Deep Learning, 3 CE-hours, $21
Course Description: This course examines the basic principles of the DEEP process.
Objectives: 1. DEVELOP practical applications at work by implementing care purposefully and proactively 2. EXAMINE priorities in that area by motivating people and communicate priorities 3. EDUCATE a colleague in your new skill area by raising professionalism and quality across the sector 4. PREPARE your heart for wisdom by learning adaptation to illness and loss along side the role of belief systems in the coping process
Course Format: Online linked resources and lectures that you can use anytime 24/7. One multi-choice test.
Course Developers and Instructors: R. Klimes, PhD, MPH (John Hopkins U), author of healthcare articles on health education, morals and religious theory.
Course Time: Three hours for online study, test taking with course evaluation feedback and certificate printing.
Meet Your Instructor
Professor Rudolf Klimes, PhD, welcomes you to this online course. Keep going.
START the course here. TAKE the exam at the end. PAY after the exam.
Go deeper than just memorizing facts. Fuse your content knowledge with real-world situations, teaching, and application to learn at a deeper level. The acronym D.E.E.P. will be used to help you remember these techniques:
E. EXAMINE your priorities in that area
E. EDUCATE a colleague in your new skills
P. PREPARE your heart for wisdom
Much education is test-based, where the student memorizes just enough to pass the given test. It uses learning theories, goals, personal learning and skill development and the teacher is usuall satisfied when the student can answer 75% of the questions satisafactorily. That is generally true of the conting education courses offered by the Klimes Institute and other providers. The tests are all important.
Deep Learning as presented by the Klimes Institute takes the test-based learning and adds to it four major components: applications, priorities, skill sharing and value clarification. Without these four components, learning is very limited and generally ineffective in the long run. Open up and go deep.
There is also a broad field of Deep Learning that can be explored. This course is mainly limited to the above four components, namely D, E, E, P.
You may want to also explore Deep Learing Global Conferences and DEEP as in Discover, Engage, Experience and Participate.
The Stanford Deep Learning Course presents a rather advanced approach to Deep Learning from a machine learning approach that may be of interest to only some selected few.
D. DEVELOP applications
DEVELOP practical applications at work by implementing care purposefully and proactively.
1. Theory-based nursing practice.
Theory-Based Nursing Practice
Abstract Theory provides nurses with a perspective with which to view client situations, a way to organize the hundreds of data bits encountered in the day-to-day care of clients, and a way to analyse and interpret the information. A theoretical perspective allows the nurse to plan and implement care purposefully and proactively. When nurses practice purposefully and systematically, they are more efficient, have better control over the outcomes of their care, and are better able to communicate with others. Health care agencies can designate a specific nursing theory to guide the nursing practice within the entire organization. The critical component in choosing a nursing theory for an organization is the ‘fit’ between the philosophical assumptions of the organization and the theory. Modelling and role-modelling, a theory and paradigm for nursing, can be implemented in any setting. Hospice is a concept of care, not a place. Hospice care illustrates the excellent ‘fit’ between an existing philosophy of care and theory-based nursing practice. The ‘fit’ is based on the similarity of the philosophical assumptions of hospice and the nursing theory of modelling and role-modelling.
Theory and Application in Nursing time: Purpose
The purposes of this paper are to explore the concept of nursing time and to identify implications for theory development, clinical and administrative practice, and research.
Both physical and psychological forms of time are viewed as fundamental to our experience of time as social beings. Nursing time has significant intrinsic and instrumental value in nursing and healthcare. A holistic approach incorporating the physical, psychological, and sociological aspects and dimensions of nursing time is advocated.
Multiple strategies to enhance the patient experience of nursing time are warranted and should address how much time nurses spend with patients as well as how they spend that time. Patterns of overlapping and competing time structures for nurses should be identified and evaluated for their effect on physical time available for patient care and the psychological experiences of time by nurses and patients.
Introduction & Background
The practice of nursing is situated within a nursing work environment embedded in the socio-cultural context of the health care organization (HCO). This creates dual roles for the practicing nurse – i.e. patient care provider and organizational employee. The allocation of nursing time is fundamental to both roles, but for different reasons, and often with competing goals. As providers of care, nurses are expected to allocate their time to establish and maintain therapeutic nurse-patient relationships and implement the nursing process to maximize patient outcomes (Foster & Hawkins, 2005; Hagerty & Patusky, 2003). The emphasis is on individualized patient-centered care and time is a resource used to produce care. Nurses and patients want more time devoted to patient care (Forsyth & McKenzie, 2006; Hendrich, Chow, & Goshert, 2009; Huber & Oerman, 2000; Williams & Jones, 2006). As organizational employees, nurses are expected to complete their work assignment efficiently to support the goal of positive profit margin. The emphasis is on standardization and efficiency and time is a resource that costs money. Employers and payors want reduced health care costs (Jones & Yoder, 2010). They seek to “save time” and eliminate “time waste”. Nursing time, therefore, has relevance for those who produce it, those who receive it and those who must pay for it.
Time is care and time is money (Huber & Oermann, 2000). Inadequate nursing time contributes to poor quality care and excess nursing time contributes to the high cost of care (Aiken, 2008; Storfjell, Omoike, & Ohlson, 2008). What then is the “right” amount of nursing time for individual patients and families? How much nursing time should we allocate and how much nursing time can we afford? The current body of knowledge relative to nursing time is insufficient to address these questions (Sulmasy & Sood, 2003). Though the term nursing time may be commonly used, a common understanding of the concept within the fields of nursing and healthcare administration is lacking (Northrup, 2002; Jones, 2001; Ring, 2009). The purposes of this paper are to explore the concept of nursing time and to identify implications for theory development, clinical and administrative practice, and research. Because conceptualization of this compound term is embedded within our understanding and use of the root terms “time” and “nursing”, these concepts will be explored first.
The conceptualization of time is informed by the disciplines of physics, psychology, and sociology. Through these disciplines we understand how time is experienced, measured, and interpreted in the human context.
The Metaphysics of Time
The structure of time is conceived as being comprised of a series of sequentially ordered points called instants (Ma & Knight, 2003; Reichenbach, 1958). Instants are considered durationless and unable to be perceived unless associated with an event. An event is anything observed through the senses or conceived in the mind – e.g. physical objects, feelings or thoughts. Each event is bounded by the instant the observer becomes aware of it and the instant awareness ceases (Zacks & Tversky, 2001). Duration of time is determined by the quantification of instants within and/or between events, making events the basic building blocks of time (Lin, 2000; Nešić & Obradović, 2002; Michon & Jackson, 1985; van Lambalgen & Hamm, 2005).
Measurement of time in physics is based on the principle of uniformity and the flow of time is thought to be determined by processes and laws of nature (Arias, 2005; Reichenbach, 1958). Naturally occurring uniform time periods, also called periodic processes, include the earth’s full rotation, the swing of a pendulum, the oscillation of the spring-balance clock, and the rotation of electrons within atoms. These uniform time periods become units of measure, and time is quantified by counting the number of periodic processes (units) between instants. Such processes are considered types of clocks and reflect measures of physical time.
Physical time, also known as public time or clock time, is the time that gets counted or numbered and the numbers are assigned the same way for everyone. It is objective, unaffected by awareness, and external to one’s being. Heidigger (1962) described this form of time as belonging to the world because it requires a common interpretation and reckoning. There is public agreement about the measurement of physical time accompanied by some expectation that behavior will be regulated accordingly.
The Psychology of Time
Psychological time is considered private time and is described as the awareness of physical time (Heidigger, 1962; Dowden, 2009). It is also known as phenomenological time, and is considered subjective and mind-dependent. Psychological time is internal and derived from the interaction between mind and environment (Klein, 2006). This form of time is influenced by sensory and cognitive processes including motion, sight, sound, memory, expectations, and consciousness (Bruce, 2007; Ornstein, 1969). Psychological time is perceptual, relative, and exhibits the property of elasticity. i.e. the ability to expand and contract (Einstein, 1931; Ornstein, 1969; Zimbardo & Boyd, 2008). While the speed of physical time is uniform, the speed of psychological time is variable (Flaherty, 1987). We sense time as passing slowly when we are thinking about it, or when our consciousness is not occupied with other matters (Klein, 2006). Likewise, we sense time passing quickly when our mind is focused on matters other than time. The experience of psychological time is personal and individual. We may agree that an interval of time is equal to ten minutes, but our perception of the duration, speed, and adequacy of that interval may differ. Therefore, the significance and meaning of an interval of time varies within and between individuals, depending on internal and external context.
The Sociology of Time
Time is said to drive society, serving as the basic mechanism through which sociological acts at all levels exist and operate (Katovich, 1987; Maines, 1987). Human actions are said to be embedded in time and time is seen as a mechanism through which human behavior is organized and regulated (Maines, 1987). Both physical and psychological forms of time are viewed as fundamental to our understanding and experience of time as social beings. Through social transaction, patterns of expected behavior based on sequential time are negotiated and mutually agreed upon (Katovich, 1987). This enables cooperative coordinated acts among multiple actors and is considered especially significant within organizations where this transaction process is known as temporal structuring (Orlikowski & Yates, 2002). Temporal structures are patterns of behavior created and used by people to give rhythm and form to their everyday work practices. They serve the purposes of guiding, orienting, and coordinating ongoing interdependent activities and shape how people approach work tasks.
The collective understanding and agreement to temporal structures results in an inter-subjective experience and the establishment of normative organizational behavior and routines. Human action is said to both shape and to be shaped by these structures, which may function to constrain or enable social actions (Orlikowski & Yates, 2002). Action is constrained when people do not perceive negotiation of new structures possible and enabled by the contrary perception. When rhythmic time structures are altered, a temporal shift is said to occur. Temporal shifts can result in changes in multiple dimensions of the experience of time. Such dimensions may include a sense of time pressure, a sense of found time (i.e. when time previously allocated becomes available), perceived discretion over time, perceived tension among competing task demands, and the time horizon considered during the planning process (Staudenmayer, Tyre & Perlow, 2002). Changes in the experience of time may ultimately function to enable organizational change.
Individuals often simultaneously engage in multiple temporal structures within an organization as well as within other social and personal roles. Multiple simultaneous time structures can be competing and interdependent, resulting in the need for balance and prioritization. Efforts to meet these needs have commonly been referred to as time management strategies (Orlikowski & Yates, 2002). Time management by isolated individuals within organizations may yield limited results. Orlikowski & Yates (2002) asserted that because temporal structuring is a social process, cooperation of other members of the community is prerequisite to time structure modification. They contend that “collective time coordination” rather than “time management,” more accurately conveys this process. The psychological responses to a perceived imbalance among these time structures and the inability to effectively complete desired activities may be experienced as time poverty/famine, and time pressure (Goodin, Rice, Bittman & Saunders, 2005; Staudenmayer, Tyre, & Perlow, 2002).
Dimensions of time also serve as semiotic codes that communicate social messages (Zerubavel, 1987). The duration, frequency, timing, and speed of events have symbolic meaning beyond the physical passage of time. A sense of value and commitment is derived from the duration of time expended on an activity and the frequency of interaction. We spend more time on activities we value and on relationships to which we are committed. People kept waiting may feel devalued, while being on time is a sign of respect. Some places and times are socially defined as more private and interactions in this context may convey messages of relative intimacy. Accessibility for interaction e.g. an open door policy, communicates commitment and importance. Moreover, definitive plans (“let’s have lunch tomorrow at noon”) convey a message of relative importance compared to open ended plans (“let’s get together some time”). Spontaneous interactions as opposed to those planned or scheduled may be seen to reflect more informal and intimate relationships. Actions completed hurriedly can communicate business and/or disinterest.
Our conceptualization of nursing is informed by historical trends in healthcare practices, theory development, and normative ethics. Nightingale (1859) was the first to define and describe modern nursing. Her classic text conveyed the image of nurses as managers of the environment for the purpose of promoting health and preventing complications of disease. Nightingale’s description of this nursing work included references to activities categorized as direct physical care, teaching, emotional support, surveillance, and supervision.
However, throughout the evolution of modern nursing the definition of nursing has been debated in the literature. In the height of nursing theory development in the 20th century, various nursing conceptual frameworks were proposed, each with a different definition of nursing (Fitzpatrick & Whall, 1983). Despite these differences, Fawcett (1984) suggested that a common meta-paradigm regarding the areas of concern to nursing had emerged. The nursing meta-paradigm continues to include nursing, environment, person, and health and is evident in the current prevailing definition of nursing (American Nurses Association, 2003). The meaning of the concept of nursing is thus tied to characterizations of and relationships among the elements in the meta-paradigm. In other words, the question, “what is nursing” subsumes the question, “how do nurses interact with patients and the environment to achieve a state of well being for persons”. Knowledge of what nurses do and how they do it is essential to understanding the meaning of nursing.
The nursing process is accepted to be the mechanism through which nurses interact with patients and environment – it constitutes the “how” of nursing (Foster & Hawkins, 2005; Hagerty & Patusky, 2003). The interventions available to nurses for implementation have grown in number and complexity since the days of Nightingale. The environment of care has likewise grown in complexity and has significantly influenced the role and practice of nursing. The “what” and “how” of nursing today is determined by scientific evidence, available technology, nursing theory and philosophy, ethical and community standards, institutional policies, and a legally defined scope of practice. Today’s nursing interventions involve significant coordination of care among providers and healthcare facilities. While the categories of interventions may have changed little, the distribution of effort and priority among these categories has changed significantly. Furthermore, the introduction of unlicensed assistive personnel, the focus on outpatient care, and the increased use of specialists has resulted in a shift of nursing effort from direct physical care to coordination and supervision of care (Norrish & Rundall, 2001).
The root terms time and nursing are rich with meaning and should be used to inform our understanding of the concept nursing time. A holistic approach to the conceptualization of nursing time is therefore advocated and the following conceptual framework (Figure 1) proposed and presented as a work in progress. Nursing time is conceived to exist in three forms – physical, psychological, and sociological. Physical nursing time is measured by the clock and assigned a number. It is exemplified by commonly used staffing metrics such as hours of care and nurse-patient ratios (Kane, Shamaliyan, Mueller, Duval, & Wilt, 2007). Physical nursing time is public – it belongs to the world outside of the nurse-patient relationship, e.g. to the world of managers, payors, researchers, and administrators. Physical nursing time provides a platform for uniformity – for a shared definition and interpretation. Such uniformity and standardization form the foundation for quantitative comparisons and expectations for regulation of behavior.
Figure 1: Conceptual Model of Nursing Time
The physical time consumed in the completion of individual nursing activities is often summed and averaged to determine how many nurses are needed and how many patients an individual nurse should be able to care for during a shift. Examples of behavioral expectations associated with physical nursing time include establishing nursing unit schedules and assignments based on pre-set boundaries around physical nursing time. Measures such as nurse-patient ratios and hours of care have become benchmarks around which nurse managers set goals and upon which organizations are evaluated. However, these measures are meaningful only to the extent that the rules of computation are clarified and applied consistently. It is important to know, for example, which census was used to determine patient days (e.g. midnight vs noon), and which types of nursing staff (registered, vocational, or unlicensed) were included. Did the computation include only productive clinical time and how was productive time defined?
In the context of human resource management, productive time is synonymous with “worked hours” as defined by the U.S. Department of Labor. Worked hours, according to the Fair Labor Standards Act (FLSA) is time spent on any activity required for employment, including time spent at meetings and educational events (29 USC § 201). The data used to compute physical nursing time typically come from hospital payroll databases designed to comply with the reporting requirements of the FLSA. Consequently, they often lack the capability of isolating direct care providers and direct clinical time. While it may be useful to include work-time of staff not providing patient care for budgeting purposes, its inclusion may pose problems with respect to clinical benchmarking. Apparent differences in hours of care, for example, may actually be due to differences in the length of orientation, number of staff in orientation, or continuing education activities among units. High nurse-patient ratios may actually reflect a higher percentage of nurses in non-clinical roles rather than more direct care providers per patient.
Measures of physical nursing time are typically reported as global rather than particular measures because they reflect an entire shift or day of work rather than specific nursing activities. Consequently they do not retain any of the experiential meaning from particular nurse-patient encounters. Global measures of physical nursing time may tell us that patients on a given nursing unit receive an average of eight hours of nursing care per day, but they tell us nothing about the nature of care for particular patients. What specific activities or events occurred in that time? Were the activities orderly? Were the activities skillfully completed? Were the activities sufficient to achieve intended goals? Though global measures of physical nursing time are associated with patient outcome (Kane et al., 2007), the specific nursing activities responsible for such outcomes have not been identified. The “what” or the “how” of nursing from global measures of physical nursing time alone cannot be realized.
Psychological nursing time is conceived as that internal to providers and recipients of nursing care. It is subjective, perceptual, and elastic. Psychological nursing time is influenced by the history, experience and expectations of the participants. It is what participants experience as nursing and how they experience it. Regardless of the quantity of physical time patients receive from a nurse, if needs and expectations are not met they may perceive the time as insufficient. Temporality and the semiotics of time are integral to the patient perception of feeling cared for (Davis, 2005; Davis, 2006; Hayes & Tyler-Ball, 2007; Henderson et al., 2007; Jennings, Heiner, Loan, Hemman, & Swanson, 2005; McCabe, 2004). For example, Henderson et al (2007) found that patients express dissatisfaction when nurses are not readily available to respond to specific requests, or when they forget to follow up and complete activities after getting distracted. Presence, described as “being there and being with,” was reported as a pervasive thread in patient exemplars of good nursing care (Davis, 2005). Patients also report experiencing a feeling of safety when staff is present, i.e. when they are watched over (Schmidt, 2003). This reflects the elastic nature of psychological nursing time and suggests that what happens and how it happens in a given period of time, are perhaps more important for the nurse-patient relationship than physical time alone.
Nurse perceptions of nursing time provide information relative to the adequacy of time to meet patient needs and other role expectations, and also identify opportunities for improvement. Upenieks, Akhavan, Kotlerman, Esser, & Ngo (2007) described which activities nurse’s perceive to add value to patient care, and how much time they spend on value-added (60%), necessary (19.7%) and non value-added (20.7%) care. Furthermore, it is estimated that nurses spend 39% of their time on activities that require a registered nurse, 12% of their time on activities that could be done by an unlicensed staff member alone, and 49% of their time on shared tasks (Gran-Moravec & Hughes, 2005). Such information directs us to look for opportunities to better use the RNs available.
Research suggests that elements of care are being missed as a result of inadequate physical nursing time (Kalisch & Williams, 2009; Schubert, Glass, Clarke, Schaffert-Witvliet, & DeGeest, 2007; Schubert et al., 2008). Interventions across multiple categories of care are missed, and nurse-perceived missed care is more strongly associated with patient outcome than are measures of physical nursing time. Therefore, knowingwhat nurses do (or do not do) is as important as knowing how much time they have available. Moreover, measures of physical nursing time are not strongly correlated with nurse-perceived missed care – i.e. care is missed across the continuum of ratios and hours of care. Although staffing is often identified by nurses as a major reason for missed care, it does not seem to be exclusively an issue of an inadequate number of available nurses across an entire shift. For example, Kalisch, Landstrom, & Williams (2009) determined that staffing problems were identified as frequently resulting from a sudden or unexpected increase in care demands within the shift. This is consistent with what has been described as turbulence in the literature (Jennings, 2008). Sources of turbulence may include sudden changes in patient volume (admissions), acuity (physical or emotional deterioration of patients), or activity (patient discharges, patient transfers, or bedside procedures).
Nursing time also is experienced within the social context of the healthcare system. As members of organizational communities, nurses participate in shared time structures that become the foundation of practice patterns and routines. Examples of time structures that influence nursing care include established work shifts, standardized medication times, standardized procedure sequences, and hours of operation for ancillary departments. Nurses make decisions and organize their actions during a shift within the social process of time structuring. Patients may be awakened at a certain time based on when food trays are routinely delivered, and preoperative medications are administered around routine operating room sequences (e.g. case order and start times). Calls to physicians may be delayed to coordinate with routine rounding practices. Answering a call light may be delayed in favor of administering the first dose of antibiotics to a patient within the expected time interval of diagnosis.
The sociological form of nursing time is therefore described as that which is experienced by providers and recipients of nursing care through shared temporal structures. It is a shared inter-subjective experience of patterns of behavior. Sociological nursing time is characterized by the sequential ordering of events within the daily routine of a practice setting. Coordination of care, which has become a primary role in nursing, involves participation in numerous time structures within a HCO. The potential for overlap among multiple interdependent time structures is significant and the need for prioritization among nurses is critical (Hendry & Walker, 2004; Waterworth, 2003). The result for patients may include missed, delayed, or inappropriately sequenced care and the result for nurses may include a sense of time pressure (Detrick, Bokovoy, Stern & Panik, 2006; Roszell, S., Jones. & Lynn, 2009; Stefancyk, 2009). The negative effects of time pressure on well-being, performance and decision making have been demonstrated in a variety of settings outside nursing (Calderwood, Klein, & Crandall, 1988; Dhar & Nowlis, 1999; Goodin, Rice, Bittman & Daunders, 2005; Höge, 2008; Lin & Carley, 1997; Peters, O’Connor, Pooyan, & Quick, 1984; Pollock & Grimes, 2002;Roxburgh, 2004; Sonnentag & Niessen, 2008; Staudenmayer, Tyre, & Perlow, 2002; Suri & Monroe, 2003). Though the experience of time pressure has not been adequately evaluated in nursing, there is some evidence to suggest that similar negative effects are experienced (Thompson et al., 2008).
The Ethics of Nursing Time
In her classic work on the science and ethics of a practice discipline, Beckstrand (1978) affirmed that the goal of a practice discipline is to bring about changes in entities such that a greater degree of defined good (value) is realized. The defined good for a practice discipline is determined in the context of normative and metaethics. Within this context the moral obligation of nurses toward patients is established, as are the standards for evaluating the relative “goodness” or “badness” of people (moral value) and things (nonmoral value). Things, such as nursing time, may be judged to be of value if they are good in and of themselves (intrinsic value), or if they lead to a good outcome (instrumental value).
A compelling logical argument for the intrinsic and instrumental value of time to the practice of medicine was eloquently articulated by Braddock and Snyder (2005). They asserted that time has ethical significance within the context of the patient-physician relationship and the inherent duties, such as respect of patient autonomy, promotion of well being, maintenance of fidelity, and preserving justice. The authors distinguished between time as quantity and quality. Perceived quality of time is viewed as fundamental to the patient experience and equivalent to the concept of adequate time. Adequate time is said to exist when there is sufficient time to meet professional and ethical obligations with patients. The following sequence of logical statements is a general summary of their thesis: 1) time as quantity is necessary for time as quality (adequate time); 2) adequate time is necessary to promote trust and patient-centered communication; 3) trust and patient-centered communication are inherent to strong therapeutic relationships; 4) strong therapeutic relationships lead to good outcomes (patient satisfaction, adherence to treatment regimens, better patient outcomes); and 5) time as quantity and quality has intrinsic and instrumental value.
The parallels between the respective conceptualizations of time and therapeutic relationships within the disciplines of medicine and nursing are strong and intuitively obvious. Getting to know the patient is germane to the nurse-patient relationship (Kirk, 2007; Macdonald, 2008), and has been identified as a fundamental form of nursing knowledge for decades (Carper, 1978). This esthetic knowledge is described as being gained through direct experience with the patient and allows the nurse to understand the meaning of the illness for the patient and recognize nuances in individual treatment responses (Macdonald, 2008). Time is the most commonly identified factor among nurses and patients that contributes to nurses knowing the patient and when time is lacking, task-oriented care based on the principle of nonmaleficence, rather than beneficence, may result (Macdonald, 2008). Time, therefore, has significant intrinsic and instrumental value in the practice of nursing.
Conclusions and Implications for Theory, Practice and Research
The conceptual model presented has implications for theory development, the practice of nursing and healthcare administration, and nursing research. Nursing time has significant intrinsic and instrumental value in nursing and healthcare. It is fundamental to the nurse-patient relationship and the achievement of nursing care goals. A holistic approach incorporating all aspects and dimensions of nursing time (physical, psychological, and sociological) is advocated. While one may choose to limit measurement to a particular dimension in some contexts, this should be done only with the understanding and acknowledgement that the “totality” of nursing time is not being addressed. Any resulting information should be interpreted with caution.
Better measures of organizational and nursing performance are needed to guide nurse staffing decisions. Measures of physical nursing time, such as hours of care and patient ratios, do not reflect the experience of psychological or sociological nursing time and have little meaning in isolation. These measures lack precision and do not capture the complete nursing care experience for patients or the complete work experience for nurses. These global measures also are extremely context dependent. Contextual influences include use of unlicensed assistive personnel, use of technology, patient acuity, geographic design of the unit, practice patterns, and time structures. Quantification and statistical control of these influences are needed to facilitate interpretation of any apparent differences in outcome due to physical nursing time. Measures that reflect specific nursing activities or role components will likely be more useful for identifying problems and opportunities for intervention
Additionally, more attention should be given to qualitative measures of psychological time in the determination of hospital staffing and resource requirements. The essence of psychological nursing time will not be found in numbers such as hours of care, but rather from the perceptions of nurses and patients. Efforts to improve the balance between the supply of and demand for nursing time should include strategies to increase the quantity of physical nursing time available for patient care as well as the quality of psychological nursing time experienced by both patients and nurses. Multiple strategies to enhance the patient experience of nursing time are warranted and should address how much time nurses spend with patients as well as how they spend that time.
Practicing nurses should be cognizant of the semiotics of nursing time. They should understand that the decisions they make regarding how their time is allocated, prioritized, and sequenced are interpreted by the patients they serve. Delayed and hurried responses to patient requests may be received as messages of disinterest and lack of concern for their well-being. Likewise, through timely interactions nurses can convey messages of care and concern. Thus, while the current environment may impose limitations on the duration of time spent with patients, psychological time quality can be enhanced through careful attention to the timing and sequence of interactions.
More theory development and empirical research is needed to examine relationships between sociological, physical, and psychological nursing time. Current time patterns on nursing units warrant careful analysis. Strategies to more evenly distribute the demand for nursing time across a shift should be explored. Patterns of overlapping and competing time structures for nurses should be identified and evaluated for their effect on physical time available for patient care and the psychological experiences of time by nurses and patients. How nurses prioritize when faced with overlapping time demands influences patient outcomes, yet has not been widely studied. The time structures most likely to result in turbulence, time pressure, and missed care should be identified. The concept of time pressure warrants further exploration within nursing. Finally, organizational leaders should work to ensure that practicing nurses and nurse managers are empowered to change existing time structures when found to be sub-optimal. Emphasis should be placed on collective time coordination to ensure a balanced distribution of role demands and minimization of time pressure for providers of care.
E. EXAMINE your priorities
EXAMINE priorities in that area by motivating people and communicate priorities.
Using Goals to Improve Performance and Accountability
A goal is a simple but powerful way to motivate people and communicate priorities. Leaders in states, local governments, Federal programs, and in other countries have demonstrated the power of using specific, challenging goals (combined with frequent measurement, analysis, and follow-up) to improve performance and cut costs. These stretch goals can be effective at changing the way an organization does business. This Administration has embraced the power of goal-setting as a way to improve the Federal Government’s performance and accountability to the American people. Federal agencies are using near-term and longer-term goals in a variety of ways to improve their effectiveness and efficiency.
The Federal Government operates more effectively when agency leaders, at all levels of the organization, starting at the top, set clear measurable goals aligned to achieving better outcomes. It is also vital that they regularly engage their organizations and delivery partners in critical reviews of progress on these goals. This leads to the discovery of what works and what does not. Federal agency leaders are increasingly using goals and measurement to reinforce priorities, motivate action, and illuminate paths to improvement. Agencies are also using goals in partnership efforts to improve outcomes.
Agencies establish a variety of performance goals and objectives to drive progress toward key outcomes. Agencies outline long-term goals and objectives in their strategic plans, and annual performance goals in annual performance plans. Twenty-four major Federal agencies have also identified a limited number of two-year Agency Priority Goals in the FY2015 budget, aligned with their strategic goals and objectives. Agency Priority Goals target areas where agency leaders want to achieve near-term performance acceleration through focused senior leadership attention. The Administration has also adopted a limited number of Cross-Agency Priority Goals to improve cross-agency coordination and best practice sharing.
E. EDUCATE a colleague
EDUCATE a colleague in your new skill area by raising professionalism and quality across the sector
Government publishes new skills strategy
Government publishes latest skills strategy for the further education sector
In April the Department for Business, Innovation and Skills (BIS) and the Department for Education (DfE) jointly published the Government’s latest skills strategy for the further education sector, outlining how the Government intends to raise the quality and standard of vocational education provision in further education colleges (FECs). It intends to establish a skills system based on greater rigour for vocational qualifications so they may provide young people with pathways to occupations or higher levels of education; and be more responsive to employers and learners needs. Below are six areas where reforms are proposed:
The Learning and Skills Improvement Service will make way for a new Further Education (FE) Guild which will be responsible for raising professionalism and quality across the sector; and a Chartered Status awarded to FE Colleges is proposed which will become the “internationally recognised mark of quality for learners and employers”. Local Enterprise Partnerships (LEPs) and FECs will be encouraged to take joint responsibility for setting local skills strategies.
The proposal to enhance the reputation and status of the FE sector is welcomed by the Science Council, but a key concern which has been expressed to Ministers remains the proposed awarding of Chartered Status to FE Colleges. It is widely acknowledged that Chartered Status is an award given to individuals and not organisations, and professional bodies have worked for many years to establish Chartered Status as an esteemed professional award for the individual. Applying the term to further education institutions is misleading and risks devaluing the prestige that Chartered Status confers. It would be a different matter is FE Colleges were to be awarded Royal Charters (as is common for higher education institutions) but of course this is not a quality assurance mark. It is also worth noting that FE is also subject to Ofsted.
The Government aims to make apprenticeships “the gold standard of vocational education” with renewed emphasis on pushing Advanced and Higher Level Apprenticeships. The Government endorsed much of the Richard Review of Apprenticeships and has decided to consult on the next stages in The Future of Apprenticeships in England: Next Steps from the Richard Review. The Richard Review recognised that professional registration is an important component of providing learners with the training and experience demanded by employers, and the Government will continue to support sectors where registration exists and is well-recognised.
Government support for sectors where registration already exists is a welcomed announcement. In the Science Council’s response to the Richard Review it was argued that linking science apprenticeships to professional registration could provide the independent quality assurance for both employers and individuals that the Government is seeking.
The implementation plan and timetable will be published in the autumn of 2013, with new apprenticeships in some sectors expected to be ‘teach-ready’ by 2014/15.
Traineeships and Pathways to Work
Designed to offer pre-employment training for young people aged 16 to 24 Traineeships will aim to provide a combination of focused periods of work preparation with work placements and further training in English and Maths. A discussion paper jointly published by BIS and DfE in January 2013 outlined a potential framework for Traineeships.
The Government is keen for employers to take greater ownership of the design and delivery of qualifications, with the view that this will raise the value of qualifications. BIS and DfE are following up the 2011 Wolf Review of 14 to 16 vocational qualifications with a joint-review of vocational qualifications for 16 to 19 year olds to introduce two new Level 3 qualifications: an Occupational Qualification route designed for direct entry into an occupation; and an Applied General Qualification route to provide progression to further or higher education. BIS will also shortly announce details of standards for the Technical Baccalaureate, designed to recognise the highest achievements in technical training by 16 to 19 year olds.
Funding and Responsiveness
Education and training providers will be given greater autonomy to design and deliver qualifications that are wanted by learners and employers. As a result, qualifications considered poor quality or irrelevant will not be publicly funded in the future. In line with higher education funding reform, qualification funding will follow the learner with the aim of incentivising training providers and employers to develop relevant and functional qualifications.
Investment will focus on young people with low-level English and Maths skills and for Advanced Learning Loans, which will be made available from September 2013 to those aged 24 and over studying at Level 3 and 4. The Government will act upon Lord Heseltine’s recommendations in his report, ‘No Stone Unturned’ to ensure that LEPs are provided with greater resources and given greater influence to shape the design and delivery of local skills provision, with particular focus on SMEs.
Good Information and Data
The Government’s stated role is to make relevant information publicly available and look to developers to create online resources and e-applications to make that information user-friendly. It is envisaged that the National Careers Service will play an important role in connecting sector bodies, employers, education institutions and local partners to work together to make opportunities and information available to young people.
P. PREPARE for wisdom
The example used here for “PREPARE your heart for wisdom” is learning adaptation to illness and loss along side the role of belief systems in the coping process.
The following article is from BMJ: British Medical Journal. (Kutz I. Job and his “doctors”: bedside wisdom in the book of Job. BMJ : British Medical Journal. 2000;321(7276):1613-1615.)
Job and his “doctors”: bedside wisdom in the book of Job
The book of Job has traditionally has been regarded as a philosophical or theological treatise on the nature of faith of a just man in an unjust world. Read by a modern clinician, the book becomes a treatise on adaptation to illness and loss, on doctor-patient relationships, and on the role of belief systems in the coping process.
- Viewed by a modern clinician, the book of Job unfolds as possibly the earliest description of patients and their healers struggling to cope with loss and illness
- Job’s lament contains all the recognised stages and elements of adaptation to calamity
- Job’s friends take on the role of healers, but, failing to recognise his needs, they blame their “patient” for his misfortunes and end up in a cycle of escalating empathic failure that renders them helpless
- The failure experienced by Job’s “healers” is not uncommon in modern doctors, who fail to recognise their own fear of helplessness and their own defensiveness
- The assumed presence of a deity can provide coherence out of confusion for modern patients, believers and non-believers alike, and help them through the adaptation process, just as it did for Job
- The book of Job, like an ancient mirror, reflects both the frail and heroic features of humans, which have changed little through the ages
Job is a thriving livestock rancher, married, and the father of 10 children. Renowned for his piety, he is even praised by God in the angelic council. Satan, a sceptical archangel, offers an experiment to test whether Job’s piety is really sincere or predicated on his God-given wealth. With God’s permission, Satan sends a series of catastrophes, from economic disaster to the death of Job’s children.
“The Lord gave, and the Lord hath taken away: blessed be the name of the Lord,” responds Job, adding, “Naked I came out of my mother’s womb, and naked I shall return there” (Job 1:21). God scolds Satan for drawing him into a needless, brutal experiment, but Satan, an ardent methodologist, argues for a second experimental phase: “Skin covers skin! For all that a man has he will give for his life. But put forth thy hand now, and touch his bone and his flesh, and he will curse thee to thy face” (2:4-5). Here Satan outlines a hierarchical scale of human suffering in which the violation of the bodily envelope and physical injury are ultimately more demoralising than loss of property or even loved ones.
With God’s permission Satan strikes Job with “evil boils,” some excruciatingly excoriating skin disorder. Job’s concerned wife urges him to break his silence and curse God, even at the risk of dying. Job refuses. Then, three of his friends arrive from afar to console him. So deformed is Job by tragedy and illness that the friends are rendered speechless themselves.
Adaptation and coping in Job’s lament
Job’s poetic lament begins with a cry of shock, denial, outrage, and despair: “Oh that the day had perished wherein I was born, and the night which said, there is a man child conceived” (3:2). He continues by describing his physical and mental anguish: “When I lie down, I say when shall I arise, and the night be gone. And I am full of tossing to and fro until the dawning of the day. My flesh is clothed with maggots, my skin is a clod of earth: it curdles and decays. My days are swifter than a weaver’s shuttle, and are spent without hope” (7:4-6). He blames God for his illness: “He will multiply my wounds for no cause. He will not let me recover my breath, but fill me with bitterness” (9:17-18). Job provides one of the most vivid portrayals of nightmares: “When I say, my bed shall comfort me, my couch shall ease my complaint; then thou dost scare me with dreams, and dost terrify me through visions: so that my soul chooses strangling, and death rather than these my bones. I loathe it; I would not live always; let me alone for my days are hollowness” (7:13-16).
With time, Job shifts from physical anguish to defensive rage directed against the injustice of God and the obtuseness of his friends. Whether one considers that the stages of coping emerge in a certain order1 or in a more unpredictable transition from one defence to another,2,3 it is clear that Job has moved from the initial stage of shock and anguish to one of confrontation, rage, and bargaining. Whether Job reprimands or begs forgiveness, despairs or yearns for hope and redemption, he is engaged in an adaptation struggle, the goal of which is the restoration of his sense of coherence.4 Finding coherence is an essential psychological manoeuvre which defends against arbitrariness and chaos, the ultimate form of annihilation.
The therapeutics of Job’s friends
Job’s friends assume the healer’s role. They wish to reduce his suffering by espousing an age old moral-theological theory of illness containing both aetiology and cure. Illness emanates from sin, while symptoms are due to divine punishment. To deny wrongdoing is to obstruct the healing process. To get well, Job must repent. Yet Job’s “healers” fail miserably. Rather than being supported, Job feels offended and betrayed by his friends’ moral preaching. He retorts with a broadside of sarcasm: “No doubt that you are the people, and wisdom shall die with you, but I have understanding as well as you. I am not inferior to you” (12:1-2).
The more Job fails to accept his friends’ moral reasoning, the more accusatory and vindictive they become, moving from gentle chiding to harsh accusations (fig 1). Job, in turn, accuses them of hypocrisy and double standards: “But you are forgers of lies, witch doctors the lot of you; O that you would altogether keep silent, and it shall be considered your wisdom” (13:4-5). The intervention has deteriorated into an escalating empathic failure. A fourth young comforter, who intervenes with sanctimonious accusations, only echoes his elders, proving again that excessive moralising and lack of empathy make poor medical intervention.
Both Job and his “healers” attribute Job’s calamity to divine intervention. But, while Job experiences his disaster as a betrayal of his world of meaning, his friends cannot accept Job’s interpretation, or even feelings, and need to reject it while tenaciously adhering to their moral belief system. They fail to recognise their own defensiveness, their own fear of losing meaning and their need to adopt rigid, moralistic dogma as a defensive mantle against their own despair. If such a disaster could befall Job, their equal or even their better, who can safeguard them from similar catastrophe? To feel safe they need to place Job on the other side of the morality fence. Job refuses to be quarantined in the sinners’ ward, and, by authentically expressing his emotions, he exposes his healers’ ineffectiveness: “So these three men ceased to answer Job, because he was righteous in his own eyes” (32:1).
The therapeutics of God speaking from the whirlwind
At this point of impasse, God appears from the whirlwind. Rather than addressing the origin of Job’s calamity, God poses a list of rhetorical questions emphasising Job’s ignorance of the awesome complexity of nature. Pounded into submission, Job relents and admits his ignorance: “I have heard of your presence with my ears, but now my eye has seen thee, wherefore I abhor myself, and repent is dust and ashes” (42:5-6).
While interpretations can be as diverse as personal belief systems, modern psychology and even theology can agree that the voice from within the divine whirlwind represents Job’s inner voice rising from within his stormy being. William Blake illustrated this by depicting God’s face and figure as identical to those of Job himself (fig 2).
God’s reply reflects Job’s moment of transformation, the final stage of coping, the stage of acceptance. Job accepts his feeble insignificance when God intervenes, after he refused to accept it from his friends. It is God’s personal presence that restores Job’s confidence in divine order. Furthermore, unlike Job’s friends, Job’s God does not point a finger of blame. His message is that cosmic law and order are as intact as they are incomprehensible. Blame and guilt are left out of the equation.
Poetic justice ends this morality play with the restitution of Job’s fortune and provision of a new family and with God’s reproach to his friends: “My anger burns against thee, and against thy two friends, for you have not spoken truthfully to me, as my servant Job has” (42:7). The failed healers are now ordered to repent, apologise to Job, and pay the price of the animal sacrifice that Job will perform on their behalf. Thus, failures of doctor-patient relationships, according to the book of Job, can be seen as a form of ethical malpractice worthy of admonition and recompense.
Job in the haematology ward
“Man’s extremity is God’s opportunity,” quotes William James in The Varieties of Religious Experience,5describing the turbulent psychological phenomena of revelation. Indeed, morality and religion play a part not only for ancient ailing believers but in the coping process of many modern patients. Over half of 50 agnostic men and women who had recently been informed that they had cancer responded with a moral or religious exclamation, such as, “What have I done to deserve this?” or “Why am I being punished?”
The following vignette illustrates this point. A 54 year old agnostic woman who had developed acute leukaemia went through an initial turbulent period of shock, denial, despair, and hope. Six weeks after hospitalisation, she developed severe complications to the aggressive chemotherapy. She spent most of her time in a darkened room “staring at the ceiling, and asking myself why I deserve this.”
“Why, indeed, do you deserve this?” inquired the consulting psychiatrist.
“Somebody up there is testing me.”
“Who is that somebody?”
“Who can it be? I have never been religious, but there’s no doubt in my mind that somebody up there is testing me.”
“Why should he test you?”
“Well, I have been through a lot in life, but it is probably not enough, because I have never encountered anything like this, and if I can prove I can withstand this, then I think he will let me live, because things can’t get worse . . . and he’ll make me stronger.”
She had never heard of the book of Job nor ever read the Bible. Yet, like Job, she had created a live deus ex morbus, a god out of illness. One could regard this god as part of the bargaining stage of coping.1 Yet, here is a de novo creation of a divine entity that ensures that the world is not an arbitrary place—an authority is in charge and, if recognised and appealed to, can increase supplicants’ chances of sanity and survival.
Helplessness and defensiveness in today’s doctors
The sort of threat and helplessness experienced by Job’s “healers” is frequently experienced, and almost as frequently denied, by modern physicians. Doctors are taught to manage illness effectively. Intractable illness provokes threatening helplessness. When patients express doubt, dissatisfaction, accusation, or ingratitude doctors may become harsh or even punitive.6
In an ongoing Balint group, a group designed to help family doctors understand their patients and mainly themselves, one doctor described how, to her surprise, she became short tempered and accusatory and even avoided encounters with a patient who had recently had metastatic disease diagnosed.7 While she could readily blame the patient for being “an ungrateful whiny nuisance,” it was not easy for her to confront her own sense of profound helplessness with regard to the patient’s relentless deterioration, one that threatened her grandiose professional identity. As with Job’s friends, however, failure to address that sense of helplessness only increases the cycle of defensiveness and rage in the doctor.
Doctors of various specialties have tried to identify specialty specific elements of pathology and wisdom in the book of Job.8–15 I view the book of Job as perhaps the earliest description of patients and healers struggling through the universal process of coping with loss and illness. Job’s poetics contain modern elements and stages of adaptation to calamity. The responses of his healer friends are common in modern doctors, who unknowingly defend themselves from being exposed to the same threat experienced by patients, the threat to the very structure of meaning and coherence. Job’s religious experience may often appear at times of crisis in today’s patients.
Viewing ancient Job from a modern perspective confirms that there is, indeed, “no new thing under the sun” (Ecclesiastes 1:8), at least with regard to people and their emotions. We can only marvel at the biblical mirror that still artfully reflects both the frail and heroic features of our essence.
“Job rebuked by his friends” (left) and “The Lord answering Job out of the whirlwind” (right) by William Blake
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