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Vsevolod Gulyaev
Vsevolod Gulyaev

More Attention, Less Deficit : Success Strategi... _BEST_

As clinical trials or controlled experiments are difficult if not impossible to conduct in this area, observational designs must be optimized as much as possible. When outcomes are compared across hospitals or other health care organizations as a whole or their clinical units or microsystems, frequently the research design that results from data linkages and analyses is cross-sectional and correlational in nature. Staffing levels and patient outcomes from approximately the same time are analyzed to determine whether a correlation exists between the two. As all students of research methods know, correlational designs are more limited than experiments for determining the extent to which causal links exist between staffing levels and outcomes. Factors other than nurse staffing can vary alongside staffing levels, so whether or not certain different staffing levels directly lead to better or worse outcomes cannot be determined with certainty from correlational designs. Such factors include other aspects of the environment in which care is provided (for example the availability of supplies, quality of physician care and/or other services and supports). Statistical methods can control for obvious factors that influence or are otherwise associated with staffing levels (such as hospital size, academic affiliation, or rural-urban location). Nonetheless, it is impossible to measure and account for all possible confounding variables (or competing explanations for findings) in the typical designs of these studies. Maximizing returns on correlational research designs involving staffing requires careful selection of variables and clearly articulating the theoretical and/or empirical bases for choosing them.

More attention, less deficit : success strategi...

The second major type of measure examines the credentials or qualifications of those staff members and expresses them as a proportion of staff with more versus less training (or vice-versa). Commonly, the composition of the nursing staff employed on a unit or in a hospital in terms of unlicensed personnel, practical or vocational nurses, and registered nurses (RNs) is calculated. The specific types of educational preparation held by RNs (baccalaureate degrees versus associate degrees and diplomas) have also begun to be studied. Additional staffing-related characteristics studied include years of experience and professional certification. The incidence of voluntary turnover and the extent to which contract or agency staff provide care have also been studied. As will be discussed, the majority of the evidence related to hospital nurse staffing focuses on RNs rather than other types of personnel.

The focus of this review is on staffing and safety outcomes. However, as was noted earlier, quality of care and clinical outcomes (and by extension, the larger domain of nursing-sensitive outcomes) include not only processes and outcomes related to avoiding negative health states, but also a broad category of positive impacts of sound nursing care. Knowledge about positive outcomes of care that are less likely to occur under low staffing conditions (or are more likely under higher levels) is extremely limited. The findings linking functional status, psychosocial adaptation to illness, and self-care capacities in acute care patients are at a very early stage37 but eventually will become an important part of this literature and the business case for investments in nurse staffing and care environments.

It is impossible to specify parameters for staffing that will ensure safety based on current evidence without many qualifiers. The adequacy of staffing (the degree to which staffing covers patient needs) even for the same patients and nurses may change from hour to hour, particularly in acute care settings. Nurse-to-patient ratios and skill mixes in specific settings that are too low for safety still cannot be identified on the basis of the research literature, but decisions must be made on the basis of the judgments by frontline staff and their managers. On a related note, the specific nursing care processes that are more likely to be omitted or rendered less safe under different staffing conditions are not well understood, empirically speaking, and deserve further attention.

The majority of nurses working in hospitals in the United States are, of course, registered nurses. Available evidence suggested that patients in hospitals that use more licensed practical nurses (LPNs) or vocational nurses may see worse outcomes.30, 40 Indeed, at least one cost-benefit analysis of drawing on findings from one of the largest studies in the field40 suggested that increasing the proportion of RNs (and decreasing the proportion of practical nurses) in the composition of hospital staffs may be a more cost-effective measure and could have a bigger impact on outcomes than increasing hours of nursing care per patient day.41 Likewise, most reports in the literature dealing with unlicensed assistive personnel (UAPs) either failed to find associations with this type of staff or suggested worse outcomes in institutions with high levels of such personnel. There is no direct evidence that it is unsafe to employ LPNs in acute care settings,42, 43 nor is there empirical support that the use of unlicensed personnel is intrinsically related to poor outcomes. Use of practical nurses and UAPs can be driven by any and all of the factors outlined in Figure 2. Nonetheless, anecdotal evidence suggests that inadequately trained and/or supervised personnel of all kinds at times provide unsafe care; that operational problems having related, but distinct, causes and consequences can lead to substituting other types of workers for RNs and to safety problems; and that the savings associated with using lesser-trained workers sometimes prove to be false economies. The models of care under which LPNs and unlicensed care providers are employed (i.e., the exact roles of non-RN personnel and degree of oversight provided by RNs) has not been considered in research. While RNs have the broadest scope of practice of frontline nursing workers, it is far from established that 100 percent RN staffing is effective in all situations. Future research needs to identify the circumstances under which LPNs and UAPs can be used safely. Until then (and even when it does), local labor market realities, experience, and judgment will need to be used by leaders to establish skill mix and to define the models of care under which RNs, LPNs, and UAPs work.

A simple system to evaluate the most common classroom problems (e.g. talking out, being out of the seat, not focusing or paying attention, disruptive behavior) appears in Figure 4.4. Information obtained is usually observed at 15-second intervals. If any of the behaviors occur, whether once or more than once, a single notation is made for that interval.

By middle elementary school and through secondary school, however, teachers begin paying increasingly greater attention to undesirable behaviors and less attention to appropriate behaviors. Unfortunately, paying attention to the undesirable behavior causes it to cease in the short run but occur more frequently in the long run.

This naturally occurring pattern of teachers paying less attention to desirable behavior and more attention to undesirable behavior, as children progress through school, places children with ADHD at a greater disadvantage than their classmates. In the first few grades, when teachers appear to be making a conscientious effort to positively reinforce their students, the child with ADHD often does not receive his or her share of reinforcement. In the later grades, as teachers exhibit less positive reinforcement, perhaps because they feel that it is not needed, the child with ADHD is placed at even greater risk.

Positive reinforcement programs should begin at the level at which children can succeed and be positively reinforced. All too often, teachers set up wonderful behavioral programs but set initial criteria for success too high. The child with ADHD in this system rarely reaches success. Problem behavior must be defined operationally and then a level of baseline occurrence must be obtained. At first, provide reinforcement when the child is at or slightly better than baseline. For example, in first grade, Jeremy was out of his seat 10 times during a work period, so his teacher provided reinforcement when he was out of his seat no more than eight times. As the child succeeds, the necessary criteria for reinforcement can be gradually increased, requiring fewer out-of-seat behaviors during a given time period.

Younger children have been reported as more frequently imitating others than older children. Children consistently model someone whom they value or look up to. They also imitate the behavior of a same-sex child more often than that of a different-sex child. They model someone whom they perceive as successful and socially valued regardless of whether the teacher perceives that child as successful and socially valued. Finally, if a child observes a model being reinforced or punished for certain behavior, this influences the likelihood that the child will then model that behavior.

Furthermore, the intensity or aversiveness of the initial delivery of the reprimand may be critical for children with ADHD (Futtersak, OLeary, & Abramowitz, 1989). In this study, children were exposed to teachers who delivered either consistently strong reprimands from the outset with immediate brief and firm close proximity to the child or reprimands that increased in severity over time. Results supported the hypothesis that gradually strengthening initially weak reprimands was less effective for suppressing off-task behavior than the immediate introduction and maintenance of full-strength reprimands. In addition, reprimands are more effective when delivered with eye contact and in close proximity to the child (Van Hauten, Nau, MacKenzie-Keating, Sameoto, & Colavecchia, 1982).

1. Target overall comprehension of language: Recent research reveals that reading comprehension difficulties may stem from an underlying oral language weakness that exists from early childhood, before reading is even taught. It turns out that students who have poor reading comprehension also often understand fewer spoken words and less of what they hear, and have worse spoken grammar. So, to address reading comprehension deficits effectively, educators may have to use an approach that teaches vocabulary, thinking skills, and comprehension first in spoken language and then in reading and written language. 041b061a72


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