Month: April 2019

What is the influence of the topic, if any, on health care revenue and expense?

Description6 page paper not included cover and references, provide background information on the topic, focusing on its impact on the provision of health care services. Students will answer all of the following questions.
1). What is the influence of the topic, if any, on health care revenue and expense?
2.How does the topic impact nursing or how is nursing impacted by the topic?
3.Evaluate your community and/or facility to identify the presence of these health care settings, organizational structures, or models of care.
4.Reflect on possible health policy and structural changes related to your topic.
5.Summarize your conclusions and recommend a future direction for the health care system or for policy developmentI have a free proof reading credit and would like to apply it to this order.

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Explain health care costs in the United States.

Overview
Financial aspects of the health care industry are introduced in Week Four. As health care spending has continued to increase over the years, it is imperative that health care administrators understand how it is financed. In the United States, several funding sources are available: publicly funded insurance, privately funded insurance, cash, and charity care.

Insurance is the main source of financing in the health care industry today, and it is important to be knowledgeable of the types of health insurance models available. Some examples include marketplace plans, managed care plans, Medicare, Medicaid, Children?s Health Insurance Program (CHIP), Program of All-Inclusive Care for the Elderly (PACE), worker’s compensation, TRICARE, Veterans Health Administration, and Indian Health Services. As one learns about these different models, it is necessary to understand why they were created. Government funded health insurance models and programs were created to address a vulnerable population whose health care needs were not being met. Privately funded insurance models were purchased either by a group or an individual as a financial protection against loss and risk should a catastrophic health incident occur.

Regardless of the type of health care financing, challenges arise. Health care administrators are continually asked to find solutions to control costs and understand and implement legislative changes as they are adopted into law.

What you will cover

1. The Financial Aspects of Health Care
a. Explain health care costs in the United States.
1) Financing
a) Who pays for the health care services?
b) Who produces or provides the health care service?
c) How much the producer or provider will be paid for this health care service?
2) Primarily funded through insurance, which is a protection against loss and risk should a catastrophic incident occur
3) Ways health care costs are covered
a) Publicly funded insurance
b) Privately funded insurance
c) Individual out-of-pocket expenses
d) Charity care: care that is provided for free to needy individuals who cannot afford the costs associated with receiving care. After the Patient Protection and Affordable Care Act of 2010 (PPACA) was implemented, it is estimated that 25 million to 30 million people will still need charity care. According to Shi and Singh (2015), the following individuals might be in need of this type of financing:
(a) Illegal Immigrants
(b) Young, healthy individuals who choose not to purchase health care insurance
(c) People who do not file income taxes and do not qualify for Medicaid
(d) Exempt people under the PPACA
b. Identify types of health insurance.
1) The marketplace (www.healthcare.gov) exchange divides insurance into five categories of plans based on cost: bronze, silver, gold, platinum, and catastrophic.
2) Private insurance can be obtained through a group or by an individual.
a) Managed care plans: insurance designed to try to control costs by setting up a network of providers and services. Flexibility of options is associated with cost in these plans.
(a) Health maintenance organization (HMO): must see a primary care physician before seeing a specialist (referral)
a. Staff model: hires physicians and providers as employees to perform services for members of the HMO
b. Group model: contracts with a group of physicians and providers to exclusively perform services for members of the HMO
c. Network model: contract with a group of physicians and providers to perform care for covered patients, but they can also see patients who are not members of the HMO
d. Independent practice association (IPA): contract with a group of physicians and providers in private practice to see HMO patients at a contracted rate per visit
(b) Preferred provider model (PPO): Networks are established with physicians and providers who agree to see HMO patients at a reduced or discounted fee schedule. No referrals are needed to see a specialist. Higher costs to patients if they seek treatment outside of the network.
(c) Exclusive provider organization (EPO): Similar to a PPO, but restricts members to the network or exclusive provider when seeking care
(d) Physician hospital organizations (PHO): When a hospital, surgical center, or other medical providers contract to provide health care services for an HMO’s members
(e) Point-of-service model (POS): Hybrid of HMO and PPO models. Member costs are lowered if they seek services within the network, but are not restricted to using only network providers
(f) Provider-sponsored organization (PSO): Physician-provider organizations created to contract with purchases to deliver health care services. They assume insurance risk for their beneficiaries.
(g) High-deductible health plans and savings options (HDHPs) or consumer- driven health care: No restrictions to networks and can self-refer to see a specialist. Large out-of-pocket expenses to member as deductible must be met before insurance benefits begin to cover costs.
3) Government?publicly funded insurance plans are often a type of managed care model.
a) Medicare
(a) Eligibility is determined by the federal government. The plan currently covers individuals 65 years of age and older. Regardless of age, it covers disabled people and those with end-stage renal disease.
a. Part A?hospital insurance that covers hospital care, skilled nursing facility care, hospice, and home health services.
i. Social Security taxes
ii. Medicare trust fund
iii. Noncontributory
b. Part B?voluntary medical insurance that is used to cover physician services, clinical research, ambulance services, durable medical equipment, mental health, inpatient, outpatient, partial hospitalization, getting second opinion before surgery, and limited outpatient prescription drugs.
i. Part B premiums
ii. General tax revenues
iii. Contributory
c. Part C?Medicare Advantage is a managed care model that covers services provided in Part A and Part B.
ii. Part B premiums
iii.ii. General tax revenues
iv.iii. Contributory: often more than Part B
d. Part D?prescription drug benefit created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
i. Prescription drug coverage
ii. Premiums
iii. Choices
b) Medicaid
(a) Definition and eligibility set by each state
(b) About 40% of long-term care spending
(c) Each state designs and administers
(d) Minimal federal requirement for each state
(e) States encouraged to expand Medicaid through PPACA but not mandated
(f) Funded through joint federal and state contribution
c) The Children?s Health Insurance Program, formerly the State Children?s Health Insurance Program
(a) Low-cost health insurance for children who are not eligible for Medicaid but whose guardians cannot afford private health insurance
(b) Financed jointly by federal and state governments and administered by the states
(c) States determine eligibility, benefits, and payments
d) Program of All-Inclusive Care for the Elderly (PACE) (www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html)
(a) Authorized by the Balanced Budget Act of 1997
(b) Helps individuals in need of nursing home level of care to receive these services in their home, community, or a PACE center
(c) Implemented at the state level; however, not all states offer this program
e) Workers? compensation
(a) Paid 100% by the employer
(b) Covers job-related injuries or illness
(c) State run program
f) Military?TRICARE
(a) Military Health System Review is a 2014 report that examines the military health care system. (http://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/MHS-Review)
(b) TRICARE covers active duty, disabled, and retired military
(c) Depending on plan selected and military status, there may be enrollment fees, deductibles, and co-pays
g) Veterans Health Administration
(a) Treats veterans who meet eligibility requirements
(b) If eligible, assigned priority group (1-8) to determine enrollment
(c) Treat family members of veterans with war-related injuries and disabilities
Programs and coverage http://www.va.gov/H

? Summarize each video in your own words with 50 word count or more.

? Films Media Group (2009). Employer Provided Health Insurance (02:58) From Title: Sick Around America.
? Films Media Group (2008). Health Insurance Considerations (01:28) From Title: Reinventing Healthcare-A Fred Friendly Seminar.
? Films Media Group (2005). Reasons for Rising Health Care Costs (01:56) From Title: Peter Jennings Reporting: Breakdown?America?s Health Insurance Crisis.

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How much have things changed since Wollstonecraft?s day? Are the problems that beset women in the eighteenth century completely solved?

Create a new thread and write a response to one of the following questions:

1. How much have things changed since Wollstonecraft?s day? Are the problems that beset women in the eighteenth century completely solved? Are you surprised at what Wollstonecraft says about the situation of women?
2. The question of what a woman?s duties should be pervades the selection and especially dominates paragraphs 15, 16, and 17. As clearly as possible, clarify what Wollstonecraft feels a woman?s duties are. Do you agree with her views?
3. Ironically, Wollstonecraft died in childbirth. Establish Wollstonecraft?s attitudes toward motherhood, particularly in reference to paragraphs 7 and 16. Have these attitudes changed radically in our time? Do you or your friends share her basic views? By using episodicalobservations, make a case for accepting or rejecting her views.

mary Wollstonecraft (1759?1797). A Vindication of the Rights of Woman. 1792.
Chap. IX. Of the Pernicious Effects Which Arise from the Unnatural Distinctions Established in Society.

FROM the respect paid to property flow, as from a poisoned fountain, most of the evils and vices which render this world such a dreary scene to the contemplative mind. For it is in the most polished society that noisome reptiles and venomous serpents lurk under the rank herbage; and there is voluptuousness pampered by the still sultry air, which relaxes every good disposition before it ripens into virtue. 1
One class presses on another; for all are aiming to procure respect on account of their property: and property, once gained, will procure the respect due only to talents and virtue. Men neglect the duties incumbent on man, yet are treated like demi-gods; religion is also separated from morality by a ceremonial veil, yet men wonder that the world is almost, literally speaking, a den of sharpers or oppressors. 2
There is a homely proverb, which speaks a shrewd truth, that whoever the devil finds idle he will employ. And what but habitual idleness can hereditary wealth and titles produce? For man is so constituted that he can only attain a proper use of his faculties by exercising them, and will not exercise them unless necessity, of some kind, first set the wheels in motion. Virtue likewise can only be acquired by the discharge of relative duties; but the importance of these sacred duties will scarcely be felt by the being who is cajoled out of his humanity by the flattery of sycophants. There must be more equality established in society, or morality will never gain ground, and this virtuous equality will not rest firmly even when founded on a rock, if one half of mankind are chained to its bottom by fate, for they will be continually undermining it through ignorance or pride. 3
It is vain to expect virtue from women till they are, in some degree, independent of men; nay, it is vain to expect that strength of natural affection, which would make them good wives and mothers. Whilst they are absolutely dependent on their husbands they will be cunning, mean, and selfish, and the men who can be gratified by the fawning fondness of spaniel-like affection, have not much delicacy, for love is not to be bought, in any sense of the words, its silken wings are instantly shrivelled up when any thing beside a return in kind is sought. Yet whilst wealth enervates men; and women live, as it were, by their personal charms, how can we expect them to discharge those ennobling duties which equally require exertion and self-denial. Hereditary property sophisticates the mind, and the unfortunate victims to it, if I may so express myself, swathed from their birth, seldom exert the locomotive faculty of body or mind; and, thus viewing every thing through one medium, and that a false one, they are unable to discern in what true merit and happiness consist. False, indeed, must be the light when the drapery of situation hides the man, and makes him stalk in masquerade, dragging from one scene of dissipation to another the nerveless limbs that hang with stupid listlessness, and rolling round the vacant eye which plainly tells us that there is no mind at home. 4
I mean, therefore, to infer that the society is not properly organized which does not compel men and women to discharge their respective duties, by making it the only way to acquire that countenance from their fellow-creatures, which every human being wishes some way to attain. The respect, consequently, which is paid to wealth and mere personal charms, is a true north-east blast, that blights the tender blossoms of affection and virtue. Nature has wisely attached affections to duties, to sweeten toil, and to give that vigour to the exertions of reason which only the heart can give. But, the affection which is put on merely because it is the appropriated insignia of a certain character, when its duties are not fulfilled, is one of the empty compliments which vice and folly are obliged to pay to virtue and the real nature of things. 5
To illustrate my opinion, I need only observe, that when a woman is admired for her beauty, and suffers herself to be so far intoxicated by the admiration she receives, as to neglect to discharge the indispensable duty of a mother, she sins against herself by neglecting to cultivate an affection that would equally tend to make her useful and happy. True happiness, I mean all the contentment, and virtuous satisfaction, that can be snatched in this imperfect state, must arise from well regulated affections; and an affection includes a duty. Men are not aware of the misery they cause, and the vicious weakness they cherish, by only inciting women to render themselves pleasing; they do not consider that they thus make natural and artificial duties clash, by sacrificing the comfort and respectability of a woman’s life to voluptuous notions of beauty, when in nature they all harmonize. 6
Cold would be the heart of a husband, were he not rendered unnatural by early debauchery, who did not feel more delight at seeing his child suckled by its mother, than the most artful wanton tricks could ever raise; yet this natural way of cementing the matrimonial tie, and twisting esteem with fonder recollections, wealth leads women to spurn. To preserve their beauty, and wear the flowery crown of the day, that gives them a kind of right to reign for a short time over the sex, they neglect to stamp impressions on their husbands’ hearts, that would be remembered with more tenderness when the snow on the head began to chill the bosom, than even their virgin charms. The maternal solicitude of a reasonable affectionate woman is very interesting, and the chastened dignity with which a mother returns the caresses that she and her child receive from a father who has been fulfilling the serious duties of his station, is not only a respectable, but a beautiful sight. So singular, indeed, are my feelings, and I have endeavoured not to catch factitious ones, that after having been fatigued with the sight of insipid grandeur and the slavish ceremonies that with cumberous pomp supplied the place of domestic affections, I have turned to some other scene to relieve my eye by resting it on the refreshing green every where scattered by nature. I have then viewed with pleasure a woman nursing her children, and discharging the duties of her station with, perhaps, merely a servant maid to take off her hands the servile part of the household business. I have seen her prepare herself and children, with only the luxury of cleanliness, to receive her husband, who returning weary home in the evening found smiling babes and a clean hearth. My heart has loitered in the midst of the group, and has even throbbed with sympathetic emotion, when the scraping of the well known foot has raised a pleasing tumult. 7
Whilst my benevolence has been gratified by contemplating this artless picture, I have thought that a couple of this description, equally necessary and independent of each other, because each fulfilled the respective duties of their station, possessed all that life could give.?Raised sufficiently above abject poverty not to be obliged to weigh the consequence of every farthing they spend, and having sufficient to prevent their attending to a frigid system of economy, which narrows both heart and mind. I declare, so vulgar are my conceptions, that I know not what is wanted to render this the happiest as well as the most respectable situation in the world, but a taste for literature, to throw a little variety and interest into social converse, and some superfluous money to give to the needy and to buy books. For it is not pleasant when the heart is opened by compassion and the head active in arranging plans of usefulness, to have a prim urchin continually twitching back the elbow to prevent the hand from drawing out an almost empty purse, whispering at the same time some prudential maxim about the priority of justice. 8
Destructive, however, as riches and inherited honours are to the human character, women are more debased and cramped, if possible, by them, than men, because men may still, in some degree, unfold their faculties by becoming soldiers and statesmen. 9
As soldiers, I grant, they can now only gather, for the most part, vain glorious laurels, whilst they adjust to a hair the European balance, taking especial care that no bleak northern nook or sound incline the beam. But the days of true heroism are over, when a citizen fought for his country like a Fabricius or a Washington, and then returned to his farm to let his virtuous fervour run in a more placid, but not a less salutary, stream. No, our British heroes are oftener sent from the gaming table than from the plow; and their passions have been rather inflamed by hanging with dumb suspense on the turn of a die, than sublimated by panting after the adventurous march of virtue in the historic page. 10
The statesman, it is true, might with more propriety quit the Faro Bank, or card-table, to guide the helm, for he has still but to shuffle and trick. The whole system of British politics, if system it may courteously be called, consisting in multiplying dependents and contriving taxes which grind the poor to pamper the rich; thus a war, or any wild goose chace is, as the vulgar use the phrase, a lucky turn-up of patronage for the minister, whose chief merit is the art of keeping himself in place. 11
It is not necessary then that he should have bowels for the poor, so he can secure for his family the odd trick. Or should some shew of respect, for what is termed with ignorant ostentation an Englishman’s birth-right, be expedient to bubble the gruff mastiff that he has to lead by the nose, he can make an empty shew, very safely, by giving his single voice, and suffering his light squadron to file off to the other side. And when a question of humanity is agitated he may dip a sop in the milk of human kindness, to silence Cerberus, and talk of the interest which his heart takes in an attempt to make the earth no longer cry for vengeance as it sucks in its children’s blood, though his cold hand may at the very moment rivet their chains, by sanctioning the abominable traffick. A minister is no longer a minister than while he can carry a point, which he is determined to carry.?Yet it is not necessary that a minister should feel like a man, when a bold push might shake his seat. 12
But, to have done with these episodical observations, let me return to the more specious slavery which chains the very soul of woman, keeping her for ever under the bondage of ignorance. 13
The preposterous distinctions of rank, which render civilization a curse, by dividing the world between voluptuous tyrants, and cunning envious dependents, corrupt, almost equally, every class of people, because respectability is not attached to the discharge of the relative duties of life, but to the station, and when the duties are not fulfilled the affections cannot gain sufficient strength to fortify the virtue of which they are the natural reward. Still there are some loop-holes out of which a man may creep, and dare to think and act for himself; but for a woman it is an herculean task, because she has difficulties peculiar to her sex to overcome, which require almost super-human powers. 14
A truly benevolent legislator always endeavours to make it the interest of each individual to be virtuous; and thus private virtue becoming the cement of public happiness, an orderly whole is consolidated by the tendency of all the parts towards a common centre. But, the private or public virtue of woman is very problematical; for Rousseau, and a numerous list of male writers, insist that she should all her life be subjected to a severe restraint, that of propriety. Why subject her to propriety?blind propriety, if she be capable of acting from a nobler spring, if she be an heir of immortality? Is sugar always to be produced by vital blood? Is one half of the human species, like the poor African slaves, to be subject to prejudices that brutalize them, when principles would be a surer guard, only to sweeten the cup of man? Is not this indirectly to deny woman reason? for a gift is a mockery, if it be unfit for use. 15
Women are, in common with men, rendered weak and luxurious by the relaxing pleasures which wealth procures; but added to this they are made slaves to their persons, and must render them alluring that man may lend them his reason to guide their tottering steps aright. Or should they be ambitious, they must govern their tyrants by sinister tricks, for without rights there cannot be any incumbent duties. The laws respecting woman, which I mean to discuss in a future part, make an absurd unit of a man and his wife; and then, by the easy transition of only considering him as responsible, she is reduced to a mere cypher. 16
The being who discharges the duties of its station is independent; and, speaking of women at large, their first duty is to themselves as rational creatures, and the next, in point of importance, as citizens, is that, which includes so many, of a mother. The rank in life which dispenses with their fulfilling this duty, necessarily degrades them by making them mere dolls. Or, should they turn to something more important than merely fitting drapery upon a smooth block, their minds are only occupied by some soft platonic attachment; or, the actual management of an intrigue may keep their thoughts in motion; for when they neglect domestic duties, they have it not in their power to take the field and march and counter-march like soldiers, or wrangle in the senate to keep their faculties from rusting. 17
I know that as a proof of the inferiority of the sex, Rousseau has exultingly exclaimed, How can they leave the nursery for the camp!?And the camp has by some moralists been termed the school of the most heroic virtues; though, I think, it would puzzle a keen casuist to prove the reasonableness of the greater number of wars that have dubbed heroes. I do not mean to consider this question critically; because, having frequently viewed these freaks of ambition as the first natural mode of civilization, when the ground must be torn up, and the woods cleared by fire and sword, I do not choose to call them pests; but surely the present system of war has little connection with virtue of any denomination, being rather the school of finesse and effeminacy, than of fortitude. 18
Yet, if defensive war, the only justifiable war, in the present advanced state of society, where virtue can shew its face and ripen amidst the rigours which purify the air on the mountain’s top, were alone to be adopted as just and glorious, the true heroism of antiquity might again animate female bosoms.?But fair and softly, gentle reader, male or female, do not alarm thyself, for though I have contracted the character of a modern soldier with that of a civilized woman, I am not going to advise them to turn their distaff into a musket, though I sincerely wish to see the bayonet concerted into a pruning-hook. I only recreated an imagination, fatigued by contemplating the vices and follies which all proceed from a feculent stream of wealth that has muddied the pure rills of natural affection, by supposing that society will some time or other be so constituted, that man must necessarily fulfil the duties of a citizen, or be despised, and that while he was employed in any of the departments of civil life, his wife, also an active citizen, should be equally intent to manage her family, educate her children, and assist her neighbours. 19
But, to render her really virtuous and useful, she must not, if she discharge her civil duties, want, individually, the protection of civil laws; she must not be dependent on her husband’s bounty for her subsistence during his life, or support after his death?for how can a being be generous who has nothing of its own? or, virtuous, who is not free? The wife, in the present state of things, who is faithful to her husband, and neither suckles nor educates her children, scarcely deserves the name of a wife, and has no right to that of a citizen. But take away natural rights, and there is of course an end of duties. 20
Women thus infallibly become only the wanton solace of men, when they are so weak in mind and body, that they cannot exert themselves, unless to pursue some frothy pleasure, or to invent some frivolous fashion. What can be a more melancholy sight to a thinking mind, than to look into the numerous carriages that drive helter-skelter about this metropolis in a morning full of pale-faced creatures who are flying from themselves. I have often wished, with Dr. Johnson, to place some of them in a little shop with half a dozen children looking up to their languid countenances for support. I am much mistaken, if some latent vigour would not soon give health and spirit to their eyes, and some lines drawn by the exercise of reason on the blank cheeks, which before were only undulated by dimples, might restore lost dignity to the character, or rather enable it to attain the true dignity of its nature. Virtue is not to be acquired even by speculation, much less by the negative supineness that wealth naturally generates. 21
Besides, when poverty is more disgraceful than even vice, is not morality cut to the quick? Still to avoid misconstruction, though I consider that women in the common walks of life are called to fulfil the duties of wives and mothers, by religion and reason, I cannot help lamenting that women of a superiour cast have not a road open by which they can pursue more extensive plans of usefulness and independence. I may excite laughter, by dropping an hint, which I mean to pursue, some future time, for I really think that women ought to have representatives, instead of being arbitrarily governed without having any direct share allowed them in the deliberations of government. 22
But, as the whole system of representation is now, in this country, only a convenient handle for despotism, they need not complain, for they are as well represented as a numerous class of hard working mechanics, who pay for the support of royalty when they can scarcely stop their children’s mouths with bread. How are they represented whose very sweat supports the splendid stud of an heir apparent, or varnishes the chariot of some female favourite who looks down on shame? Taxes on the very necessaries of life, enable an endless tribe of idle princes and princesses to pass with stupid pomp before a gaping crowd, who almost worship the very parade which costs them so dear. This is mere gothic grandeur, something like the barbarous useless parade of having sentinels on horseback at Whitehall, which I could never view without a mixture of contempt and indignation. 23
How strangely must the mind be sophisticated when this sort of state impresses it! But, till these monuments of folly are levelled by virtue, similar follies will leaven the whole mass. For the same character, in some degree, will prevail in the aggregate of society: and the refinements of luxury, or the vicious repinings of envious poverty, will equally banish virtue from society, considered as the characteristic of that society, or only allow it to appear as one of the stripes of the harlequin coat, worn by the civilized man. 24
In the superiour ranks of life, every duty is done by deputies, as if duties could ever be waved, and the vain pleasures which consequent idleness forces the rich to pursue, appear so enticing to the next rank, that the numerous scramblers for wealth sacrifice every thing to tread on their heels. The most sacred trusts are then considered as sinecures, because they were procured by interest, and only sought to enable a man to keep good company.Women, in particular, all want to be ladies. Which is simply to have nothing to do, but listlessly to go they scarcely care where, for they cannot tell what. 25
But what have women to do in society? I may be asked, but to loiter with easy grace; surely you would not condemn them all to suckle fools and chronicle small beer! No. Women might certainly study the art of healing, and be physicians as well as nurses. And midwifery, decency seems to allot to them, though I am afraid the word midwife, in our dictionaries, will soon give place to accoucheur, and one proof of the former delicacy of the sex be effaced from the language. 26
They might, also, study politics, and settle their benevolence on the broadest basis; for the reading of history will scarcely be more useful than the perusal of romances, if read as mere biography; if the character of the times, the political improvements, arts, &c. be not observed. In short, if it be not considered as the history of man; and not of particular men, who filled a niche in the temple of fame, and dropped into the black rolling stream of time, that silently sweeps all before it, into the shapeless void called?eternity.?For shape, can it be called, ‘that shape hath none?’ 27
Business of various kinds, they might likewise pursue, if they were educated in a more orderly manner, which might save many from common and legal prostitution. Women would not then marry for a support, as men accept of places under government, and neglect the implied duties; nor would an attempt to earn their own subsistence, a most laudable one! sink them almost to the level of those poor abandoned creatures who live by prostitution. For are not milliners and mantua-makers reckoned the next class? The few employments open to women, so far from being liberal, are menial; and when a superiour education enables them to take charge of the education of children as governesses, they are not treated like the tutors of sons, though even clerical tutors are not always treated in a manner calculated to render them respectable in the eyes of their pupils, to say nothing of the private comfort of the individual. But as women educated like gentlewomen, are never designed for the humiliating situation which necessity sometimes forces them to fill; these situations are considered in the light of a degradation; and they know little of the human heart, who need to be told, that nothing so painfully sharpens the sensibility as such a fall in life. 28
Some of these women might be restrained from marrying by a proper spirit of delicacy, and others may not have had it in their power to escape in this pitiful way from servitude; is not that government then very defective, and very unmindful of the happiness of one half of its members, that does not provide for honest, independent women, by encouraging them to fill respectable stations? But in order to render their private virtue a public benefit, they must have a civil existence in the state, married or single; else we shall continually see some worthy woman, whose sensibility has been rendered painfully acute by undeserved contempt, droop like ‘the lily broken down by a plow-share.’ 29
It is a melancholy truth; yet such is the blessed effect of civilization! the most respectable women are the most oppressed; and, unless they have understandings far superiour to the common run of understandings, taking in both sexes, they must, from being treated like contemptible beings, become contemptible. How many women thus waste life away the prey of discontent, who might have practised as physicians, regulated a farm, managed a shop, and stood erect, supported by their own industry, instead of hanging their heads surcharged with the dew of sensibility, that consumes the beauty to which it at first gave lustre; nay, I doubt whether pity and love are so near akin as poets feign, for I have seldom seen much compassion excited by the helplessness of females, unless they were fair; then, perhaps, pity was the soft handmaid of love, or the harbinger of lust. 30
How much more respectable is the woman who earns her own bread by fulfilling any duty, than the most accomplished beauty!?beauty did I say!?so sensible am I of the beauty of moral loveliness, or the harmonious propriety that attunes the passions of a well-regulated mind, that I blush at making the comparison; yet I sigh to think how few women aim at attaining this respectability by withdrawing from the giddy whirl of pleasure, or the indolent calm that stupefies the good sort of women it sucks in. 31
Proud of their weakness, however, they must always be protected, guarded from care, and all the rough toils that dignify the mind.?If this be the fiat of fate, if they will make themselves insignificant and contemptible, sweetly to waste ‘life away’ let them not expect to be valued when their beauty fades, for it is the fate of the fairest flowers to be admired and pulled to pieces by the careless hand that plucked them. In how many ways do I wish, from the purest benevolence, to impress this truth on my sex; yet I fear that they will not listen to a truth that dear bought experience has brought home to many an agitated bosom, nor willingly resign the privileges of rank and sex for the privileges of humanity, to which those have no claim who do not discharge its duties. 32
Those writers are particularly useful, in my opinion, who make man feel for man, independent of the station he fills, or the drapery of factitious sentiments. I then would fain convince reasonable men of the importance of some of my remarks, and prevail on them to weigh dispassionately the whole tenor of my observations.?I appeal to their understandings; and, as a fellow-creature, claim, in the name of my sex, some interest in their hearts. I entreat them to assist to emancipate their companion, to make her a help meet for them! 33
Would men but generously snap our chains, and be content with rational fellowship instead of slavish obedience, they would find us more observant daughters, more affectionate sisters, more faithful wives, more reasonable mothers?in a word, better citizens. We should then love them with true affection, because we should learn to respect ourselves; and the peace of mind of a worthy man would not be interrupted by the idle vanity of his wife, nor the babes sent to nestle in a strange bosom, having never found a home in their mother’s.

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Using the ?Levels of Evidence? chart provide in the attachment below, read each abstract and then identify the level of evidence of the study. In a brief comment, explain your answer.

Description
Using the ?Levels of Evidence? chart provide in the attachment below, read each abstract and then identify the level of evidence of the study. In a brief comment, explain your answer.

Learning Activity for Identifying Levels of Evidence

Level Description

Level I Systematic Reviews (Integrative/Meta-analyses) CPGs (Clinical practice guidelines) based on Systematic Reviews/Large Multi-Center Clinical Trials

Level II Single Experimental Study (RCTs)

Level III Quasi-Experimental Studies

Level IV Non-Experimental Studies

Level V Case Report/Program Evaluation/Narrative Literature Reviews

Level VI Opinions of Respected Authorities

@ 2010 by Rona F. Levin and Jeffrey M. Keefer
Adapted from the work of Stetler, Morsi, Rucki, Broughton, Corrigan, Fitzgerald, et al. (1998); Melnyk and Fineout-Overholt (2011); Levin (2008).

Using the ?Levels of Evidence? chart above, read each abstract and then identify the level of evidence of the study. In a brief comment, explain your answer.
1. McDonald, M. V., Pezzin, L. E., Feldman, P. H,, Murtaugh, C. M., & Peng, T. R. (2005). Can just-in-time, evidence-based ?reminders? improve pain management among home health care nurses and their patients. Journal of Pain & Symptom Management, 25(5), 474-488.

Abstract: The purpose of this randomized, controlled home care intervention was to test the effectiveness of two nurse-targeted e-mail-based interventions to increase home care nurses? adherence to pain assessment and management guideline, and to improve patient outcomes. Nurses from a large urban nonprofit home care organization were assigned to usual care or one to two interventions upon identification of an eligible cancer patient with pain. The basic intervention consisted of a patient-specific, one-time e-mail reminder highlighting six pain-specific clinical recommendations. The augmented intervention supplemented the initial e-mail reminder with provider prompts, patient education material, and clinical nurse specialist outreach. Over 300 nurses were randomized and outcomes of 673 of their patients were reviewed. Data collection involved clinical record abstraction of nurse care practices and patient interviews completed approximately 45 days after start of care. The intervention had limited effect on nurse-documented care practices but patient outcomes were positively influenced. Patients in the augmented group improved significantly over the control group in ratings of pain intensity at its worst, whereas patients in the basic group had better ratings of pain intensity on average. Other outcome measures were also positively influenced but did not reach statistical significance. Our findings suggest that although reminders have some role in improving cancer pain management, a more intensive approach is needed for a generalized, nursing workforce with limited recent exposure to state-of-the-art pain management practices.
a. Level I
b. Level II
c. Not applicable
d. Level IV
e. Level V/VI

2. Clark, L., Fink, R., Pennington, K., & Jones, K. (2006). Nurses? reflections on pain management in a nursing home setting. Pain Management Nursing, 7(2), 71-77.

Abstract: Achieving optimal and safe pain-management practices in the nursing home setting continues to challenge administrators, nurses, physicians, and other health care providers. Several factors in nursing home settings complicate the conduct of clinical process improvement research. The purpose of this qualitative study was to explore the perceptions of a sample of Colorado nursing home staff who participated in a study to develop and evaluate a multifaceted pain-management intervention. Semi-structured interviews were conducted with 103 staff from treatment and control nursing homes, audiotaped, and content analyzed. Staff identified changes in their knowledge and attitudes about pain, and their pain assessment and management practices. Progressive solutions and suggestions for changing practice include establishing an internal pain team and incorporating nursing assistants into the care planning process. Quality improvement strategies can accommodate the special circumstances of nursing home care and build the capacity of the nursing homes to initiate and monitor their own process improvement programs using a participatory research approach.
a. Level I
b. Not applicable
c. Level III
d. Level IV
e. Level V/VI

3. Dewar, A. (2006). Assessment and management of chronic pain in the older person living in the community. Australian Journal of Advanced Nursing, 24(1), 33-38.

Abstract: This paper reviews the nursing research literature on chronic pain in the older person living in the community and suggests areas for future research.
Background: Chronic pain is a pervasive and complex problem that is difficult to treat appropriately. Nurses managing chronic pain in older people in domiciliary/home/community nursing settings face many challenges. To provide care, the many parameters of chronic pain, which include the physical as well as the psychosocial impact and the effect of pain on patients and their families, must be carefully assessed. Beliefs of the older person about pain and pain management are also important.
Method: Relevant nursing studies were searched using CINAHL, Cochrane Database of Systematic Reviews, and Embase and PubMed databases using key words about pain and the older person that were appropriate to each database.
Results: Tools to assess pain intensity in the older person have been studies, but there has been less research on the other parameters of pain assessment or how the older person manages pain. An effective nurse-patient relationship is an important component of this process and one that needs more study. Few research studies have focused on how nurses can be assisted, or on the challenges nurses face when managing this vulnerable population.
Conclusion: A broad approach at the organizational level will assist nurses to manage this helath care issue.
a. Level I
b. Level II
c. Not applicable
d. Level IV
e. Level V/VI

4. Vallerand, A. H., Collins-Bohler, D., Templin, T., & Hasenau, S. M. (2007). Knowledge of and barriers to pain management in caregivers of cancer patient receiving homecare. Cancer Nursing, 30(1), 31-37.
Abstract: Cancer treatment is increasingly being provided in outpatient settings, requiring many of the responsibilities for patient care to be undertaken by family caregivers. Pain is one of the most frequent and distressing symptoms experienced by cancer patients and is a primary concern for the family caregiver. Caregivers struggle with many issues that lead to inadequate management of cancer pain. The purpose of this study was too determine pain management knowledge and examine concerns about reporting pain and using analgesics in a sample of primary family caregivers of cancer patients receiving homecare. The Barriers Questionnaire and the Family Pain Questionnaire were administered to 46 primary caregivers. Between 46% and 94% of the caregivers reported having at least some agreement with the various concerns that are barriers to reporting pain and using analgesics, and up to 15% reported having strong agreement. The areas of greatest concern were about opioid-related side effects, fears of addiction, and the belief that pain meant disease progression. Results showed that caregivers with higher pain management knowledge had significantly fewer barriers to cancer pain management, supporting the importance of increasing caregivers? knowledge of management of cancer pain.
a. Nor applicable
b. Level II
c. Level III
d. Level IV
e. Level V/VI

5. Haynes, R. B., Yao, X., Degani, A., Kripalani, S., Garg, A., & McDonald, H. P. (2005). Interventions for enhancing medication adherence (Article No. CD000011). Cochrane Database of Systematic Reviews Issue 4. DOI: 10.1002114651858.CD00001 1.pub2.

Background: People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.
Objectives: To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for fmedications for medical problems, including mental disorders but not addictions.
Search strategy: Computerized searches were updated to September 2004 without language restriction in Medline, Embase, CINAHL, the Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO, and Sociofile. We also reviewed bibliographies in articles in patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

a. Level I
b. Level II
c. Not applicable
d. Level IV
e. Level V/VI

6. Feng, C., Chu, H., Chen, C., Chang, Y., Chen, T., Chou, Y., ? Chou, K. (2012). The effect of cognitive behavioral group therapy for depression: A meta-analysis 2000 to 2010. Worldviews of Evidence-Based of Nursing, 9(11).
The goals of the meta-analysis were to investigate the overall effectiveness of cognitive behavioral group therapy (CBGT) for depression and relapse prevention in depression from 2000 to 2010, and to investigate how certain variables (e.g., group size, therapist, experience) could mediate the size of the treatment effect. The sample of studies was from the published literature during 2000 to 2010. The quality of the studies was assessed using the Cochrane Collaboration Guidelines. Thirty-two studies were included in the meta-analysis. CBGT showed an immediate and continuous effect over 6 months, but no continuous effect after 6 months. Also, the CBGT lowered relapse rate of depression. Researchers and clinicians should take note that CBGT has a moderate effect on level of depression and a small effect on relapse rate of depression. The results of this study suggest that the patient should receive a course of therapy at least every 6 months.
a. Level I
b. Level II
c. Not applicable
d. Level IV
e. Level V/VI

7. Marek, K. D., Popejoy, L., Petroski, G., & Rantz, M. (2006). Nurse care coordination in community-based long-term care. Journal of Nursing Scholarship, 38(1), 80-86.

Abstract: To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options (MCO).
Design: A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination (NCC) and 30 clients who received MCO services but no nurse care coordination.
Methods: Nurse care coordination consists of the assignment of a registered nurse who provides home care services for both the MCO program and Medicare hone health services. Two standardized datasets, the Minimum Data Set (MDS) for resident care and planning and the Outcome and Assessment Information Set (OASIS) were collected at baseline, 6 months, and 12 months on both groups. Cognition was measured with the MDS Cognitive Performance Scale (CPS), activities of daily living (ADL) as the sum of five MDS ADL items, depression with the MDS-Depression Rating Scale, and incontinence and pressure ulcers with specific MDS items. Three OASIS items were used to measure pain, dyspnea, and medication management. The Cochran-Mantel-Haenszel (CMH) method was used to test the association between the NCC intervention and clinical outcomes.
Findings: At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain, dyspnea, and ADL [activities of daily living]. No significant differences between groups were found in eight clinical outcome measures at 6 months.
Conclusions: Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults.
a. Not applicable
b. Level II
c. Level III
d. Level IV
e. Level V/VI

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Assume that a surgeon who is not in the PPO network actually performed the surgery. Will James?s policy cover this fee? Explain your answer.

Explain the various definitions of disability that are found in disability-income insurance.
b. Briefly explain the following disability-income insurance provisions: Residual disability, Benefit period, Elimination period, Waiver of premium.

2. Identify five major provisions of the Affordable Care Act that will have an impact on individuals and families. Document your source and attach a copy of your information.

3. a. Describe the basic characteristics of individual medical insurance.
b. Why are deductibles and coinsurance used in medical expense policies?

4. Briefly explain the major characteristics of a health savings account (HSA).

5. Identify the optional benefits that can be added to a disability-income policy.

6. Explain the following renewal provisions that may appear in individual health insurance policies:
a. Guaranteed renewable
b. Noncancellable
c. Conditionally renewable

7. James, age 28, is insured under an individual medical expense policy that is part of a preferred provider organization (PPO) network. The policy has a calendar-year deductible of $1000, 75/25 percent coinsurance, and an annual out-of-pocket limit of $2000. James recently had outpatient arthroscopic surgery on his knee, which he injured in a skiing accident. The surgery was performed in an outpatient surgical center. James incurred the following medical expenses. (Assume that the charges shown are the charges approved my James?s insurer and that all providers are in the PPO network.)

1. Workers compensation laws provide considerable financial protection to workers who have a job-related accident or disease.
a. Explain the fundamental legal principles on which workers compensation laws are based.
b. List the various ways that covered employers can comply with the state?s workers compensation law.
c. Explain the eligibility requirements for collecting workers compensation benefits.

2. What are three basic benefits provided in the OASDI program?

3. The OASDI program provides retirement benefits to covered employees and their dependents. Explain whether each of the following persons would be eligible for OASDI retirement benefits based on the retired worker?s earnings record. Treat each situation separately.
a. A retired worker?s unmarried son, age 25, who became totally disabled at age 15 because of an auto accident.
b. A spouse, age 63, of a retired worker who is no longer caring for an unmarried child under age 18.
c. A retired worker?s spouse, age 45, who is caring for the 12-year-old daughter of the retired worker.
d. A divorced spouse, age 55, who was married to a retired worker for six years.

4. The Original Medicare Plan consists of Hospital Insurance (Medicare Part A) and Medical Insurance (Medicare Part B). For each of the following losses, indicate whether the loss is covered under Medicare Part A or Medicare Part B. (Ignore any deductible or coinsurance requirements. Treat each situation separately.)
a. Jane, age 66, is hospitalized for five days because of a heart attack.
b. Alan, age 62, has prostate cancer and visits his family doctor for treatment.
c. Margaret, age 80, is a patient in a skilled nursing facility. She has been confined to the nursing home for more than two years.
d. Joseph, age 72, has a hearing impairment and obtains a hearing aid from a local firm.
e. Margie, age 68, has a speech impairment and is confined to her home because of a stroke. A licensed speech therapist visits her in the home and provides services to restore her speech.
f. Albert, age 78, has an arthritic hip that makes it painful to walk and needs surgery to have the hip replaced.

5. A critic of state unemployment insurance programs stated that ?unemployment insurance programs are designed to maintain economic security for unemployed workers, but several critical problems must be resolved.?
a. What type of unemployment is covered under a typical state unemployment insurance program?
b. Describe some actions that may disqualify a worker for unemployment benefits.
c. Why is the fraction of unemployed workers who receive unemployment benefits relatively low?

? Outpatient X-rays and diagnostic tests $800
? Covered charges in the surgical center $12,000
? Surgeon?s fee $3000
? Outpatient prescription drugs $400
? Physical therapy expenses $1200
In addition, James could not work for two weeks and lost $2000 in earnings.
a. Based on the above information, how much of the expenses will be paid by the insurance company?
b. How much of the expenses will James have to pay? Explain your answer.
c. Assume that a surgeon who is not in the PPO network actually performed the surgery. Will James?s policy cover this fee? Explain your answer.

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Discuss health care implications of school-age vaccinations at the macro-system level.

Question
Professional Coalition/Organization

Project:Guidelines with Scoring Rubric

Purpose:

Involvement in interdisciplinary professional coalitions/organizations allows the healthcare professional to stay current in one?s field or specialty, gain an understanding regarding navigating socio-political environments as well as contributing ideas to one?s healthcare specialty. The purpose of this project will be to address a current healthcare controversy related to vaccination of school-age children. The project will entail researching school-age vaccinations at a state level and taking a stance on this debatable issue. Leadership skills at the macro-level will be applied.

This assignment will be presented as a PowerPoint Presentation.

The Professional Coalition/Organization Project will need to be completed by the end of Week 7 of this course and will require the following objectives to be addressed:

1. Discuss the pros and cons of the health carescenario noted below.

In a highly unusual outbreak of measles in Springfield, Missouri, 18 children became ill, 10 of which of the children had not been inoculated against the virus because their parents objected. These parents do not perceive risk of the disease, but perceive risk of the vaccine. They use information gained from mainstream media, connecting the vaccines with neurological disorders,.nytimes.com/health/guides/disease/asthma/overview.html?inline=nyt-classifier” title=”In-depth reference and news articles about Asthma.”>asthma,autism, and immunology?and, decide not vaccinate their children.

2. Discuss health care implications of school-age vaccinations at the macro system levels.

3. Discuss your macro-level leadership stance of this controversial health care risk.

4. Find a professional coalition/organization that supports your stance regarding use of vaccines for school-age children and your involvement with this professional coalition/organization.

Course Outcomes

Through this assignment, the student will demonstrate the ability to:

CO #2: Analyze goal-directed leadership actions that foster positive healthcare outcomes and effective processes at individual, community, and global healthcare settings. (MPH PO 1, MSN PO 1, 7)

CO #5: Incorporate ongoing leadership character development, values, and ethical principles into a living leader role that collaborates with and engages individuals, teams, agencies, and organizations locally as well as globally. (MPH PO 8, MSN PO 5)

Due Date:Sunday 11:59 p.m. MT at the end of Week 7

Total Points Possible:140

REQUIREMENTS:

Description of the Assignment

The purpose of this project will be to address a health care controversy related to school-age vaccination. The project will entail researching the laws entailing the vaccination of school-age children at a state level, and taking a stance on this debatable issue. Leadership skills at the macro-level will be applied.

The following objectives will need to be addressed:

1. Provide an introductory PowerPoint slide(s) denoting the controversial issue related to vaccination of school-age children.

a. Provide a high-level overview of why school-age vaccination is a health care concern.

2. Discuss the pros and cons of the school-age vaccinationscenario as described within this assignment.

a. Discuss the pros related to children receiving vaccinations.

b. Discuss the cons related to children receiving vaccinations.

3. Discuss health care implications of school-age vaccinations at the macro-system level.

a. Provide an overview of the medical stance of children receiving vaccinations.

b. Provide an overview of a parent?s stance in children receiving vaccinations.

c. Discuss the healthcare implications of children receiving or not receiving vaccinations at the macro-global level.

4. Discuss your macro-level leadership stance related to this controversial issue.

a. Describe your understanding as a macro leader in why there is or there is not a risk for population at large.

b. As a macro leader, describe your support or nonsupport at the macro-global level of children receiving vaccinations.

5. Find the professional coalition/organization that supports your stance on the use of vaccines for school-age children and your involvement with this professional coalition/organization.

a. Identify a professional coalition/organization at your state level that addresses the use of vaccines for school-age children.

b. Describe your involvement with this professional coalition/organization based on your stance.

6. Conclusion

a. Highlight the main points for this project?healthcare implications of this controversial issue, your macro leadership stance on this issue, and a professional coalition/organization that supports the use of vaccines for school-age children.

Criteria for Format and Special Instructions

1. The PowerPoint Presentation (excluding the Title slide and References slide) should equal

15?18 PowerPoint slides. Points will be lost for not meeting these length requirements. Estimated slide length for each section of the paper is outlined in the description of the Assignment section.

2. Font and sizes acceptable: 12-point Times New Roman or 11-point Arial; also per discretion depending on the creativity of the slide.

3. Use of the following subheadings to organize the content of your presentation:

? Pros and Cons Related to Vaccination of School-Age Children

? Health care Implications

? Macro Leadership Stance

? Professional Coalition/Organization at the State Level

? Conclusion

4. This assignment must be submitted to TurnItIn?, as required by the TurnItIn? policy. A Similarity Index of ?blue? or ?green? must be obtained. A score in the blue or green range indicates a similarity of less than 24% which is the benchmark for CCN graduate nursing students. Any other level of similarity index level requires the student to revise the assignment before the due date and time. To allow sufficient time for revision, early submission of the assignment to TurnItIn? is highly encouraged. The final submission will be graded by faculty. If a Turnitin? report indicates that plagiarism has occurred, the Academic Integrity policy will be followed.

5. The textbooks required and lesson information for this course may not be used as a reference for this assignment.

6. A minimum of 4 (four) scholarly references must be used. Scholarly references need to be current, 5years or less (anonymous authors or web pages are not acceptable).

7. Must follow APA guidelines as found in the 6th edition of the manual. Ideas and information that come from readings must be cited and referenced correctly.

8. Rules of grammar, spelling, word usage, and punctuation are followed and consistent with formal written work as found in the 6th edition of the APA manual.

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Why might providers need to communicate with one and other specific to this case?

Case Scenario: Subacute Care
Unfortunately, Mrs. Fox?s right leg could not be saved, and a surgical amputation was performed below the level of the knee. At that time, the patient also displayed impairments to the following: swallowing solid foods, speaking words and full sentences, anterograde memory, fine and gross motor function of the right upper and lower extremity.

Mrs. Fox spent 2-3 weeks in inpatient care receiving all necessary rehabilitation services with good improvement in objective measurements. However, it was determined that the patient was not yet prepared to return home safely with her family. The necessary paperwork was processed so that the patient could be transferred to Helen Hayes Hospital, a skilled nursing facility, where she could continue to receive rehabilitative and nursing services.

Prior to her accident, Mrs. Fox had a 15 year history of cigarette smoking. Her physician strongly advised her to cease smoking due to its negative effect upon tissue healing and overall negative effects upon her health. During a rehabilitation session, the patient reported that her situation had left her feeling depressed, particularly because of her difficulty communicating with her husband and 2 children. She also expressed fear that she would never walk ?normally? again or be able to do things such as brush her hair or feed herself like she did before. She stated that the only time she felt ?happy? lately was when she was painting in the common room.

Based on the case scenario above, answer the following questions:
1. Of the health professionals discussed after the midterm exam, which may be involved in Mrs. Fox?s care?
2. What would be the role of each provider?
3. Why might providers need to communicate with one and other specific to this case?
4. How might they communicate?
5. What other healthcare team members, previously or not yet discussed, might be involved and what would be their roles?

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Consider a clinical process or task that you perform on a frequent basis. Do you do it the same every time? Why do you proceed the way you do? Habit? Protocol?

Consider a clinical process or task that you perform on a frequent basis. Do you do it the same every time? Why do you proceed the way you do? Habit? Protocol? Each day nurses complete certain tasks that are considered routine, but have you ever stopped to reflect on why things are done the way they are? Perhaps you have noticed areas where there is a duplication of efforts or an inefficient use of time. Other tasks might pass seamlessly from person to person. In order to design the most efficient flow of work through an organization, it is useful to understand workflow and the ways it can be structured for the most optimal use of time and resources.he implementation of a new technology can dramatically affect the workflow of an organization. Newly implemented technologies can initially limit the productivity of users as they adjust to their new tools. Such implementations tend to be so significant that they often require workflows to be redesigned in order to achieve improvements in safety and patient outcomes. However, before workflows can be redesigned, they must first be analyzed. This analysis includes each step in completing a certain process. Some systems duplicate efforts or contain unnecessary steps that waste time and money and could even jeopardize patient health care. By reviewing and modifying the workflow, you enable greater productivity. This drive to implement new technologies has elevated the demand for nurses who can perform workflow analysis. In this Discussion you explore resources that have been designed to help guide you through the process of workflow assessment. To prepare: Take a few minutes and peruse the information found in the article ?Workflow Assessment for Health IT Toolkit? listed in this week?s Learning Resources. As you check out the information located on the different tabs, identify key concepts that you could use to improve a workflow in your own organization and consider how you could use them. Go the Research tab and identify and read one article that is of interest to you and relates to your specialty area.Post a summary of three different concepts you found in ?Workflow Assessment for Health IT Toolkit? that would help in redesigning a workflow in the organization in which you work (or one with which you are familiar) and describe how you would apply them. Next, summarize the article you selected and assess how you could use the information to improve workflow within your organization. Finally, evaluate the importance of monitoring the effect of technology on workflow.McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning. Chapter 14, ?Nursing Informatics: Improving Workflow and Meaningful Use? Huser, V., Rasmussen, L. V., Oberg, R., & Starren, J. B. (2011). Implementation of workflow engine technology to deliver basic clinical decision support functionality. BMC Medical Research Methodology, 11(1), 43?61. https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit

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Have you ever had a drink first thing in the morning to steady your nerves to get rid of a hangover?

Order Description
Combine all elements completed in previous weeks (Topics 1-4) into one cohesive evidence-based proposal and share the proposal with a leader in your organization. (Appropriate individuals include unit managers, department directors, clinical supervisors, charge nurses, and clinical educators.)
Obtain feedback from the leader you have selected and request verification using the Capstone Review Form. Submit the signed Capstone Review Form to

RNBSNclientcare@gcu.edu.
For information on how to complete the assignment, refer to “Writing Guidelines” and the “Exemplar of Evidence-Based Practice Capstone Paper.”
Include a title page, abstract, problem statement, conclusion, reference section, and appendices (if tables, graphs, surveys, diagrams, etc. are created from tools required in Topic 4).
Prepare this assignment according to the APA guidelines 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.

Currently 1 writers are viewing this order
NRS-441V: Capstone Project
Writing Guidelines

Use the headings listed below and ensure that your papers contain the needed information for each section.
1) Abstract
a) Length is between 250-450 words.
b) Presents a complete, concise overview of all phases of the proposed project
c) Addresses a problem or issue related to patient care quality
d) References appropriate evidence-based literature; identifies at least one evidence-based solution that may resolve the problem or issue.
2) Problem Description
3) Solution Description
4) Implementation Plan
5) Evaluation Plan
6) Dissemination Plan
7) Review of Literature
8) Appendices
9) APA Style/Mechanics
10) APA format is used consistently in the proposal for the cover page, page header, margins, in-text citations, double-spacing, font size, and reference page.
a) Style is consistent with that expected of a formal project proposal.
b) The highest levels of evidence are used. (Note: Information from Web sites is not considered a professional reference source.)
c) At least 15 professional references (e.g., books, journal articles) are used to develop the proposal.
d) At least eight references are peer-reviewed and from quantitative or qualitative research study reports.
e) Text is free of grammatical, punctuation, typographical, and word-usage errors.
f) Project proposal is within word length requirements.

NRS-441V: Capstone Project
Exemplar of Evidence-Based Practice

Running head: SIGNIFICANCE OF EARLY ASSESSMENT AND INTERVENTION

Significance of Early Assessment and Intervention on the Severity of Alcohol Withdrawal
(Student Name)(Grand Canyon University
(NRS 441V: Professional Capstone)
Instructor: (Name)
(Date)

Abstract
Based on documented studies, the prevalence of alcohol dependence in medical settings indicates that as many as 1 in 5 patients may require treatment for alcohol withdrawal (AW) while hospitalized for a concurrent illness. Research has indicated a definitive problem in recognizing and treating those patients at risk for AW. Symptom-triggered treatment, based on the use of appropriate assessment tools and treatment protocols, has been shown to be safe, and it is associated with a decrease in the quantity of medication required and the duration of treatment. Implementing standardized screening tools and initiating treatment based on established protocols, can prevent disease progression and an increased complication rate. These interventions can potentially decrease length of stay and health care costs.

Key words: alcohol withdrawal, assessment, CAGE, CIWA-Ar, symptom-triggered, protocol.

(Problem Statement- Module 1)
Significance of Early Assessment and Intervention on the Severity of Alcohol Withdrawal
Patients admitted to the acute care setting with a secondary diagnosis of alcohol abuse carry a significant risk of alcohol withdrawal (AW) when there is a failure to recognize and treat their alcoholism. Early recognition of AW is essential to early intervention, which, in turn, has the potential to prevent or decrease serious complications associated with AW.
(Support from Literature Review- Module 2)
Alcohol withdrawal has been described as a syndrome that affects those people accustomed to regular alcohol intake, who suddenly stop drinking and subsequently develop those clinical manifestations associated with AW (Saitz, 1998). An estimated 15-20% of hospitalized patients are dependent on alcohol, putting them at risk for prolonged or complicated hospital stays (Lussier-Cushing, Repper-DeLisi, Mitchell, Lakatas, Mahmoud, & Lipkis-Orlando, 2007).
Dependence on alcohol usually remains undetected in the hospitalized patient until withdrawal signs appear, secondary to cessation of their alcohol intake. Nursing staff must recognize the warning signs and symptoms of AW. Without an established assessment process, it is difficult to predict withdrawal symptoms or assess risk factors associated with an increased severity of withdrawal symptoms and subsequent impact on the patient?s treatment plan. An established assessment process/protocol has the potential to reduce patient morbidity and mortality as well as health care costs.
One fifth of the total national expenditure for hospital care is related to alcohol dependence, as evidenced by prolonged hospital stays (particularly in the Intensive Care setting) and characterized by major complications for patients progressing through AW, with an increase in utilization of health care resources/services (Phillips, Haycock, & Boyle, 2006). In addition to the increase in required health care resources, patient and staff safety must be considered; consideration for the physical safety of the patient during a withdrawal episode and for the safety of the health care worker exposed to patient behaviors during a withdrawal episode is paramount. Further significant issues related to AW are found/indicated in the progression of symptoms during the course of AW including the increased use of restraints and the increased use of sitters during the progression period (Chaney & Gerard, 2003).
The determination of need for a program directed at identifying and addressing AW within a population should begin with retrospective chart audits of identified patients, and data collection related to cost and length of stay (LOS). Development of an audit tool for an initial risk assessment and the development of an ongoing assessment process should follow. Development of treatment protocols/interventions would be the final step in addressing the identification and treatment of the patient with AW.
Once the process has been developed and approved for implementation, initial and ongoing education for the administrative team, physicians, and nursing staff would be a priority. Updated summaries of program progress during a pilot period should be made available to administration, physicians, and staff alike.
One or more outcome measures should be initiated to determine success of the process. Quality monitoring and data collection through retrospective audits should be completed to determine compliance with the program, as well as the success of the patient assessment and intervention processes as determined by LOS and subsequent health care costs. Further quality monitoring could be obtained through subjective data collection related to patient and staff satisfaction.
Implementation (From Module 3 Plan)
Theories of health behavior and promotion play a decisive role in helping to improve health by directing plans and processes that assist in the identification of risk issues, the management of disease processes, the development of implementation processes, and the measurement of process outcomes. When addressing alcohol withdrawal (AW), referred to as Alcohol Withdrawal Syndrome in some literature, theory helps to understand why AW is problematic and/or a significant health care issue; to identify what information is required in addressing the identified problem and how to use that information; to define and/or develop the necessary changes and processes; and to define what and how to monitor and evaluate the change for outcomes.
(Incorporated Theory from Module 2)
There are two types of theory significant to the planning of health care, and to change in health care planning. Explanatory theory helps to identify why a problem exists and assists in the search for modifiable factors, while change theory guides the development of health promotion interventions (National Cancer Institute, 1998). Consideration of theory allows for review of research, in this case, related to AW and recognized interventions. Explanatory theory allows for focus on the problem of AW, its variables (i.e., co-morbidities, variations in clinical presentation, appropriate treatment); why it is a problem (i.e., increased severity of illness, increased health care costs); and what can be changed. Change theory is directed at improvement processes and helps to identify the strategies for process change (i.e., early identification and assessment of patients at risk for AW, appropriate interventions based on assessments) and makes assumptions related to the success of those interventions. These theories incorporate concepts that can be translated or developed into strategies, plans, and evaluations. The use of theory allows for a complete review and appraisal of available information related to AW, with appropriate emphasis on solutions and interventions. Theory also provides the basis for judging the appropriateness of those solutions and intervention through an evaluation process.
Alcohol withdrawal is most often defined as a group of symptoms that occur with the cessation, usually abrupt, of alcohol intake. It affects people who are accustomed to regular alcohol intake, and is the most common withdrawal syndrome next to nicotine withdrawal. Alcohol addicted patients admitted to an inpatient setting may not be recognized as at risk for AW, which can produce negative outcomes and increase health care costs (Patch, Phelps, & Cowan, 1997). Ten million Americans consume alcohol excessively on a regular basis. Fifteen to forty percent of hospitalized patients are addicted to alcohol, putting them at risk for prolonged and/or complicated hospital stays; 25% of them may experience seizures within the first 24 hours of hospitalization. Alcohol withdrawal has a 1-10% mortality rate with the majority of those deaths occurring from cardiovascular or metabolic complications as a result of severe withdrawal, particularly delirium tremens (DT). Delirium tremens occurs in approximately 5% of patients undergoing withdrawal, appearing 2-4 days after the patient stops drinking (Myrick & Anton, 1998). Twenty percent of the total national expenditure for hospital care is related to alcohol dependence (Phillips et al., 2006). In the year 2008, a total of 90 patients were hospitalized at Casa Grande Regional Medical Center (CGRMC) with a diagnosis of AW: 10 of them with an admission diagnosis of AW, 27 with a principal diagnosis of AW, and 53 with a secondary diagnosis of AW. Despite a significant patient population with documented or verbalized histories of AW, CGRMC currently has no program in place for assessment and intervention related to AW. If changes are not implemented within the Casa Grande Regional Medical Center organization, the impact will remain significant as it relates to patient care, patient safety, and health care costs. Thus, the development of an assessment process and interventional protocol, the initiation of education for the physicians and staff on the new process and protocol, and evaluation of the effectiveness of the process and protocol should be given high priority. If process changes are not considered, developed, and implemented, a health care system already compromised, will continue to be impacted by issues such as AW.
Manifestations of mild AW may begin as soon as 5-12 hours after the patient?s last drink, while major withdrawal syndromes tend to occur 48-72 hours after the last drink, manifesting themselves as hallucinations, seizures and/or delirium tremens (Hartsell, Drost, Wilkens, & Budavari, 2007). Though there are many tools and processes for evaluating the patient with a history of alcohol abuse and/or at risk for AW, a screening process using the CAGE questionnaire (Ewing, 1984)(Appendix A) readily determines whether the patient may be at risk. The CAGE, designed to be a screening tool, was developed by Dr. John Ewing and introduced for international use in Australia in 1970; its simplistic question format has made it the instrument of choice in most clinical settings (O?Brien, 2008). This questionnaire would serve as an initial screening tool for patients having been identified with a past or current alcohol dependency. The CAGE questionnaire can be administered in as little as five minutes; a positive CAGE (a score of 2 or greater) would prompt further assessments of the patient, based on developed protocol, using the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989) (Appendix B) which has a documented utility for measuring withdrawal symptoms. Pharmacological therapy using the symptom-triggered approach would be initiated according to an approved and established physician order set/protocol, based on the patient?s CIWA-Ar scores.
Nurses can help to improve patient outcomes by developing a plan of care that includes assessment for AW, providing interventions accordingly, and evaluating the outcomes of those interventions. Implementation of a process change, related to a plan of care for those patients identified as at risk for AW, would begin with a patient history and assessment. Early physical indicators of AW can be identified during routine assessments; these indicators occurring as early as 5-12 hours after the patient?s last drink and manifested as mild tremors, diaphoresis, agitation, insomnia, and increased heart rate and blood pressure (Phillips et al., 2006). When implementing the CAGE questionnaire, those patients receiving a score of 2 or greater would then be assessed initially, and at established intervals, using the CIWA-Ar to determine the existence and severity of withdrawal symptoms. A score of less than 10 would prompt supportive care to include maintaining a quiet and safe patient environment and providing psychosocial support. A score equal to or greater than 10 would prompt the initiation of an approved physician treatment order set/protocol (Appendix C) for pharmacological therapies, including symptom triggered dosing of Lorazepam. Thiamine and electrolyte replacement and ongoing assessment guidelines would be also addressed. Patients should be reassessed using the CIWA-Ar every 4 hours while their score remains under 10; when their score equals or exceeds 10, assessment should be completed every hour following the initiation of pharmacotherapy times three doses of medication (Crumpler & Ross, 2005). If a score of less than 10 is not achieved at that time the physician should be notified and further direction obtained. Studies demonstrate that symptom triggered pharmacotherapy/treatment achieves symptom control and has demonstrated a decreased amount of drugs used, decreased duration of treatment, a decrease in the occurrence of oversedation or undersedation, a decrease in the number of adverse events, and a decrease in the use of restraints and sitters (Stanley et al., 2003). All documentation would initially be in paper form using an approved assessment and treatment flow sheet (Appendix D). Pertinent information required by the flow sheet includes hourly assessments, medication administration, any additional nursing interventions applied. Following a 6 month trial period, the suitability of converting the documentation of all process components to an electronic format would be discussed and determined. It is anticipated that electronic documentation would promote consistency, expediency, and efficiency. In addition, there would be an opportunity to write a report within the documentation software to expedite data collection and analysis. Policy and procedure would be developed to support the process change (Appendix E).
The process plan in its entirety would initially be presented to the Senior Administration members at a specifically scheduled meeting, using a PowerPoint presentation and handouts. In addition to the planned process change itself, the group would be given information on the impact of AW on patient morbidity and mortality as well as health care costs. Following presentation to, and approval by this group, a presentation in the same manner would be given to the members of the Medical Executive Board. A third presentation of the same information and in the same format would be given to the Nursing Directors. Following approval by the Medical staff and review by the Nursing Directors, the plan for the process change would be rolled out to the staff. An abbreviated PowerPoint presentation and handouts, with specific focus on process and intervention would be given to the nursing unit Patient Care Coordinators at their monthly meeting. Written information and education would be presented to general nursing staff by means of the hospital?s ?Topic of the Week? education process; additional information by means of oral presentation and handouts would be provided at individual nursing department meetings as needed. Ongoing education would be provided using the Care Learning computerized process during annual competency reviews. Education of the nursing staff would include a pre- and post-test (Appendix F); information/direction on conducting a risk assessment, including patient observation, recognition of early signs and symptoms, and use of the CAGE questionnaire; information on withdrawal management, including use of the CIWA-Ar tool and review of the protocol and/or order set; and discharge planning to include social service referrals and patient education on AW (McKay, Koranda, & Axen, 2004). Education would include orientation focused on the appropriate use of the CAGE questionnaire and the CIWA-Ar assessment tool, using the actual forms as a reference point. In addition, an assessment and treatment algorithm (Appendix G) would be provided to nursing staff to assist in decision making. A review of that form would be included in their process focused education. As well, the treatment protocol/order set would be reviewed/discussed at length during the education process.
Evaluation (From Module 4 Plan)
Outcomes of nursing care must be shown to relate to the specific care aspects of the process change (Frisch & Kelley, 2002). The general purpose of an evaluation is to measure the impact of the process change and to determine if compliance with all aspects of the process has been met. A 6-month pilot will be completed to test the efficacy and feasibility of a process change related to the early recognition and effective management of AW. The AW Protocol Quality Management/Performance Improvement Data Collection Tool (Appendix H) will be used when doing a retrospective audit of charts for all patients admitted with a principal, primary, or secondary diagnosis of AW during the 6-month trial period. Questions to be answered during that audit will include:
? Were the assessment tools (CAGE and CIWA-Ar) appropriately and successfully completed?
? Was the treatment protocol appropriately initiated?
? Was documentation adequately and appropriately completed based on the protocol and policy?
? Was additional supportive care in the form of restraints and/or sitters required?
Data collection for this evaluation process will be limited to a retrospective chart audit that may be labor intensive. However, the actual number of patients diagnosed with AW at Casa Grande Regional Medical Center (90 patients in 2008) may impact the time/work necessitated by this audit. Patient identification for the intent of the audit will be based on information obtained from Health Information Management (HIM), related to and restricted by admission diagnosis type as defined earlier.
Data for this pilot time frame will be collected by the author and prepared for oral presentation to identified groups. Handouts recalling the general outline of the process change/protocol and the results of the chart audit, in graph format, will be made available to all groups. The initial presentation will be made to the senior administrative group and will allow them to review and determine how the data may impact patient care and safety, as well as possible financial impact. The Medical Executive Board will receive the information to review for the appropriate use of the CAGE and CIWA-Ar tools in successfully and accurately identifying patients at risk and in need of treatment. As well, this group will examine the appropriateness of the protocol orders, specifically pharmacotherapy. They would further review data for the accuracy and efficacy of the documentation flowsheet as it relates to assessment and intervention. The nursing department directors will review the data and address the efficiency and efficacy of the assessment tools (CAGE and CIWA-Ar) and the treatment protocol as it relates to nursing assessment and documentation and for any impact on nursing care delivery as it relates the use of restraints and/or sitters. The Patient Care Coordinators and nursing staff groups will review the data and discuss any impact related to the assessment tools, the treatment protocol, and the documentation flowsheet, and they will discuss the use of restraints and/or sitters as it impacts their care delivery. All recommendations will be forwarded to a committee, yet to be formed, at the completion of the pilot.
Following the initial data review by the indicated groups, a quality management/performance improvement team composed of four to six nursing department staff and a medical advisor will be formed. Data will be collected monthly using the same process previously outlined; data will be collated and reported quarterly to all groups. Team meetings will be held monthly to address any newly identified limitations to the protocol and/or the evaluation process, discussing any necessary process changes related to the protocol, and to discuss continued validity of the data collection tool. These activities will help to establish and validate an evidence-based and standardized process for the early identification of AW and any required interventions. In addition, collected data may provide the basis for additional changes including expansion of electronic documentation for AW, development of nursing care plans specific to AW, and development of AW clinical pathways.
Dissemination (From Module 4)
The ultimate impact of a process change rests in the effectiveness of the dissemination strategy and presentation (RUSH, 2001). To promote and expedite the proposed protocol/process change, the intent is to complete the dissemination plan in a 2-month time frame. This would allow for sufficient time to schedule presentations with all groups comprising the audience. The intended audience for the introduction of the protocol/process change at CGRMC is the senior administration team, the medical staff, the nursing department directors, the PCCs, and the professional nursing staff. The variation in audience needs, which is based on position within the CGRMC organization, can be met on all levels by the information provided. The goal of the dissemination plan is for all members of the audience, as previously noted, to have access to information related to the significance and impact of AW, and to the design and implementation of the AW protocol/process change. By way of an objective, that same group will acknowledge an understanding of the significance of the development and implementation of the AW protocol/process change. Content of the presentation will include research data related to the significance and impact of AW on the patient and the health care delivery system, and an outline of the proposed protocol/process change. Secondary to time constraints, all groups will be addressed through oral presentations. Handouts which include data related to the significance/impact of AW and copies of the policy, the assessment tools, the treatment protocol, the documentation flowsheet, and the process evaluation tool will be made available to all members of the audience. A review of all handout information will be included in the presentation.
Ultimately the intent of the presentation is for the audience to improve practice. All members of the identified audience have the skills and awareness levels to effectively promote and implement the protocol/process change. Continued monitoring following implementation will help to keep the group engaged as they become aware of the successes and failures, and what needs to be done to achieve success with the new protocol/process change.
Evaluation of the proposed process change would be based on retrospective chart audits using a specifically developed paper data collection tool. Elements to be examined would include compliance in the use of the Cage and CIWA-Ar screening/assessment tools, compliance in initiating and following the physician order set/protocol, review of the need/use of restraints and/or sitters, and review of the level of care required by the patient. Results of those audits would be reviewed, collated, and made available to Senior Administration, the Medical Executive Board, the Nursing Directors, and the staff on a quarterly basis. Recommendations related to the process and any suggested or needed change would be considered at the end of the 6-month trial period.
Conclusion (Should pull major themes of paper together in concise manner)
Studies and data have demonstrated the significance of AW on patient safety, patient care, and health care in general. Alcohol withdrawal affects as many as 1 in 4 hospitalized patients. Twenty percent of the national expenditure for hospital care is related to alcohol dependence. Early recognition of those patients at risk for AW and early intervention for those affected by AW, is essential to the prevention of the serious complications, or even mortality, which may accompany AW.
The need for a program/process change, directed at identifying and addressing AW within a population, has been determined. This process change has several facets, beginning with using recognized tools for the risk recognition and assessment processes; CAGE and the CIWA-Ar are seen as the tools of choice for this process. Positive risk (= 2) and assessment scores (= 10) would trigger pharmacological interventions based on a written order set/protocol. All ongoing assessments and interventions would be documented on a specifically designed flowsheet. Dissemination of information related to the process change would target an identified audience, using an established presentation mode/method. Education of all identified personnel would ensue, based on a formalized educational process including initial and annual education. Organized data collection would assist in determining the success of the change and provide the basis for any future change or edition to the process.
The risk of AW can be effectively addressed and controlled with early assessment and intervention. Early assessment and intervention can prevent or decrease the severity of AW complications, potentiating safe and effective care.

Review of Literature (from module 2)

Bayard, M., Hill, K. R., Keith, R., & Mcintyre, J. (2004).Alcohol withdrawal syndrome.

American Family Physician, 69(6), 1443-1450.

After briefly addressing the pathophysiology of alcohol withdrawal (AW), and

discussing the diagnosis and evaluation of the patient in AW, this article focuses

extensively on pharmacological interventions. Also includes attachments related to

diagnostic criteria, symptomatology, and treatment regimes. Provides general

information related to assessment, evaluation, and general care of the patient with AW.

Of greater significance and value is the more extensive information related to

pharmacological interventions.

Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a

community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Focuses on a quality improvement process/opportunity as the basis for the development of a process to identify and treat patients with alcohol withdrawal. The process includes the development of an assessment flowsheet. It is significant in that it provides a guideline for this author?s assessment flowsheet design. Also provides insight into criteria selected for the process evaluation.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.

Discusses the introduction of a formal symptom-triggered protocol at Wake Forest University Baptist Medical Center. Protocol includes use of CIWA-Ar for assessment, an alcohol withdrawal algorithm, and a physician order set. Also discusses the implementation and education processes simply and concisely. It is extremely helpful in the formulating and validating this author?s process change plan and very helpful in directing the implementation and education processes.
Daeppen, J. B., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S. et al. (2002).

Symptom-triggered vs. fixed-scheduled doses of benzodiazepine for alcohol withdrawal: A randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121.

Addresses symptom-triggered versus fixed-scheduled doses of medication for the treatment of alcohol withdrawal syndrome (AWS).The method used is defined as a prospective, randomized, double blind, controlled trial of 117 participants. The study is directed at modification of previously accepted treatment methods.The intervention outcomes noted in this study are purposeful to this author?s study in developing a plan/protocol for symptom-triggered pharmacotherapy.

Day, E., Patel, J., & Georgiou, G. (2004). Evaluation of symptom-triggered front-loading

detoxification technique for alcohol dependence: A pilot study. Psychiatric Bulletin, 28(11),

407-410.

Evaluates a symptom-triggered front-loading alcohol detoxification technique. Subtopics include patient and health care worker satisfaction related to the study topic and process, and a defined process for a patient assessment tool. The problem/purpose of the study and the significance to patient careare well stated.This is a simple randomized controlled trial, with a small sample size (23). New information related to different types of intervention and discussion related to a variation in drug therapy is purposeful to author?s study. Information related to health care worker satisfaction is of interest for future considerations related to this author?s project.
Driessen, M., Lange, W., Junghanns, K., & Wetterling, T. (2005). Proposal of a comprehensive

clinical typology of alcohol withdrawal: A cluster analysis approach. Alcohol and

Alcoholism, 40(4), 308-313.

Evaluates alcohol withdrawal symptomatology and the opportunity for clustering of withdrawal symptoms based on severity. Each phase of the study is clearly defined. The significance of the identification of alcohol withdrawal and appropriate treatment is clearly indicated. Hierarchical cluster analysis and discriminate analysis is applied to the research subjects (sample size of 217). The clustering process discussed may be beneficial in the development of a withdrawal identification process, helping to define the various stages of alcohol withdrawal so as to better provide the appropriate intervention.
Hardern, R., & Page, A. V. (2005). An audit of symptom triggered chlordiazepoxide treatment of

alcohol withdrawal on a medical admissions unit. Emergency Medicine Journal, 22, 805-6.

This brief article is based on information obtained using a 2-tailed Mann-Whitney U test for comparisons. The trial process uses symptom-triggered pharmacological intervention and the the CIWA-Ar assessmentin an inpatient setting. The conclusion contains information related to time for resolution of symptoms, length of stay, duration of treatment, and staff benefits. Though this article is brief, it provides statistically sound information related to symptom-triggered treatment and outcomes of that treatment. This information provides further validity for data obtained in other articles, related to pharmacological intervention.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol.Nursing2007,37(10), 50-55.

Gives a brief overview of the impact of alcohol abuse/withdrawal on adult patients in the United States. It also includes general information related to the physiology of alcohol abuse. Of the most interest is the discussion related to the interaction with patients and the identification of abuse/withdrawal; and to the nursing care requirements/suggestions for these patients.This article does not provide any significant information related to formulation of a process change, but does include information on nursing care which could become part of an extended education process.

McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Provides substantial background on a symptom-triggered approach to the pharmacological management of AWbased on the physiology of AW. Also provides significant discussion related to education on the management of AW. Provides this author with substantial information on the impact and significance of AW. The clinical management piece provides significant direction on education processes that will help in the development of an educational piece to the process change plan.
Myrick, H., & Anton, R. F. (1998).Treatment of alcohol withdrawal.Alcohol Health and

Research World, 22(1), 38-43.

Examines the actual detoxification of patients with a primary diagnosis of alcohol withdrawal (AW).Focuses on the clinical features of AW, supportive care for AW, treatment settings for detoxification, and pharmacological versus nonpharmacological interventions.Provides significant information on supportive care as well as nonpharmacological therapies, both of interest as they relate to nursing education and patient care. Additional information on the clinical features of AW is also of interest and benefit.
O?Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism.A remarkably useful but simple tool.Journal of the American Medical Association, 300(17), 2054-2056.

Discusses the significance and simplicity of the CAGE questionnaire in detecting alcoholism and identifying those at risk for alcohol withdrawal. O?Brien also makes note that there is a significant issue related to physician tendency to overlook alcoholism in diagnostic consideration. Gives this author additional information related to the use of the CAGE tool and insight into the opportunity for change in the process of identifying patients at risk for alcohol withdrawal.
Saitz, R., Mayo-Smith, M.S., Roberts, M. S., Redmond, H.A., Bernard, D. R., & Calkins,

D.R.(1994). Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. The Journal of the American Medical Association, 272(7), 519-523.

Discusses individualized treatment for alcohol withdrawal, focusing on symptom-triggered treatment/therapies versus standard fixed-scheduled treatment.Conclusions related to the specific treatment are significant to author?s study as they relate to symptom-triggered treatment.
Saitz, R. (1998). Introduction to alcohol withdrawal.Alcohol Health and Research World, 22(1),

5-12.

Examines and discusses the mechanisms of alcohol withdrawal (AW), the clinical features of AW, and the management and treatment of AW. Also suggests possible future studies related to all of these aspects of AW, as well as specifics related to treatment settings, methods, clinical practice, and the use of evidence-based practice in treatment. Provides this author with extensive clinical information related to AW and information related to different interventions using a variety of medications. A discussion related to medical conditions easily confused with AW is informative but more directed to physicians.
Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development

of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and

Alcoholism, 41(6), 611-615.

Focuses on the development of a rating scale to predict the severity of alcohol withdrawal syndrome.Evaluates the clinical feasibility of a single assessment tool or process, the LARS (Luebeck Alcohol Withdrawal Risk Scale).Limitations are noted related to concurrent medical conditions of the subjects, as well as to treatment required for ethical reasons. Proposes further studies to validate the findings of this study as there are no known comparison scales.Provides additional information related to the development of an assessment toolas part of author?s study even though the study itself is weak from a validation standpoint.
Williams, D., Lewis, J., & McBride, A. (2001). A comparison of rating scales for the alcohol- withdrawal syndrome. Alcohol and Alcoholism, 36(2), 104-108.

Addresses a comparison of rating scales for AWS.Uses literature to identify rating scales for AWS and then compares their content and ease of application. Concludes that trials designed to assess reliability and validity are necessary to improve the measure of any scale. Difficult to read/comprehend and providesthis author with little new significant/useful information.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140.

Discusses a project led by a multidisciplinary team to address the patient safety concerns related to the management of alcohol withdrawal. Goals include: identify an evidence-based practice guideline for pharmacological management of alcohol withdrawal (AW); identify a standardized clinical assessment tool to guide assessment and treatment; and educate staff on the selected process. Helps to provide some of the framework for the process change discussed in author?s paper. It also provides some direction as to staff education.

References
Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a
community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.
Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire.JAMA, 252(14), 1905-7.
Frisch, N. C., & Kelley, J. H. (2002). Nursing diagnosis and nursing theory: exploration of factors inhibiting and supporting simultaneous use. Nursing Diagnosis, 13(2), 53-61.
Hartsell, Z., Drost, J., Wilkens, J. A., & Budavari, A. I. (2007).Managing alcohol withdrawal in hospitalized patients.Journal of American Academy of Physicians Assistants, 20(9), 20-25.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol.Nursing2007,37(10), 50-55.
McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Melynk, B. M., & Fineout-Overholt, E. (2005).Evidence-based practice in nursing and health care: A guide to best practice. Philadelphia: Lippincott Williams & Wilkens.
Myrick, H., & Anton, R. F. (1998).Treatment of alcohol withdrawal.Alcohol Health and

Research World, 22(1), 38-43.
National Cancer Institute. (1998). Foundations of applying theory in health promotion practice Retrieved on May 11, 2011 from:http://www.orau.gov/cdcynergy/soc2web/Content/activeinformation/resources/Theory_at_Glance.pdf
O?Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism.A remarkably useful but simple tool.Journal of the American Medical Association, 300(17), 2054-2056.
Patch, P. B., Phelps, G. L., & Cowan, G. (1997). Alcohol withdrawal in a medical-surgical setting: The ?too little too late? phenomenon. MedSurg Nursing, 6, 79-89.
Phillips, S., Haycock, C., & Boyle, D. (2006). Development of an alcohol withdrawal protocol: CNS collaboration exemplar. Clinical Nurse Specialist, 20(4), 190-198.
Research Utilization Support and Help (RUSH) (2001).Developing an effective dissemination plan. Retrieved June 7, 2009, from http://www.researchutilization.org/matrix/resources/depd/
Saitz, R. (1998). Introduction to alcohol withdrawal.Alcohol Health and Research World, 22(1),

5-12.
Stanley, K. M., Amabile, C. M., Simpson, K. N., Couillard, D., Norcross, E. D., & Worrall, C. L. (2003).Impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes.Pharmacotherapy, 23(7), 519-523.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140..

APPENDIX A

CASA GRANDE REGIONAL MEDICAL CENTER
CAGE Questionnaire
The CAGE is a brief questionnaire for detection of alcoholism. It is to be administered to all patients with a documented or verbalized history of alcohol abuse, or to all patients exhibiting early signs of alcohol withdrawal.
Score 0 for NO and 1 for YES.
A total score of 2 or more is considered clinically significant
and requires further assessment, using the CIWA-Ar.

Score
1 Point Score
0 Points
1. Have you ever felt you should cut down on your drinking? YES NO
2. Have people annoyed you by criticizing your drinking? YES NO
3. Have you ever felt bad or guilty about your drinking? YES NO
4. Have you ever had a drink first thing in the morning to steady your nerves to get rid of a hangover? (eye-opener) YES NO
POINTS
TOTAL =

APPENDIX C

CASA GRANDE REGIONAL MEDICAL CENTER
Alcohol Withdrawal Protocol* (Patient Sticker)
* Requires bedside assessment and/or written orders
by the physician for implementation.

1. Complete CIWA-Ar assessment every 1 hour until score is less than 10, and then reassess every 4 hours.

2. For CIWA-Ar score of 10-20:
Give Lorazepam 1 mg ___ orally ____ intramuscularly ____intravenously
every 1 hour until score is less than 10.

3. For CIWA-Ar score greater than 20:
Give Lorazepam 2 mg ___ orally ____ intramuscularly ____ intravenously
every 1 hour until score is less than 10.

4. If CIWA-Ar score has not decreased after 4 consecutive doses of Lorazepam, contact the physician.

5. Call physician stat if there is delirium tremens.

6. Give Thiamine 100 milligrams in 100 ml. NS, to infuse over 1 hour every 24 hours x 3 doses.

7. Multivitamins orally daily.

8. Baseline labs to include: (check all applicable)

0 CMP with magnesium

0 CBC with differential

0 Liver enzymes

9. Complete I&O every 4 hours or per unit protocol.

10. Discontinue protocol when CIWA-Ar is less than 10 for 48 hours.

11. Other medications:
a.
b.
c.

Physician Signature: Date:

APPENDIX E

CASA GRANDE REGIONAL MEDICAL CENTER
System Wide Policy and Procedure Manual
Nursing Department
Chapter

D Section

H Subject:
ALCOHOL WITHDRAWAL PROTOCOL Date

1 of 2

I. PURPOSE The purpose of this policy is to direct the process for identifying the patient at risk for AW and utilizing the AW protocol when initiated via physician order.

II. POLICY STATEMENT The goal of CGRMC is to minimize the effects of AW in a safe, humane and proactive manner while the patient is hospitalized.

III. DEFINITIONS AW: Alcohol Withdrawal
CAGE: Standardized questionnaire used to determine possible alcohol abuse.
CIWA-Ar: Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised

IV. PROCEDURE A. The CAGE questionnaire (attached) will be initiated when a history of alcohol abuse is verbalized or documented. The CAGE questionnaire will be initiated when a previous history of AW is documented or verbalized.

B. The CIWA-Ar (attached) assessment will be complemented when the patient scores 2 or greater on the CAGE questionnaire or manifests early symptoms of AW, including ALOC, tremors, anxiety, diaphoresis, and increased heart rate and blood pressure.

C. The CGRMC AW protocol will be initiated upon a physician?s order when the patient scores 10 or greater on the CIWA-Ar assessment.

D. Assessments and interventions will be completed by a licensed nurse per established protocol (attached).

E. Nursing documentation will be completed on the Alcohol Withdrawal Assessment/Flowsheet (attached) and in Cerner as per policy.

SA GRANDE REGIONAL MEDICAL CENTER
System Wide Policy and Procedure Manual
Nursing Department
Chapter

D Section

H Subject:
ALCOHOL WITHDRAWAL PROTOCOL Date
Issued
6/2009 Date
Revised
Page

2 of 2

V. REFERENCES None

VI. ATTACHMENTS CAGE
CIWA-Ar
Alcohol Withdrawal Protocol
Alcohol Withdrawal Assessment/Flowsheet

Signature: Date:

Title:

Signature: Date:

Title:

Signature: Date:

Title:

Signature: Date:

Title:

APPENDIX F

CASA GRANDE REGIONAL MEDICAL CENTER
Alcohol Withdrawal Education Program
Pre- and Post-Test
1. Alcoholism affects approximately 15 million adults in the United States. True False
2. An estimated 20-50% of all hospital admissions are related to the effects of alcoholism. True False
3. 15-20% of all hospitalized patients are dependent on alcohol. True False
4. Approximately 25% of patients withdrawing from alcohol have seizures. True False
5. GI upset, insomnia, tachycardia, or hypotension may be early signs of alcohol withdrawal. True False
6. Symptoms of alcohol withdrawal can manifest as soon as 6 hours after the patient?s last drink. True False
7. Alcohol withdrawal cannot be confirmed until the patient displays significant agitation, confusion, DT, or seizure activity. True False
8. Lorazepam is the drug of choice in treating patients with hepatic compromise. True False
9. Symptom-triggered drug treatment regimens are less effective than fixed dose regimens because of the inconsistency of dosing. True False
10. Early intervention in alcohol withdrawal can decrease the amount of drugs required in the treatment of alcohol withdrawal. True False

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What are some of the broader questions about this Case Study that you want to know more information about ?

Order Description
I have attached all the relevant information. Please read through everything carefully as this assignment has a 40% weighting. Refer to uploaded instructions for the number of references and what kind of references you are meant to use. Make sure all references to health systems are in AUSTRALIA.
Students are expected to use the Case Study template to complete this case study. Students who do not use the template will receive a Zero F2 Grade. Please make sure you use the template and follow all instructions and marking criteria very carefully.

The purpose of this assignment is to explore the personal and social implications of mental illness, as well as, ethical, legal and clinical practice implications related to a mental health patient being admitted to a medical ward. Using a recovery and person-centred approach, explore the issues raised in the case study and how you can support this person during your early shift.

Case study
Students will be given a number of important documents related to this case study of a person who experiences a major mental illness. These documents will appear in the Learnonline Notice Board over the duration of the course. Students will need to access these documents in order to complete this case study.
Students are expected to use the Case Study template (available from the Learnonline environment) to complete this case study. Students who do not use the template will receive a Zero F2 Grade.

Please read the sections on the Case Study template and ensure that you answer all sections on the template.
Please also take note of the Marking guide for this assessment item as this will provide some additional guidance for students.

You will be expected to analyse these documents, extract the main issues and reflect on how the information impacts on the client, the family, the case manager and how it informs your nursing care and approach. You will have opportunity to discuss these documents in your tutorial sessions or in the Virtual Classroom.

Assignment Task

You are a newly registered nurse working in a large metropolitan hospital on an early shift in a busy medical ward. You have been allocated Sallyanne to care for her as a 1:1 special in a single bed side-room. You are given the following hand-over by the night duty RN.

Sallyanne is a 37 year old woman admitted yesterday post overdose of Sodium Valproate and Seroquel, and self inflicted lacerations to both wrists. Sallyanne has a diagnosis of Schizoaffective Disorder and is currently on an ITO-L1 which requires review today. Overnight Sallyanne has had a fluctuating sensorium ? has been occasionally drowsy, but at other times very restless and agitated. Her conversation has had a paranoid and delusional flavour at times. Sallyanne is confused and likely has a delirium related to the ingestion of prescribed medications.

Sallyanne has an intravenous line of normal saline 1 litre over 8 hours ? started 4 hours ago. Urinary catheter insitu which is draining well. The last ECG showed lengthening of Q-T interval and a repeat ECG is booked for 10:00 AM. TPR & BP are within normal limits ? for checking 4 hourly along with neurological observations until reviewed by treating medical team.

Sallyanne’s behaviour has not presented any significant management problems overnight in the ward. However she did present to the Emergency Department in a severely agitated state when a Code Black (Aggressive incident) was initiated. Because of her fluctuating sensorium she is to be considered at risk.

The self inflicted wounds to her wrists were sutured in ED, both wound sites are intact but there is some ooze from the left suture site; the dressing will need to be changed during the day. Sallyanne is not to be given any medication unless severely agitated. The Consultation-Liaison psychiatry team are aware of her admission to the medical ward and will review her later this morning. Over the next few hours it is likely that Sallyanne will become more alert and likely more distressed and agitated. You are advised to call for assistance if you have any concerns.

In a parting comment the night duty RN states that – “I do not know why we are wasting time on looking after people who want to kill themselves, there are plenty of sick people out there who need hospital beds”.

Following this handover you have the time to review Sallyanne’s admission notes where you will find a number of documents which highlight past and recent concerns.
(All of these documents can be found in the Learnonline Notice Board over the duration of the course).

1. Emergency Department Mental Health Assessment
2. Private Psychiatrist letter to Mental Health case manager
3. Letter from employer to Mental Health case manager
4. Letter from Mother to Mental Health case manager
5. Recent letter from identified client to Mental Health case manager

Assessment 3 ? Case Study (Updated 2016)
Using an Inquiry Based Learning Approach
You will be expected to analyse these documents, extract the main issues and reflect on how the information impacts on the client, the family, the case manager and how it informs your nursing care and approach.

Learning strategy
What you need to do to critically analyse the Case Study Thought processes
What you need to demonstrate to your lecturer in terms of your critical thinking about this Case Study Learning Outcomes Section
Demonstrate your learning in each section by presenting the information that you have examined to improve your knowledge and understanding of this particular Case Study

STEP 1 – CONNECT

Analyse each of the case study documents Think about what are some of the key issues or information that you consider are important in this Case Study?

You do not need to write anything here

Document what you consider are the key issues in this Case Study here

STEP 2 – QUESTION

What are some of the broader questions about this Case Study that you want to know more information about ?

Identify the additional information you need to know
Document your questions here

1.

2.

3.

4.

5.
Provide a rationale – Why are these questions relevant to your learning about this Case Study?

STEP 3 – INVESTIGATE

Review your current knowledge about the clients mental illness in this Case Study

Research this disorder further. Record the resources you used to improve your knowledge of this mental illness below

Answer the questions in the
Learning Outcomes Section on the right
Describe the disorder presented in this scenario ? include in-text referencing

What are the clinical manifestations associated with this disorder? ? include in-text referencing

What are the common treatment options for this disorder? ? include in-text referencing

STEP 4 – CONSTRUCT

Using a recovery and person-centred approach, explore the issues raised in this case study and how you can support this person during your early shift
Consider the ANMC RN Competency Standards

You do not need to write anything here

Consider the nursing interventions and clinical skills that are required for this Case Study

You do not need to write anything here

Consider the patient safety concerns related to this Case Study

You do not need to write anything here

Identify the appropriate ANMC RN Competency Standards that would be applicable for you as an RN in supporting the person in this Case Study

Provide an outline of how you would support this person during your shift

Provide justification for your chosen interventions

Identify the safety concerns for the patient in this Case Study
STEPS 5 and 6

Reflect on the parting comments made by the night duty RN
STEP 5 – EXPRESS

Document your thoughts about these comments made by the night duty RN below

STEP 6 – REFLECT

Provide a justification for your thoughts using the professional literature to support your argument here ? include in-text referencing

References ? Please include a list of all your references used in this case study

Assessment 3 (Case Study) ? Feedback Rubric

Learning Strategy HD
85-100% D
75-84% C
65-74% P1
55-64% P2
50-54% F1
40-49% F2
0-39%

Step 1 Connect

Analysis of the case study documents

The student has demonstrated a high level of critical analysis and synthesis of the key issues indicating original insights

The student has demonstrated a critical analysis and synthesis of the key issues
The student has demonstrated a detailed analysis of highly relevant key issues
The student has provided an adequate identification of relevant key issues
The student has identified some relevant key issues
The student has identified key issues of limited relevance
The student has not identified relevant key issues

Step 2 Question

Developing critical questions about this Case Study

The student has identified highly relevant questions with persuasive justifications demonstrating an exceptional level of understanding of the case study to stimulate their further learning

The student has identified highly relevant questions with thorough justifications demonstrating a sound understanding of the case study
The student has identified relevant questions with appropriate justifications demonstrating a sound understanding of the case study
The student has identified relevant questions and justification demonstrating a satisfactory level of understanding of the case study
The student has identified some relevant questions and justification demonstrating a minimal level of understanding of the case study

The student has identified inadequate questions with limited justification, demonstrating a lack of understanding of the case study

The student has not identified relevant questions

Step 3 Investigate

Demonstration of further research

The student has demonstrated an exceptionally high level of critical analysis and synthesis of the available literature
The student has demonstrated a high level of analysis of the available literature
The student has demonstrated a sound level of clinical knowledge and understanding
The student has demonstrated a adequate level of clinical knowledge and understanding
The student has demonstrated a minimal level of clinical knowledge and understanding

The student has demonstrated an inadequate level of clinical knowledge and understanding of the case study and care requirements
The student has demonstrated a poor level of clinical knowledge and understanding of the case study and care requirements

Learning Strategy HD
85-100% D
75-84% C
65-74% P1
55-64% P2
50-54% F1
40-49% F2
0-39%

Step 4 Construct

Linking competencies
Nursing skills and interventions
Patient safety
Competencies are specific
Plan of care is exemplary of the ?recovery and person centred? approach and is exceptionally well justified
Safety concerns are specific Competencies are specific
Plan of care encapsulates recovery and person centred approach and is very well justified
Safety concerns are specific Competencies are identified at a satisfactory level
Plan of care is accurate and clear with convincing justification
Safety concerns are appropriate
Competencies are adequately identified
Plan of care is satisfactory with justification
Safety concerns are appropriate Competencies are identified at a minimal level
Plan of care is minimal with limited justification
Safety concerns are identified Competencies are inadequately identified or are incorrect
Plan of care is inadequate with little justification provided
Safety concerns are inadequate Competencies are not identified
Plan of care is not identified
Justification not provided
Safety concerns are not identified

Steps 5 and 6 Express & Reflect

Professional reflection
An exceptionally high level of professional reflection and synthesis of the available professional literature High level of professional reflection and analysis of the available professional literature
Sound level of professional reflection and use of the professional literature
Satisfactory level of professional reflection and justification using the professional literature
Minimal level of professional reflection and justification using the professional literature
Reflection is inadequate, justification is poorly supported using the professional literature Reflection is poor and not supported using the professional literature

REFERENCING AND ACADEMIC INTEGRITY
Adherence to UniSA (2011) Harvard author-date system
Extensive sources correctly referenced as per UniSA Harvard System Guidelines. No evidence of plagiarism Multiple sources correctly referenced as per UniSA Harvard System Guidelines.
No evidence of plagiarism. Range of sources all correctly referenced as per UniSA Harvard System Guideline. No evidence of plagiarism Correct use of UniSA (2011) Harvard author-date system for in-text referencing, with no evidence of plagiarism.
Reference list correctly written Mostly correct use of UniSA (2011) Harvard author-date system for in-text referencing, with no evidence of plagiarism.
In-text referencing is insufficient.
Reference list is incorrect or incomplete. OR some evidence of plagiarism.
Possibly refer to AIO* Many statements not referenced. No reference list.
OR evidence of extensive plagiarism
Possibly refer to AIO*

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