Strategic Framework for Reform of the Health Service

Strategic Framework for Reform of the Health Service Introduction: In 2012 the Department of Health (2012) (DoH) launched its Strategic Framework for Reform of the Health Service. The rationale behind the release of this Framework, through the Health Service Executive (HSE) was the continued improvement of societal health and wellbeing within the State of Ireland. Four key areas were identified for reform: Health and Well Being; keeping people healthy, Service Reforms; providing healthcare that people need, Structural Reforms; delivering high quality services and Financial Reform; getting the best value for health system resources. To achieve these reforms there must be a symbiotic relationship in situ between all four key areas, providing the best provision of care and best practice to all stakeholders involved, through the continued and correlated use of Management, Leadership, Quality Management and Information Management. Examining some of the principles of Information and Quality Management this student will endeavour to critically discuss some key areas. Information Management: With the advancement in technology, reliance on and use of computer based Information Management has increased dramatically. Insuring the design, implementation and continued development of Information Management there are a number of key principles to successful Information Management including effective Management of Information and Data Knowledge. Management of Information: Effective Management of Information is a multifaceted combination of People, Process, Technology and Content and it is how these are managed that allow us to provide a high quality of care to all. It is how this information is managed that allows recognises the value of information, whilst being readily available, protected shared and is always evidence based. A good process of Management Information allows all healthcare professionals collect data and to communicate this information through various avenues to other health care professionals, not only allowing for a greater flow of information, but also an ease of access to the relevant concise information. Patient records can now be accessed and shared with far greater ease than they have historically (Wallis 2011) remotely by authorised professionals, access to imaging data and laboratory results is almost instantaneous allowing for Healthcare professionals to make informed decisions. Data can be collected and correlated to local and national policy makers regarding the provision of health care, including Care Planning, Prioritising Workloads and Resource planning (Murnane 2005) Effectual Information Management can help maintain and protect documented information. Two separated inquires exposed the purposeful practice of interfering with documented records, Leas Cross (O’Neill 2006)and the Neary Report (Harding Clark 2006), indeed Sexton et al. hypothesised that written nursing handovers could be simplified, leading to increased efficacy in time management ergo allowing more time for patient interactions through the centralised use of patient information and reducing potential for errors. Spooner et al. (2013) Data Knowledge: One of the challenges of having a good information Management system in situ is to ensure that the data correlation is relevant, true and fit for purpose. Data collection as outlined by the Health Information Quality Authority (HIQA) (HIQA 2012) should be, where possible collected once and then used continually, thus preventing the patient asked on numerous occasions for the same information, this is more applicable to long term service users of health care. Due to the enormity of data available it must be validated, reliable, accurate and complete where possible, however, records must be updated following all interactions between patients and caregivers insuring that the most up-to-date information is readily available. Good data may give the care giver/hospital a competitive advantage, allowing all stakeholders to make strategic, informed decisions, increase productivity leading to a possible long term increase cost efficiency, however, it must be noted that this data knowledge should be bidirectional allowing for patients to access the Data Services such as the HSE Dashboard. Data is only as good as what is imputed on to the system, therefore clinical governance needs to be policed to ensure good quality data is entered, there may be initial cost implications during data gathering. Whilst there are multifaceted benefits of implementaning, maintaining and continual development of good information management systems and Data Quality protocols in place it; must be also noted that there are a number of areas of concern, most notably patient confidentiality, insuring the safety of all patient records, implementation and upkeep costs, fail safe back up and intrusion systems and lack of end user involvement in the design process and implementation of the Information Management system (Huryk 2010). One must also examine the legality and accountability of information transcribed onto databases/patient records and examine who is going to manage and take ownership of these E documentations, as this is currently still an area growing concern, taking into account what are the consequences for those who misuse and abuse data collected and stored under The Data Protection Act 2003. (Irish Government 2003) Quality in Health Care: Over the past number of years there have been a growing number of inquiries into the quality of care delivered to the Lourdes Hospital Inquiry (Government of Ireland 2006), Leas Cross (DoH 2009) and the more recent Halappanavar case (HIQA 2013), whereby the provision and delivery of care has been called into account in a legal context. All reports make various recommendations; however, it is how these recommendations and findings are then implemented into an accountable structure regarding the delivery of healthcare. From an Irish context, Evidence based standards in collaboration with users of healthcare are pivotal to the continual improvement of our Health Service (DoHC 2001) Quality Improvement: Critical to the establishing a basis for quality improvement and reform in healthcare is the establishing and contextualising the values, mission and core competencies of the organisation. This should incorporate codes, responsibilities for performance and quality, documentation of key policies and procedures, public information on available services, relevant updated information. Procedures must be systematic, measurable and comply to local, national and in some cases, international law(s) and health policies, more importantly, for the delivery of care one must embrace the Patient/Service User/Client into the melee to create a Person Centred delivery of service orchestrated by Quality Improvements, these may encompass medical errors and empowering the patient but must have their foundations built upon evidence based practice (HSE 2012). In theory, this sounds achievable and one may question why such measures were not in place already, however in practice, there are a number of elements to consider that may impact on quality improvements. A recent report from The Commission on Patient Safety and Quality Assurance (Department of Health, 2011) identified â€Å"cultural issues† as a major obstacle to accepting change, most notably from an organisational and professional stance. Therefore, it is essential that to have effective leadership in place to help with the development and implementation of change, however, as Fealy et al. (2010) summarised that there are a number of barriers to nurses developing as efficient interdisciplinary leaders which need to be addressed. Patient/Service User Focus: There have been a number of initiatives to establish a patient/service user focus within healthcare. From a service user perspective the HSE has established a ‘Patient Form’ allowing service users the prospect of having active participation in the design, implementation and assessment of developing ‘National Clinical Care Programmes’ (HSE 2014) National Standards Agencies such as the Mental Health Commission (MHC) and HIQA have been established to protect the service user and caregiver. The Quality Framework for Mental Health Services in Ireland (MHC 2007) delivers a structure manner for safeguarding continual improvements and monitoring of all mental health services, by setting expectations of all those who come into contact with the Mental Health Services in Ireland, aided by a modality of staff and services being proactive. There is a greater duty with the service user to have increased impetus in their own care through the knowledge of services available, focus groups and readily available Patient Information Leaflets. Conclusion: Oroviogoicoechea et al. (2008) recognise that there is a strong association between the Quality of Care offered to patients and Quality of Information, received, documented and managed, as with all systems, there is scope for improvement, however, following on from lessons learnt we have seen the introduction and implementation of Policy and procedures with the setting up of the Government Standards Body of HIQA as a state body with the power to implement changes and recommendations. Health must stop treating itself as an isolated entity and embrace modern technological developments in information management as they do within other areas in the delivery of care, such as Imaging, Surgical Interventions and so forth, however strong and systematic procedures should be in situ to insure the safe management of Patient information. Correct Clinical Governance will ensure that standards are met and that policy and procedures are stringently adhered to, however this can only be accomplished by nurses’ accepting changes, evaluating evidence based practice and performing to the best of their ability. References: Department of Health and Children (2001) Quality and Fairness, a health system for you, Health Strategy, Stationary Office: Dublin. Department of Health (2009) The Leas Cross Commission The Commission of Investigation (Leas Cross Nursing Home) Final Report June 2009. Stationary Office: Dublin. Department of Health (2011) Report of the Implementation Steering Group on the Recommendations of the Commission on Patient Safety and Quality Assurance. DoH, Dublin. Department of Health (2012) Future Health. A Strategic Framework for Reform of the Health Services 2012- 2016. DoH, Dublin. Gerard M Fealy, Martin S McNamara, Mary Casey, Ruth Geraghty, Michelle Butler, Phil Halligan, Margaret Treacy and Maree Johnson (2010) Barriers to clinical leadership development: Findings from a national survey. Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2023–2032 Government of Ireland. 2006. The Lourdes Hospital Inquiry: An inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda. (By Judge Harding Clark). Stationery Office, Dublin http://health.gov.ie/wp-content/uploads/2014/05/lourdes.pdf  (Accessed 07/10/14) Harding Clarke, M. (2006). The Lourdes Hospital Enquiry; An inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda, Stationary Office. Dublin Health Information and Quality Authority, (2012) Guidance on information governance for health and social care services in Ireland: Health Information and Quality Authority. Dublin Health Information and Quality Authority, (2013) Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar. Health Information and Quality Authority. Dublin Health Service Executive (2012). A vision for Psychiatric /Mental Health Nursing. Health Service Executive. Dublin Health Service Executive (2014) http://www.hse.ie/portal/eng/about/Who/qualityandpatientsafety/Advocacy/QPS_service_users/Service_User_Involvement_in_Clinical_Care.html  (Accessed 06/10/14) Huryk, L. (2010) Factors influencing nurses’ attitudes towards healthcare information technology. Journal of Nursing Management. 18, 5, 606-612. Irish Government (2003) Data Protection (Amendment) Act.. The Stationary Office. Dublin Mental Health Commission (2007) Quality Framework: Mental Health Services in Ireland. Mental Health Commission, Dublin Murnana, R., (2005) Empowering nurses—Improving care Nurses’ response to the new Health Services Reform Programme in Ireland. International Journal of Medical Informatics 74, 861—868 O’Neill, D. (2006) A review of the deaths at Ideas Cross Nursing Home 2002-2005, Dublin: Department of Health and Children. Oroviogoicoechea, C. Elliot, B. Watson, R. (2008) Journal of Clinical Nursing 17, 567–575. Sexton, A.C., Chan C., Elliot M. , Stuart J. , Jaysuriya R. Crookes P. (2004) Nursing handovers: do we really need them? Journal of Nursing Management 12, 37–42 Spooner, A.J., Chaboyer, W., Corley, A., Hammond N., Fraser JF. International Journal of Nursing Practice 2013; 19: 214–220 Wallis, A. (2012) Management, http://rcnpublishing.com/doi/abs/10.7748/nm2012.03.18.10.14.c8957  (Accessed 08/10/14)

Anxiety, stress and burnout in nursing Essay

Anxiety, stress and burnout in nursing is a significant issue, which affects many nurses during their professional career (McVicar, 2003). Graduate nurses transitioning from university education to a hospital setting face additional causes of stress and new challenges at this time and require accommodating measures such as a supportive work environment (Chang & Hancock, 2003). At present the nation is experiencing a severe nursing shortage that is impacting greatly on the work conditions of nurses that remain (Chang & Hancock, 2003). In this critical appraisal stress and burnout will be defined, as will all major terms throughout this paper. The author will discuss the critical nursing shortage and describe the symptoms of stress and burnout. Causes of burnout and stress will be discussed in relation to the graduate and experienced nurse. The author will present and discuss stress and burnout prevention strategies. Throughout this essay empirical evidence will be used to demonstrate validity of concepts. A literature search was conducted using computerized databases that were searched over the time period 2003-2008 and included Academic Search Premier, psycINFO, Psychology and Behavioral Sciences Collection, EJS E-Journals Database, Professional Development Collection, Medline, Health Source: Nursing/Academic Edition, Health Source: Consumer Edition and Cinahl. Key words searched included burnout, nursing, anxiety, stress, shortage, graduate, and strategies. Stress is thought to be connected to an individual’s response to specific demands, if the individual assesses the demand as beyond their resources this generates a stress response (Clancy & McVicar, 2002, as cited in McVicar, 2003). Stress responses include variation in an individual’s biochemical, physiological and behavioural processes (Billter-Koponen & Freden, 2005). According to McVicar (2003) the ability of the individual to handle the stress response is dependent on specific experiences, coping mechanisms and the environment where demands are produced. Stress is usually part of a larger problem and is noted as the first phase of a ‘chronic process’ (Gillespie & Melby, 2003). If severe stress and anxiety persist without interventions being implemented this may lead to burnout, which is typically characterized by emotional exhaustion, depersonalisation and reduced personal accomplishment (Maslach & Jackson, 1986 as cited in Chang &  Hancock, 2003). Chang, Daly & Hancock et al., (2006) suggests that stress from work reduces the quality of work environment, job satisfaction, psychological wellbeing and physical health on nurses. Since stress has been identified as prevalent in nursing there have been various research studies discussing the causes and impacts of stress (Billter-Koponen & Freden, 2005). As well as the effects of work place stress on nurses, there is the larger issue of the consequences for the health care system, with many nurses finding the only way to cure burnout is leaving the workforce, this is further impacting the serious shortage of nurses world wide (Chang et al., 2005; Edwards and Burnard, 2003 as cited in Chang, Bidwell & Huntington, 2007). A literature review of stress in nursing by Chang, Hancock & Johnson et., 2005 commented that currently the severe shortage of nurses in Australia is the largest since World War II and reports that by 2010, there will be a shortage of approximately 40, 000 nurses (RMIT University, 2003 as cited in Chang, Hancock & Johnson et al., 2005). A report by AIHW (2005), found that the nursing work force has persisted to age, with the average age of nurses increasing from 42.2 years old in 2001 to 45.1 years old in 2005 and the amount of working nurses aged over 50 years has increased from 24.4% to 35.8%. The older population of nurses will eventually be leaving the profession in years to come when the shortage of nurses is at its worst, this will further compound the issue (Janiszewski Goodin, 2003). The Australian government has responded to the issue of an aging workforce by encouraging older nurses to continue with further study and actively discouraging them from retiring (Wickett, McCutcheon & Long, 2003). After many years of decline of enrolments to tertiary nursing courses there has been a considerable influx of applicants, this is thought to be created by the governments increasing media campaigns to generate interest in nursing as a career, however, the boost in enrolments does not necessarily solve the nursing shortage as the larger issues of why retention of nurses has not been successful have not been addressed and media campaigns could almost been seen as a ‘band-aid’ covering up the larger problems (Wickett, McCutcheon & Long, 2003). The nursing shortage has seen many ‘unskilled’ workers entering the aged care sector as a ‘substitution’ of registered  nurses; currently the aged care system is overwhelmed with demand and †˜patient complexity’ (Wickett, McCutcheon & Long, 2003). Duffield & O’Brien-Pallas (2002, as cited in Wickett, McCutcheon & Long, 2003) suggest three main reasons for the growing nursing shortage, these include, personal issues that pertain to stress, burnout and an inadequacy of balance in their personal lives. Secondly Duffield & O’Brien-Pallas (2002, as cited in (Wickett, McCutcheon & Long, 2003) cite organizational and management issues, which relate to workplace violence, either verbal or physical between patients or staff, as issues of concern in retention of nurses as well as professional issues with dissatisfaction stemming from the ability of the nurse to provide quality of care in circumstances of high demand (Chang, Hancock & Johnson, 2005; Wickett, McCutcheon & Long, 2003). These unresolved problems contributing to the nursing shortage emphasize the urgency of studying the nursing profession and environment so that the sustainability of the health care system can continue (Chang, Hancock & Johnson, 2005). There are multiple symptoms of anxiety and burnout, as noted, prolonged stress and anxiety can result in burnout. Physical effects of stress include persistently elevated arterial blood pressure, indigestion, constipation or diarrhoea and weight gain or loss (McVicar, 2003). In cases of severe prolonged stress physical effects can progress to clinical hypertension, gastric disorders, nausea, fatigue, headaches and exacerbated symptoms of asthma (McVicar, 2003; Billter-Koponen & Freden, 2005). The possible cause of fatigue in severe stress and anxiety is high levels of cortisol, which is a hormone that can be produced in excess when a person is stressed leading to cortisol affecting sleep patterns and resulting in sleep difficulties (Billter-Koponen & Freden, 2005). According to Hugo (2002, as cited from Billter-Koponen & Freden, 2005) symptoms of stress in European countries are rising, in 2003 over 5,000 nurses in Sweden were sick for over 30 days with approximately 40% of the diagn osis for the long-term absence from work being emotional exhaustion (burnout), the 2003 statistics were reported to have increased by 20% from the previous year. Billter-Koponen & Freden (2005) suggests that the larger proportion of demands for nurses are psychologically related and in turn this creates more psychological  disturbances than physical symptoms. The three core elements of burnout; emotional exhaustion, depersonalisation and reduced personal accomplishment can produce various psychological effects. Emotional exhaustion may occur when the nurse experiences the inability to function professionally at a psychological level, the symptoms may include depression, sleep disturbances and the inability to control emotions (Maslach et al., 1996 p.4 as cited in Gillespie & Melby, 2003; Patrick & Lavery, 2007). A nurse who develops depersonalization may have feelings of irritability, anger and a general negative attitude towards clients, according to Leiter (1993, as cited in Patrick & Lavery, 2007) depersonalization transpires from a need to create distance from the work that is emotionally draining (Maslach et al 1996 p.4. as cited in Pa trick & Lavery, 2007; Chang & Hancock, 2003). Reduced personal accomplishment can create feelings of inadequacy, self-doubt, low self-esteem and the predisposition to view their level of skill and care negatively (Chang & Hancock, 2003; Patrick & Lavery, 2007). These symptoms are especially worrying as they can reduce quality of care and decrease patient satisfaction (Janssen et al ., 1999; Garrett & McDaniel, 2001 as cited in Chang & Hancock, 2003). It is generally accepted that nurses who are excessively stressed or experiencing burnout typically have poor job satisfaction, high absenteeism rates and many nurses contemplate leaving the profession altogether (Larson, 1987; Callaghan & Field, 1991 as cited in Chang & Hancock, 2003). A qualitative study by Billter-Koponen & Freden (2005) interviewed nurses about their own experiences regarding work place anxiety, stress and burnout, the nurses commented they felt ‘powerless’ to avoid burnout and had inadequate time or energy to take on patient demands. The nursing profession involves demands beyond clinical technical skills, teamwork and constant care of patients; the role of nursing requires a high level of ‘emotional labour’, which can lead to many complex causes of stress and burnout (Phillips, 1996 as cited in McVicar, 2003). Gillespie & Melby (2003) found that the length of shifts and shift patterns, which included night duty contributed to emotional exhaustion, personal relationship problems, difficulty concentrating and fatigue. Similarly, Efinger et al., (1995 as cited in McVicar, 2003) reported shift work as  having a negative influence on social and personal aspects of the nurses’ lives, it was also mentioned that night shift work was particularly draining in terms of physical health and disrupted family life. Furthermore a study by Chang, Daly & Hancock et al., (2006) consisting of 320 randomly selected Australian registered nurses who were listed on the New South Wales registration board database found that workload was the most common source of stress with indications that high workload negatively affected the mental health of nurses. Chang, Daly & Hancock et al., (2006) also comment on the legal requirements of providing a safe work place in which workers are not under excessive stress, which is affecting their mental health. However, a study by Patrick & Lavery ( 2007) based on a random sample of 574 division 1 Victorian Australian Nursing Federation members were surveyed on burnout in nursing stated that hours worked by nurses have a weak correlation with emotional exhaustion. Yet it could be argued that these results are not a true indication of full-time nurses feelings as 65.73% of the participants worked part-time or casual nursing roles with the average amount of hours that nurses worked in this study being 32.17 hours, which amounts to a ‘lower average’ than full time work (Patrick & Lavery, 2007). A cross-sectional study by Spooner-Lane & Patton (2007) found that nurses who worked full-time experienced higher levels of emotional exhaustion compared to part-time or casually working nurses. Increases in workload exist in other areas such as recent updating of technology, extra responsibilities, paper work and increasing staff shortages (Chang & Hancock, 2003). A study by Gillespie & Melby (2003) that consisted of a triangulated research design, which incorporates both qualitative and quantitative methods as well as using questionnaires, focus groups and interviews found that staff shortages were cited numerous times as a significant cause of anxiety and stress. The nurses specifically identified the use of agency staff as a concern as many nurses expressed the issue of spending valuable time assisting agency staff in locating equipment and explaining the way that particular ward operated (Gillespie & Melby, 2003). A nurse that was interviewed in Billter-Koponen & Freden’s (2005) study reported trying to bridge the gap of time lost from extra demands by coming in early, working through meal breaks, and staying back to work longer. Nurses interviewed in  Gillespie & Melby’s (2003) study also stated that ‘junior nurses’ were forced to take on roles beyond their experience. A focus group by the Australian Governmen t further reports levels of growth in turnover and the increased amount of more acute patients as a source of stress due to staff levels remaining stagnant while demands escalate (Chang & Hancock, 2003). Considering levels of demand are high and staff levels are not increasing as well as substituting agency staff or pressuring junior staff to meet senior roles these pressures would certainly contribute to anxiety, stress and potentially, burnout. Role ambiguity can be described as insufficient information about specific responsibilities and roles that a nurse must undertake (Chang & Hancock, 2003). Role ambiguity can occur in the form of objective ambiguity, which arises from ‘lack’ of information for that particular role, and subjective ambiguity, which is associated with the ‘social’ and ‘psychological’ features of ‘role performance’ (Kahn et al., 1964, as cited in Chang & Hancock, 2003). Chang & Hancock (2003) conducted a qualitative study of 110 tertiary nursing graduates from 13 institutions across New South Wales, Australia who work in one of four teaching hospitals about role stress in graduate nurses, the participants were surveyed during 2-3 months of working and then again between 10-11 months. Chang & Hancock (2003) reported the graduates experienced role ambiguity within the first few months of working and this continued throughout the 12 months as well as being a contributor to lower job satisfaction. However, Chang & Hancock’s (2003) study was limited due to the use of self-reporting by the graduates, which is subjective and not objective data. Patrick & Lavery (2007) suggests role ambiguity is an extra stressor as graduates endeavor to fulfill their expected roles whilst experiencing new challenges. Role overload typically occurs whilst graduates are learning time management skills and learning new roles (McVicar, 2003). Chang & Daly (2001, as cited in Chang & Hancock, 2003) identify that role overload can intensify the effects of role ambiguity. Chang & Hancock (2003) found that role overload became a larger contributor to stress than role ambiguity in nursing graduates after 10-11 months of working. Gillespie & Melby (2003) notes a significant difficulty for graduate nurses  as they transition into a hospital environment as opposed to learning at university, this ‘gap’ between skills learned in theory within university education and the ability of realistic demands within the hospital environment could present additional stress on the graduate nurse. Madjar et al., (1997 as cited in Chang & Hancock, 2003) describes this as the ‘theory-practice gap’, which causes a clash between personal standards and own values (Jasper, 1996; Reutter et al., 1997 as cited in Chang & Hancock, 2003). Patrick & Lavery’s (2007) study supports this ‘theory-practice gap’ and goes on to further state that nurses who acquired their nursing degree at a university have higher levels of emotional exhaustion and depersonalization than hospital-trained nurses. Graduate nurses also report low levels of confidence, lack of support, unrealistic expectations of other clinical staff, unexpected work situations, adjusting to shift work and the increase in responsibility as added sources of stress (Chang & Hancock, 2003; Kelly, 1998 as cited in Chang, Hancock & Johnson et al., 2005; Patrick & Lavery, 2007). Allenach & Jennings (1990, as cited in Chang & Hancock, 2003) explain that stress from these new challenges includes anxiety. It could be assumed that normal stressors that affect all nurses regardless of age and experience affect graduate nurses as well as other specific experience- related stressors. Patrick & Lavery (2007) found that age and experience was negatively associated with burnout, suggesting that young and inexperienced nurses have a higher rate of burnout compared to older and more experienced workers. This finding is consistent with Spooner-Lane & Patton’s (2007) study of 273 nursing staff, which reported age as a signif icant indicator of burnout. Jackson et al., (2002, as cited in Chang, Hancock & Johnson et al., 2005) suggest nurses are at risk of workplace violence in the forms of verbal or physical violence from their patients, relatives and staff. Participants from Chang, Daly & Hancock’s et al., (2006) study completed four different questionnaires regarding workplace stressors and findings suggested workplace conflict between nurses and physicians was a significant cause of stress. According to Ball et al., (2002, as cited in McVicar, 2003) conflict between staff has become a more important issue throughout the previous 10  years. Due to the nature of nurses’ work where patients’ emotions are highly sensitive, as they may be scared or have a higher expectation of required care than they are receiving, nurses can be venerable to violence and research by Carter (2000, as cited in Chang, Hancock & Johnson et al., 2005) comments workplace assault is more common for nurses than any other health professi onals. The consequences of workplace violence are increased levels of anxiety, high levels of sick leave, lower levels of job satisfaction, burnout and lower retention rates (Jackson et al., 2002 as cited in Chang, Hancock & Johnson et al., 2005; RCN, 2000 as cited in Gelsema & Van Der Doef et al., 2006). The flexibility of working hours and shift patterns was a significant cause of stress for nurses, it would be safe to assume that greater flexibility in working hours could possibly reduce stress, assist nurses in achieving a more balanced life as they contend with family and other personal pressures. Strategies to achieve greater flexibility in working hours will require a concentrated effort by management and staff to achieve ‘equity’ when allocating shifts and empowering nursing staff to have preferences regarding overtime and in particular, night shift (McVicar, 2003). The workload of nursing is consistently reported to lead to an increase in anxiety, stress and burnout, therefore lowering workload would be a reasonable intervention, however workload is a complex issue which includes determinants that can be influenced by the individual or organization in which they work (Gelsema & Van Der Doef et al., 2006). The main issue that needs to be addressed is to ensure staffing levels are sufficient for that particular setting, this would greatly reduce pressures relating to patient care and reduce the incidence of staff working outside of their roles (McVicar, 2003). Other measures such as time management skills and delegation skills may further assist in reducing workload pressures. Hayhurst, Saylor & Stuenkel (2005) recommends further research into workload pressures that are associated with specific specialty areas so that programs can be implemented to target the needs of that specialty. In Chang & Hancock’s (2003) study of role stress and role ambiguity in  Australian nursing graduates it was noted that graduates experienced a high level of role ambiguity in their transition from university to the workplace. A study by Mrayyan & Acorn (2004) assessed nursing students to determine causes of burnout and invited students to suggest solutions to stressors affecting burnout. The nursing students highlighted role ambiguity as a contributor to stress and suggested a comprehensive update of job descriptions that included the scope of practice, skills and experience needed, explanation of knowledge required and a regular assessment if changes of the job expectations change. Greenwood (2000. as cited in Chang, Hancock & Johnson et al., 2005) reported that preceptor programs, orientation programs, ‘open communication’, and staff development considerably aids graduates transition and experience of role ambiguity throughout the year. Violence in the workplace in the form of verbal abuse from other colleagues is a negative experience for nurses and is the cause of significant amounts of anxiety and stress Chang, Daly & Hancock et al., 2006). McVicar (2003) suggests that conflict with staff is the responsibility of management, nurses and all other professionals. Tourangeau & Cranley (2006) advise that relationships with co-workers have a potential influence on the retention of nurses and suggests further strategies, which include praise and recognition of co-workers as well as team building strategies that increase social interaction. A qualitative study by Abuairub (2004) surveyed 303 nurses from various locations throughout the world on the effect of social support from co-workers in which, participants who ‘perceived’ having additional social support from co-workers reported lower levels of stress. Abuairub (2004) comments that extra social support from co-workers may assist in creating a more friendly and pleasurable working environment as well as nurses feeling they could call on co-workers for assistance. Graduate nurses would benefit from social support as they are constantly challenged and require guidance from all staff. Chang, Daly & Hancock et al., (2006) further support the notion of social support by reporting that a positive social climate can decrease levels of stress and ‘prevent’ burnout. The leaders of the work  environment need to foster a more socially supportive culture by demonstrating co-operation, encouraging teamwork, social equality, supportive attitudes and ed ucation about stress education and helpful coping mechanisms (Abuairub, 2004; Hayhurst, Saylor & Stuenkel, 2005). Coping strategies can be defined as psychological and ‘behavioural efforts’ to control demands that are considered as â€Å"exceeding the resources of the person† and are either problem focused which attempts to deal with or alter the problem that is the source of the stress or emotionally focused which attempts to ease ‘emotional distress’ (Lazarus and Folkman 1984, p. 141 as cited in Chang, Daly & Hancock et al., 2006). Chang, Daly & Hancock et al., (2006) comment that many studies suggest problem-focused coping to be more effective in preventing burnout than emotion-focused coping. It would be beneficial to address coping strategies with nursing staff to educate them about different methods and to assist them in recognizing coping methods that are unhelpful so that they may employ personal control to their responses of stress (Chang, Bidwell & Huntington, 2007). These strategies would greatly assist nurses in reducing stress and burnout as well as providing graduate nurses with a firm foundation of clear guidelines and support. In conclusion, the nursing profession is under high demand as our population is growing older and the acuity of patients is increasing. To ensure sustainability of the nursing profession it is essential that graduate nurses are supported in their transition from university to a hospital environment so they continue to remain in the profession. To retain more experienced nurses there must be change within nursing environments and organizations to create a more flexible and supportive workplace. The main causes of anxiety, stress and burnout have been well documented, and it is the implementation of strategies that is lacking. Further investigation into the effectiveness of prevention strategies for burnout should be explored, as better working environments will encourage more people and ex-nurses into the profession and therefore lessening the staff shortages that directly contribute to anxiety, stress and burnout.

Censorship in Television and Movies: How It Has Changed Throughout the Years

1 1 Censorship in Television, Media, and Film throughout the Years: How Has it Changed? By Heather Soileau and Alexys Peron Abstract This project is about Censorship in television and movies: How it has changed throughout the years.This project will describe the past television shows and major movie productions’ use of nudity, profanity, and violence and what they did to protect censorship in our homes. This project will show that in our new day and age censorship is being pushed to the limit, the children of our nation will hear and see violence, profanity, and nudity through their lifetimes. Information for this project was secured from various sources such as, books, internet websites, and government documents. Also, included with the project will be interview from various adults, seniors, and children so that they can explain their view on censorship.This project intends to demonstrate that even though you trust you children to watch appropriate show we can’t help w hat comes on every channel. 4 4 The main purpose of this report is to learn and educate people of censorship over the years. Censorship is â€Å"the suppression of speech or other public communication which may be considered objectionable, harmful, sensitive, or inconvenient as determined by a government, media outlet, or other controlling body†. Many factors have influenced me and my partner to do our project on how censorship in American television, media, and films has changed over the years.Most of these influences come from lessons in our English I class about The Adventures of Huckleberry Finn and many other classic novels that have been changed and modified over the years. However, we found more of an interest in censorship on television, being that there is much more profanity on television than books. In this research, a few questions that were very important for us were, â€Å"Has censorship gotten stricter over the years, or less of a worry† and â€Å"How h ave people reacted to censorship over the years†.We found that in the past, women and society were very modest and it was very negative to speak harshly on television. Over the years, very foul words and actions have progressed to become tossed around and taken more lightly in America, such as in the popular antique television show â€Å"I Love Lucy†, the main character Lucy found out that she was expecting a baby with her husband. The television producers would not allow her to use the word â€Å"pregnant† on the screen. One of the main influences of foul language television is the channel MTV.MTV was largely debated over because of its inappropriate music videos and shows, which were accused of Satanism by many. The article on Wikipedia also states that MTV was criticized for being too â€Å"politically correct†. Many shows and movies these days are poorly censored, mostly sitcoms. The way most people with children react to poorly censored movies and sho ws in negative, because they don’t want their children being exposed to that. On the other hand, majority of young adults that don’t have any children find these shows and movies amusing.The show â€Å"Jersey Shore† which aired on MTV for 6 consecutive prosperous seasons, however, the show was protested against for a while because the town of Stanton Island, NJ thought that the show used stereotypical Italian people and that it poorly viewed Stanton Island. However, the viewer reacts to censorship depends on their age and personality. 5 5 6 6 Conclusion My partner and I have come to the conclusion that censorship has greatly changed over the years. Some features, such as more freedom, are better, but others, such as profanity, violence, and nudity, are causing society to change, and not for the better. 7 Bibliography Robicheaux, Ken. â€Å"Movie Censorship. † Movie Censorship. Key Light Enterprises, LLC, 2007. Web. 15 Jan. 2013. . Chicago Historical Socie ty. â€Å"Film Censorship. † Film Censorship. Encyclopedia of Chicago, 2005. Web. 13 Jan. 2013. . Corliss, Richard. â€Å"Censuring the Movie Censors. † Time. com. Time Entertainment Time Inc. , 02 Sept. 2006. Web. 18 Jan. 2013. . Anonymous Wikipedia Editors. â€Å"Censorship. † En. wikipedia. org. Wikimedia Foundation, Inc. , 18 Jan. 2013. Web. 28 Jan. 2013. . Anonymous Wikipedia Editors. â€Å"MTV. † En. wikipedia. org. Wikimedia Foundation, Inc. , 28 Jan. 2013. Web. 28 Jan. 2013. . Anonymous Wikipedia Editors. â€Å"Censorship on MTV. † Wikipedia. Wikimedia Foundation, 28 Jan. 2013. Web. 28 Jan. 2013. .

Parents Child Observation Essay - 1889 Words

Parent Child Observation The setting is a home environment of a friend; the environment is clean, warm and sunny. It is not set up for children however, there are no toys, the child does not have other children to play with, and there are about eight other adults present for a get together. The situation seems like it could be possibly boring to a four year old child as there are not any toys, he can not run around in the house, and is expected to sit still for a while. In terms of safety everything is fine. Since some of the adults are using equipment to detoxify, the child did have the supervision of his Mom while using the same equipment. In terms of intellectual stimulation realizing that the child might become bored the Mom†¦show more content†¦He did seem hurt at the way his mother was reacting. You could see the hurt on his face, and he kept seeking his mothers approval, and attention. When he did not get what he wanted the behavior escalated. (Heath, p. 291) The other friend Barbs got a very strict tone and raised her hand and told the child That is not the way you speak to your mother. You better go talk to her the right way. The child cried for a very long time. He then sought his mothers attention by attaching himself in an embrace wherever she went. At first she was receptive and consoled him, and then later on she became quite annoyed. He desired to be with her wherever she went. There were several theories I saw throughout this parent child interaction. I clearly saw attachment theory or attachment in the interaction. First, he kept asking for attention, and then proceeded to misbehave. Finally he became disrespectful towards his Mom. Finally, when he was scolded by Barbs he became very tearful and could not calm himself. The child needed mothers attention, and physical touch to calm down. The mother was very warm towards her son at first. It was obvious the mother and child were attached. 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