurse. This problem also comes in the form of stress or strain and may have a considerable impact on the performance of the nurse and the relationship between the nurse and the patients or coworkers. Nursing burnout is often evaluated through the Maslach Burnout Inventory (MBI) that measures the level of emotional exhaustion in a nurse, their depersonalization or detachment from other people, and their personal accomplishment (Ribeiro et al., 2014). The problem affects both nurses and physicians. However, its prevalence among nurses has been found to be more common than in other healthcare professionals (Ribeiro et al., 2014). Nurse burnout is a common problem that requires to be addressed more frequently as a strategy for improving the quality of care and patient safety. Unfortunately, many healthcare facilities do not realize the occurrence of this problem and its impact on healthcare professionals (Hall et al. 2016). It was not until the problem became a common area of research that healthcare providers realized the need to evaluate their professionals and implement measures that could address the problem. However, Hall et al. (2016) note that, while many healthcare facilities strive to implement such measures, small and medium healthcare facilities do little to address the problem. While many healthcare providers focus on optimizing the performance of their employees, they fail to realize that the different forms of fatigue or exhaustion can significantly derail their success. Focusing on nursing practice has been shown to improve patient safety by reducing the chances of preventable errors by up to 50%, which could be an important way of raising the credibility of healthcare facilities, improving their health outcomes, lowering their costs of care, and improving compliance with healthcare regulators (Panagiotis et al., 2017). This is a clear indication that every healthcare provider should prioritize addressing this problem as it p

Nursing

Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Attached is a copy of my PIP (so it can be fixed like you did the other PIP one). I have also attached her copy so you can see how it flows and how mine needs to look. I have also attached additional resources and copies of PIPs from other universities to try and help and make mine look better. Please let me know if there are any questions so we can work on this project together. PLEASE! Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper attachment_1 attachment_2 attachment_3 Why Nurse Burnout is a Real Issue in Healthcare and What Organizations Can Do about It Jesus G Rebolledo The University of Texas at Rio Grande Valley NURS 7302 LET Dr. Lilia A. Fuentes 07/24/2019 Introduction Nursing is a field that allows no margin for error. For nurses to provide services that guarantee high-quality and patient safety, it is essential that they are at their best physical, psychological, and physiological state. Unfortunately, nurses are susceptible to physical, mental, and emotional strain that arises from working for long hours and their inability to handle these pressures. This results in nurse burnout, which is defined as the physical, emotional, and psychological stress or strain that affects nurses, and which leads to dulled emotions, detachment, and low levels of motivation in one’s work (Van Bogaert, Peremans. Van Heusden, Verspuy … Franck, 2017). This is a problem that affects both nurses and patients. In nursing practice, the relationship and interaction between nurses and patients are vital as it has a major influence on the quality and relevance of services that these nurses offer. In this regard, research has shown that nurse burnout negatively affects the satisfaction of both the nurses and the patient often leads to poor health outcomes and high chances of errors (Hall, Johnson, Watt, Tsipa & O’Connor, 2016). Thus, it is important that every healthcare facility strives to resolve any cases of nurse burnout as a way of raising its quality of services and improving the welfare of the patient. Nurses encounter many risks of burnout than most other professions. Watching the patients suffer, striving to ensure the recovery of all patients, having busy schedules, putting others ahead of oneself, and having to work for extended hours, among others, not only expose nurses to physical strain and stress, but they also expose them to high risks of emotional and mental stress (Ribeiro, Filho, Valenti, Ferreira, de Abreu … Ferreira, 2016). In the past, many healthcare organizations did not clearly understand the concept, diagnosis, effects, and measures to address the problem of nurse burnout. Despite increased research and awareness of the problem, Van Bogaert et al. (2016) reports that many facilities still fail to mitigate the problem. In return, this negatively affects service delivery and the welfare of the patients and the nurses alike. However, ongoing research and increased attention in this field present healthcare providers with a solution and an opportunity to design projects or programs that can address this problem. The purpose of this practice intervention project (PIP) is to help healthcare organizations understand nursing burnout, explore the significance, its characteristics, and identify this condition to help prevent this phenomenon. With the use of Maslach Burnout Inventory (MBI) self-assessment survey healthcare organizations can implement this tool to increase awareness of who is at risk. The application of this survey will not only empower organizations to learn to recognize and become aware but also rethink its structure and examine recommendations to lessen employee exhaustion, depersonalization, and aid in personal achievement development. Significance of the ProblemPatient safety and quality of care have always been guiding factors in nursing practice and other healthcare fields. Unfortunately, these values have been ignored in the past, and they have never been accorded the attention that they deserve. In 1999, a study report by the Institute of Medicine (IOM) that was corroborated by many other studies showed that the healthcare industry lacked the necessary measures to address the problem of patient safety. In its report, IOM attributed between 44,000 and 98,000 annual deaths to preventable medical errors (Makary & Daniel, 2016). Surprisingly, this number exceeded many of the leading causes of death at the time despite medical errors not being recognized as a major cause of death or an inhibitor of patient safety and quality care. As such, healthcare providers were tasked with formulating measures that could uphold these two values in their practice through the prevention of unnecessary medical errors. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Nurse burnout is one of the key inhibitors of quality services and patient safety as it directly inhibits the attachment between nurses and the patients while also raising the chances of errors. As Ribeiro et al. (2016), the emotional health of nurses is important as it enhances communication among themselves and between themselves, physicians, and patients. In this case, detachment results in poor relations that may negatively affect the welfare of the patients. This is more so the case in vital sections of healthcare, such as primary care that requires personal engagement and interaction between nurses and patients. Burnouts impair communication and collaboration among healthcare providers. In this regard, nursing practice is a field that demands critical concentration and collaboration among different parties. Any breakdown in communication can lead to errors that could be costly for a healthcare provider. Studies have shown that, besides the close to 98,000 patients who die due to preventable medical errors, between $73.5 and $98 billion are directly associated with these errors each year (Makary & Daniel, 2016). The relevance of nurse burnout in medical errors is too high as it is ranked as a key cause of these errors. For instance, a recent study reported that addressing nursing and physician burnouts could reduce medical errors by 50% (Panagiotis, Geraghty, Zhou, Hodkinson … Riley, 2019). Addressing burnout among nurses and other healthcare professionals should thus be prioritized in all healthcare settings as it could be a key solution to the reduction of healthcare costs and medical errors as well as improvement of patient safety, quality of care, healthcare outcomes, patient experiences, and satisfaction of the nurses and other professionals. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Burnout is one of the most prevalent problems among nurses and other healthcare professionals. As reported earlier, there are numerous risks that nurses encounter in their profession that exposes them to burnout. As such, many of them may experience this problem at any one time if healthcare professionals do not adequately monitor their practices and implement sufficient controls. A recent study showed extremely high Maslach Burnout Inventory (MBI) scores of nurse burnout among 10.1% of the nurses in Sao Paulo and a high propensity among 55.4% of all the nurses (Ribeiro, Filho, Valenti, Ferreira … Ferreira, 2014). The same study also cited this problem as one of the reasons that most of the nurses in these regions are childless women past 35 years. While presenting their solutions to the problems, the authors insisted that the prevention of nurse burnout should be prioritized as it is more effective than other forms of management. These assertions are consistent with a report by Hall et al. (2016) that termed nurse burnout as one that can easily turn into a permanent problem if inadequately unaddressed. With the emergence of reliable tools to test nurse burnout rates and potential solutions, healthcare organizations should work collaboratively with the nurses as one of the ways to address nurse burnout and create an improvement at both personal and organizational level. There are several studies that have broken down this topic into the distinct forms of burnout. In this case, emotional exhaustion has been found to vary from 28% to 31% depersonalization at 15% to 21% and low personal accomplishment at from 31% to 39% (Monsalve-Reyes, San Luis-Costas, Gómez-Urquiza, Albendín-García … Cañadas-De la Fuente, 2018; Pradas-Hernández, Ariza, Gómez-Urquiza, Albendín-García, De la Fuente & Cañadas-De la Fuente, 2018). From these two studies, it is clear that nurse burnout has an effect on both patient experience and the ability of nurses. This is in the sense that a nurse will have poor performance while the patients will experience poor quality health that is also of low safety standards. As such, addressing nurse burnouts could serve as a key solution to both personal and professional problems in nursing practice, which could eventually improve the healthcare sector from all areas. Nurse burnout is a significant issue among nurses because it leads to detachments and dulled emotions among nurses. Also, organizations must take nurse burnout with seriousness because it undermines motivation among the nurses, leading to a sense of hopelessness among the nurse staff. Burnout cascades to the patients and thus healthcare organizations must prioritize the quality of healthcare provided to the patients (Jennings, 2016). A high rate of burnout among nurses will thus lead to negative reviewed and feedback from patients to the low patient satisfaction with the quality of healthcare they receive. Therefore, nursing burnout is an issue that must worry about all stakeholders in the healthcare sector. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Quality Measures Every program should have a set of measures that should help in evaluating its effectiveness. In this practice intervention project, the focus is on early peer education as a solution for nurse burnout. As has been identified in the section above, this is a problem of great significance in nursing practice, and that should be prioritized by all healthcare providers aiming at improving the satisfaction of their staff, improving the quality of their services, enhancing patient safety, and improving the general outcomes of care. However, every program that an organization implements should be closely monitored against a set of goals and objectives to ensure that it yields the desired results. The performance and quality measures should provide a clear view of the improvements that have been achieved and its impact on various elements of patient care. One of the most important quality measures is the National Academy of Medicine (NAM). This is a non-profit agency that was widely known as the Institute of Medicine (IOM) before it was renamed to NAM. This agency is an important source of data regarding nurse burnout programs and particularly in relation to patient safety and the occurrence of preventable medical errors. As mentioned earlier, research has shown that when addressing the physical, emotional, and mental exhaustion known as burnout, this could reduce medical errors by 50%. “To Err is Human,” which is a popular report published by IOM attributed a maximum of 98,000 annual deaths to preventable medical errors (Makary & Daniel, 2016). Data from the agency regarding the prevalence of medical errors could thus be an important quality measure for peer education as a solution for nurse burnout. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper The project will be guided by three critical quality measures of the MBI tool alongside other measures like the prevalence of preventable errors, patient satisfaction, absenteeism, productivity, and changes in the cost of care, among others. The three core MBI measures are emotional exhaustion, personal accomplishment, and depersonalization. As explained by Loera, Converso and Viotti (2014), emotional exhaustion is measured through a series of nine items from the MBI scale that test the emotional outcomes from one’s work. The peer education program’s outcomes will be measured in the changes in the MBI scores of a nurse before and after its implementation. On the other hand, depersonalization will be measured through a series of items along the MBI scale that tests the impersonal response of a nurse towards the patients. The scores of the nurses are expected to decline if the program is successful. Regarding the third measure, the personal accomplishment of a nurse is important as it measures how competent nurses consider themselves. According to Heeb and Haberey-Knuessi (2014), this is particularly important as it also helps to understand the perception that nurses have on their job, which could then be used to improve their experience and satisfaction in their work. This measure will thus be used for improvement in areas outside the burnout boundaries. Nurse burnout is the mental physical and emotional state that nurses experience after chronic overwork and a sustained lack of support and job fulfillment at their workplace. The symptoms of nurse burnout include emotional and physical exhaustion having a low sense of personal accomplishment at work, and cynic related to their work. Untreated burnout may advance into clinical depression manifesting itself as unaddressed symptoms. The Center for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the American Nurses Association (ANA) would also be important quality measures. These agencies track health outcomes and clinicians’ welfare data. They also fund several research studies related to nurse burnout and its impact on health outcomes. Data from these sources could be used together with results from the evaluation of nurse burnout through the MBI scale. Evaluation results that show nurse burnout rate that is higher than that recorded by the above agencies would be an indication that an intervention program has failed. Additionally, related outcomes including the prevalence of preventable health outcomes will also be analyzed against data provided by these agencies. They are thus some of the most important quality measures in the sector. Among the major ways through which nurse burnout may be addressed by first of all studying and understanding the stressors that cause the burnout. Depending on whether the cause of the nurse burnout is emotional, physical, or environmental stress, the burnout should be addressed by solving the exhaustion among the nurses (Cañadas-De la Fuente, Vargas, San, 2015). Once these symptoms of exhaustion are identified and addressed before the nurse becomes overwhelmed, the nurse should be advised to take remedial and break form the nurse activities to relieve self from such stressors. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Recognizing the warning signs would thus enable various agencies to initiate necessary intervention measures to prevent the situation by facilitating the evaluation of nurse burnout through the MBI scale (Jennings, 2016). Prioritizing authentic leadership will help in measuring the strain of burnout, thus identifying the areas of stress that need attention. Giving the nurses a positive wellness program will help the nurses to confide in professionals who can help them overcome the burnout (Erickson & Grove, 2007). Nurses should also give priority to their health and pay attention to control their health. Managing stressful emotion and protecting one’s passion would also help nurses overcome burnout. Resilience, self-care, recognizing triggers and stressors, as well as creating a strong relationship with co-workers also help overcome burnout. Most nurses experience nurse burnout due to work-related issues going by the findings of the Center for Medicare and Medicaid Services (CMS). Regularly, nurses work in an environment where they deal with life and death, thereby facing an emotional strain of losing their patients. CMS (nd) also notes that the nurses may experience burnout as a result of the emotional distress of helping the grieving family members to overcome the pain of losing their loved one. Also, CMS (nd) notes that nurses in the emergency and critical care department are the most affected group because they get overwhelmed with the stressful environment which makes them susceptible to these burnout symptoms. The Center for Disease Control and Prevention (CDC) argue that nurses may suffer burnout as a result of the long shifts that last for more than 12 hours leading to stress and exhaustion. While these causes of nurse burnout are work-related, CDC (nd) also notes that the individual personality of the nurses may also be a major contributing factor to burnout. The collaborative work environment of nurses makes nurses lack independence when it comes to clinical decision-making (Erickson & Grove, 2007). Also, the nurses are always under constant pressure to meet the expectation of the patients and their families, thus making them susceptible to mental exhaustion. If a nurse gets into the professional with a sole aim of providing help to patients and their families, the chances of experiencing nurse burnout are very high because they tend to get personal with their success or failure at work. The American Nurses Association (ANA) argues that nurse burnout may arise out of the relationship that nurses such as those in the oncology department form with patients. The time that nurses spend with patients as they battle chronic conditions leads to an emotional attachment which makes the nurses develop an acute feeling of loss in case the patients pass away (Holdren Paul, David & Coustasse, 215). The greater sense of urgency with which nurses in the emergency departments are required to attend to the patients also exposes the nurses to more risks of experiencing burnout. The nurses also experience burnout as a result of the pressure they face regularly and the exceptionally large volume of patients that these nurses, especially those in the emergency department handle (Rushton, Batcheller, Schroeder & Donohue, 2015). Also, the shortage of nurses in the market has contributed to the overwhelming of nurses as they attend to patients, thereby leading to stressful situations that develop into burnout. Description of the ProgramThe planned resolution is to implement education and awareness on the pediatric floor within a nursing organization to detect and obtain information on the prevalence of nurse burnout. Nurse burnout is a global phenomenon that has led to turnover, job dissatisfaction, poor quality of work and essentially decreased patient outcomes. A survey conducted in 2017 by Kronos, Inc uncovered that 93 percent of nurses reported feeling mentally and or physically tired at the end of the workday, 90 percent had considered leaving the hospital they worked at to find something more balanced, 37 percent of nurses reported that they worried about how their fatigue could increase the chance of making mistakes and 11 percent actually admitted to making mistakes as well as 28 percent who admitted to calling in sick just to get some time to rest. Understanding these statistics represents the dire need of an education program to be implemented in the United States as well as in different countries within organizations to identify employees who are potentially at risk for burnout, and employees who are indeed burned out. Early identification of burn out can help the nurse individually as well as organizationally. Individually because the nurse is able to seek and obtain help and organizationally because of the cost of an organization losing nurses to burnout. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper With the implementation of a strong education and awareness program the need for an appropriate scale to measure and analyze is required. The MIB is a tool that will be administered to nurses to self-assess and provide information as to whether they may be at risk for burn out, which is essential in this education program. The Maslach Burnout Inventory (MBI) is a vital tool in covering three major components which include exhaustion, depersonalization and personal achievement and should be placed in organizations where ever nurses work. Using the Maslach Burnout Inventory (MBI) self-assessment survey, healthcare organization increase awareness of the nurses who are at risk of experiencing burnout. However, the healthcare organizations must, first of all, identify the nurses in the departments with a high probability of experiencing disengagement due to work overload and longer working hours such as the emergency department, the critical care, and chronic care nurses (Rushton, Batcheller, Schroede, & Donohue, 2015). Healthcare organization can rely on this tool to encourage the nurses to conduct a self-assessment survey, thereby identifying the risk factors that make the nurses susceptible to burnout. From the outcome of the survey of each nurse (Maslach, 2017). A healthcare organization will come up with appropriate intervention measures that address the unique risk factors identified by each nurse to achieve an effective outcome. The Maslach Burnout Inventory (MBI) self-assessment survey also enables healthcare organization to recognize and become aware of the specific issues of concern among nurses which require immediate attention. Also, the outcome of the self-assessment survey enables healthcare organization to rethink about their structure and examine recommendations that may promote a reduction in disengagement, exhaustion, and depersonalization (Bocéréan, Dupret & Feltrin, 2019). Above all, the survey tool provided a clue on the issues that the organization may address to motivate the nurses to focus on personal achievement development as opposed to caring for others during their professional engagement with patients. There is a current gap in knowledge present on the topic of nurse burnout and any tools and or resources to minimize this occurrence. There are no resources in place that provide nurses with primary intervention techniques to stress and or education on the effects of nurse burn out. Stress is present in the everyday functions of nurses and effective ways of managing this stress is not addressed. Negative effects of stress on nurses there for leads to poor quality of care provided, dissatisfaction within the nurse and the patient and increase in potential medical errors. If organizations implement the use of the MIB, information on nurse burnout risk can help to guide organizations to what areas are more effected and begin to use this education program to make improvements and changes. Having a solid team who is thoroughly educated on this nurse burn out education program will help to increase the movement and awareness of the issue. If there are different stakeholders involved in this program it can create a more positive outcome not only on the pediatric floor, but within the organization as a whole. The stakeholders involved in this program include registered nurses, licensed practical nurses, nurse practitioners and nurse managers. In order to decrease stress during the day the nurses will be given 15 minute sessions on ways to decrease stress such as…..encourage work life balance, encourage peer support, furnish resources for self care and mental health, ( The section in blue is something that I wrote and had a thought in mind but was not sure in regards to how to help the nurses and the organization resolve the issue of burnout. I believe there has to be something else that I do besides the actual education program and tool such as like interventions and such) Burnout among nurses has become a major concern for many healthcare organizations, given that it also affects the efficiency of healthcare service delivery to the patients. Patients are also adversely affected by the nurse burnouts because nurses fail to offer quality healthcare that leads to quality patient outcome. However, the Maslach Burnout Inventory (MBI) self-assessment survey enables healthcare organizations to detect signs and symptoms of nurse burnout early enough and then implement the appropriate intervention measures to mitigate the adverse effects of the nurse burnout. Coincidentally, new ideas may not be easily introduced for this tool as a way of lessening nursing burnout. This practice intervention project (PIP) evaluates how health care organizations can implement the tool to prevent burnout. Theoretical Framework There are several nursing theories that can help in improving one’s understanding of nurse burnout and peer education program as a solution of the problem. One of these is the theory of Nursing as Caring was developed by Anne Boykin and Savina Schoenhofer. This theory is founded on the framework that every human is naturally caring and that they have the potential to support other people in a caring way (Alligood, 2014). From this theory, one can consider nurses as people whose services are aimed at achieving beneficence. This theory is important in understanding the various forms of nurse burnout, and particularly the concept of detachment, and their impact on the welfare of a nurse. According to Salvagioni, Melanda, Mesas, González, Gabani and Andrade (2017), nurses have to be attached to their patients to understand their problems better and to work with them collaboratively towards developing a more appropriate intervention. When a nurse is physically or mentally detached from the patient and other healthcare professionals, the element of caring may become lost, and this could impair the quality of services and patient safety as well. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper This practice intervention project has suggested nurse burnout education and particularly with a focus on peer education. This theory is supported by several theories, including the theories of social learning, reasoned action, diffusion of innovation, participatory education, and differential association theory, among others. In social learning theory, Abdi and Simbar (2013) argue that human behavior and social situations can elicit behavioral change and particularly if an individual develops the right interpretation of the system and the values. This theory promotes social learning, learning in groups, or learning with a high level of flexibility as a way of enhancing the values that a nurse develops from the training process. As such, organizations should encourage peer education as much as possible as this theory supports their success over other instruction-based learning. Nurses are likely to have people whom they look up to for guidance and mentorship. This is a concept that is supported by the theory of reasoned action. According to Hackman and Knowlden (2014), this theory asserts that nurses can easily learn from influential people they trust, and whose ideologies and values have been proven to succeed. When designing peer education programs, healthcare organizations need to allow nurses to learn amongst themselves while availing role models or successful people from within or outside the organization. This theory is founded on similar analogies to the theory of diffusion learning that considers opinion leaders or influential people as ones who are capable of influencing the behavior of others by sharing values that have helped them to excel (Mohammadi, Poursaberi & Salahshoor, 2018). In this regard, peer education allows nurses to share their experiences, including their challenges, things that have worked, and those that have failed. For nurses who are known to succeed, and particularly nursing leaders or those who receive occasional promotion, it is likely to influence new nurses and those experiencing challenges in realizing their problems, potential solutions, and implementing solutions to their problems. Peer education is widely considered as an empowerment process. Rather than offering instructions and dictating things that nurses should do to improve themselves, organizations ought to allow them to share among themselves and develop one another. According to this theory, nurses who feel powerless can easily regain control through participatory learning and particularly since it allows them to accept themselves and to have a better understanding of their problems. This theory’s assertions are reinforced by communication of innovations theory that perceives nurses as capable of realizing their competence and developing more appropriate and personalized solutions to their problems. As such, organizations should only provide influential or successful people as moderators of the training programs and allow the nurses the much-needed flexibility and freedom. Such a program has better chances of success as the nurses can also learn from one another without the limitation of risks of burnout and potential solutions that can be provided by a single individual as is the case with instruction-based learning. Phoenix NURS6247 Nurse Burnout Issue in Healthcare Paper Literature ReviewNurses are expected to be at their optimum physiological, physical, emotional, and mental status during service delivery. According to Makary and Daniel (2016), nursing practice is one of the most critical professions that allow no room for error while at the same time requiring nurses to always be in their optimum status for the best outcomes. Unfortunately, nurses experience several problems that face employees in every other sector. Demotivation, stress, burnout, depression, fatigue, depression, and low levels of satisfaction are common among nurses (Iglesias & Vallejo, 2013; Vermeir, Blot, Degroote, Vandijck … Vogelaers, 2018). Unlike most other professions, however, nursing practice tends to be more demanding and particularly due to the relationship that nurses share with the patients. It is for this reason that problems related to emotions, including stress, depression, and burnout, tend to be more common among nurses than in other areas (Van Bogaert et al., 2017). Nursing burnout is defined as the physical, emotional, and psychological exhaustion that nurses experience in the course of service delivery (Van Bogaert et al., 2017). While it is common for the three forms of exhaustion to manifest themselves at the same time, it is also possible for one or two to affect the nurse. This problem also comes in the form of stress or strain and may have a considerable impact on the performance of the nurse and the relationship between the nurse and the patients or coworkers. Nursing burnout is often evaluated through the Maslach Burnout Inventory (MBI) that measures the level of emotional exhaustion in a nurse, their depersonalization or detachment from other people, and their personal accomplishment (Ribeiro et al., 2014). The problem affects both nurses and physicians. However, its prevalence among nurses has been found to be more common than in other healthcare professionals (Ribeiro et al., 2014). Nurse burnout is a common problem that requires to be addressed more frequently as a strategy for improving the quality of care and patient safety. Unfortunately, many healthcare facilities do not realize the occurrence of this problem and its impact on healthcare professionals (Hall et al. 2016). It was not until the problem became a common area of research that healthcare providers realized the need to evaluate their professionals and implement measures that could address the problem. However, Hall et al. (2016) note that, while many healthcare facilities strive to implement such measures, small and medium healthcare facilities do little to address the problem. While many healthcare providers focus on optimizing the performance of their employees, they fail to realize that the different forms of fatigue or exhaustion can significantly derail their success. Focusing on nursing practice has been shown to improve patient safety by reducing the chances of preventable errors by up to 50%, which could be an important way of raising the credibility of healthcare facilities, improving their health outcomes, lowering their costs of care, and improving compliance with healthcare regulators (Panagiotis et al., 2017). This is a clear indication that every healthcare provider should prioritize addressing this problem as it promises to address many of the issues that are associated with the industry. Nurse burnout affects a large proportion of nurses. Depending on location, assig

Nursing

Economic Evaluation of Health and value Judgment and Evaluation ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Economic Evaluation of Health and value Judgment and Evaluation Chapter 1 Output of the Healthcare Sector OBJECTIVES Describe the product medical care and its components. Define the concepts of risk and risk shifting and show why they are relevant to medical care. Describe health care and its components. Describe the concept of health outcome. Explain the theoretical relationship between health and medical care, and demonstrate the meaning of the term flat-of-the-curve medicine. Economic Evaluation of Health and value Judgment and Evaluation 1.1 INTRODUCTION In this chapter, we introduce the descriptive elements in the study of the healthcare system. This involves identifying the phenomena with which we are concerned, defining them so we can know their nature precisely, and measuring them so we can obtain an understanding of their magnitude. At this stage, we wish only to discover what phenomena exist, not what causes them (explanation) or in what quantities they should exist (evaluation). The processes generated within the healthcare system can be looked at in two ways. The first approach is to directly examine factors that influence health. These health-influencing factors can be classified as lifestyle elements, such as diet, sleep, and other individual behaviors; environmental factors, such as air and water purification; genetic factors; and medical care, such as examinations and treatments. Section 1.2 focuses on the definition and measurement of medical care. It identifies and defines the phenomena associated with medical care and discusses measures that indicate how much medical care is provided. Section 1.3 describes another aspect of the healthcare system: risk shifting. Because most medical expenditures do not occur with certainty, individuals will place a value on buying insurance to cover possible losses. Risk shifting provides benefits to consumers and is an important output of the healthcare sector. The second approach stems from the assertion that the true end of the healthcare sector is not the care itself, but rather the health that results from this care. When measuring the output of health care, according to this approach, the measure should be how much health is being produced. If it is believed that the volume of medical care provided is not necessarily a good indicator of the benefits provided, a more fundamental approach would be to measure what medical care is ideally supposed to produce, that is, health. Section 1.4 examines issues of definition and measurement associated with health. Section 1.5 focuses on the output of the healthcare system derived from the education of healthcare personnel. The healthcare system includes the training of the professionals who work within the system, and these individuals will produce output (health care) during their training and after it is completed. In economic terms, the output of the education and training production process is called “human capital.” 1.2 MEDICAL CARE Medical care is a process during which certain inputs, or factors of production (e.g., healthcare provider services, medical instrument and equipment services, and pharmaceuticals), are combined in varying quantities, usually under a physician’s supervision, to yield an output. An individual visiting a physician’s office receives an examination involving the services of the physician or a nurse practitioner, nurse, or medical technician, and the use of some equipment. The inputs vary from one visit to another. One patient may receive more friendly treatment than another, and healthcare providers vary in their thoroughness, knowledge, and technique. Thus, the quality of one visit may differ considerably from the quality of another. Much of the difficulty in measuring the medical care process stems from the issue of quality. If physician care is measured by the number of patient visits to a physician’s office, two cursory examinations count as two visits. But one cursory examination followed by a thorough examination involving a battery of tests also counts as two visits, even though more medical care was provided. It should be stressed that quality is a very broad term, and its meaning is elusive (Donabedian, 1988). For example, organizations providing medical care can have substantially different characteristics. To begin with, they can differ in terms of structure, that is, the amount and type of training of the care providers and the type of medical equipment used. Further, differences in structure are associated with the use of different techniques in the provision of care. For example, a computerized axial tomography (CAT) scan machine that takes cross-sectional radiographs is generally considered to provide a higher quality product than a standard radiology machine (Sisk, Dougherty, Ehrenhaft, Ruby, & Mitchner, 1990). A second aspect of the quality of care involves the process of providing care, in particular, the amount of personal attention providers devote to consumers, and incorporates what is actually done in the provision and receipt of care. Examples of quality-of-care measures that reflect the degree of personal attention given to consumers include the volume of services performed per individual and patient evaluations of physician performance. Another set of characteristics is associated with outcomes, or the effects of care on the health status of the individual or the populations. In this instance, the measure of outcomes deals with the accuracy of diagnoses and the effectiveness of treatments in producing health. Examples of measures reflecting this set of characteristics include hospital mortality rates adjusted for patient condition, the rates of other adverse events in hospitals, such as postsurgical infections, or the reduction in influenza because of immunizations. All of these characteristics, as well as others, have been identified as aspects of quality. The challenge of measuring quality, then, derives from the fact that there are many ways of viewing quality and many different ideas as to what constitutes quality. For this reason, the raw measure “visits” should be only guardedly used as a measure of physician care. The measurement of hospital care requires the same caution. Hospital output has frequently been measured by bed days or by the number of cases admitted to the hospital. Over time, however, the typical admitted patient receives a greater intensity of services as a result of advances in technology. To count an admission in 1965 as having the same output as an admission in 2011 (given the type of case) would be to neglect the greater intensity of services likely to be provided at the later date. Despite these objections, physician visits as a measure of the output of medical care and hospital admissions or bed days as a measure of the output of hospital care have frequently been used because of their immediate availability. Recently, efforts have been made to develop additional measures that incorporate the changing quality of inputs per admission or per bed day. Output measurements are usually conducted to make comparisons, either against other output measures or against some standard. There are two types of output comparisons: time series and cross-sectional comparisons. A time series comparison measures the output of the same good or service at different times. A cross-sectional comparison measures the output of the good or service among different groups at the same time (e.g., the medical care provided to consumers in different age groups, ethnic groups, or geographic areas, or with different diagnoses). Medical care output can be measured at three sources: The providers can be surveyed to determine how much medical care they have produced. The payers for medical care can be surveyed to determine for how much medical care they have paid. The consumers can be surveyed to determine the quantity of consumption or utilization. With perfect measurement, all three sources will yield the same results; however, because of measurement difficulties, considerable differences will arise. A continuing source of data on medical care received by consumers is the National Health Interview Survey, an annual nationwide sample survey of households on health-related matters compiled for the U.S. Public Health Service. Much of the information from this survey is summarized in the Public Health Service’s annual compendium of health-related data, Health United States (www.cdc.gov/nchs/hus.htm). The National Health Interview Survey (www.cdc.gov/nchs/nhis.htm) is also the major source of data on medical care administered by physicians outside the hospital. This care is measured by the number of visits to physicians (the numbers of visits are often adjusted for the size of the relevant populations to yield utilization rates), with utilization defined as the amount of services consumed. As an illustration of the use of time series data, comparisons were made of physician’s office visits per year for individuals in the 65 and over age group. For this group, visits per person were 4.5 in 1975, also 4.5 in 1985, 5.3 in 1995, and 6.9 in 2008. These numbers indicate that there was no increase in the output of physician office care for this group between 1975 and 1985, but that a marked increase did occur in the following decades (see U.S. Department of Health and Human Services, 1994, 1999, 2011). Also, one visit in 1975 was counted as the equivalent of one visit in 2008 because quality-difference adjustments were not made. It is very likely that quality did increase in this period because of new technology, better equipment, and better training. Unfortunately, this aspect of output is usually neglected in data collection efforts (Freiman, 1985). An alternative way of measuring physician output is to focus on procedures or services. Procedures (e.g., an appendectomy) can be measured in a number of dimensions (e.g., average time of performance, complexity, overhead expenses), and based on these dimensions, comparable weights can be developed for each procedure (Hsiao & Stason 1979; Hsiao et al., 1992). This approach better captures the differences among various physician tasks. There are several different measures of hospital output. One way of measuring output is to examine the number of admissions on a per-population basis. In 1964, there were 190 admissions per 1,000 population, while in 2007 there were 114 admissions. However, the length of stay per admission has changed radically in this time period, from 12 days per admission to 4.8 days. As a result, total days in hospital per 1,000 population fell from 2,292 to 540. The number of days is a better measure of resources used than admissions, but even days does not tell the whole story, as it leaves out the consideration of quality (U.S. Department of Health and Human Services, 1999, 2011). Because of the vast differences in types of illnesses, in disease severity, and in medical treatment patterns (including quality of care), hospital output is difficult to characterize from an economic viewpoint. One method of doing so that captures a mixture of illness types and severities, as well as treatment patterns, is the diagnosis-related group (DRG) classification system. The DRG system has many variants, but all of them are simply patient classification systems. In the 1998 version of the DRG system, which was used by the Health Care Financing Administration to reimburse hospitals, hospital inpatient output was divided into 511 different groups based on the major reason for hospitalization, whether the case was medical or surgical, patient age, and the presence of significant complications and comorbidities (conditions in addition to the primary). In 2007, the Centers for Medicare and Medicaid introduced the Medicare Severity Diagnosis-Related Groups (MS-DRG), expanding the number of groups to 745. While the MS-DRGs do not measure quality, they do incorporate more data on the severity of illness of the patients within the diagnosis. In a nationwide study of hospital costs conducted at the Agency for Health Care Policy and Research (AHCPR), average annual charges for specific DRGs were as follows: normal delivery, $3,094; craniotomy without complications, $32,594; liver transplant, $204,000 (Agency for Healthcare Research and Quality, 1997). Despite the fact that the DRG system develops average costs among groups, the range of costs within, as well as between, DRGs was considerable; this variation is reduced, but not eliminated, with the MS-DRG system. DRGs do not measure “quality of care.” To gather a picture of hospital product quality, we must look at data collected from hospitals. Hospital output data are available from Vital and Health Statistics (Series 13), published by the Public Health Service; Hospital Statistics, the annual compendium of the American Hospital Association (AHA), and various issues of Hospitals: Journal of the American Hospital Association. The Hospital Compare website (http://www.hospitalcompare.hhs.gov) provides another source of quality measures in hospitals, including patients’ perceptions regarding their hospital stays. The AHA formerly published a series of indexes that extensively covered the concept of measuring quality changes in hospital care over time (Phillip, 1977). This index attempted to measure the quality change of a day of care by changes in service intensity, which was defined as the quantity of real services that go into one typical day of hospitalization. The AHA’s Hospital Intensity Index (HII) incorporated 46 services, including the number of dialysis treatments, obstetric unit worker hours, and pharmacy worker hours. A weighted average of these 46 services was calculated annually on data from a sample of hospitals to derive an average number of services per patient day offered during the year. With the calculation for 1969 as a baseline (the value for that year equals 100), the annual averages formed an index that measured changes in the service intensity component of output over time. Although these data are no longer published, they did provide an excellent illustration of how important service intensity is as a component of medical care output. While intensity of service has been associated with quality of hospital services, there is no evidence that increased intensity always results in increased quality of care. There are a number of other factors impacting actual quality of care delivered. In Table 1-1, national data are shown for three components of hospital utilization between 1980 and 2007. The three general measures are hospital patient days per 10,000 population, hospital discharges per 10,000 population, and average lengths of stay (ALOS) in days. These three categories are then presented as crude rates and as age-adjusted rates. The crude rates are simply numbers of events that occurred. The age-adjusted rates are statistical calculations to adjust the population to a “standard” distribution. Age-adjusted rates enable better comparisons among populations with different age distributions, which is particularly important in health care, because there are substantial differences in health simply because of the aging process. For example, if there is interest in comparing hospital utilization across different areas, and one area has a high rate of younger individuals (possibly because of a college town within its borders), compared to another area with an older population, the age-adjusted rate can be used to reduce the confounding impact of age differentials. Table 1-1 Output in Short-term, Acute Care Hospitals in the United States image As can be seen in Table 1-1, the utilization of hospitals has been declining since 1980. The decline was large in the 1980s and early 1990s, and has leveled off somewhat in recent years, especially in terms of the length of stay of individuals admitted to hospitals. The age-adjusted number of days of care per 10,000 population in 2007 was only about 40% of what it was in 1980. The decline in days of care reflect both a decrease in the number of times individuals were admitted/discharged from the hospitals and the average length of time they stayed in the hospital once admitted. 1.3 RISK SHIFTING AND HEALTH INSURANCE Another type of healthcare sector output is risk shifting through the purchase of health insurance. Illnesses are often unexpected and accompanied by monetary losses. These losses can be in the form of medical expenses, lost earnings from work, and other expenses. Individuals can be said to face a risk of losing some of their wealth, which means that the existence of the loss and its amount are uncertain. This risk creates concern on the part of the consumers, and they are usually willing to pay something to avoid the risk. One way of dealing with the risk is to shift it to someone else. Insurers are organizations that specialize in accepting risk. When an insurer accepts a large amount of risk, the average loss to the insurer becomes predictable. Of course, there are costs of operating such a risk-sharing organization. These include the administrative expenses associated with determining probabilities, setting prices, selling policies, and adjudicating claims. The owners also expect a return on their investment (profits). These expenses and profits are included in the fee (called a premium) that each individual must pay to obtain insurance. The essential point here is that, in its own right, risk shifting is an additional output that is distinct from the output called medical care. Someone can obtain medical care without risk shifting (by paying for it when the product is received). Such an individual is still faced with the risk of incurring losses, but has done nothing to shift the risk. It is the additional activity of shifting the risk in advance—taking action to reduce the loss should illness occur—that is the output. There are a variety of ways in which risk can be shifted. It can be done privately, by the purchase of insurance. Insurance organizations, such as Blue Cross Blue Shield, Prudential, and Aetna, sell health insurance policies, either directly to individuals (individual policies) or through groups, such as employers and professional associations (group policies). In addition, health maintenance organizations (HMOs) act as both insurers and providers of care. The government also acts as a payer of healthcare bills for large numbers of individuals, although, strictly speaking, it is not an insurer; most of its revenues are in the form of taxes, not premiums, and often the covered individuals are not the ones who pay these taxes. Thus, the government does not manage its healthcare related expenditures on an insurance (risk assessment) basis. Government-style risk sharing is referred to as risk pooling. Health insurance can cover all an individual’s expenses. Full insurance has become quite costly, and so insurers have come to resort to “cost-sharing” provisions, in which insured persons pay a portion of their healthcare bills and the insurer covers the rest. These provisions allow the insurers to limit expected payouts and charge the insured persons lower premium rates. In cost-sharing arrangements, the risk shifting is not complete. Cost sharing can be done in several ways. The insurance policy can require the individual to cover the first dollars of expenses—a deductible—and the insurer then pays all, or a portion, of the rest. For example, the individual might be required to pay a deductible of $100 before the insurer begins to kick in. The insurer can also specify a limit above which payments will cease. For example, it might cover expenses up to a lifetime limit of $1,000,000. Beyond that, the individual would again bear the risk. So-called catastrophic insurance can be obtained to cover very large losses. The amount and type of insurance coverage is inextricably tied to the workings of the medical care market. Thus, although insurance and medical care should be thought of as separate products, they do affect one another. In the case of insurance coverage, distribution issues have arisen as a cause for concern. In the United States in 2010, some 18.5% or roughly 49.1 million people under age 65 were uninsured (CDC, 2011). Among those lacking insurance were a number of children (8.2% of those under 10), a fact that has generated a considerable amount of concern. This number of uninsured children is much lower than previously, mainly the result of the implementations of the SCHIP (State Children’s Health Insurance Program). Additionally, many employed individuals have no insurance. Because employment is the traditional source of health insurance in the United States, the lack of insurance among workers is viewed as a worrisome development (Monheit & Short, 1989). The mere possession of some sort of coverage does not guarantee adequate risk protection. Medicare is a government plan that covers hospital expenses and (optionally) medical and drug expenses for individuals age 65 and older. Because of the cost-sharing arrangements incorporated into the program, many of those who are covered under Medicare still face a substantial financial risk should they become ill. Indeed, 70% of those who are age 65 and older now purchase private supplemental insurance plans, also called “Medigap” policies, to cover the risk resulting from the cost-sharing elements (Health Care Financing Administration, 1998). At the same time, it also should be pointed out that a complete absence of risk on the part of insured individuals (the shifting of the entire risk onto insurers) has its problems as well. A totally riskless policy may be very expensive, because individuals are more prone to demand care when it has a zero price (as under full insurance coverage). The costs of such care must still be covered by the insurer, and so premiums must increase to cover these costs. 1.4 HEALTH STATUS 1.4.1 Concepts The concept of health seems so familiar to us that we can almost reach out and touch it. It seems easy to distinguish the 97-pound weakling from the bodybuilder who kicks sand in his face at the beach or to recognize a radiant complexion when we see one in a facial soap commercial on television. More precise measures, however, are hard to obtain. The categories “healthy” and “unhealthy” are not exact. The main reason for this is that we have not defined health precisely. Lacking such a definition, two observers can have different opinions as to whether one person is healthier than another. An essential task of the scientific method is to obtain widespread agreement about the nature of a phenomenon. If we lack an operational definition, we can hardly expect two independent observers to reach agreement about the status of the phenomenon. A definition is useful if it helps pinpoint the characteristics of the phenomenon we are trying to describe and eventually measure. Health is not an easy concept to define with any degree of precision. As the English epidemiologist Sir Richard Doll remarked concerning the concept of health, “Positive health seems to be as elusive to measure as love, beauty, and happiness” (Doll, 1974). Yet, in an effort to give some hold on the concept, the World Health Organization (2000) has defined health as “a complete state of physical, mental and social well-being, and not merely the absence of illness or disease.” This is a very broad definition, and the characteristics of health suggested by it are not easy to pinpoint and measure. The definition stresses that there are three components of health, and even if a person is physically healthy, he or she can still be lacking in the other categories. 1.4.2 Measures of Individual Health For many years, health was identified by the presence of disease (morbidity) or by death (mortality). Individual measures, such as the diagnosis rates for certain conditions or rates of hospitalization, were used as indicators for morbidity. Mortality was usually adjusted for such population factors as age and gender. More recently, mortality has been addressed in terms of premature mortality, with the difference between expected age of death and the actual age of death being forwarded as a measure of life-years lost prematurely. Thus, if the expected age of death for a male aged 20 is 75, then a 20-year-old man who dies in a car accident is considered to have lost 55 years of life. Researchers have been looking for other measures of health with a more positive focus. Attempts at identifying and measuring health have focused on certain characteristics we would expect in a healthy person. These characteristics include the physical functioning of the individual’s body in relation to some norm, the physical capability of the individual to perform certain acts (e.g., getting up or dressing), the social capabilities of the individual (i.e., how well he or she interacts with others), and how the individual feels. These characteristics are, by no means, distinct from one another, a fact that has led to much disagreement among researchers who have tried to invent a unique measurement of health status. Different research efforts have focused on clinical characteristics; on individual capabilities (Boyle & Torrance, 1984; Culyer, 1976); on the physical functioning of people’s bodies in relation to some norm (Kass, 1975; Williamson, 1971); and on a mixture of physical, mental, and social characteristics (Breslow, 1972). Despite the considerable difficulties in arriving at widely accepted indexes of health status, the importance of the topic ensures that researchers will keep trying. One widely used measure is the 15-D (for 15 health dimensions), which categorizes health status into 15 groups, as shown in Table 1-2. These groups include breathing, hearing, moving, and so on. Subjects rate each dimension on a 5-point scale. For the breathing dimension, for example, a “1” would indicate normal breathing, and a “5” would indicate that the individual experiences breathing difficulties almost always. Within each dimension, each point on the scale is assigned a value, which scores the functioning level. For example, normal breathing is scored as 1.0000, and level 5 breathing is scored as 0.0930. The 15-D investigators have assigned a second set of weights to each of the 15 dimensions. These weights were obtained from community surveys and reflect the importance of each dimension. Example weights are shown in Table 1-2. For example, breathing has an importance weight of 0.0805. The 15 importance weights sum to 1.0000. Investigators can use instruments such as the 15-D to provide measures of an individual’s quality of life. Further, a time dimension can be added to provide a measure of quality-adjusted life years, or QALYs. Investigators often standardize these measures, with a score of 1.0000 being the highest level of health and 0.0000 being the lowest (or perhaps even death). Thus, for example, a group of patients with asthma had an average overall 15-D score of 0.89 (out of a maximum possible score of 1.00) (Kaupinnen et al., 1998). If the condition persisted for 1 year, then the average patient’s quality of life index would be 0.89 QALYs for the period. The individual would have lost 0.11 QALYs due to his asthmatic condition. The figure 0.11 represents the loss of full health over the year. If the condition persisted over 2 years, then the individual would have experienced 1.78 QALYs during that period. The translation of health-related quality of life (HRQOL) measures into QALYs has one very convenient benefit. By evaluating death as 0.0000, one can compare interventions, some of which result in death. For example, if one person lived for 5 years at a QALY value of 0.5 rather than being dead (QALY value of 0.0000), then the difference in QALYs would be 2.5000–0.0000, or 2.5 QALYs. Of course, there are conceptual problems with placing a 0.0000 value on death; death is beyond the conscious experience of people, and so they may have great difficulty comparing different levels of health with death. Table 1-2 Health Dimensions in the 15-D Health-related Quality of Life Index Dimension Importance Weight Breathing 0.075 Mental functioning 0.044 Speech 0.065 Vision 0.075 Mobility 0.046 Usual activities 0.057 Vitality 0.074 Hearing 0.104 Eating 0.040 Eliminating 0.033 Sleeping 0.090 Distress 0.079 Discomfort/symptoms 0.072 Sexual activity 0.084 Depression 0.062 Total 1.000 Source: Adapted from H. Sintonen. The 15D Instrument of Health-related Quality of Life: Properties and Applications, Annals of Medicine 33: 328–335, © 2001. The 15-D weights can be used both to assess the HRQOL of an individual over time or to compare different individuals or groups. For example, women with breast cancer can take different forms of chemotherapy. The 15-D can measure differences in health-related quality of life among the interventions. There are several general HRQOL measures in use (Bowling, 1995); those used mostly by economists include the Euroquol 5D (Kind, 1996) and the Health Utilities Index (Feeny et al., 1996). In addition, there are a large number of HRQOL measures for specific diseases (Bowling, 1995). 1.4.3 Population Health Measures The most commonly used population health measures have been mortality rates and morbidity (usually hospitalization) rates. Mortality, or death rates, are standardized by age and sometimes gender and can be expressed for the entire population or for subgroups, such as Whites and Blacks. In Figure 1-1, we show the trends in death rates for the total population and for Whites and Blacks from 1970 to 2009 in the United States. All rates have been falling, but the death rate for Blacks is substantially above that for Whites. Death rates are also used for subgroups; for example, the neonatal mortality rate, which expresses deaths up to the first 28 days of life as a percentage of total live births, was 4.5 in 2006. For the White and Black populations, the respective rates were 3.7 and 9.1 (U.S. Department of Health and Human Services, 2011). image Figure 1-1 Age-adjusted Death Rates by Group, United States, 1970–2009 (Deaths per 100,000 Residents). Source: 1970–2005 data from U.S. Census (2010). Statistical Abstract of the United States, 2010, Table 107; Table A: National Center for Health Statistics, National Vital Statistics Reports, Deaths: Preliminary data for 2009. Increasingly, analysts have been focusing on survival time as an indicator of health status. They choose survival-time indicators because these place emphasis on the duration component of health status; a person’s well-being is a function of the time spent in each health state, not merely the health state at a given moment in time. Measures that look at survival time adopt this important dimension of health. One such measure is that of potential years of life lost (PYLL) before a target age. The analyst selects a target age below which most individuals are expected to live. Deaths that occur at an age earlier than the target age are considered to be premature. The measure of premature deaths is considered to be one of the best population-level indicators of health. This indicator for Whites and Blacks in the United States is shown in Table 1-3. The PYLL for males, expressed in terms of 100,000 persons, is almost 14,000 life years, while for females it is only about half that, at 7,400. The number for Blacks, on the other hand, is almost 18,000 compared to Whites at less than 10,000. Table 1-3 Years of Potential Life Lost before Age 75, per 100,000 Population under 75 Years of Age, United States, Selected Years (Age Adjusted) image Of course, mortality rates do not take quality of life into account. In an effort to incorporate both mortality and quality of life into a single index, analysts at the World Health Organization have developed an index called healthy adjusted life expectancy (HALE) (WHO, 2010), which reflects the average number of years an individual can expect to live in “good health.” To estimate HALE, the investigators determine the prevalence of both fatal and nonfatal conditions in each country and adjust life years in light of disability rates d

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