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Analysis of Nurse Staffing and Patient Outcomes Using Comprehensive Nurse Staffing Characteristics in Acute Care Nursing Units

Sung-Heui Bae, PhD, MPH, RN; Maureen Kelly, MS, RN; Carol S. Brewer, PhD, RN, FAAN; Alexandra Spencer, MSN, RN

Associations between comprehensive nurse staffing characteristics and patient falls and pressure ulcers were examined using negative binomial regression modeling with hospital- and time-fixed effects. A convenience sample was collected from 35 nursing units in 3 hospitals. Rates of patient falls and injury falls were found to be greater with higher temporary registered nurse staffing levels but decreased with greater levels of licensed practical nursing care hours per patient day. Pressure ulcers were not related to any staffing characteristics. Key words: nurse staffing, patient falls, pressure ulcers, temporary nursing staff, turnover

IT has been predicted that in the UnitedStates, 300 000 to 1 million new regis- tered nurses (RNs) will be needed in 2020.1

Although the current economic recession has seen an increase in RN employment and some

Author Affiliations: School of Nursing, University of Texas at Austin (Dr Bae); Roswell Park Cancer Institute, Buffalo, New York (Ms Kelly); School of Nursing, University at Buffalo, New York (Dr Brewer); and Catholic Health System, Cheektowaga, New York (Ms Spencer).

The John R. Oishei Foundation provided funding for this research.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

The authors declare no conflict of interest.

Correspondence: Sung-Heui Bae, PhD, MPH, RN, Assis- tant Professor, School of Nursing, University of Texas at Austin, 1710 Red River Street, Austin, TX 78701 (sbae@nursing.utexas.edu).

Accepted for Publication: January 20, 2014

Published ahead of print: February 6, 2014

DOI: 10.1097/NCQ.0000000000000057

easing of the nursing shortage, researchers still project renewed post-recession demand and large shortages for the future.2 These shortages are expected to have severe effects on the quality of patient care. Nursing short- ages often lead to suboptimal staffing char- acteristics such as low staffing levels, high turnover, high use of temporary (agency) staff, low RN professional staff mix, and greater use of nurse overtime.3-5 Previous studies have shown that nurse staffing levels and RN skill mix are related to lower quality of patient care.6-9 However, limited empirical research has been conducted to examine the impact of nurse turnover and the use of tem- porary nursing staff on quality of care in com- bination with staffing levels and RN skill mix in acute care hospital settings. Therefore, the purpose of this study was to examine the rela- tionship of nurse staffing to quality of patient care outcomes, by including not only nursing turnover and temporary nursing staff but also nurse staffing levels and RN skill mix.

A major consequence of turnover is the loss and disruption of organizational processes,

318http://www.jncqjournal.com mailto:sbae@nursing.utexas.edu

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Analysis of Nurse Staffing and Patient Outcomes 319

which can be detrimental to both the effec- tiveness and productivity of care delivery.10,11

High turnover creates an unstable workforce and has a negative impact on workgroup dy- namics. As turnover increases, the remain- ing staff must constantly adjust to new staff; turnover can then affect the interactions and integration within the workgroup,12 resulting in poor workgroup cohesiveness, demoraliza- tion, communication breakdowns, and frag- mented coordination.12-14 Researchers have found that high levels of staff turnover were associated with poor quality of care.15-18

Conversely, however, other researchers have suggested that some turnover might be ben- eficial, improving the quality of patient out- comes as new people and ideas enter the workgroup and keeping the organization from becoming stagnant.19 Employee mobil- ity is also important for innovation because it enables organizations to become more flexi- ble and adaptable to change.20 Innovation can enable a workgroup to learn from errors.15,21

Research findings about the use of tempo- rary staff are also mixed. The main reasons for employing temporary nursing staff include staff absences, recruitment, retention, and vacancies.22 Hiring temporary nursing staff can help to increase staffing levels; however, it can also affect other staff as well as facility operations, thus leading to poorer patient care.23,24 Higher use of temporary staff can increase administrative burdens, disrupt rou- tines and teamwork, and require additional supervision by permanent staff.23 It may also interfere with continuity of care. The use of temporary nurses has been related, for exam- ple, to the spread of nosocomial infections among patients,25 needlestick injuries among temporary nurses,26 and medication errors.27

However, Aiken and colleagues have argued that using temporary nurses may not hinder quality of care because current working schedules do not permit continuity of care (ie, prevalent use of 12-hour shifts for 3 days per week) and found that temporary nursing staff were not less qualified than permanent staff.28,29 Using temporary nursing staff was not related to the quality of patient care, but

other work environment characteristics were related to that.29,30

As stated earlier, there is strong, though mixed, evidence regarding the impact of nurs- ing turnover and the use of temporary nursing staff on the quality of patient care, and there is evidence regarding staffing levels and RN skill mix. However, previous studies on nurse staffing and quality of care have not consid- ered nursing turnover and temporary nurse staffing characteristics together with nurse staffing levels and professional skill mix in acute care hospital settings.

METHODS

Design and sample

The data used in the study were col- lected by the Western New York Center for Workforce and Quality. These data consist of nursing-sensitive quality indicators and nurse staffing data obtained in 75 nursing units at 6 hospitals. Among those 6 hospitals, only 3 hospitals provided data for all variables re- quired for this study. As a result, we only used the subset of 3 hospitals’ data. The subset of the data was collected retrospectively from October 2010 to March 2012 in 35 nursing units at the 3 hospitals.

Data for 4 nurse-staffing characteristics (nurse staffing, skill mix, nursing turnover, and temporary nursing staff) and for 1 pa- tient outcome (patient falls) were collected monthly. Injury falls were collected monthly. However, incidents of injury falls were rare with small variation in monthly data, so we aggregated monthly data of injury falls into quarterly data, which were used for the cur- rent study. For total pressure ulcers and unit- acquired ulcers, only quarterly data were available for the analysis. Thus, quarterly data for these 2 patient outcomes (patient falls with injuries; pressure ulcers, including both total pressure ulcers and unit-acquired pres- sure ulcers) were used (see Supplemental Digital Content, Table, available at http:// links.lww.com/JNCQ/A73). A total of 511 unit-month data points and 171 unit-quarter

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data points were used for the analytic sample. This study was approved by the institutional review boards of the authors’ universities and the 3 participating hospitals.

Measures

Patient outcome variables

Nursing unit patient falls, patient falls with injuries, and pressure ulcers (both total pres- sure ulcers and unit-acquired pressure ulcers) were used as measures of patient out- comes. These patient outcomes are recog- nized nursing-sensitive quality indicators.31,32

For this study, the operational definitions of each patient outcome variable are the same as those used for the National Database of Nurs- ing Quality Indicators.33 Monthly patient falls and quarterly patient falls with injuries were defined as the number of incident adjusted per 1000 patient days. Quarterly pressure ul- cers (total pressure ulcers and unit-acquired pressure ulcers) were defined as prevalence rates. The Supplemental Digital Content Table (available at http://links.lww.com/JNCQ/ A73) presents definitions for each patient out- come variable.

Nurse staffing variables

To capture the effects of different types of nurse staffing, we used nursing hours per patient day for RNs, licensed practical nurses (LPNs), and unlicensed assistive per- sonnel (UAP). Skill mix indicated the propor- tion of RNs to LPNs and UAPs. For nursing turnover and temporary nursing staff, we used RN turnover rate and temporary RN care hours per patient day, because RNs make up the majority of nursing staff and provide the most critical components of nursing care. After assessing the distribution of RN tempo- rary nursing care hours, we categorized RN temporary nursing care hours into 3 groups by using zero and 0.3 care hour as cutoff points (low, moderate, and high). There are 2 reasons for that. First, more than 60% of the sample had zero care hours, so we cre- ated this as a group (low levels). Second, among those units using temporary nursing staff, we created 2 other groups to distinguish

those units with higher levels of the use of temporary RNs (≥0.3 care hour) from those units with moderate levels (>0 and <0.3 care hour). Detailed information of definitions of the nurse staffing variables is presented in Sup- plemental Digital Content Table (available at http://links.lww.com/JNCQ/A73).

Unit covariates

To control for other nursing unit character- istics that might affect both nurse staffing and patient outcomes, several nursing unit charac- teristics were included as covariates: unit size, unit type (critical care units, step down units, medical/surgical units, and other units), and quality improvement initiatives (transforming care at the bedside units and dedicated ed- ucation units). In addition, statistical meth- ods such as hospital- and time-fixed effects were used to control for other potentially con- founding factors.

Analytic model and data analysis

To isolate the effect of nurse staffing on pa- tient falls, we used a negative binomial model to investigate whether comprehensive nurse staffing characteristics affected the likelihood of patient falls. The following equation (1) presents the details as

Yuhym = F (Nurse Staffinguhym, Unit Covariatesuhym, Hh, Yeary,

Monthm, εuhym),

where the subscripts u, h, y, and m represent nursing unit, hospital, year, and month. Y rep- resents monthly patient falls. After assessing the distribution of monthly patient falls, we used a count model. So, F(·) represents a neg- ative binomial distribution function.

Nurse staffing characteristics included the key predictor variables: RN, LPN, and UAP care hours per patient day; skill mix; RN turnover; and temporary RN care hours per patient day. With the exception of temporary RN care hours per patient day, all other nurse staffing variables were continuous. For tempo- rary RN care hours per patient day, 2 dummy variables (moderate, high) were created; units

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Analysis of Nurse Staffing and Patient Outcomes 321

without any temporary RN use (low) served as a reference group. Unit covariates were those mentioned earlier. Hospital-fixed ef- fects (H) were also included to eliminate bias from unobserved hospital-level confounding factors that do not change over time, such as general hospital characteristics. We also in- cluded 2 time-fixed effects, year and month, and thereby controlled for fixed time effects that do not vary across units, such as the pro- motion of nationwide awareness of quality of care that are not observed empirically.

Similarly, to isolate the effect of comprehen- sive nurse staffing characteristics on quarterly falls with injuries, total pressure ulcers, and unit-acquired pressure ulcers, the same model in the equation (1) was estimated for quarterly falls with injuries, quarterly total pressure ul- cers, and quarterly unit-acquired pressure ul- cers. On the basis of assessment of the dis- tribution of these patient outcome variables, for injury falls and unit-acquired pressure ul- cers, Y represents binary outcomes, and F(·) thus represents a cumulative logit distribu- tion function. For the total pressure ulcers, F(·) represents a negative binomial distribu- tion function. To make correct statistical in- ferences, standard errors were adjusted for unit clustering.

To summarize, we used 2 analytic models (negative binomial and logit models) depend- ing on the distribution of the outcome vari- ables. Using these analytic models, we can estimate the relationship between compre- hensive nurse staffing characteristics and the likelihood of patient outcomes. In addition to controlling for unit characteristics using unit covariates, we also controlled for unobserved hospital characteristics and the time trend, which might affect patient outcomes by the analytic methods to reduce omitted-variable bias and to draw rigorous study findings. All the analyses were performed in STATA, ver- sion 10.0 (Stata Corp, College Station, Texas).

RESULTS

The Supplemental Digital Content Table (available at http://links.lww.com/JNCQ/

A73) presents descriptive statistics for the study variables. The average monthly staffing levels were 8.23, 0.42, and 1.41 care hours per patient day for RNs, LPNs, and UAPs, re- spectively. The average quarterly staffing lev- els were similar. In the case of LPN care hours per patient day, we found that about 45% of the sample units used zero LPN care hours. The average professional staff mix (ie, RNs/ [RNs + LPNs + UAPs] × 100) both monthly and quarterly was around 79.50%. The RN monthly turnover rate was 1.82%, whereas the RN quarterly turnover rate was 5.00%. Av- erage temporary RN care hours per patient day were 0.08 both monthly and quarterly. About 74% of nursing units did not use tem- porary RN staff in any month. The other 17% used more than zero and less than 0.3 care hour per patient day provided by temporary RN staff. Temporary RN staff provided equal to or greater than 0.3 care hour per patient day in another 9% of nursing units. When calcu- lated per quarter, 64% of nursing units did not use any temporary RN staff, 26% used more than zero and less than 0.3 care hour per pa- tient day, and 10% used equal to or greater than 0.3 care hour per patient day.

Table 1 presents the associations between (1) monthly patient falls and quarterly falls with injuries and (2) comprehensive nurse staffing characteristics. The first panel of Table 1 presents the impact of comprehen- sive nurse staffing characteristics on monthly patient falls. Two staffing characteristics were significantly related to the occurrence of pa- tient falls. With all other variables held con- stant, an hour increase in LPN care hours per patient day led to a decrease in patient falls by a factor of 0.540. In other words, when all other conditions are same, an increase of LPN care hours was related to a decrease in patient falls. Compared with nursing units without any temporary RN staff, units that used tem- porary RN staff to provide equal to or more than 0.3 care hour per patient day had a rate 1.552 times greater for patient falls, which means that nursing units using the higher lev- els of care hours of temporary RNs experi- enced greater occurrence of patient falls.

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Table 1. Associations of Patient Falls and Injury Falls With Nurse Staffing Characteristics

Monthly Patient Falls Quarterly Injury Falls

Negative Binomial Regression

Logit Regression

Nurse Staffing Characteristics IRR (SE) OR (SE)

Staffing levels RN nursing hours per patient day 1.060 (0.079) 1.330 (0.322) LPN nursing hours per patient day 0.540 (0.150)a 0.058 (0.115) UAP nursing hours per patient day 0.720 (0.156) 0.178 (0.200)

Professional staff mix Skill mix 0.956 (0.023) 0.820 (0.118)

Turnover RN turnover rate 1.015 (0.008) 0.996 (0.034)

Temporary nursing staff RN contract nursing care hours per

patient day No RN contract care hours

(reference group) 0 < RN contract care hours < 0.3 1.099 (0.162) 4.169 (2.684)a

RN contract care hours ≥ 0.3 1.552 (0.260)b 4.679 (4.907) N 470 158

Abbreviations: IRR, incident rate ratio; LPN, licensed practical nurse; OR, odds ratio; RN, registered nurse; UAP, unlicensed assistive personnel. All models controlled for unit size, unit type, dedicated education units and transforming care at the bedside units status and included hospital fixed-effects and time (year and either month or quarter) fixed-effects. Standard errors (SE) are reported in parentheses, and are adjusted for clustering at the nursing unit level. aP < .05. bP < .01.

The second panel in Table 1 presents the impact of the comprehensive nurse staffing characteristics on quarterly falls with injuries. Only temporary RN staff use was significantly related to the occurrence of falls with injuries. Compared with nursing units without any use of temporary RN staff, units that used greater than zero but less than 0.3 care hour per pa- tient day provided by temporary RN staff had a rate 4.169 times greater for injury-related falls. Table 2 presents the associations between (1) comprehensive nurse staffing character- istics and (2) quarterly pressure ulcers and quarterly unit-acquired pressure ulcers. None of the staffing characteristics were signifi- cantly related to the occurrences of pressure ulcers.

DISCUSSION

In this study, with all other conditions held constant, greater use of LPNs was related to a decrease in patient falls, and increased use of temporary RN staff was related to in- creased patient falls and falls with injuries. Given the Centers for Medicare and Medicaid Services’ decision not to reimburse for cer- tain preventable adverse outcomes such as patient falls,34 the present findings provide valuable evidence regarding the linkages be- tween nurse staffing and patient outcomes. Using comprehensive characteristics of nurse staffing and a longitudinal methodology pro- vide a more definitive test of the relation- ships between staffing and outcomes than that

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Table 2. Associations of Pressure Ulcer and Unit-Acquired Pressure Ulcer With Nurse Staffing Characteristics

Quarterly Pressure Ulcer

Quarterly Unit Acquired Pressure

Ulcer

Negative Binomial Regression

Logit Regression

Nurse Staffing Characteristics IRR (SE) OR (SE)

Staffing levels RN nursing hours per patient day 0.946 (0.090) 0.837 (0.127) LPN nursing hours per patient day 1.287 (0.608) 1.900 (1.290) UAP nursing hours per patient day 0.792 (0.244) 0.665 (0.392)

Professional staff mix Skill mix 1.016 (0.036) 1.003 (0.047)

Turnover RN turnover rate 0.998 (0.011) 1.038 (0.028)

Temporary nursing staff RN contract nursing care hours per

patient day No RN contract care hours

(reference group) 0 < RN contract care hours <0.3 0.847 (0.126) 0.564 (0.286) RN contract care hours ≥0.3 0.928 (0.304) 0.623 (0.378)

N 161 160

Abbreviations: IRR, incident rate ratio; LPN, licensed practical nurse; OR, odds ratio; RN, registered nurse; UAP, unlicensed assistive personnel. All models controlled for unit size, unit type, dedicated education units and transforming care at the bedside units status and included hospital fixed-effects and time (year and quarter) fixed effects. Standard errors (SE) are reported in parentheses, and are adjusted for clustering at the nursing unit level.

offered by earlier studies and may account for the robust associations identified between the comprehensive staffing characteristics and pa- tient quality indicators found here.

The US Department of Health and Human services found a strong association between nurse staffing levels and quality of patient care by using data from more than 4000 hospitals.35 Those nursing-sensitive outcomes included urinary tract infections, pressure ul- cers, hospital-acquired pneumonia, and deep vein thrombosis. The present findings add to the evidence of this relationship between nurse staffing and quality of patient care.

Our most important finding is that in- creased levels of temporary RN staffing re-

sulted in greater patient falls—both non– injury-related and injury-related falls. This is consistent with findings of previous studies,23,36 and it suggests that the use of temporary RN staff may be detrimental to the quality of patient care. Given the present study’s limitations, one should be cautious in interpreting its results. As mentioned earlier, 74% of unit-month data points and 64% of unit-quarter data points were zero temporary RN care hours per patient day. About 9% to 10% of sample reported equal to or greater than 0.3 temporary RN hours. That means in this study sample, relatively fewer nursing units used temporary RN staff. Although we found the statistically significant findings of

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relationships between use of temporary RN staff and patient falls, this may not have enough power to have clinical significance given small variations of temporary RN staffing variables with the study sample. How- ever, using the small sample, we found sta- tistically significant findings so that the re- lationship between temporary RN staff and patient falls may also be seen in a larger sample. Future research needs to investigate the levels of temporary RN staffing, which might be harmful to patient falls, with larger samples.

Another concern in interpreting the results is related to variables not accounted for in this study that might also affect the quality of patient care. Aiken and colleagues,29 after accounting for nurse staffing, RN education, and work environment, found that the asso- ciation between temporary RN staffing levels and quality of patient care was not significant. It is possible that unfavorable work environ- ments for nurses can lead to both increased use of temporary RN staff and poor quality of care. Using temporary RN staff can aggra- vate unfavorable work conditions. Either way, this reciprocal relationship between the use of temporary RN staff and unfavorable work conditions can have a negative effect on qual- ity of patient care.

Thus, one practical implication for qual- ity of care in this study is that nursing units should be aware that the use of temporary RN staff may have an impact on quality of patient care, and thus they should try to re- duce the use of temporary RN staff. If they have to use temporary RN staff, they should monitor their work environments to ensure the quality of patient care. Another implica- tion for quality of care is related to the reason behind the use of temporary RN staff. As men- tioned earlier, the main reasons for employing temporary RN staff are staff absences, recruit- ment, retention, and vacancies.22 One way to reduce the use of temporary nursing staff is to make staffing levels stable. Providing favor- able work conditions would help staffing lev- els remain stable, which ensures the quality of patient care.

The finding that adding more LPN care hours led to decreased levels of patient falls is in contrast with previous findings for patient outcomes. Glance and colleagues37 found that an increased ratio of LPNs to total nursing staff was related to an increase in mortality and sepsis in hospital patients. These contra- dictory findings might be due to the types of patient outcomes considered. Mortality and sepsis can be more complicated and require more care from RNs, whereas adding an LPN can lead to a decreased level of patient falls be- cause LPNs can conduct patient surveillance rounds and prevent such events. Another pos- sible explanation could be omitted variable biases. Although this study controlled nurs- ing unit covariates, patient characteristics and case mix were not controlled. Those omit- ted variables could relate to both levels of LPN staffing and patient outcomes. For fu- ture studies, it is important to understand the level at which we can use LPNs to provide pa- tient care to ensure quality of care (eg, hours per patient day or proportion of nursing care hours). Similar to the findings for temporary RN staff care hours, we need to consider that about 45% of the sample reported zero LPN care hour. Although the study findings were statistically significant, readers need to be cau- tious to interpret this as clinical significance.

Another practical implication of this study is that organizations should not focus solely on nurse staffing levels. This study used compre- hensive nurse staffing characteristics, includ- ing nurse staffing, skill mix, RN turnover, and temporary RN staff. Significant findings were identified for LPN staffing level and tempo- rary nursing staff use. This suggests that staff nurses and nurse managers should pay atten- tion to staff composition as well as staffing levels. To capture both staffing levels and staff composition, nurse managers can exam- ine the care provided by RN and LPN staff and number of hours or proportion of nursing care hours. It is also important to understand that nursing staff other than RNs, including LPNs and temporary RN staff, influence the qual- ity of patient care. In health care facilities, staffing standards should be established not

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Analysis of Nurse Staffing and Patient Outcomes 325

only for RNs but for LPNs and temporary nurs- ing staff as well. Currently, staffing strategies emphasize RN staffing due to State staffing policy (eg, mandating minimum nurse to pa- tient ratios, public reporting, having staffing committees).38 However, LPN staffing may help to prevent certain kinds of adverse pa- tient outcomes, such as patient falls. For those units with higher risk of patient falls, hiring more LPNs may be a cost-effective way to pre- vent patient falls at the same time to reduce health care costs related to falls. According to the Bureau of Labor Statistics,39 LPNs are $24 000 less expensive than RNs on average per year, and when used to supplement RNs rather than replace them, they may be effec- tive in reducing falls. Thus, health care facili- ties need to develop the staffing strategies us- ing such evidence to reduce cost and improve quality of patient care.

Regarding temporary RN staffing, re- searchers should investigate levels of tem- porary RN staffing in relation to quality. The present analyses did not suggest recom- mended levels because they are based on the sampling distribution of temporary nursing care hours. A replication with a larger sam- ple is needed to establish staffing standards.

Although the State of California has im- plemented mandatory nurse-to-patient ratios, these include no specific recommendation about temporary RN staff. Also, it is not yet known whether consistent use of tem- porary RN staff might be harmful to patient care in comparison with occasional use of temporary RN staff. The levels and fluctua- tion of temporary RN staff usage should be investigated.

This study has several limitations. The convenience sample used lacked population representativeness, and the findings are not applicable to hospitals in other regions. An- other potential limitation is that other miss- ing variables might affect patient quality of care. Although the study controlled for sev- eral time-invariant nursing unit characteris- tics, it did not control for time-variant charac- teristics such as leadership change. Also, the study did not control for the unit case mix and individual patient characteristics such as age or comorbidity related to risk of falls and pressure ulcers, because these data were not available for all units. Further research is needed to account for confounding vari- ables that might affect the quality of patient care.

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38. American Nurses Association. Nurse staffing plans & ratios. http://www.nursingworld.org/MainMenu Categories/Policy-Advocacy/State/Legislative-Agenda -Reports/State-StaffingPlansRatios. Updated 2014. Accessed January 2, 2014.

39. Bureau of Labor Statistics, United States Department of Labor. Occupational outlook handbook. http:// www.bls.gov/ooh/Healthcare. Published March 29, 2012. Accessed January 2, 2014.

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database.aspx http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database.aspx http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database.aspx http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-Database.aspx http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios http://www.bls.gov/ooh/Healthcare http://www.bls.gov/ooh/Healthcare

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What are the potential ethical and legal implications for each of the following practice members?:

July 24, 2019/in Uncategorized /by

You are a family nurse practitioner working in an outpatient primary care office of a large hospital system. The practice has been operating for over 15 years, and many of the administrative and clinical staff were hired when the practice opened. You have been in the practice for less than 3 months. In that short amount of time, you have witnessed several of the clinical staff engaging in heated arguments with each other, sometimes in patient areas. You overhear an argument occurring today between two staff. You pick up a patient’s chart and notice a very low blood pressure that the medical assistant failed to notify you about. When you confront the MA, she states that she was going to report the vital signs to you when she became engaged in the heated argument you overheard and forgot to notify you.

Unfortunately, this pattern of behavior is not unusual in this practice. Working with staff who cannot cooperate effectively can negatively influence your ability to spend time with patients, can impede the flow of patients through the office, and could impact patient safety.

Discussion Question:

What are the potential ethical and legal implications for each of the following practice members?:

Medical assistants
Nurse Practitioner
Medical Director
Practice

What strategies would you implement to prevent further episodes of potentially dangerous patient outcomes?

What leadership qualities would you apply to effect a positive change in the practice? Be thinking about the culture of the practice.

Provide rationales and evidence to support your decisions

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Emergency Preparedness And Disaster

July 24, 2019/in Uncategorized /by

Watch the “Diary of Medical Mission Trip” videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this natural disaster by answering the following questions:

Propose one example of a nursing intervention related to the disaster from each of the following levels: primary prevention, secondary prevention, and tertiary prevention. Provide innovative examples that have not been discussed by previous students.
Under which phase of the disaster do the three proposed interventions fall? Explain why you chose that phase.
With what people or agencies would you work in facilitating the proposed interventions and why?

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Accident Prevention And Safety Promotion For Parents And Caregivers Of Infants

July 24, 2019/in Uncategorized /by

The growth, development, and learned behaviors that occur during the first year of infancy have a direct effect on the individual throughout a lifetime. For this assignment, research an environmental factor that poses a threat to the health or safety of infants and develop a health promotion that can be presented to caregivers.

Create a 10-12 slide PowerPoint health promotion, with speaker notes, that outlines a teaching plan. For the presentation of your PowerPoint, use Loom to create a voice over or a video. Include an additional slide for the Loom link at the beginning, and an additional slide for references at the end.

Include the following in your presentation:

Describe the selected environmental factor. Explain how the environmental factor you selected can potentially affect the health or safety of infants.
Create a health promotion plan that can be presented to caregivers to address the environmental factor and improve the overall health and well-being of infants.
Offer recommendations on accident prevention and safety promotion as they relate to the selected environmental factor and the health or safety of infants.
Offer examples, interventions, and suggestions from evidence-based research. At least three scholarly resources are required. Two of the three resources must be peer-reviewed and no more than 6 years old.
Provide readers with two community resources, a national resource, and a Web-based resource. Include a brief description and contact information for each resource.
In developing your PowerPoint, take into consideration the health care literacy level of your target audience, as well as the demographic of the caregiver/patient (socioeconomic level, language, culture, and any other relevant characteristic of the caregiver) for which the presentation is tailored

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Nurses Working To Improve The Socioeconomic Status Of Impoverished Citizens Through Government Actions

July 24, 2019/in Uncategorized /by

The influence of poverty on health is a problem that transcends national borders. This week’s readings discussed some of the political, economic, and ethical issues that lead to health disparities in developed and developing countries. In addition, in this week’s first media presentation, Dr. Mancuso and Dr. Huijer shared insights on working within political systems to bring about positive changes in health care. Think about the importance of nurses in addressing these needs and in bringing about change.

To prepare for this Discussion:

Review the case study “Improving the Health of the Poor in Mexico.” Then, prepare your response to the following questions:
- How do politics and economics influence health and health care?
- What might the benefits be of awarding the mothers cash grants?
- What social problems might be created by giving the mothers cash grants?
- Do you think the resources were ethically distributed? (Think about stereotyping.)
- What changes do you think should be made to the program, if any?
- If the program were to be discontinued for any reason, what could you, as a nurse, say that might help to maintain funding?
- Do you think a similar program might work in your community? Why or why not?

By Day 3

Post your response to the following prompts:

Explain how politics and economics may influence health and the health care system from your own perspective. Analyze whether the political and/or economic systems play a major role in your or your family’s access to health and explain why. Then, describe how government intervention might benefit a health care system. Be specific and provide examples.

Support your response with references from the professional nursing literature.

Note Initial Post: A 3-paragraph (at least 350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old).

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Death and Dying – Ethical Dilemmas and Nursing Interventions

July 24, 2019/in Uncategorized /by

Background/Introduction: Chose a culture, other than their own, to write about, describing the current culture’s views, rituals and ceremonies regarding death and dying.

5 points

Values: Described the current culture’s views on death and dying, in contrast to your own similarities or differences in values between them and how you feel about that. 2.5 points each component

5 points

Conclusion: Concluding summary and statement of nursing implications. 2.5 points each component ? summary and implications

5 points

APA formatted body, citations and references 0-10 points depending upon level of fidelity to APA formatting ? more mistakes will equal more points lost.

10 points

Proper writing mechanics (freedom from typos, format irregularities, poorly constructed paragraphs, poor grammar, etc.) 0-10 points depending upon level of fidelity to APA formatting ? more mistakes will equal more po

Different cultures view death and dying differently. For this assignment you will research a culture, other than your own and using your Culturally Competent Health Care textbook by Larry Purnell or the internet to address the following:

Describe the current views and possible ceremonial processes, honoring the death and dying of their loved ones for the culture you chose to research.
You may find some differences in values between your culture and the one you have researched. If you did, what are they and how do you feel about them? If not, what similarities between your culture and the one you have researched did you find, how do you feel about them?
Use APA formatting for your paper, using headings as shown below:
Title page
Body
- Heading: Introduction of your paper topic ? the culture you have selected to research. (this is the first bullet point above)
- Heading: Background. Discuss value differences or similarities between your culture and the one you researched. (this is the second bullet point above)
- Heading: Conclusion ? a summary statement, in a few sentences, about the last two sections (background info, and value differences) and what that information means for the end-of-life care of those clients (implications for nurses caring for this clients experiencing the ends of their lives).
Reference page
Use APA formatting throughout your paper:
- Headings ? centered and capitalized first letter (Introduction, Values, Conclusion, and References).
- In-text citations ? as taught and discussed earlier.
- References ? as taught and discussed earlier.
Demonstrate proper writing mechanics (typos, proper paragraphs, grammar, font, etc.)

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Epidemic In The Community

July 24, 2019/in Uncategorized /by

To prepare for this Discussion, visit the CDC Wonder site in this week’s resources. Investigate the incidence and prevalence of TB in your community. What information did you find? Analyze how your community compares to county, state, or national data for the same topic. Was the incidence and prevalence of each higher or lower than you expected?

Consider the following scenario: This is Debbie’s first year working as a nurse at the local health department in a rural county. Most of her days are spent in the clinic seeing clients who often do not have health insurance.

Over the past month, Debbie has noticed that several young Hispanic men have come to the health department, each diagnosed with tuberculosis. Debbie is concerned about what the outbreak of tuberculosis among the migrant workers could mean for the community. Through a community health profile, Debbie identifies the group of migrant farm workers as being at highest risk for contracting tuberculosis.

Using the Epidemiologic Triangle concept, consider the relationship among causal agents, susceptible persons, and environmental factors. Then, respond to the following:

As a BSN-prepared community health nurse, what steps should Debbie take next?
Considering economic and social considerations within the community, what are the primary, secondary, and tertiary interventions that Debbie might use in managing this outbreak?
Can similar interventions be applied to your community and its TB prevalence?
What considerations need to be addressed within your community that are different form Debbie’s community?

By Day 3

Post your response to this Discussion.

Support your response with references from the professional nursing literature.

Notes Initial Post: This should be a 3-paragraph (at least 250–350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old).

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Provide a concise introduction for your posting.

July 24, 2019/in Uncategorized /by

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Peer Engagement Forum

Purpose

The Peer Engagement Forum will take place during four weeks in the NR 504 course and is designed to provide students with an opportunity to engage and dialogue at a deeper level with a small group of peers. Weeks during which Peer Engagement will occur include weeks two, five, six, and seven.

Course Outcomes

Throughout the course of the four Peer Engagement Forums, the following Course Outcomes will be addressed:

· CO #1 – Discern leadership approaches that facilitate achievement of health outcomes through interprofessional collaborative practice within micro-, meso-, and macro-level systems.

· CO #2 – Appraise the role of the MSN-prepared nurse to lead safe, efficient, ethical, high-quality, person-centered health care across complex systems.

· CO #3 – Integrate communication modalities which convey cultural humility, value the diverse nature of individuals, and cultivate healthful work environments.

· CO #4 -Apply change and leadership theories to plan sustainable, evidence-based quality improvement within an atmosphere which supports care for self and others.

· CO #5 – Recognize individual strengths and opportunities for enhancement regarding leadership characteristics reflective of a MSN-prepared nurse.

Due Date

· Primary (initial) posting to the Peer Engagement Forum is due by Wednesday, 11:59 pm MT during the designated week in which the forum occurs

· All responsive postings and answers to questions posed directly to students are due by Sunday 11:59 PM MT at the end of the designated week in which the forum occurs.

Total Points Possible: 100 points

Requirements

Criteria for Content

· Based upon readings and learning activities within the class lessons, create a primary (initial) posting in response to the specific Peer Engagement Forum discussion questions which are described within the module. Please refer to the modules for weeks two, five, six, and seven to locate specific discussion instructions.

· Your primary posting must be a minimum of 300 words and no more than 500 words in length (not including the reference list).

· Include a minimum of two current, peer-reviewed, scholarly sources to support your primary posting in the Peer Engagement Forum.

· Respond in a substantive manner to at least two peers during the assigned week. Responsive postings must be a minimum of 100 words and no more than 300 words in length (not including any reference list, should one be included).

· Respond in a substantive manner by Sunday at 11:59 pm MT to all questions directed specifically to you. You are required to address questions posed before Saturday at 11:59 pm MT directly to you.

Preparing the Assignment

Criteria for Format and Special Instructions

1. Abide by the Chamberlain College of Nursing Academic Integrity Policy.

2. Post your primary (initial) response to the Peer Engagement Forum by Wednesday at 11:59 pm MT during the assigned week.

a. Primary posting must be at least 300 words and no more than 500 words in length (not including the reference list).

b. A minimum of two peer-reviewed scholarly sources, current within five years, are required to support the primary posting.

3. Post a minimum of two substantive, responsive postings to peers by Sunday at 11:59 pm MT at the end of the assigned week.

a. Responsive postings must each be at least 100 words and no more than 300 words in length (not including any reference list, should one be included).

4. Respond in a substantive manner to all questions directed specifically to you. You are required to address questions posed before Saturday at 11:59 pm MT directly to you.

5. No direct quotes may be used in this forum.

6. Sources older than five years may not be used without the permission of the class professor.

7. Rules of grammar, spelling, word usage, punctuation, sentence and paragraph structure are followed and consistent with formal, scholarly writing as noted in the APA Manual (6th edition).

8. Correct APA format is used for citing and referencing of sources.

Assignment Criteria

Grading Criteria –

Category	Points	%	Description
Quality and Depth of Primary (initial) Posting	40	40%	Primary posting is comprehensive and meets the following criteria:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as future leader in the chosen specialty track· Integrates scholarly support to validate assertions made
Quality and Depth of Peer Engagement	40	40%	Evidence of meaningful peer engagement meets the following criteria:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.
Graduate-level Writing Style	20	20%	Graduate-level writing style is included, evidenced by integrating the following standards:· Correct use of spelling, grammar, punctuation, sentence and paragraph structure· Clarity, organization, and logical flow of ideas within writing· APA format for citing sources· APA format for referencing sources· No direct quotes are used within the forum
Quality of Literature Support	It is an expectation that a minimum of two peer-reviewed scholarly sources, current within five years, are integrated to support your primary (initial) posting.If the above expectation is not met, 10 points shall be deducted.
Length of Primary and Responsive Postings	It is an expectation that the postings meet the following length requirement:· Primary (initial) postings must be 300 words minimum to 500 words maximum (not including the reference list)· Responsive postings must each be 100 words minimum to 300 words maximum (not including any reference list, should one be included)If either of the above expectations are not met, 10 points shall be deducted
TimelinessOfForum Participation	The following participation guidelines are required:· Primary posting is made before Wednesday 11:59 pm MT during the assigned week· Two responsive postings are made before Sunday 11:59 pm MT at the end of the assigned week· Responds by Sunday 11:59 pm MT to all questions directed specifically to the student. Students are required to address questions posed before Saturday 11:59 pm MT directly to them.If any of the above requirements are not met, 10 points shall be deducted
Total	100	100%	A quality assignment will meet or exceed all the above requirements.

Chamberlain College of Nursing NR504: Leadership and Nursing Practice: Role Development

NR504 Peer Engagement Forum 10/3/18 AS

Grading Rubric

Assignment Criteria	Exemplary(100%)	Accomplished(92%)	Average(84%)	Marginally Acceptable(76%)	Insufficient(0%)
ContentPossible Points = 80 Points
Quality and Depth of Primary (initial) Posting	40 Points	36 Points	33 Points	30 Points	0 Points
	Exemplary presentation of information evidenced by all content areas covered in a comprehensive and concise manner.All of the following are included:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as a future leader in the chosen specialty track· Sufficient integration of scholarly literature to support information presented	Accomplished presentation of information evidenced by most content coveredin a comprehensive and concise manner, but with one area where coverage is superficial.All of the following are included:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as a future leader in the chosen specialty track· Sufficient integration of scholarly literature to support information presented	Average presentation of information evidenced by content covered in a superficial manner in two or more of the content areas.All of the following are included:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as a future leader in the chosen specialty track· Sufficient integration of scholarly literature to support information presented	Marginally acceptable presentation of information evidenced by content that is limited, missing, or unsatisfactory in one of the following:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as a future leader in the chosen specialty track· Sufficient integration of scholarly literature to support information presented	Insufficient presentation of information evidenced by content that is limited, missing, or unsatisfactory in two or more of the following:· Includes an introduction to the posting· Addresses each element within the discussion question in a thorough manner· Demonstrates insightful application of course concepts and information· Includes a summary of key points shared· Discusses how learning specific to this topic contributes to growth as a future leader in the chosen specialty track· Sufficient integration of scholarly literature to support information presented
Quality and Depth of Peer Engagement	40 Points	36 Points	33 Points	30 Points	0 Points
	Exemplary engagement evidenced by all content areas covered in a comprehensive and concise manner.All of the following are included:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.	Accomplished engagement evidenced by most content coveredin a comprehensive and concise manner, but with one area where coverage is superficial.All of the following are included:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.	Average engagement evidenced by content covered in a superficial manner in two or moreof the content areas.All of the following are included:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.	Marginally acceptable engagement evidenced by content that is limited, missing, or unsatisfactory in one of the following:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.	Insufficient engagement evidenced by content that is limited, missing, or unsatisfactory in two or more of the following:· Minimum of two responsive postings· Responsive postings are made to a minimum of two individual peers· Each responsive posting includes substantive content which poses new ideas, asks questions, prompts additional dialogue, and adds to the discussion topic in a meaningful and constructive manner· Substantive responses are provided to all questions directed specifically to the student. Students are required to address questions posed before Saturday night at 11:59 pm MT directly to them.
Content Subtotal ________of 80 points
FormatPossible Points = 20 Points
Graduate-level Writing Style	20 Points	18 Points	16 Points	15 Points	0 Points
	Exemplary graduate level writing style is evident, which fully meets all of the criteria below:· Correct spelling, grammar, punctuation, sentence and paragraph structure· Exceptional writing style with clarity, flow, and organization of information· Correct APA format for citing sources· Correct APA format for referencing sources· No direct quote is used within the assignment	Accomplished graduate-level writing style is evident which fully meets four of the criteria below:· No more than 2 errors in spelling, grammar, punctuation, sentence and paragraph structure· No more than 2 errors in writing style with clarity, flow, and organization of information· No more than 2 errors in APA format for citing· No more than 2 errors in APA format for referencing sources· No direct quote is used within the assignment	Average graduate-level writing style is evident which fully meets three of the criteria below:· No more than 2 errors in spelling, grammar, punctuation, sentence and paragraph structure· No more than 2 errors in writing style with clarity, flow, and organization of information· No more than 2 errors in APA format for citing· No more than 2 errors in APA format for referencing sources· No direct quote is used within the assignment	Marginally acceptable graduate-level writing is evident which fully meets two of the criteria below:· No more than 2 errors in spelling, grammar, punctuation, sentence and paragraph structure· No more than 2 errors in writing style with clarity, flow, and organization of information· No more than 2 errors in APA format for citing· No more than 2 errors in APA format for referencing sources· No direct quote is used within the assignment	Insufficient graduate-level writing style is evident which fullymeets one or less of the criteria below:· No more than 2 errors in spelling, grammar, punctuation, sentence and paragraph structure· No more than 2 errors in writing style with clarity, flow, and organization of information· No more than 2 errors in APA format for citing· No more than 2 errors in APA format for referencing sources· No direct quote is used within the assignment
Quality of Literature Support	0 Points Deducted				10 Points Deducted
	A minimum of two peer-reviewed scholarly sources, current within five years, are integrated to support the primary (initial) posting.				The assignment fails to meet the requirement for quality of literature support.
Length of Primary (initial) and Responsive Postings	0 points Deducted		10 Points Deducted
	The following requirements are met:· The primary (initial) posting is a minimum of 300 words and does not exceed 500 words in length (not including the reference list)· Responsive postings are each a minimum of 100 words and do not exceed 300 words in length (not including any reference listing, should one be included)		The assignment fails to meet one or more of the requirements noted for length of postings.
Timeliness of Forum Participation	0 Points Deducted		10 Points Deducted
	The following participation guidelines are met:· Primary (initial) posting is made before Wednesday 11:59 pm MT during the assigned week· Minimum of two responsive postings are made before Sunday 11:59 pm MT at the end of the assigned week· Responds by Sunday 11:59 pm MT to all questions directed specifically to the student. Students are required to address questions posed before Saturday 11:59 pm MT directly to them.		The assignment fails to meet one or more of the requirements for participation.

Format Subtotal	_____of 20 points
Assignment Total Points Earned	_____of 100 Points

NR504 Peer Engagement Forum 12/3/2018 AS

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Evolving Practice Of Nursing And Patient Care Delivery Models

July 24, 2019/in Uncategorized /by

As the country focuses on the restructuring of the U.S. health care delivery system, nurses will continue to play an important role. It is expected that more and more nursing jobs will become available out in the community, and fewer will be available in acute care hospitals.

Write an informal presentation (500-700 words) to educate nurses about how the practice of nursing is expected to grow and change. Include the concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics.
Share your presentation with nurse colleagues on your unit or department and ask them to offer their impressions of the anticipated changes to health care delivery and the new role of nurses in hospital settings, communities, clinics, and medical homes.
In 800-1,000 words summarize the feedback shared by three nurse colleagues and discuss whether their impressions are consistent with what you have researched about health reform.
A minimum of three scholarly references are required for this assignment.

While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

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Hypertension Case Study

July 24, 2019/in Uncategorized /by

C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.

PMH

Allergic Rhinitis

Depression

Hypothyroidism

Family History

Father died at age 49 from AMI: had HTN

Mother has DM and HTN

Brother died at age 20 from complications of CF

Two younger sisters are A&W

Social History

The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.

Medications

Zyrtec 10 mg daily

Allergies

Penicillin

ROS

States that his overall health has been fair to good during the past year.

Weight has increased by approximately 30 pounds in the last 12 months.

States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.

Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.

Denies any nausea, vomiting, diarrhea, or blood in stool.

Self treats for occasional right knee pain with OTC Ibuprofen.

Denies any genitourinary symptoms.

Vital Signs

B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.

HEENT

TMs intact and clear throughout

No nasal drainage

No exudates or erythema in oropharynx

PERRLA

Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits

Thyroid normal

No lymphadenopathy

Lungs

Mild basilar crackles bilaterally

No wheezes

Heart

RRR

No murmurs or rubs

Abdomen

Soft and non-distended

No masses, bruits, or organomegaly

Normal bowel sounds

Ext

Moves all extremities well

Neuro

No sensory or motor abnormalities

CN’s II-XII intact

DTR’s = 2+

Muscle tone=5/5 throughout

What you should do:

Develop an evidence-based management plan.
Include any pertinent diagnostics.
Describe the patient education plan.
Include cultural and lifespan considerations.
Provide information on health promotion or health care maintenance needs.
Describe the follow-up and referral for this patient.
Prepare a 3–5-page paper (not including the title page or reference page)

quantitative research paper

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What are the potential ethical and legal implications for each of the following practice members?:

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Emergency Preparedness And Disaster

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Accident Prevention And Safety Promotion For Parents And Caregivers Of Infants

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Nurses Working To Improve The Socioeconomic Status Of Impoverished Citizens Through Government Actions

By Day 3

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Death and Dying – Ethical Dilemmas and Nursing Interventions

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Epidemic In The Community

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Provide a concise introduction for your posting.

Purpose

Total Points Possible: 100 points

Requirements

Preparing the Assignment

Assignment Criteria

Grading Criteria –

Grading Rubric

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Evolving Practice Of Nursing And Patient Care Delivery Models

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Hypertension Case Study

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