Nursing

Response Cards in Classrooms Response Cards (ARC) have boomed as a teaching resource with classrooms throughout Australia and internationally. Their aim is to limit the amount of avoidable disruption that occurs in the learning environment by helping to keep students engaged and on-task. Supporters of ARC implementation in classrooms report heightened student participation, in turn, leading to improved academic achievement of students.

Heard (1994) proclaims that ‘response cards are cards, signs or items that are held up simultaneously by all students to display their response to a question or problem presented by the teacher. This new form of “low-tech” learning technology can be used across many key learning areas as they provide equal opportunity for all students to actively participate and contribute during lessons.

Furthermore, ARCS generate an engaging and lively classroom environment contradictory to the lack of participation that is characteristic of more teacher-centered classrooms. Furthermore, the variability of activities that ARCS allow for help to generate a more positive and productive teacher-student relationship. Rationales and Evidence Base A substantial amount of research has been conducted on ARC use to determine the outcomes they improve, and how significant these improvements may be.

Current research purports similar rationales and findings, including that ARCS stimulate engagement from an entire class during a lesson, allow students to clearly communicate their understanding of specific course content, allow the educator to detect when a student does not fully comprehend a particular concept within course material, and help decrease disruption and the prevalence of off-task behavior (Blackwell & McLaughlin, 2005; Heard, 1994; Maroon, 2007; Randolph, 2007). In The Classroom Experiment, William argues that ARCS are an incredibly important educational development.

William expected that Arcs, such as “mint-whiteboards” would help teachers to quickly identify when pupils did and did not have a solid understanding of specific course content. Further, William hypothesized that these ARCS would promote the engagement of every student in the classroom, as they would have no chance to “hide” an incorrect response. It was clear from the observations and reflections of the students and the teaching staff, that the implementation of these “mint-whiteboards” was achieving Williams goals.

Teachers at the school reported that the “mint-whiteboards” were lawful in quickly identifying the students’ misconceptions and that they thoroughly increased classroom participation. It was further found that students also had a through the use of this type of ARC, with some children saying that on the whole, the use of this new learning technology improved their time within the classroom, by allowing them to help each other with their work.

One student proclaimed it was an easier method of receiving information, and more interesting than reading it out of a book. In order for ARCS to be effective they must multitudinously engage and involve all members of the class, and disallow for any biases regarding individual differences in ability (Heard, 1994). In the Classroom Experiment, Williams implementation of the “mint-whiteboards” is concurrent with this. ARCS require all learners to provide a response, thereby eliminating the teacher’s challenge of engaging and including all students.

Previous pedagogies, such as the “raise your hands” approach, promoted higher ability students to constantly offer their answers, disallowing the opportunity for lower ability students have their misconceptions realigned. This provided a difficult task for the teachers as they were unable to determine the cognitive ability, and learning of some crescents. In the Classroom Experiment, William rationalists the use of Arcs, such as “motherboards”, by purporting that they allow teachers to clearly identify who does and does not understand, so that no student is left behind.

Further, this form of ARC allowed the students who frequently gave responses, in the previous hand-raising environment, to still participate in classroom activities. Moreover, the students who, previously, did not often participate get the chance to show what they do know, and eave their misconceptions corrected. Heard (1994), in his examination of Arcs, reports identical hypotheses to those of William in the Classroom Experiment. It is discussed that ARCS provide all students the opportunity to respond, and further, they are able to learn by observing each other.

Following this, Heard (1994) suggests that ARCS allow teachers to more easily detect understanding of the students, through individual response. Heard (1994) discusses the cavalcade of experimental paradigms that have tested these hypotheses, one such is the Nary Experiment. This experiment clearly portrayed how effective ARCS are within he classroom setting. When students began to use the Arcs, every student made about 30 responses during the lesson, this is compared to the average two responses from each child per lesson when using the “raise your hands” approach.

Extrapolating these findings, Heard (1994) highlights that by replacing the “raise your hands” approach with Arcs, for only 20 minutes during the day, lead to approximately 5000 more responses from a student per year. It is therefore evident that Warhead’s (1994) rationale purporting that ARCS promote higher student engagement and response was found to have significant empirical support. Another of Warhead’s (1994) key rationales for the use of ARCS is his assertion that ARC implementation will promote higher test scores.

In order to support this rationale, Heard (1994) looked at the daily quiz scores of students, finding that when ARCS were used, average quiz scores were higher than those found during the use of the “raise your hands” approach. Thus, the positive effect of ARCS on improving pupils’ grades is highly evident. By Stanchion’s Principle of Connectivity, in order for the new pedagogy to be deemed efficacious, it must be founded on, and substantiated by, empirical search (Stanchion & Stanchion, 2003).

There is significant statistical support in the literature to suggest that widespread implementation of ARCS is necessary to improve students’ learning outcomes (Randolph, 2007; Blackwell & McLaughlin, 2005). There is a vast array of research that supports the claims that ARCS decrease classroom disruptions, decrease students’ off-task behavior and increases student engagement, all of which lead to improved academic results. When comparing the “raise your hands” approach to the implementation of Arcs, Randolph (2007) reports some convincing findings.

The proportion of students achieving 80% or better in the “hand-raising” condition was 41. 8% for test scores, and 29. 7% for quiz scores. However, through the use of Arcs, the group of high achieving students rose to 52. 1% for test scores and a staggering 62. 2% for quiz scores. Finally, students taught using ARCS achieved test scores 0. 8 standard deviations higher than those taught using the “raise your hands” approach. Not only efficacious in improving academic performance, ARCS have been demonstrated to provide significant reductions in classroom disruption and off-task behavior of students.

In his ARC condition, Randolph (2007) found that student participation was 35. 6% higher in the ARC condition than in the “raise your hands” condition. Blackwell and McLaughlin (2005) further report that fatsos behavior, in the “raise your hands” condition, was prevalent 56% of the time, compared to 6% in the ARC condition. Finally, it is also reported that the use of ARCS led to 8% disruptive behavior, compared to 33% in the “raise your hands” approach. Thus, the evidence suggests that ARC implementation has great effect in reducing the amount of classroom disruption and off-task student behavior.

Further, ARCS have been continually shown to increase the participation and engagement of students, compared to the “raise your hands” response technique. Thus the empirical research on ARCS is clear in supporting the rationales purported by educational experts. In the Classroom Experiment, William was able to demonstrate that ARCS are incredibly beneficial for both student and teacher, through the increasingly positive atmosphere generated in the classroom, and the academic achievements of the students. As reported above, the literature is expansive in its support of the claims of

ARC advocates (Blackwell & McLaughlin, 2005; Heard, 1994; Maroon, 2007; Randolph, 2007). This new, “low-tech” learning technology has been shown to increase student participation, decrease the amount of off-task behaviors, limit the amount of classroom disruption and have an overall positive effect on the test scores of learners. Student Welfare, Good Discipline and Effective Learning Policy When used in any classroom environment, response cards are a very effective tool in promoting the learning of all students in the class, regardless of ability, as their premise is heavily founded on inclusively and participation.

Not only do ARCS assist in the students’ level of engagement within the classroom environment, but they also assist the teacher in their behavior management of the class (good discipline), the confidence and mindset of the students (student welfare) and the ability of the students to process the information (effective learning). The “motherboards” featured in the Classroom Experiment, act as an important formative assessment within all classrooms to allow the teachers to actively self-assess.

Teachers are able to quickly assess whether their current teaching method and style is allowing the students to get the most out of the Essen and conduct their behavior in a manner that meets the goals of the policy. This is sanctioned through the immediate formatively assessed response provided by ARCS (Heard, 1994; Maroon, 2007). The first part of the policy that can be addressed through the use of the ARCS is the student welfare component. The welfare of students is paramount within any educational facility.

Wanes (1996) stresses the importance of a welfare system to be a network that provides social and emotional support. ARCS are an excellent way of understanding how the students are progressing and how they are feeling about ACH topic and also school life, and thus, satisfy Wanes’ (1996) assertion. By using ARCS in different environments in the school, teachers are able to better regulate student behavior (Blackwell & McLaughlin, 2005). This is important as it links in with the discipline component of the welfare policy.

Student welfare is heavily reliant on the behaviors and attitudes of the students, and ARCS help to create a greater sense of community as the students are given increased responsibility in their learning, and nurturing of the school environment. No longer are they able to sit idle in class, ARCS force each and every student to be accountable for their understanding of the content. Activities that involve ARCS may be related to listing the most interesting thing in the school in their opinion.

This allows the students to find their own connection to the school and their community, ultimately bettering their behavior due to their community pride, and creating a better student welfare system in the school environment. Many of the “good discipline” goals, presented within the “Student Welfare, Good Discipline and Effective Learning Policy’, can be reached and accomplished through the use of ARCS in a variety of ways. Arcs, being an interactive and entertaining resource can be presented to the class as a privilege, with bad behavior resulting in less time with the resource.

This promotes the students’ responsibility to their behavior and the resource, and further, increases their on-task engagement (Skinner & Belmont, 1993). Within the Classroom Experiment, William argued that by presenting the “mint-whiteboards” to the students as a privilege, where misbehaver led to removal of this privilege, and when used in conjunction with other teaching techniques (“lollipop-sticks”, “traffic-light cups”) teachers were able to create a costive and active learning classroom environment for all the students.

Initially, in the Classroom Experiment, teachings displayed indecision and hesitancy during Williams introduction of the “mint-whiteboards”. When the students were first presented with this form of ARC there was a generally positive reaction. However, their attention quickly wavered and the privilege was briskly revoked by the teacher. This action used the “mint-whiteboards” as a form of discipline.

All students were given the responsibility to appropriately use the “mint-whiteboard”, however, they did not et the objectives outlined within the policy, which states that ‘students will be able to learn without disruption from unruly behavior’ (New South Wales Department of School Education, 1996, p. 7). In turn, the privilege was removed, thus the students had to learn from this punishment, so that they would have more respect for the ARC resource in the next opportunity.

Furthermore, Arcs, such as “mint-whiteboards”, effectively help teachers and students reach the goals of the “Student welfare, Good Discipline and Effective Learning Policy’ by having the responsibility of their learning and welfare being put back on the student. The New South Wales Department of School Education (1996) highlights the importance of students participating as equals in all facets of their schooling life. This goal, being a core element to student welfare, is achieved by growing student confidence, another positive outcome of Arcs.

Within the school environment, confidence is of enormous importance when examining student morale and in turn, student welfare. In Shuck and Sears’s (2007) comparative study, teachers reported that when primary school students were given interactive whiteboards or similar resources, the students thrived. One teacher stated ‘Students re “exhibitionists” and hence liked to use the whiteboard for “projecting” their work and their thinking. ‘ (p. 52). Here, it is evident that the implementation of Arcs, such as interactive whiteboards allow students to confidently, and proudly, display their work.

This method of teaching is highly effective in increasing students’ motivation and concentration maintenance. An assistant principal reported that ‘shy students now want to share and present their work… They’re Just freely talking because they have the visual prompt’ (Carney & Shuck, 2007, p. 52). The responsibility is shifted to the dents to get the most out of the work and use the resource productively, thereby creating a better learning environment. Further, teachers are able to better manage discipline and behavioral issues within the classroom.

Effective learning is an essential component of the “Student Welfare, Good Discipline and Effective Learning Policy’. As such, there are many outcomes and objectives to be addressed, and most of these can be assisted by the use of a learning resource, particularly, Arcs. Arguably, the most important and relevant objectives are the ‘establishing [of] well-managed teaching and learning environments… And] encouraging students to take responsibility for their own learning (New South Wales Department of School Education, 1996, p. ). These crucial objectives of effective learning are centered on the classroom environment and the ability of the teacher to create an engaging lesson. In classroom settings, engagement is particularly important because it functions as a behavioral pathway through which students’ motivational processes contribute to their subsequent learning and development (Connell & Hellebore, 1991). Thus, any learning resource must promote student engagement and motivation, and this is the Tara effect of ARC implementation.

The use of a “mint-whiteboard” actively shifts the onus of learning onto the students as they know that they are being formatively assessed during the course of their learning. ARCS such as “mint-whiteboards” encourage the students to participate in the lesson, and further can highlight to the teacher where their teaching styles may need adapting. The teacher is able to quickly and effectively see when students are participating and attending to the content, and where misconceptions may lie.

Therefore, they are able to take the student aside, without the humiliation of the rest f the class knowing they are struggling, and work to increase performance. The advantage of this technique is its efficacy in a range of classrooms, at any grade level (Randolph, 2007). In the Classroom Experiment, the “mint-whiteboards” were deemed effective by the mathematics, English and humanities teachers. Further, William argued that ARCS are appropriate for all ability levels, helping under-confident students to express their skills and knowledge.

This is reflective of the outcomes in the “Student Welfare, Good Discipline and Effective Learning Policy’ in which Students will develop competencies which enhance the quality of their relationships with others… [and] students will feel valued as learners’ (New South Wales Department of School Education, 1996, p. 5). Other forms of formative assessment, such as checking workbooks as the lesson progresses are less productive than Arcs.

This method has none of the engaging capabilities of ARCS and further disrupts the rhythm of the lesson, creating opportunities for distraction and misbehaver. Thus, the implementation of Arcs, such as the “mint-whiteboards” used in the Classroom Experiment are effective in promoting the effective learning of students, in turn, promoting better results, and greater productive work. There are many different techniques that can be employed by teachers, with the use of Arcs, to effectively meet and exceed the goals of the “Student Welfare, Good Discipline and Effective Learning Policy’.

Using different teaching styles and methods, teachers can engage students of all abilities in the content of each lesson while being able to formatively assess each student during the learning of the content. Used effectively, ARCS can act as a motivation for the students to regulate heir own learning and behavior, and allow teachers to discipline within the class and school environment. Strengths and Weaknesses of Response Cards As reported above, the strengths of ARCS are quite substantial. The literature has empirically supported the claims of many educational practitioners that purport the positive outcomes associated with Arcs.

Implementing ARCS in classrooms leads to greater student participation and engagement in on-task behaviors, improved academic performance, the teacher is able to identify students’ misconceptions, and students learn from each other at a higher rate than in a hand-raising approach Blackwell & McLaughlin, 2005; Heard, 1994; Maroon, 2007; Randolph, 2007). Furthermore, as discussed previously, ARCS are effective in satisfying the stipulations in the “Student Welfare, Good Discipline and Effective Learning Policy’.

ARCS have been found to be generally well-liked by students, and this is arguably one of the greatest strengths of Arcs. Heard (1994) discusses that ARCS are a relatively low-cost learning technology, and hence, do not present a great expense for schools. By using Arcs, the teacher can formatively assess not only the students’ understanding of the content, UT their own teaching style and efficacy. Research emphasizes that expert teachers engage in constant reflection of their teaching, adapting it so to improve the learning of their students (Thus, 2009).

ARCS allow teachers to quickly and effectively gauge how well the majority of the students are comprehending the lesson, and can alter their approach if needed. Further, Maroon (2007) discusses the importance of mild pressure in promoting student motivation and engagement, and ARCS effectively allow teachers to do so. Each student knows that their individual response will be seen by he teacher, and potentially their peers, and as a result engages more in the lesson, and attempts to provide a more accurate response. Finally, ARCS have been shown to be efficacious in a broad range of contexts (Randolph, 2007).

ARCS have been attributed to higher achievement in test, quiz and essay scores in all stages of education (primary, secondary, tertiary), across various key learning areas (I. E. Mathematics, English, science, etc. ) and for both disabled and general learning environments. Although ARCS have a wealth of associated advantages, there are some practical limitations of this technology (Randolph, 2007). Heard (1994) highlights that whilst increasing active student responding is important, it is only one third of the broader learning trial involving the content, response and teacher feedback.

It is thus reported that in order for ARCS to be effectively implemented into classrooms, they must be supported by a strong and direct curriculum that helps to support the students’ learning. Furthermore, the feedback the teacher provides during each learning trial must be corrective and constructive, though non-humiliating. It is therefore evident that Arcs, alone, will not deliver on academic and behavioral gains unless supplemented by a wallpapered curriculum and appropriate teacher response. Herein lies another limitation of Arcs, one shared by any new pedagogy.

New technologies are limited by the teacher’s ability to adapt the technology to their classroom, adapt their teaching style to the technology, maintain their pace, and have patience enough to allow the students to practice with the technology before it becomes effective (Randolph, 2007). As seen in the Classroom Experiment, teachers are often hesitant to implement these new strategies as it requires additional work and practice. Teachers’ concerns lie in the time-consuming process of handing out the Arcs, and the requirement of additional stationary to use the resource, I. E. Whiteboard markers for the “mint-whiteboards”.

Furthermore, ARCS are limited by the time it takes for students to formulate their answer, and then write it down (Heard, 1994). Additionally, some forms of ARC use depends on a certain level of literacy amongst the students, the must be able to write down their answers which can cause discord amongst higher ability students who must wait for the lower ability students. In his meta-analysis, Randolph (2007) reports that in some cases, older students mound the use of ARCS to be somewhat childish, and thus, it is clear the ARCS are limited by how the teacher introduces and uses the technology in the classroom.

Arguably the greatest limitation of ARCS is highlighted by Maroon (2007) in his exploration of the types of questions ARCS are useful for, and the answer students can provide. Student responses must be kept to a relative minimum when using ARCS such as “mint-whiteboards”. Due to the limited space and the necessity of the teacher being able to read the responses, students are unable to write anything longer than a few words. This is problematic in that the teacher can only effectively utilities ARCS in the classroom when forced-choice style questions (I. . True/false, multiple choice, etc. ) are used. This may require additional work for the teacher to come up with pre- planned multiple choice questions and answers. Thus, whilst primarily positive in outcomes, ARCS have practical limitations associated with space to write answers, time spent engaging in handing out of the resource, and the ability of the teacher to promote a classroom environment that stimulates a lively pace and allows students the confidence to surrender their responses. Randolph, 2007).

Response Cards in the Teaching of Federal Government The experiences of educational professionals using ARCS in the classroom have been hallucinated. In an Internet blob, Waxier (n. D. ) discusses his use of pre-printed response cards in the teaching and reviewing of the three branches of the federal government. Each student receives three cards, pre-printed with either Legislative, Judicial, or Executive. The teacher then asks questions regarding the powers held by each of these branches. Students are to listen to the question, and when signaled, hold up the appropriate card.

Waxier uses the example of “Which branch has the power to veto laws? “, noting that the correct student response is the Executive. If the majority of students are correct in holding up that particular ARC, the teacher repeats the correct answer, and moves on to the next question. However, if more than a third of the students are incorrect in their response, Waxier stresses the importance of revising how the initial material was taught, and planning following lessons to be more adaptive to the students’ learning.

This is a crucial component to the teaching process. Formative assessment is incredibly useful in highlighting to the teacher hat the students comprehend during the teaching of content, rather than testing understanding at the end of the unit, as is the case with summation assessment (Heard, 1994). This helps teachers like Waxier to identify when their teaching is successful, and when important changes need to be made. Washer’s (n. D. ) use of these pre-printed response cards coincides with many of the strengths of a ARC system.

In the blob, Waxier reports that all his students were more actively involved, rather than Just the more confident students, and this supports the results found by William in the Classroom Experiment. Further, Washer’s ARCS are a successful example of a low-cost and low-tech teaching resource in that they are simply laminated sheets of paper. Another strength of his method is the speed and ease of use. Waxier is able to ask assorted questions regarding the branches of the government, and students are able to all respond using the cards.

As the ARCS are pre-printed, student responses are quick and efficient, and could be easily read by Waxier, a necessary consideration when using ARCS (Heard, 1994). Furthermore, this use of ARCS allows the students to learn from each other, rather than having the coacher, alone inform them of their misconceptions (Randolph, 2007). Maroon (2007) stresses the importance of mild pressure in helping keep students engaged, and Washer’s use of ARCS optimists this, by ensuring that each student is made accountable for their response and thus, classroom participation. As with all pre- printed Arcs, Washer’s (n. D. Are limited by the small number of different learning trials they can be used for. In this example, Washer’s ARCS can only be used for questions specific to the features of the branches of the federal government, thus, additional cards would need to be created to test other topics. Alternatively, write-on Arcs, such as the “mint-whiteboards” featured in the Classroom Experiment, negate the need to create a wide variety of pre-printed responses, and would thus be an appropriate resource to use. As Heard (1994) argues, pre-printed Arcs, such as Washer’s, limit the array of material the teacher is able to assess.

In this example, students could still answer with the correct branch, however, other questions could be included in the quiz, I. E. “Name the two houses of parliament”, with correct students writing “Lower – House of Representatives and Upper – Senate”, or some variation thereof on their Arcs. Summary Arcs, whether pre-printed or write-on, are an effective low-tech, low-cost teaching resource, and have been well supported by empirical evidence and research. In implementing “mint-whiteboards” in the Classroom Experiment, William was able to find empirical support for his claims of the advantages of Arcs.

Students benefit from the formative assessment that ARCS allow, as shown through improved academic performance, increased student participation and generally positive reactions to ARC implementation in classrooms. Teachers report that ARCS generate more on-task, and reduce disruptive, behavior, and allow them to not only recognize and correct detent misconceptions during the teaching of the content, but also identify where modifications to their teaching style are necessary to stimulate greater classroom understanding.

As discussed, ARCS are an important development as they satisfy the stipulations outlined in the “Student Welfare, Good Discipline and Effective Learning Policy’. Whilst teachers and students report the cavalcade of strengths associated with Arcs, there are limitations. Teachers must have patience to allow students to become familiar with the resource, and develop the confidence to display their answers. Further, teachers need to ensure that they maintain a lively pace in the classroom, and use ARCS as a privilege, rather than a right. In this way, students are more likely to see the removal of the ARCS as a punishment for misbehaver.

ARCS are limited by the styles of questions they are appropriate in answering, and as such work best in tandem with other pedagogical strategies. As Washer’s (n. D. ) blob demonstrates, teachers are effectively utilizing ARCS in their classrooms to stimulate greater learning in their students, improved academic performance, and heightened student engagement.

Introduction

I propose to study the attitude, knowledge and experiences of nurses on prioritizing comfort measures in care of the dying patient in an acute hospital setting. I am particularly interested in this field as I worked in a hospice during semester break where palliative care of the dying concentrated on the quality of life of the patient. When the prognosis for the patient was imminent death, care was focused on reducing the severity of the disease symptoms rather than vainly trying to stop or delay development of the disease itself or provide a cure.

When the prognosis for a patient is imminent death, hospice care concentrates on the quality of life of the patient, reducing the severity of the disease symptoms rather than vainly trying to treat the disease itself. To assist in delivery of this type of quality end-of-life care to patients in acute hospitals the Alor Setar Hospital developed a Hospice Friendly Hospital programme (HFH). This HFH developed the Quality Standards for End-of-Life Care in Hospitals to set out a shared vision for the type of end-of life care that each hospital should aim to provide.

This development is significant as almost 50% of those who die in Kedah die in hospital and care of the dying in Alor Setar hospitals, while regarded as good, is described as ‘care at the end of life’ rather than ‘end-of-life care’ because the care seems to lack an effective palliative care component”

Literature Review

To investigate international perspectives on end-of-life care, the current international literature was reviewed using the key themes of identifying the dying phase, comfort care and symptom control for the dying patient.

It was conclude from the literature review that nurses and medical staff often differed in their approach to care of the dying patient and this hindered effective delivery of end-of-life-care. Education on end-of-life care was recommended in the literature as being a solution to the problems in delivering this care even though research had not been done on the status quo in education.

Research Problem

Before planning such specific education programmes, it would seem necessary to conduct research studies to establish the education and training levels of nurses and doctors in end-of-life care and to establish if attitudes and experience also influence the medical and nursing models in the delivery of this care. This research proposal is concerned with the nursing model and it proposes to establish what influences the nurse’s approach in delivering end-of-life care.

Methodology

A quantitative approach using a descriptive design is proposed for this study.

Questionnaires will be used as the data collection method with a simple random sample of 200 staff nurses employed in a Alor Setar hospital being selected as participants in the study.

Research Question

The research problem leads to the following research question: “What are the attitude, knowledge and experience of nurses on prioritizing comfort measures for dying patients in an acute hospital?

Objectives

• To establish the attitude of nurses on prioritizing comfort measures for dying patients.
• To establish if nurses’ knowledge of prioritizing comfort measures for dying patients is adequate.
• To establish if nurses’ experience in prioritizing comfort measures for dying patients is significant.

The methodology selected for the proposed study will be detailed here. The planned research design, methods of sample selection, data collection and analysis of results will be explained. Ethical considerations for this particular research study will also be detailed.

It is hoped that the chosen methodology will generate useful information through the collection and analysis of data on the attitude, knowledge and experiences of staff nurses on the effect of comfort measures in care of the dying patient in the acute hospital setting. Research Design The research design of a study outlines the basic approach that researchers use to answer their research question (Polit & Beck 2010). To meet the aims and objectives of the study it is important that the researcher selects the most appropriate design for achieving the aims of the study (Parahoo 2006).

The quantitative approach arises from the belief that human phenomena and variables in human behaviour can be studied objectively (Parahoo 2006) and so this approach has been chosen as an appropriate research method. Quantitative research uses a fixed design that organises in advance the research question and a detailed method of data collection and analysis (Robson 2007). It is proposed that this survey will collect details of the current attitude, knowledge and experience of nurses on comfort care of the dying patient.

The method of data collection chosen is a written questionnaire, allowing large sample size without major expense, to produce quantitative data that can be analysed by statistical computer programmes, Population/sample Parahoo (2006, p. 258) defines a population as “the total number of units from which data can potentially be collected”. The population in this study will be staff nurses working in the acute hospital setting in Ireland. This population will be delimited to a homogenous group of subjects through inclusion/exclusion criteria.

Proctor et al. (2010) maintain that the use of probability sampling in quantitative research reduces errors and biases in the study. Sampling is the process by which researchers select a proportion of the target population, as the study population, to represent the entire unit.

It is more practical and economical to work with samples rather than with large target populations (Polit & Beck 2010). The researcher will obtain the names of all eligible nurses from the Human Resources Department in the hospital. This list of nurses will form a sample frame from which the researcher will select nurses at random by assigning a number to each name and ‘picking the numbers out of a hat’. Data collection Quantitative data are collected to classify and describe attributes, behaviours and activities of populations according to Parahoo (2006).

Data collection should be objective, systematic and repeatable (Lacey 2010). Robson (2007) maintains that a researcher should use the simplest manner of collecting the data to get answers to the research question and should not collect any more data than necessary. Mindful of these conditions the data collection instrument selected for this study is a questionnaire. Questionnaires A questionnaire is a method of data collection that asks participants to give written or verbal replies to a written set of questions (Parahoo 2006).

It is a quick,convenient and inexpensive method of collecting standardised information . A questionnaire can be used to collect information on attitudes,knowledge and experience of staff (Parahoo 2006). A structured writtenquestionnaire that uses a quantitative self-report technique, as outlined by Polit & Beck (2010), will be used to collect data in this study. The questionnaire will have three parts (see Appendix ). Part A of the questionnaire will use a Likert-type scale to gather data on the attitudes of nurseson the effect of comfort in care of the dying.

The questionnaire will consist of positively and negatively worded statements with six different response options ranging from strongly disagree to strongly agree. Positive statements are scored one to six (one for strongly agree through to six for strongly disagree) and scores are reversed for negative statements. The score for each item will be reported individually. Parts B and C will use a fill the box format and will gather data on the knowledge and experience of nurses on comfort care of the dying respectively.

Ethical Consideration

According to Polit and Beck (2010), researchers must deal with ethical issues when their intended research involves human beings. Ethical approval will be requested in writing from the Director of Nursing (as gatekeeper) and the Hospital Ethics Committee of the hospital involved in the research . As gatekeeper, the director of Nursing must be made aware of all nursing research taking place in the organisation to monitor the effect of all such projects taking place. She will also need to be convinced of the value of the research and the competency of the researcher (Lee 2005).

The main ethical principles that will be considered in conducting this research study are respect for persons, confidentiality and beneficence /non-maleficence. 3. 0 PROPOSED OUTCOME Following this proposed study, a report will be compiled discussing all aspects of the research process including the results, limitations and benefits. It is anticipated that the results of the study will give an indication of nurses’ attitude, knowledge and experience in the domain of comfort care of the dying in Ireland and indicate where interventions are needed through education, training or management.

It is also anticipated that the findings of the research study will reveal if other factors such as attitude or experience impact on the effective delivery of care of the dying patient. It is anticipated that these results will contribute to recommendations in future nursing practice, nurse education and research and that this will in turn move palliative care higher up on the agenda of the nursing profession in general. This study will have limitations as it will be conducted in only one acute hospital. It will give a general overview of the current attitude, knowledge and experience of nurses in this hospital.

The researcher recommends that other studies, both quantitative and qualitative be carried out in hospitals in other Irish cities so that a more general picture could be established of end-of-life nursing care in acute hospitals in Ireland. Qualitative research is explanatory and descriptive in nature and so it could help in determining the nature of the phenomena being studied (Barroso, 2010) and consequently give a more complete picture of care of the dying. It is the intention of the researcher to share the findings of the study with management of the partaking hospital and the schools of nursing and midwifery in Ireland.

It is hoped that this will highlight the necessity of planning on-going education and training for nurses in end-of-life care. To present the research report to a broader audience the researcher intends applying for publication of the study report in relevant nursing journals. Time Scale A clear and practical time scale is necessary to facilitate the organisation and coordination of each stage of the research process and the successful integration of the stages (Cormack, 1991).

Periodic Performance Review A Periodic Performance Review is a compliance evaluation instrument used to assist organizations with their ongoing observation of performance and routine development actions. The PPR is an outlines for constant standards compliance and concentrations on the direction and processes that affect patient safety and care. Noncompliant Trends The Joint Commission medical staff standards defines evaluation standards, the commission pushes hospitals toward unbiased and evidence-based decisions in credentialing and privileging.

In this scenario the rules and policies are clearly mapped out, yet they are not being properly followed. The verbal order audit results seem to have no consistency. These standards now outdate a lot of hospital policies and practices prevailing equally internal and external peer review, and call for a comprehensive revision to comply with Joint Commission performance evaluations. The month of March is the highest, while August is the lowest month. The months in between were about the same from eighty-two to eighty-eight. The issue that needs to be address is what took place between March and August.

After carefully looking over the charts provided for both 3 & 4-east, there isn’t a huge indicator that supports the similarity for falls vs. nursing care hours per patient. November and April were the only two months that a noticeable improvement was made, meaning the nursing hours increased and the falls decreased. Although, the very next month the falls increased drastically, it went from two to eleven falls, while only one hour was increased. Staffing Patterns The safety and quality of patient care is honestly correlated to the size and experience of the staff.

These working conditions have deteriorated in this facility because the hospitals have not kept up with the growing demand for medical staff. The Joint Commission along with some state regulations measures some bare minimum level of staffing that all hospitals must meet regardless of the types and severity of patients. Pressure ulcer prevalence vs. nursing care hours was more of a parallel comparison, as the staffing hours increased the pressure ulcer prevalence decreased. While the intensive care unit was very noticeable in relating the falls vs. ours. In September when the nursing hours per patients dropped it was evident that the number of patient falls increased and they came was with VAP vs. hours. The corrective action plan should take this data into consideration to improve the staffing model, to also decrease patient falls which was be shown through this root cause analysis. The hospital requires at least one fire drill per shift per quarter. It seems that only the 1st shift is in compliance. Both the 2nd and 3rd shift have no rhyme or rhythm to how they are conducting the fire drills.

This needs to be address immediately by a member of management. Also, a manager or assistant should be required for scheduling the fire drill and must sign off on completion. Moderate Sedation Monthly Audit is overall in the ninety percentile there are still many areas for improvement. Any of the area that was below the ninety marks is an area for opportunity. Such as Mallampati Classification, ASA, Sedation Plan. Reassessment, and oxygen saturation monitored for thirty minutes, all of these area were below ninety percent for all for quarters.

Therefore, it’s a trend that needs to be addressed. The number of falls in the 4-East wings is disturbing when it’s put next to the targeted number, this is unacceptable. A substitute process that has the possibility to improve staffing issues and improve payment to hospitals would be to frankly connect the costs and billing for inpatient health care with hospital reimbursement. The action plan needs to provide that appropriate equilibrium and to make sure that the correct nurse is providing the right care to every one of the patients.

Staffing Plan There are two sides to the staffing issues. One side would be the nurses point to confirmation linking quality patient care to higher nurse-to-patient staffing ratios. While the other side would be hospital economic teams are being asked to discover ways to improve manage costs in expectation of declining expenditure under health development. The argument is not new. Nursing and financial management have had long debates on how to staff efficiently and make certain the right number/mix of nurses to meet patient needs.

An action plan needs to be put into place and monitored extremely closely by a member of management. There is no reason why they actually and targeted number are so off track. A patient care assistant should be there to assist patients with movements, especially for those patients who have a history of falls or injuries. Reviewing the overall hospital falls and injuries I noticed that it’s closer to the targeted number, but there are still many areas for development. The suggestion is that hospital must address conflict of interest when credentialing, privileging and conducting peer reviews of physicians. |

Explain the various patterns of knowing as they influence theory construction or development in nursing: In 1978, Barbara Carper identified four types of knowing in nursing. The first type is called empiric knowing and represents knowledge that is verifiable, objective, factual, and research based. The second type called ethical knowing provides us with knowledge that is about what is right and wrong and what are good and bad, desirable and undesirable. The third type of knowing is labelled aesthetic knowing.

It gives us the knowledge that focuses on the art of nursing – tacit knowledge, skill and intuition. Also, there is personal knowing and this represents knowledge that focuses on self-consciousness, personal awareness and empathy. Chinn & Kramer (2008) mention an additional pattern of knowing labelled emancipatory knowing The fundamental reason for developing knowledge in nursing is for the purpose of creating expert and effective nursing practice. It is through inquiry processes for each pattern that knowledge is formulated for the discipline.

The main concept of knowledge is that all patterns of knowing form an integrated whole, and the whole of knowing is essential as a basis for best practices in nursing. Chinn & Kramer(2008) states failure to develop knowledge integrated within all of the patterns of knowing leads to uncritical acceptance, narrow interpretation, and partial utilization of knowledge which is called “the patterns gone wild”(p. 20). Chinn & Kramer (2008) also states that a shift to a balance in knowledge development to reflect each of the patterns of knowing in nursing holds potential to bring the realm of knowledge development and the realm of practice together.

Bringing together “knowing” and “doing” is praxis-the synchronous, thoughtful reflection and action to create a desired future of emancipatory change. Images of a desired future are not confined to any one pattern but rather are reflected in all knowing patterns (p. 22). If we as a discipline fail to integrate all patterns of knowing to further develop nursing theories and knowledge, the gap between knowledge and practice will never lessen. References: Chinn, P. L. & Kramer, M. K. (2008). Integrated Theory and Knowledge Development in Nursing (7th ed. ) St. Louis, MO: Mosby Elsevier

Pain is a complex phenomenon whose understanding is subjective and relative to each individual. It is difficult to explain and measure; however, healthcare specialists believe that it is whatever the patient describes it to be. The concept of pain management is often inadequately defined. A concept analysis of pain therefore would assist healthcare professionals to have a better understanding of pain management and how it impacts on patients.

Lack of universal definition of pain management is an obstacle to its growth in practice. Pain management understanding is fundamental nursing knowledge requiring a proactive approach. This presents challenges to nurses as they spend most of their time with patients and therefore must have a clear understanding of pain management. Efficient healthcare professionals acts as advocates for patients and must ensure that their pain is managed properly (Larsen, 2007).

The purpose of this concept analysis is to clarify the defining attributes of pain management in practice with a view to encourage communication and the development of skills and tools to estimate and asses pain management quality. Concept analysis helps in clarifying the ambiguities of concepts common in nursing so that a widely accepted definition is arrived at (Walker and Avant, 2005). Background Pain management depends on the causes of the pain. Depending on the causes managing it can either be a simple or a complex process.

Simple cases of pain could be alleviated by performing simple therapy. However, at times the pain does not disappear and therefore pain management calls for a range of techniques in order to treat pain. These techniques might include medical and intervention procedures as well as conducting psychological counseling. Pain management is guided by different aspects of pain. These aspects includes past history of pain, the intensity of pain, its duration and the structure responsible for the pain.

A potential pain causing structure has a nerve center which must be susceptible to any injury and stimulation. Pain management therefore involves identifying the sources of the pain and isolating them for optimal treatment to be achieved Thompson (2008). Isolating questions of the concept Because of lack of a clear definition of pain in the available literature, several questions are asked. These questions include: (1) what are the characteristics and nature of pain? (2) What are the symptoms of pain?

(3) Does pain differ from discomfort and suffering? (4) Can pain be treated? Separating these questions under categories of the concept, fact and value provides a framework upon which these questions can be addressed in the context of fact and value. The first and third questions are therefore categorized as concept questions while the second and the third questions are grouped under fact. Finally, the last question is a question of value as it requires both the definition of pain and decisions based on these values Thompson (2008).

General Overview and Analysis of Data

The Mercy Hospital in its present condition looks good because of its innovative management approach which is highly regarded in the industry. The hospital has 300 beds and just recently, it undertook an advertising program “highlighting the quality of its professional staff and extolling the virtues of patient-care program (Rakich, Longest, & Darr, par. 1). The hospital’s affiliation with the medical school of the local university provided Mercy with medical resources as well as training site and some cost advantages as part of the salaries of the physician involve in teaching are shouldered by the medical school. Outwardly, the Mercy hospital has strategic advantage in view of the benefits of their partnership with medical school.

 However, closer analysis of internal condition reveals that the hospital management is laden with problems that led to the resignation of the current Vice President for nursing. The problem lies in the administrative level involving the vice president for nursing Helene Swanson, associate vice president Michael Ryan, and the vice president for dietary and house keeping.

 What is the situation at hand? The Situation at hand at the Mercy hospital is much worse given the impact of the problem stated above, among the personnel. There was conflict between physicians and nurses causing mutual hostility and mistrust among them and everything in the nursing department is problematic. There are no clearly defined duties and responsibilities among administrative level management, and there is no professional discipline among the health care professionals. The hospital is also facing acute shortage of competent nurses and lacks educational activities that will introduce innovations in nursing practice.

What are the environmental factors influencing the overview? The environmental factor influencing the overview could be the hospital’s innovative management approach because they are highly regarded for this in the industry. It gives an impression that Mercy hospital is in better shape. Aside from this however, nothing more could be consider as environmental factor influencing the hospital’s overview.

Is there a need for a competitive or SWOT analysis for the organization? If so, illustrate. There is certainly a need for the Mercy hospital for SWOT analysis in order for them to determine their strength and weaknesses. Looking from data, it appears that the problem of Mercy hospital has to do with miscommunication and misconception of the duties and responsibilities, which seemed to suggest the top management, have nothing to do with it. In the principle of accountability however, the top management have greater accountability for the failures or success. Thus, top management cannot be detached from the problem. SWOT analysis could help determine where the problem really is and it could help enhanced the management strength, and work on to improved the weaknesses. According to an internet article, SWOT analysis is divided between internal and external analysis. Internal analysis is a wide-ranging evaluation of the internal environment’s possible strengths and weaknesses while external analysis are the threats brought by changes and new opportunities that arises (Strategic Management).

What types of strategies can we look at (for example, vertical integration) for the organization as a whole? I would suggest that Mercy hospital should use intensive strategies because of potential benefits it can contribute to growth and improvement of the hospital. This grand strategy fits the situation of the Mercy hospital in view of its defined purpose. Goldman and Niewenhuizen (2006) stated,

“Intensive strategies are used to improve small business’s competitive position with regard to existing products and attempts to improve sales or profitability by getting more out of resources currently available within the small business. These strategies allow a small business to develop heightened expertise in its products and services by specialization” (Goldman & Nieuwenhuizen, p. 82)

Financial Analysis

It was not really clear whether the Mercy hospital is a charitable institution or a semi government hospital, nevertheless, it appears that there is no integration of indigent care and paying patient’s care. Indeed this one of the problems faced by Swenson as vice president for nursing. She points out “certainly tea and a piece of toast couldn’t hurt anyone who is not going to be anesthesized shortly. And it would be a way of saying to patients that they were being cared for and welcomed” (Rakich, Longest, & Darr, p. 342) in reference to the in hospitable dietary treatment to patients by the hospital.

Are there ways to demonstrate cost reduction and/or revenue enhancement? Given the present situation, there seems to be no way the hospital can have justifiable cost reduction except in the salaries of personnel who also work part time at the medical school. Revenue enhancement could be perhaps next to impossibility, unless the hospital effectively address all the problems and implement strategies that would poster growth and development. The strategies suggested could greatly help in this aspect.

What is the financial integrity of the health care organization? The financial integrity of the hospital is in bad light not because it is on brink of bankruptcy but because it is not well managed. The hospital should also practice the reward system in order to boast the morale of its personnel by acknowledging their hard efforts with financial rewards through salary adjustment. This is one way of saying “keep up the good works” and it could effectively encourage employees to give their best. However, this not done and there seems to have no plans to do it but spend much on expensive but doubtful undertakings thereby reflecting a bad financial integrity of the hospital.

References

1. Goldman, G. & Nieuwenhuizen, C. (2006) Strategy: Sustaining Competitive Advantage in a Global Context South Africa: Juta and Company Ltd
2. Rakich, J.S., Longest, B. B. & Darr, K. Cases in Health Services Management (Fourth Edition)
3. “SWOT Analysis” Strategic Management NetMBA.com 2002-2007 http://www.netmba.com/strategy/swot/

The nursing role is rapidly evolving as nurses are tasked with an even wider range of health care responsibilities. In hospitals, clinics, and care centers around the US, nurses are rising to meet these challenges. Today’s nurses are not just caring for the sick; they are changing our very notion of modern medicine and health care delivery. A nurse’s role is about being a more effective member of the health care team and navigating clinical systems. No matter the work environment, all nurses are members of the profession which implies accountability for one’s professional image (Essentials of

Baccalaureate Education, 2008, p. 9). In my career as a nurse, my role has changed many times and began as a provider of direct patient care. My first job after graduation I worked as a bedside nurse on an Orthopedic and Rehabilitation floor in the hospital setting. As rehabilitation staff nurse, provided direct care and education on self-care including safe medication administration, sleep, nutrition, safety, bowel and bladder care. I helped perform activities that served to maintain and restore function and prevent complications.

I feel lucky to have had this opportunity as my first nursing role because of the team-based care coordination and the value based on each member of the interdisciplinary team. As I transitioned from a novice nurse to a more competent nurse, I gained perspective from planning my own actions based on critical thinking and organization. It was during this time that began to think of long-term goals pertaining to my nursing career. After two years, I was approached to train to cover the Care Coordinator role for the department of Orthopedic during her times of vacation and medical eave.

This quickly turned into a full time position for me and took me away from direct bedside nursing. My main responsibilities were to assist the patient with transitions between healthcare settings, identify skills and expectations of patients and families in regard to the rehabilitation process and help ensure the patient and his or her family understood their healthcare benefits. Enjoyed learning all the aspects of coordinating patient care for this population. Five years passed and accepted the Manager position of the Orthopedic Institute.

It served me well to rely on the team based environment when I began honing my skills as a leader. I quickly learned to supervise and delegate to staff, manage a million dollar budget and remain visible and open to staff. Served my clinical area by developing, implementing and evaluating systems that ensure cost effective, quality patient care. There were times as a manager that my priorities were to maintain multiple projects in alignment with our vision. Communication was always a must for an effective relationship with staff and providers.

As a ember of the profession of nursing I have been able to take part in many activities. Have joined professional organizations. I have enjoyed participating in research for our Orthopedic population. Have participated in community events. It is very rewarding to be able to serve the community in which you live. Throughout my career, as a direct care provider and currently a manager of a patient care center, I have always insisted that patients and families come first and my primary goal is to provide safe quality care.

A professional nurse must have the ability to think critically, mufti-task ND prioritize appropriately. I am truly honored to have chosen a profession that has allowed me the opportunity to grow and become the successful leader I am today. Am fully committed to furthering my education and focusing on the next chapter in my career. Nursing has become more complex in ways that could not have been imagined a generation ago. Now there is an imperative to be not just a great caregiver but a great innovator too. The demands of health care are calling for a new generation of thinkers who want to be agents of care innovation.

Nursing is a profession for the intellectually curious, lifelong learner. However, as nursing continues to evolve with new hospital structures, wonderful technology, and political challenges, the heart of the profession stays the same. Whatever the tools and technologies, the job of the nurse will remain caregiver and advocate for the most sick and vulnerable members of our communities. The field is growing and so are opportunities for nurse practitioners, DNA and PhD nurses, nurse educators, nurse-anesthetists, and nurse researchers.

Great nurses take what they learn in their formal education and apply it to make surprising, difficult, life-or-death decisions every day. Feel that is why nursing education has such a crucial role to play. Getting an advanced nursing degree means preparing myself for a changing world of possibility. With the right skills and knowledge, the next generation of nurses can make a bigger difference for patients, communities, and our national health care environment. I am glad to be part of such a rewarding profession.