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Introduction

The acquisition of L2 is a process that is complex as many individuals may not achieve proficiency as expected. An individuals ability to achieve proficiency in pronunciation of an L2 is influenced by a complexity of factors besides the age factor, such as; socioeconomic status, gender, amount of exposure to culture, and others. These factors affect an individuals ability to reach L2 proficiency (Ellis 478). A good number of these studies have concentrated on finding the ages of the critical period (Lenneberg 198). A period during which abilities to learn language peaks and thereafter levels off and achievement of proficiency in pronunciation become a more daunting task. The studies examined depict the age at which an individual begins acquiring a second language to affect proficiency in pronunciation of that language.

Ellis (2003) depicts that, despite the rationale that adults can reach the same levels of proficiency as children, they face challenges in attaining proficiency on pronunciation in L2 compared to children (p. 480). Ellis (2003) attributes the overall problem to be that age as a factor influencing attainment of proficiency in pronunciation is not fully conceptualized. This is because learning a second language is a complicated process that cannot be fully comprehended. L1 acquisition occurs naturally and individuals require minimal efforts to succeed. Acquisition of L2, however, is more difficult depending on the age aspects of individuals attempting to learn the new language (Ellis 482). The main objective of this study is to establish the characteristics that influence the attainment of proficiency in pronunciation. These characteristics play a great part in determining whether adult Iranians can reach the same level of proficiency as children.

In this paper, I will first review the literature related to age variables that influence the attainment of proficiency in pronunciation in L2. I will examine in detail studies on the critical period of achieving proficiency in pronunciation of L2 following Lennebergs 1967s critical period publication. Critical studies examined include studies by Collier (1988, p. 76). Secondly, I will examine studies that follow Piagets conception of egocentric and socialized speech in determining the influence of age on pronunciation; Thirdly, I will examine studies on different forms of processing new language to attain proficiency in pronunciation; lastly, in this section, I will examine studies on the effects of the first language on L2 proficiency. The second section of the literature review will look at: the criticisms of age factor as a limitation to the realization of proficiency in pronunciation of L2; studies on effects of biological factors on age in achieving proficiency in L2; and studies on the effects of the rate of exposure to L2 in attaining proficiency in L2. Finally, I will examine the literature on how Iranians learn SLA to determine whether Iranian adults can reach the same level of proficiency as children

A Review of Related Literature

Can Adults Reach Same Level of Proficiency in Pronunciation as Children

As children, L2 is similar to L1 acquisition in that learners do not need to think about it (DeHouwer 167). The majority of children all over the world learn to speak at least two languages. Bilingualism is inevitable in every nation around the globe, in different classes of society and all age groups. The acquisition of a second language in children follows a similar process as they learn the first language (Perez 94). Children who develop proficiency in pronouncing L1 to communicate, think and solve issues easily acquire a second language in a similar way (Perez 96). Children who learn SLA learn it to carry all the knowledge about language acquisition they had received through their L1 acquisition. Tabors (1997, p. 12) posits that SLA for these children is not the process of discovering about language, rather finding out what language is.

there is variation, however, is how fast individuals learn the second language. Tangible evidence is not available of biological constraints to the acquisition of L2. No evidence depicts children as more advantaged in SLA compared to adults. The critical period of language acquisition ends by the time children reach adulthood. Adults face challenges in achieving proficiency on proficiency in L2 compared to children (Bley-Vroman 201). Adults find pronunciation as the main limitation in their second language acquisition. The ability to process speech in adults is altered through their experience of the first language. This incapacitates them in terms of achieving high levels of L2 proficiency. This topic requires further comprehensive research that focuses more on the levels that determine proficiency in pronunciation. However, this does not mean that adults cannot achieve fluency in pronunciation. Research has indicated that young adults and adolescents are better at learning second language (Coa later 24). Collier postulates that children tend to forget language fast compared to adults. This can lead to negative cognitive effects (DeKeyser 378). For instance, children before the age of five tend to learn a second language quickly followed by the loss of their first language. This impedes their ability to communicate to speak proficiently with their family members. (Hakuta 24). A number of studies try to explain the effects of age on the attainment of proficiency in pronunciation. Studies examined in this paper are examined as follows;

Studies on the Critical Period of Attainment of Proficiency in Pronunciation

Several studies on the influence of age on L2 attainment have followed Lennebergs 1967 publication on the critical period of acquiring a second language. The studies concentrate on trying to prove or dismiss the critical period hypothesis by comparing observations in the area of proficiency in pronunciation between children and adults. DeHouwer (2006 p. 297) dismiss studies that focus on pronunciation proficiency. These studies on pronunciation fluency discovered that after reviewing learners attainment of pronunciation in L2 after being exposed for three years, young learners achieved more fluency in pronunciation compared to adult learners (Lenneberg 480). Collier dismisses this research noting that the intention to test the critical period hypothesis concentrates more on the pronunciation aspect of language fluency, and the dichotomy of adult and child. Collier preferred researchers and educators to concentrate more not just on pronunciation by analyzing the period needed to attain proficiency in multiple content areas. In her analyses, she discovered that within 4-5 years, children of ages 8-12 attained set norms of proficiency. A group of children between ages 5-7 attained the set norms in about 8 years (Collier 43). The age group of 12-15 years had the hardest problem attaining the set grade norms. Most importantly, she also deduced that the influence of age recedes over time as L2 learner achieves more proficiency (DeHouwer 231).

According to Loup (1990, p. 266), it is not possible to attain proficiency in pronunciation unless first exposure occurs early, possibly before age of 6 in many people and by about age 12 in the remainder. Long avers that both proficiency in pronunciation is unattainable beyond the critical period. If the Critical Period Hypothesis affects SLA in the same manner as First Language Acquisition, adult L2 proficiencies would be lower compared to that of a native speaker (Birdsong 18).

Studies following Piagets Conception of Egocentric and Socialized Speech

A significant number of studies also followed Jean Piagets conception of egocentric and socialized speech. Studies on these aspects have led to the discovery of many other interesting aspects of speech in children during his investigations. As a result, Piaget triggered a lot of research about the most important area of language development during childhood (Cutler 70). The hypothesis advocated by Lenneberg and observations by Piagets observations contents a childs brain to undergo critical development between ages 2-12 years (Cutler 71). During this period, children have an innate ability to peak up on things rather faster, particularly language. DeKeyser (1995, p. 279) notes a study in this interest conducted to determine lexical comprehension in bilingual children. The yielded results indicated that children as young as 13 months were considered to be bilingual. At that age, these children were able to understand translation equivalents (DeKeyser 280). In addition, the research proves that comprehension is critical to the L2 attainment process and that it is noticeable as early as infancy (Cutler 72).

Studies on Different Forms of Processing New Language

Further, other studies point acquisition of language by children and adults to involve different forms of processing for language acquisition. In the Fundamental Difference Hypothesis, Bley-Vroman (1990, p. 201) states that L2 in adults needs mechanisms of solving problems that are explicit and general compared to children.. This bodes well ineffective grammar acquisition and less in attaining proficiency in pronunciation by adults. Apparently, DeKeyser (1995, p. 379) agrees with this thinking and contends that for adults to acquire a second language (L2), they need analytical thinking. According to Zobl (1989, p. 50), children achieve higher proficiency levels as compared to adults. This is occasioned by a change in the adult language faculty. In adulthood, there is a slight decline of the computational module hence the difference. Clearly, this may explain why adults cannot reach the same level of proficiency in L2 as children. Typically, there are different views concerning the relationship of age of L2 learning and the level of proficiency in pronunciation.

Studies on the Influence of the First Language on L2 Proficiency

There exist age limitations that prove the differences in language acquisition among children and adults (Hakuta 8). Adults find pronunciation as the main limitation in their second language acquisition. The ability to process speech in adults is altered through their experience of the first language. This incapacitates them in terms of achieving high levels of L2 proficiency. Thus, second language adults normally process input with mechanisms already attuned to their first language. Further investigations by Cutler (2002, p. 27) on adult speech segmentation discovered that adults do not utilize syllabification mechanisms when listening to their first language. This testifies how difficult it is for adults to reach proficiency levels as children. When listening, children engage in syllabification structures in the L2, unlike adults, thus, attaining proficiency in accent naturally. In this study, adult native English speakers engage a segmentation mechanism that is not stressful when listening to English (Cutler 47). They also followed the same strategy when listening to Japanese. Accordingly, Iranian adults cannot reach the same proficiency levels as children following the overview of these studies. Iranian adults just like Japanese speakers use moral related mechanisms in L2.

There are different perceptions about the relationship between the age of second language learning and the level of foreign accent/pronunciation. According to Long (1990, p. 251), a second language is spoken fluently before children attain the age of six. Those who learn L2 after age six will learn with a foreign accent. Similarly, Patkowski (1990) justified the critical period to explain why many adults speak their second language with a foreign accent (p. 254). However, this view was contested by Bongaerts (1999, p. 133) who discovered some motivated adults who began acquiring L2 after the critical period and spoke fluently. Moreover, Flege (1999,) also contested this view arguing Patkowskis suggestions were influenced by other circumstances other than pronunciation, such as speakers selection of words (p.239). He suggested 3 hypotheses that were concerned with proficiency in SLA (Flege 240). Exercise hypothesis was named as the first hypothesis as it explained ones ability to learn to produce and perceive speech which remains intact across the life span only if one continues to learn speech uninterruptedly (Flege 240). The unfolding hypothesis was named second as it explained the developed L1 phonetic mechanism at the time the second language begins (Flege 245). The third and last hypothesis was the interaction hypothesis. On testing it, Flege ascertained that the L1 and L2 phonetic systems in bilinguals could not be separated since there was a close interaction between them (Flege 246).

Studies on Effects of Biological Factors on Age in Achieving Proficiency in L2

Some biological factors explain why the achievement of pronunciation fluency is advanced in children compared to adults. According to Penfield (1959, p. 75), the flexibility or plasticity of a human brain recedes with age. As Hyltenstam (2003, p. 541) stated, acquisition of L2 proficiency was included. Hyltenstam (2003) concludes the process as one that plays a significant part in enabling neurons to make connections early in life. They explain that attainment of fluency in a second language is: a physical-chemical process in the brain necessary for providing neurons with nutrition so that they can extend the information transfer to larger distances in the brain (p. 540). Further, brain maturation is considered to take place when most of the cortical areas have completed the process of myelination (Hyltenstam 543). These biological processes are more active in children compared to adults. Therefore, these studies by and large explain why adults cannot reach the same level of proficiency as children.

According to Hakuta (2003, p. 31), there is a reduction in reduction in L2 fluency with age. This plays contrary to what the critical period hypothesis advocates. The critical period does not lead to the achievement of fluency in pronunciation of L2 among learners. However, it relates to specific cognitive mechanisms such as working memory capacity, speed cognitive processing and attention among learners (Hakuta, 41). Accordingly, Hyltenstan denies any:

co-variation between problem-solving, meta-linguistic abilities and language proficiency. If these cognitive explanations accounted for age-related differences, there would be different learning processes for children and adults, but research has shown otherwise (Hyltenstan 571).

An accurate interpretation of these studies indicates that late learners are hardly fluent in a second language. Children, on the other hand, acquire fluency in pronunciation. Additionally, fluency in pronunciation cannot be fully achieved by both children and adults. They contest that data deduced from studies on children and adult attainment of proficiency levels in L2 is under utilized. These types of learners are exceptional and cannot be easily differentiated from native speakers. In their perception, learning strategy has to be triggered from birth in order to avoid its decline. They attributed aging as the cause for decline in learning of people with increasing age onsets (Ellis 34)). However, maturation does not cause difference between exceptional and non- exceptional late SLA learners within the same Acquisition Onsets 3. They attribute social/psychological issues to what accounts to all these cases. In this way, they agree to existence of difficulty in attainment of proficiency in pronunciation levels among adults.

There is similarity in achievement rate of proficiency in pronunciation among normal developing children. This occurs irrespective of differences in patterns of interaction between parents and children. Inherently, learning in children occurs in a systematic pattern. The age factor is necessary in enhancing proficiency in pronunciation/accent of second language acquisition. According to Ellis (2009) children are more successful in being proficient in pronunciation of second language compared to adult (p. 329). Age The relationship between age of learning and achieving proficiency in L2 is backed by Critical Path Hypothesis approach. In this hypothesis, Lenneberg (1967) posits that proficiency in language must occur before puberty for the learner to achieve native like proficiency (p. 330).

Studies on the Effects of the Rate of Exposure to L2 in attaining proficiency in L2

Substantial variability in achievement of proficiency in pronunciation among learners exists. A number of factors underlie this variability in proficiency in accent among learners of which age difference being one of the factors. In order for an individual to achieve high proficiency in pronunciation, one has to begin being exposed to new language at an early age. The effects of age on fluency in pronunciation are a factor used in determining individual differences in language acquisition (Krashen 222). There are substantial studies that support the assumption that children become more proficient in pronunciation compared to adults. We may wonder whether one needs to begin new language before attaining a certain age in order to achieve proficiency in pronunciation (Loup 73).

In studying the influence of age on proficiency in pronunciation, one needs to separately consider its impact on the route of acquisition, rate of acquisition, and achievement of proficiency or fluency in pronunciation. The age factor does not have much effect on proficiency in pronunciation as regards to the route of acquisition. Krashen (1979, p. 221) showed using bilingual syntax measure, that adults acquired grammatical morphemes in a manner similar to L2 learning children. However, age effect is essential in the case of pronunciation. In normal adaptive settings, children learners achieve more proficiency in pronunciation than teenagers or adult.

A number of perspectives explain the success of proficiency in pronunciation in Second language attainment (Ellis 3). Learners need to understand what is to be learnt, how to learn it, and why it should be learnt. However, the process of attaining proficient accent in second language is complex and involves a number of interrelated factors (Ellis 4). These perspectives discuss how attainment of proficiency in SLA is clearly influenced by age differences (Brown 329). Although these approaches have resulted to success in learning second language and achieving proficiency, it remains that children attain proficiency in pronunciation faster than others. Studies in this area have looked at children and adult variables and their capacities to attain proficiency in second language.

Age as a factor of individual differences affects achievement of proficiency in pronunciation of second language especially among adults. According to Ellis (2000, p. 32), it is not easy to arrive at a coherent picture of individual differences. He categorizes the variables involved in individual differences into three main classes: learners belief about language learning was classified as the main type. Learners under this category have pre-conceived ideas about matters such as significance of language aptitude, nature of learning new language, and strategies that work well; secondly, Ellis (2000, p. 5) recognizes affective states as the second main type of variable that affects proficiency in pronunciation of second language. He cites fear of beginning to learn the second language by some learners, and over confidences by others as reason. For Iranians fear of embracing Western values compounds this fear. Other learners develop anxiety due to competitive natures and how they perceive whether or not they are progressing (Coppieters.545).

Szuber (2006, p. 125) posits that most studies on language tend to concentrate on early childhood compared to adulthood. In this regard, adolescence as an interesting period is commonly ignored. World over, majority of adolescents are either born in a foreign country or speak a language other than their native languages (Szuber 121). Acquisition of second language in this group is first rising and more attention must be accorded by researchers and educators alike (Szuber.126). It is common knowledge that children achieve high proficiency levels in normal settings. Adults on the other hand, may attain their proficiency in pronunciation in a structured setting such as classroom. This attests that adults cannot achieve same level of proficiency in pronunciation in L2 compared to children.

What are the Criticisms of Age Factor as Limitation to Achieving Proficiency in L2

There have been numerous attempts to criticize the existence of age limitations as shown by L2 learners who acquired fluent accent. The prominent and critical feature is lack of foreign accent when adults speak second language. Let us have a look at these studies. According to Coppieters (1987, p. 544), the first study conducted to ascertain the effects of age on fluency on second language pronunciation was carried out by Coppieters. Twenty one foreign learners were identified as the sample population for the investigation. Semantic judgment task and follow up interviews were the main involvement of this sample group made up of French learners (Coppieters 545). These learners were selected as they had no fluent foreign accent. The overall performance of these learners was discovered to be under that of native accent controls despite the fact that they had no fluency in accent. Some of these experimental investigations have shown that achievement of pronunciation proficiency is not impossibility for adult learners of L2. An investigative study sample in which proficiency in pronunciation was noticed includes the research work of Birdsong (1992, 700) and Bongaerts (1992, p. 699). These researches dealt with a variety of grammatical features which included proficiency in pronunciation. In these researches, the incidence of fluency in pronunciation achievement ranged from 5% of the sample to 15% or above (Birdsong 701). Nevertheless, evidence relating to proficiency in pronunciation in adult SLA is ambiguous. For instance, 6% of the adult participants in the research of Flege et al. (1999, p. 85) performed with proficiency in pronunciation, but all had ages of arrival younger than 16 years.

Birdsong (1992, p. 706) discovered majority of French adult learners performed well just as native speakers. This is supported by the fact that out of twenty one French learners, fifteen were able to achieve the same level of hard grammar task as the native speakers. Bongaerts (1992, p. 707) concentrated his studies on phonology. He studied L2 learners of English and French among fluent Dutch students (Bongaerts 708). These learners were selected because of their fluency in pronunciation in English and French. They were requested to pronounce a series of sentences aloud. Words that Dutch speakers found challenges in pronouncing were included in sentences. Interestingly, a good number of these learners performed well as native speakers at all levels. Bongaerts (1992, p. 712) on their part studied pronunciation of advanced and naturalistic learners of Dutch as a second language. Bongaerts selected 30 educated learners with different first languages and different age onsets. The selected ages ranged within 11 and 34. Observations indicated that two participants (age 21 and 14) excelled as native speakers. Moyer (1999, p. 82) researched fluency in pronunciation/accent among 24 year olds American adults and were discovered to very fluent of German. These American adults were taken to German to learn German language to determine their fluency. They were offered work to read aloud. This work had a word list, paragraph and full sentences. Apart from this, each Germany judge singly evaluated and awarded marks on the American adults speech samples. The outcome indicated that the judges were able to differentiate between the native speakers and non-native speakers. Curiously, only one speaker was judged to have spoken like natives cross all pronunciation work provided. This was an exceptional adult learner who had high motivation for German language fluency (Moyer 87).

When these learners were exposed to shorter tasks which included word list reading, researchers found movement towards more achievement of fluency in ratings. Foreign accent emerges once the task is extended to include full sentences and paragraphs. Hyltenstam interprets this as a risk as the studies seemed to concentrate on skills rather than concentrate specifically on pronunciation proficiency (Hyltenstam 539). They were concerned whether these adult second language learners who excelled as fluent speakers would have done so if they had been given longer tasks that required spontaneous speech (Hyltenstam 540). However, Moyer (1999, 87) notes that challenges involved in engaging long naturalistic speech to evaluate pronunciation fluency. This is because there are other linguistic features which could influence second language learners performance. These linguistic features include lexical and syntactic features.

According to White (1996, p. 234), L2 learners who seem to attain proficiency in pronunciation differed from native speakers in subtle ways. Their investigations they considered the control group in a strict sense for the purpose of separating native speakers from non-native speakers. It was observed that majority of subjects deemed to be close native began learning English as L2 before age 12. However, non-native speakers were observed to begin learning English after attaining age 12. Significant contrasts were realized between native and non-native control groups on the parameters that were assessed. Universal grammar was found to be unaffected by age as late second language learners were also able to attain native-like fluency (White, 234). Hyltenstam (2003, p. 353) dismisses Whites investigations strongly for considering individuals who spoke French as their first language arguing that, in spite of having been very rigorous in their selection criterion. Therefore, it is natural that the speakers did not encounter any challenges regarding these aspects.

In other studies, investigators were concerned with young learners finding out whether it was possible to find SLA learners who attained high levels of accent at earlier ages. Hyltenstam (2003) tested:

grammatical and lexical performance of 24 highly proficient Spanish and Finnish L2 learners of Swedish with Age Onset of six years or earlier (16 subjects) and seven years or later (eight subjects) (p. 356). The age of 6 was discovered to be a critical period that differentiated between near-native and native-like ultimate achievement of proficiency (p. 364).

However, he observed that, not all early learners reached native-like proficiency hence his conclusion that early age onset is not the only requirement for sufficient acquisition of native-like proficiency.

Finally, Hyltenstam (2003) concluded that, there were significant differences between first language speakers and second language speakers regardless of their age onsets (p.234). The studies indicate that delay in age onset has an impact on the level of language proficiency (Hyltemstam 241). It is apparent that, when studies conducted on adult L2 learners and those conducted on childrens SLA learners are compared, both did not find learners who attained overall native like proficiency. When studying late and advanced L2 learners, Hyltemstam observed some limitations (Hyltemstam 160). Other studies also observed that advanced SLA learners could not achieve full proficiency (Coppieters, 1987, p. 544).

In relation to mistakes typical of the fossilization processes, a learner has to understand his own learning strategies for the purpose of monitoring his fluency in L2 pronunciation. Critics however pointed out those subjects performed fluently as other speakers in other areas that were not specifically investigated (Birdsong 9). The investigator found that those speakers who were as good as native speakers conformed to native norms. Non-native features as explained by Bongaerts (1999, p. 544) contend that non-native characteristics go a step further than determining proficiency in pronunciation in his advanced control group when making free oral speech. Considering this evidence, Hyltestam (2003, p. 564) states exceptional learners with ability to acquire native-like proficiency in some areas of second language, although not at all levels. This can happen to adult learners who are highly motivated to achieve high proficiency levels in L2 (DeKeyser 201).

Common evidence exists on the effects of age on pronunciation proficiency. Syntactic complexity among learners starts forming at the age two according to (Lenneberg 330). Singleton on his part proposed six months as an early age since during this period, phonetic sensitivity is already present for different categories. Alternatively, he proposes an early age to be at birth because at birth children are sensitive to segmental and prosodic differences (Singleton 89). In addition, he point out that the first language has different domains and therefore there are different age onset for the different domains (Singleton 54). Criticisms allude that low age onset (children) does not guarantee high level proficiencies in pronunciation as this process is directly influenced by other factors.

Can Iranian Adults Reach Same Level of Proficiency as Children

In Iran, proficiency in pronunciation in foreign languages is taught through a context-restricted environment. In this environment proficiency in pronunciation is learnt by classroom practices that use specific textbooks and teachers classroom work management for children and adult learners. Learners in Iran do not experience support from social contexts outside the classroom. According to Sadighi (2000), fluency in foreign languages such as English was formally taught from the second grade of junior high school after Iranian Revolution (p. 14). Presently, proficiency in English fluency is taught from the first grade of junior high schools (at the age of 10-11) (Hussein 13). The Iranian Ministry of Education is taxed with res0ponsibility of compiling, developing and publishing textbooks for foreign languages. The Ministry of Education also publishes teaching materials for public and private high schools nationwide (Hosseini 11).

The rate of proficiency in pronunciation is favorable to adult learners than children learners when the amount of exposure to the language is controlled. However, the amount of exposure of foreign languages to Iranian adult learners is restricted, thus cannot reach high levels of proficiency on graduation. Most emphasis of proficiency in pronunciation learning in 1990s concentrated on reading skills to allow learners read and translate English texts more easily. Iranian general curriculum placed emphasis on developing learners grammatical knowledge in reading and translation. It placed less focus on proficiency in pronunciation. Therefore, most techniques used by high school teachers involve grammar translation to prepare learners for expectations of Iranian national curriculum. The curriculum puts more emphasis on grammar and less concern on enhancing proficiency in pronunciation. For this reason, therefore, it is not easy for adult Iranian learners to reach high proficiency levels in pronunciation as children.

Proficiency in pronunciation of second language demands contact with native speakers. Tourism and travel is another factor to be taken into consideration to Iranian learners mastery of English as a second language. Few tourists visit Iran, and only visit historical cities like Isfahan and Shiraz, and only a few make visits to Tehran where majority of Iranian students are learning English (Menashri 11). Tourists make it possible to individuals to communicate in English even if the state restricts media for learners on religious grounds. Travelling also assist greatly in terms of practicing the language. Due to prohibitive bureaucracy, Iranians find it extremely difficult to travel abroad. It i

Introduction

Human health outcomes are often products of the interplay between several biological and environmental factors. Based on this relationship, scientists have often strived to learn a lot of information surrounding the physiological, anatomical and biological issues underpinning human health outcomes with mixed outcomes (Blau, Brown, Mahanta, & Amir, 2016). The concept of personalized medicine has helped to improve the process because it helps them to understanding how each of the selective factors, highlighted above, affect human health outcomes and how they possibly intersect to determine human health outcomes (Blau et al., 2016). The concept of personal medicine hails from a common philosophy in the health practice (shared by philosophers, such as Hippocrates) which says, It is far more important to know what person the disease has than what disease the person has (Management Association Information Resources, 2016, p. 298).

In the last decade, there has been a range of new medical products that have come to the market, courtesy of advances in personal medicine. However, these developments have not been homogenously distributed in different fields of medicine because some health sectors have embraced the concept better than others (Management Association Information Resources, 2016). For example, many researchers agree that the oncology field has benefitted the most from advances in personalized medicine (Schleidgen, Klingler, Bertram, Rogowski, & Marckmann, 2013). In fact, in the last three years alone, the Federal Drug Administration (FDA) has approved four cancer drugs that have been developed from the concept (U.S. Department of Health and Human Services, 2013). These drugs have specifically been targeted at patients who have developed certain types of tumours, but who have specific genetic characteristics. Recently, the FDA also approved specific therapies for some patients who suffer from specific cystic fibrosis (U.S. Department of Health and Human Services, 2013). Most of these patients have genetic mutations that cause the disease. New technologies that stem from personalized medicine have also allowed medical researchers to use 3-D printing to treat critically ill infants (Schleidgen et al., 2013). For example, this technology has been used to create a bioresorbable tracheal splint to treat this group of patients.

Each of the aforementioned examples explains the contributions of personalized medicine in the health field. Generally, this field of medicine advocates for the development of precision drugs to suit individual characteristics or preferences of different patient cohorts. However, in as much as developments in personalized medicine are more concentrated today than in the past, the concept is not new.

According to Rehm, Hynes, and Funke (2016), the concept of personal medicine has existed for more than 100 years and it was not until the 19^th century that scientists started to appreciate its relevance in the field of medicine. Researchers in the fields of chemistry and microscopy spearheaded this new development (Management Association Information Resources, 2016). They were among the first researchers to use personal medicine to investigate the underlying causes of different diseases affecting human societies during the 19^th century (U.S. Department of Health and Human Services, 2013). Since then, advances in health and medicine have aided the dissipation of different tenets of the concept to the wider medical practice, thereby making it granular over time. For example, developments in the pharmaceutical and medical industries led to the spread of the concept in different fields of medicine through developments in imaging technology and data mining skills (Albanese et al., 2013). In the middle of the 20^th century, researchers started investigating how different people respond to different drugs, including how they metabolize them and how they help them to cope with the diseases affecting them (U.S. Department of Health and Human Services, 2013). These improvements emerged as a foundation for developments in the pharmacogenetics sector. Based on such developments, the transformation of the personalized medicine industry, from an idea into practice, was concentrated in the 20^th century. Relative to this development, the U.S. Department of Health and Human Services (2013) says, Rapid developments in genomics, together with advances in a number of other areas, such as computational biology, medical imaging, and regenerative medicine, are creating the possibility for scientists to develop tools to truly personalize diagnosis and treatment (p. 5).

Although there have been many developments made in personalized medicine, researchers still agree that they have a long way to go in understanding why patients respond to differently to varied drugs and treatments (Blau et al., 2016). This problem partly comes from the inability of clinical practitioners to predict (accurately) the outcome of different treatment methods to specific groups of patients. Coupled with the availability of other treatment options and the lack of genetic biomarkers for every patient that would allow them to predict their reactions to different therapies, these methods are often less than optimal (Management Association Information Resources, 2016). For example, current practice dictates that a patient suffering from high blood pressure would be subjected to only one line of treatment, without the proper understanding of whether this treatment is ideal for his/her individual preferences or not. In fact, currently, most doctors select a treatment method based on general information about the patient. The personalized approach focuses on assigning treatment plans to these groups of patients, based on specific information about their genetic makeup (Personalized Medicine Coalition, 2014). Comparatively, current practice dictates that if the patient fails to respond to one line of treatment, the doctor switches to another. Generally, this treatment plan is based on trial and error. Some negative outcomes associated with it may be adverse drug responses, or even patient dissatisfaction, or complaints, about the services offered (Personalized Medicine Coalition, 2014). In extreme cases, patients may refuse to follow the laid down treatment regimens and lead to the worsening of health outcomes (U.S. Department of Health and Human Services, 2013).

Personalized medicine strives to eliminate these challenges by streamlining the medical decision-making processes by making it more receptive to individual health profiles. In this regard, the concept helps practitioners to understand which treatments would work for a specific cluster of patients and which ones would cause adverse side effects, or outcomes, for the same group of patients. This contribution explains why some observers consider personalized medicine as an art that helps medical practitioners to provide patients with the right medicine, at the right dosage and at the right time (U.S. Department of Health and Human Services, 2013, p. 6).

Indeed, medical researchers have always observed that, although people may suffer from the same diseases or conditions, treatments may work differently for different groups of people (Management Association Information Resources, 2016). Advances in technology, in different fields of medicine, such as genomics, and regenerative medicine, have created the opportunity to provide personalized medicine because they have allowed medical experts to treat and monitor their patients more precisely and effectively (Buriani et al., 2012). In other words, what is new is the promise that personalized medicine will develop targeted therapeutic tools for understanding who will respond better, or worse, to a specific medical treatment. Similarly, the concept promises that medical practitioners would be able to better assess the health risks that specific groups of patients could suffer from, based on their genetic biomarkers (Rehm et al., 2016). The increased use of personalized medicine in the last decade is proof of the power of science in advancing medical practice. However, these developments do not understate the complexity associated with understanding human health and diseases. In this review, we explore the different aspects of personalized medicine through a review of how bench research could improve bedside utility. This paper is divided into five chapters that explore the role of certification and surveillance in personal medicine, adherence to the disruption caused by the concept, what works and what does not work (from bench to bedside), the future technology trends in personalized medicine and the infrastructure needed to support the concept in the healthcare practice.

Assuring a Solid Infrastructure

Many health care institutions often find it difficult to implement the concept of personalized medicine without a proper or solid infrastructure to support the process (Blau et al., 2016). Concisely, there are many challenges associated with the implementation of this concept and they make it difficult for medical practitioners to implement personal medicine without considering the structures needed to make the concept workable in their places of work. Scaling challenges and the challenge of managing huge populations are some issues that highlight the need to have a solid infrastructure when implementing personalized medicine (Personalized Medicine Coalition, 2014). The process of developing the right infrastructure to meet the needs of personalized medicine requires an evaluation of existing technology, optimization of the clinical trial network, and an understanding of the support that scientists need in identifying new biomarkers that would help to provide personalized care to different patient groups (Halim, 2015). Similarly, there needs to be well thought out strategies that would help stakeholders to understand the clinical utility of personalized trials, as a standard procedure for choosing the best treatment methods to give patients (Moore, 2015).

Karlson, Boutin, Hoffnagle, and Allen (2016) draw our attention to the need for a solid information technology (IT) infrastructure as a core area of implementing the personal medicine concept because it would help to increase collaboration across different facets of the healthcare practice. This collaboration could lead to the development of a joint infrastructure for collecting and storing biological information and data regarding different cohorts of patients. In addition, there is a need to have a nationwide technological infrastructure for accommodating both treatment and research data in key areas of personal medicine (U.S. Department of Health and Human Services, 2013). Indeed, some nations have built this infrastructure and connected it with existing local and central health infrastructures within their jurisdictions (Management Association Information Resources, 2016). Such infrastructural networks are often notable within their health care systems.

Some institutions have developed such IT infrastructures, with high precision, as is seen from the works of the Massachusetts General Hospital, which has built an IT infrastructure for personalized medicine (Weiss & Shin, 2016). Through a program called the Partners Personalized Medicine, the hospital developed this unique infrastructure, which contains four key tenets. The first one is a laboratory for molecular medicine. In this facility, the hospital undertakes genetic testing for different patients around the world. The main aim of developing this unit was to bridge the gap between research and clinical medicine within the facility (Weiss & Shin, 2016). Having been in existence for more than 13 years, the facility has evolved to maintain a specialization in germ line mutation testing. The second tenet of the hospitals IT infrastructure is the translational genomics core (TGC), which performs next generation sequencing (Weiss & Shin, 2016). Genotyping and gene expression analysis are other activities that go on within this unit. It is available for research to all partner investigators and even those who are not partners in the hospital.

Through this open-policy advantage, the healthcare facility provides a platform for collaboration to different types of researchers in the area. The third component of the IT infrastructure is the partners bio-bank, which contains gene samples of more than 50,000 patients (Weiss & Shin, 2016). The samples include DNA, Plasma and Serum samples for different groups of patients from different partners. In this regard, this component of the IT infrastructure acts as a bank for storing biological samples for research and analysis. Closely related to this component of the institutions IT network is the bio-bank portal, which acts as a platform for researchers to investigate the different biological samples available (Ishikawa, 2012). In this platform, they bring together different phenotypes, genotypes and samples of biological specimen from different patient groups for analysis. Collectively, this information technology infrastructure is broad and encompasses the input of different health personnel, including clinicians, patients and researchers. Their collective contribution promotes enhanced research and optimal patient care. Generally, this example shows how the IT infrastructure is important in the implementation of personalized medicine because it supports different functions associated with the concept (Weiss & Shin, 2016).

The development of a solid infrastructure to support personalized medicine has not only occurred at an institutional level, but regionally as well. This is because countries have collaborated to improve the quality of their medical research on personalized medicine through the development of joint infrastructural platforms. For example, according to Sun (2016), Asian countries have pooled their resources to develop joint infrastructure projects that would support the implementation of personalized medicine. For example, the International Cancer Genome Consortium is one such platform that has been developed by these countries to aid in cancer research and assist in the development of cancer treatment methods within the wider framework of personalized medicine (Sun, 2016; American Society of Clinical Oncology, 2017). China, India, Japan, and Singapore are four Asian countries that are part of the initiative as well (Sun, 2016). However, the list of nations funding the project is longer because Saudi Arabia and South Korea are equally part of the nations funding the initiative (Sun, 2016).

Assadi and Nabipour (2014a) say the danger associated with the adoption of personalized medicine rests in the socioeconomic inequalities that persist throughout the world. In other words, developed or wealthy countries are in a better position to manage the challenges associated with the concept, thereby providing the ground to increase health inequalities around the world. The high cost of processing and storing data is only one challenge associated with this inequality. The others are the high costs associated with research and development as well as the technical skills that are required in the process, which some of these countries may lack. Assadi and Nabipour (2014a) say that, compounding this problem is akin to the concept of the tragedy of the commons, where the interests of a few individuals may trample over the interests of the majority. However, Noble Laurette Elinor Ostrom says that this problem should not be alarming because it is not common among human societies in the first place (Assadi & Nabipour, 2014a). He bases his view on the fact that human beings have often found solutions to their problems by developing trust between one another. Through clear regulatory frameworks, human societies have learned to work well with each other, considering trust and respect becomes the key currency of cooperation. However, there is a strong need to understand the role that institutional diversity may play in making human societies prosper even more.

The diversity of human societies should be reflected in the diverse applications of personalized medicine. Creating different tiers of health care systems is one way of doing so because having only one-tier of health care may compromise the need to have an equitable and efficient resource distribution method in the health care industry (Assadi & Nabipour, 2014a). A nested regulation system should promote this kind of framework because there needs to be a neutral ground where science and ethics, within the wider framework of personalized medicine meet. In other words, all stakeholders in the health care sector should be accountable for their actions because no person should be above another, or try to undercut what another party is doing.

In the last few decades, the infrastructure supporting personalized medicine has started to evolve because institutions and health agencies are starting to focus on building their educational and legal infrastructures, which are supposed to complement the implementation of personalized medicine (Hood & Flores, 2012). For example, at an institutional level, different medical schools have started to develop training programs that strive to educate people about the benefits of personalized medicine and how they could use the concept in their practice (U.S. Department of Health and Human Services, 2013). The initiative has also spread to intergovernmental levels where federal and state authorities are introducing new programs to educate practicing physicians about personalized medicine and how they could incorporate it in their practice (U.S. Department of Health and Human Services, 2013). Health-based institutions, such as the Genetic Nursing Credentialing Commission, which gives practicing nurses a licence to practice personalized medicine (their certification mostly focuses on genetics), have spearheaded such initiatives (Sweet & Michaelis, 2012). Different medical centres around the world have also taken the initiative of branding themselves centres of personalized medicine, based on these developments. Hospitals have also not been left behind because they have changed their policies to accommodate personalized medicine as a core area of their practice (Management Association Information Resources, 2016). These policies have mostly been used to guide treatment decisions from the beginning to the end of a patients care.

The involvement of the national governments in enabling the development of the legal infrastructure needed in the implementation of personalized medicine comes from the fact that they recognize the efficiency and cost-reduction advantages the concept introduces to the healthcare practice (Personalized Medicine Coalition, 2014). Different governments have reported different paces in enabling the development of this legal infrastructure. For example, in America, the Obama administration introduced the Genomics and Personalized Medicine Act and the American Recovery and Reinvestment Act, which were aimed at complementing the existing legal infrastructure for personalized medicine (U.S. Department of Health and Human Services, 2013). Both legal instruments were pivotal in deploying more than $19 billion in federal resources to the upgrading of the countrys electronic information platform to support personalized medicine (Sweet & Michaelis, 2012). Particularly, this investment helped in the effective and efficient use of genetic testing data for cancer management. The outcome was a reduction in the cost of health care (Sweet & Michaelis, 2012). Such infrastructural developments also help in the improvement of communication networks between basic researchers and clinical researchers because both sets of stakeholders could communicate more efficiently and effectively on the improved electronic platform. The same initiatives have also been associated with a reduction in the misuse of genetic information gathered and stored in the personalized medicine bio-data (Hood & Flores, 2012).

The development of the health infrastructure supporting personalized medicine is not only improving communication among different researchers, but also integrating different sub-domains of several fields associated with the concept. For example, the National Cancer Institute, in America, has benefitted from these infrastructural developments by integrating the activities of different clinical and research laboratories (Burock, Meunier, and Lacombe, 2013). The Biometrics Normative Grid Initiative, which began in 2004, has also benefitted from the same development by maintaining an integrated cycle of medical discovery, which has been merged with clinical application, thereby making the process more efficient and effective (Hood & Flores, 2012). The American Centre for Disease Control and Prevention has intervened to regulate the process by assessing the ethical, social, and legal implications of practicing personalized medicine, especially as it relates to genetic tests (Burock et al., 2013).

However, major changes in the creation of a solid infrastructure for the deployment of personalized medicine cannot occur without the involvement of insurance agencies. Their involvement in the development of the necessary infrastructure is becoming increasingly important, especially after studies have shown that personalized medicine helps to reduce treatment costs (Management Association Information Resources, 2016). Indeed, as explained by Sweet and Michaelis (2012), a better understanding of the genetic basis for disease risk can help some people tailor their diet, environment and lifestyle to reduce their preventable risk of diseases for which their genetic susceptibility is greatest, avoiding the cost of treatment (p. 29). Furthermore, by improving health care decision-making processes, insurance companies are attracted to the fact that personalized medicine could help to reduce the costs associated with ineffective treatments (Management Association Information Resources, 2016). The same cost reduction measure could occur through the reduction of treatment costs associated with adverse side effects. Other players in the heath sector, such as the American Association of Health Plans and the United Health and Kaiser Permanente, have also acknowledged the cost reduction advantages associated with personalized medicine (Albanese et al., 2013). Individual insurers, such as Aetna have also acknowledged the same finding.

As part of their risk management procedures, some insurance companies are also paying for pre-symptomatic genetic tests to assess their level of risk before committing to any insurance plan. The CDC is at the forefront in trying to help these firms get ahead of the personalized medicine trend by making it easy for them to get approval for tests and to make easy payments while doing so (U.S. Department of Health and Human Services, 2013). Accessibility is one aspect of insurance that is identified by medical researchers to be of critical importance in personalized medicine because they say it is vital for all patients to access precision medicine (Management Association Information Resources, 2016). Through the increased investments in payment structures and insurance payment processes, patients should be easily billed.

The provision of a decision support structure is also central in creating a solid infrastructure for the deployment of personal medicine because the concept increases the medical options available for most patients (Burock et al., 2013). Consequently, patients need to make the right decisions when evaluating these options. Without a proper decision support infrastructure, they would be unable to do so effectively. Since personalized medicine also demands advanced data analysis methods, Aronson et al. (2016 say there is a need to develop a strong infrastructure that would support such a decision-making structure.

Boutin et al. (2016) say that countries also need to develop sound infrastructures with innovative facilities that would accommodate the different processes, such as genomics, associated with precision medicine. As part of the same infrastructure, there needs to be sober efforts to include advanced analytical tools and digital performance tools that would not only have a high storage capacity but also have high processing capabilities to enhance service delivery (Burock et al., 2013). The need to have a qualified and capable management team to oversee the implementation of this infrastructure is also important because without it, it would be difficult to extract the value that could be extracted from personalized medicine (Management Association Information Resources, 2016). Such professionals may include mathematicians, computer scientists, biologists and the likes (Management Association Information Resources, 2016). At the same time, countries and hospital agencies should also make parallel investments in security management to protect the privacy of patients who are part of the research process. Institutional support should also be a central theme in the creation of a solid infrastructure for the deployment of the personalized medicine concept because without the commitment of health institutions, it would be difficult to regulate the quality of findings or health outcomes that emerge from the process (U.S. Department of Health and Human Services, 2013).

Comprehensively, assuring a solid infrastructure for personalized medicine is important because the concept always comes with a large number of patients who require personalized medicine services. As seen in this chapter, different researchers, such as Tsai et al. (2016) and Albanese et al. (2013), have emphasized the importance of doing so. They say investments in infrastructure could lead to cost-effective assays across different levels of care. Based on their assertions, having a solid infrastructure to support personalized medicine is akin to setting the stage for the implementation of the concept.

Role of Certification and Surveillance

Although many medical professionals know the benefits of personalized medicine, the regulatory framework surrounding its implementation and adoption has not been straightforward. Different regulatory aspects of personalized medicine have been keen to regulate what works, develop new knowledge to understand patient needs, and understand the sources of this knowledge (Tsai et al., 2016). The nature of these regulatory frameworks often dictate the pace of adopting personalized medicine and how people would accept its use in the short-term and in the long-term. In this chapter, the policies we highlight here are regulations surrounding personalized medicine tests, surveillance, and certification standards that are of paramount importance to our understanding of personalized medicine. Different jurisdictions have unique surveillance standards and regulations surrounding the concept. The table below presents an overview of FDAs policies governing personalized medicine tests in America.

The FDA has developed different regulations for undertaking laboratory tests to ascertain the gene makeup of different patients that would eventually lead to better administration of drugs and dosage, or improved decision-making processes surround health dilemmas (Personalized Medicine Coalition, 2014).

Different authorities have surveyed personalized medicine processes at different levels, but laboratory testing has received most of the coverage (Tsai et al., 2016). Diagnostic testing has often happened within two large clusters that include laboratory-developed tests and diagnostic kits which contain regents and materials needed to undertake the tests. The FDA regulates most of the products used to undertake these tests (Personalized Medicine Coalition, 2014). Few types of equipment used in personalized medicine are often classified as medical devices because most of them are considered laboratory developed testing devices (Tsai et al., 2016). Nonetheless, many jurisdictions around the world often exercise regulatory discretion when surveying laboratory-developed tests. For example, the FDA often exercises risk-based oversight methods on regulating the kinds of equipment and tools used to undertake laboratory developed tests (Personalized Medicine Coalition, 2014). They often use existing Acts to do so, but some observers have questioned their jurisdiction in regulating this field of personalized medicine (Weiss & Shin, 2016). These concerns have often emerged after other health-based agencies have claimed jurisdiction over the same process. For example, the Centre for Medicare and Medicaid Services (CMS) has also claimed that it should regulate laboratory-developed tests and all the equipment associated with it (Blau et al., 2016). This claim has been made from the understanding that such laboratory testing methods are subject to rules outlined in the Clinical Laboratory Improvement Amendment (CLIA) (Blau et al., 2016).

CLIA is a certification requirement of laboratory testing facilities in America (Schleidgen et al., 2013). Usually, the duty of enforcing these compliance standards is undertaken by state agencies. Some accredited organisations are also in a position to certify laboratory-testing facilities in the country (Schleidgen et al., 2013). The College of American Pathologists is a leading accredited institution that could offer CLIA certification to these testing facilities (Personalized Medicine Coalition, 2014). The same is true for other organizations, such as COLA (Personalized Medicine Coalition, 2014). Before certification is granted, these institutions are often required to ensure that the organisations seeking it conform to the stringent certification requirements outlined in the CLIA guidebook. However, the presence of additional requirements for different CLIA certification may cause variations in certification standards (Blau et al., 2016).

The developments in personalized medicine research have also elicited concerns among different stakeholders regarding the safety of the processes (Weiss & Shin, 2016). This concern particularly manifests in the context that misinterpretations may occur when using test findings. Some negative outcomes that may stem from such concerns may be misdiagnosis, making improper medical decisions or undertaking a preventive surgical procedure that is not needed in the first place. Based on some of these outcomes, some observers have often said there should be more oversight undertaken by authorities, such as the FDA, to manage the process. For example, Smoller et al. (2016) say that molecular tests undertaken in the context of personalized medicine should be subject to FDA approval. Based on the seriousness of these effects and their associated long-term effects on human health, the FDA has shown its intention to institute tiered regulation requirements for all parties to follow (Weiss & Shin, 2016). Studies that are more rigorous will also be subjected to elaborate regulations to make sure that their findings are safe to use. The National Institute of Health has also taken a dominant approach in creating a testing registry that would guarantee the transparency of molecular tests undertaken by researchers who specialize in personalized medicine (Smoller et al., 2016). According to Gainer et al. (2016), the testing registry includes more than 16,000 tests in molecular testing.

Regulatory bodies, which oversee the activities of medical practitioners in the field of personalized medicine, are also facing new dilemmas regarding their activities because personalized medicine introduces new requirements in their regulation and certification standards. For example, safety is one controversial subject that has eluded most of these regulatory bodies because personalized medicine has intro

Health Care Initiative and Rationale for Choice

India is a low-middle-income country, as its GNI per capita calculated using the Atlas method was around 1,900 current US dollars in 2020 (The World Bank, 2020). At the same time, in 2020, India ranked 131 out of 189 participants in HDI, being placed in the category of Medium human development (UNDP, 2020), much below the world average. One of the problematic areas for India is connected to smoking and subsequent health issues. For instance, the number of male smokers in India increased by 36% between 1998 and 2015 (Daily News and Analysis, 2016). This is especially true for illiterate men; among them, the number of smokers rose 3.6 times. In 2010 alone, smoking caused about 1 million deaths in India, which is around 10% of all deaths for that year. Overall, India is the second-largest consumer of tobacco globally, and accounts for approximately one-sixth of the worlds tobacco-related deaths (Mishra et al., 2012). Furthermore, India is perceived as the oral cancer capital of the world based on the Global Adult Tobacco Survey data (Gambhir et al., 2016).

Dozens of anti-tobacco, anti-smoking, and anti-bidi campaigns have been launched in India in recent years as various local and international organizations, governments, and communities contributed to the fight against tobacco usage. These efforts demonstrated some effectiveness  there has been a decline in the prevalence of smokeless tobacco use, from 25.9% to 21.4% and a decline in smoking, from 14.0% to 10.7% (Lahoti & Dixit, 2021, p.1). On the other hand, India is still a country that has the most tobacco consumers in absolute terms.

Therefore, due to the widespread prevalence of smoking, and its devastating outcomes on individual and community health, smoking and tobacco use were chosen as a field for healthcare intervention. This is a focus of the Tobacco Intervention Initiative (TII) that my organization is a part of. The main goal of the TII is to reduce the number of deaths and diseases due to tobacco consumption by raising awareness about the outcomes of this process (Thelwell, 2020). The overall strategy involves establishing tobacco cessation centers, training dental professionals, creating awareness, promoting research, coordinating efforts of different actors, etc. TII is part of the National Oral Health Program created by the Indian Dental Association to improve the countrys overall health. The initiative implies training specialists to counsel the citizens on the matter. At the same time, oral healthcare professionals are encouraged to join the initiative and implement tobacco intervention and prevention methods in their care. The ultimate goal of TII is a tobacco-free India by 2022.

Situational Analysis

The WHO situational analysis framework was used to evaluate the situation regarding the usage of tobacco in India. It was chosen as it is a flexible tool for comprehensive analysis, applicable in different situations. Essentially, the WHO situational analysis tool was designed as a questionnaire to collect necessary information regarding health issues in a country (WHO, 2015). The first stage of situational analysis that will be reflected in this study involves desk-based data collection regarding country profile, the burden of disease, health status indicators and other factors. For the Tobacco Intervention Initiative, the following factors were analyzed: determinants of health, population needs and expectations, health system performance, capacity and available resources.

Initiative

The TII initiative mentioned above is expected to bring a massive change to the current situation in India. Specifically, the initiative will be aimed at raising awareness about the dangers of smoking and the health issues that it entails, including the possibility of lung cancer. Additionally, people with high tobacco dependency will be provided with therapy, counseling, and medications that will alleviate their craving for tobacco,

The initiative in question is largely supported by national trends in the target setting. Indeed, reports assert that the percentage of smoking adults has increased to 34% in India over the past decade (World No Tobacco Day: 34.6 percent adults in India are smokers, 2019). Therefore, the initiative has strong grounds to be introduced into the target setting. However, due to the lack of incentive for changing their lifestyle, the target audiences may dismiss the offered opportunity, which is why an awareness campaign must be carried out to draw public attention to the problem.

Health system performance

Health system performance is another concern to be addressed. The quality of the health system performance in India can be defined as moderate, with a substantial amount of resources being introduced, while the availability of the services remains questionable (Thakur & Paika, 2018). Therefore, supporting the current healthcare system with the introduction of PII should be considered essential.

In the context of TII and its goals, the main external factors include the impact of social media and popular culture, the resulting peer pressure, and the marketing techniques that tobacco companies utilize. Each of the specified factors has a large influence on the target population, minimizing the efforts of TII. Moreover, the fact that these influences are interconnected makes the effect of the overall influence almost irreversible (Kostygina et al., 2020).

In turn, the internal factors defining the success of TII includes the extent of cooperation and coordination of actions within the program. In addition, the factors such as the availability of a broad range of resources, including the opportunity to engage the target audience in a dialogue via social networks, create rather favorable conditions (Sanders et al., 2018). However, the lack of alternative sources for funding may represent an issue.

WHO Framework

Determinants of tobacco usage

There are various factors that affect tobacco usage within the Indian population. These factors may depend on the age of consumers, their gender, their geographical location, socio-economic status, the influence of others, types of tobacco products used, etc. Multiple studies that reflect different aspects of tobacco users will be reviewed in this section.

Regarding the younger population, their behavior may depend highly on the social norms they adopt from adults. According to the study by Ladusingh et al. (2017), conducted in India, parents tobacco usage behavior can directly affect their childrens tobacco usage patterns. It was concluded that the likelihood of using tobacco was found to be 3.4 and 1.14 times more for the youths coresiding with mothers who use tobacco and fathers who use tobacco (Ladusingh, 2017, p.1). In both cases, the probabilities were compared to those of youngsters whose parents did not consume any tobacco products.

Additionally, the role of peer pressure is not to be underestimated when it comes to evaluating the factors that incline Indian citizens toward smoking. The described effect should be considered in conjunction with the high levels of exposure to the habit of smoking. Specifically, due to the regular and pervasive advertisements issued by tobacco companies and broadcasted on nearly every type of media, Indian people, especially young ones, are forced to accept smoking as a part of popular culture (Ladusingh, 2017). As a result, Indian people develop the habit of smoking at a particularly young age, which makes further efforts of abandoning the need for smoking particularly difficult (Ladusingh, 2017).

Therefore, to address the current situation in India, it is vital to construct a program the influence of which will be significantly higher and greater in scope than those of the campaigns launched by tobacco companies in India. At first glance, the described outcome is nearly impossible, given the tremendous economic power that tobacco firms hold within the industry, including in the Indian setting (Thakur & Paika, 2018). However, at a second glance, one will notice the increasingly high effect of social media as the mean of engaging young people in political and social activism, as well as the tool for building awareness in general audiences. Indeed, due to the increased outreach, social media has been affecting the lives of a tremendous number of people, including Indian citizens (Thelwell, 2020). Therefore, by conducting an online campaign and advertising it with the help of social media, one will be capable of attracting the majority of the target population and, most importantly, convincing them of the harm that smoking can cause.

Finally, the issue of awareness should be mentioned as one of the driving factors in Indian people being increasingly inclined to use tobacco. Because of the absence of campaigns that could explain the harms of smoking to the target population, as well as the available health management resources that would insist on the importance of leading a healthy lifestyle, an increasing number of Indian people accept smoking as an inevitable part of their lives (Ladusingh, 2017). Combined with the factors listed above, the absence of awareness about the effects that smoking may entail, as well as the lack of mental health literacy in regard to managing bad habits, has an effect that is truly devastating in its scale.

Regarding dual use of smoked tobacco and SLT, there is a notable decreasing trend. Findings reveal that dual-use has declined in India from nearly 5% in 200910 to 3.4% in 201617 (Singh et al., 2020, p.1). Such factors as education and income had negative relationships with dual tobacco use  more educated people and wealthier people tend to dual-use tobacco less often. At the same time, age was positively correlated with dual-use; and men practiced it more often than women. Finally, awareness about the negative health effects of tobacco consumption reduced the likelihood of dual usage, in the same way, it influenced each type of usage in particular.

Expectations and demands for services

As it was mentioned before, various anti-tobacco campaigns have been launched across India in recent years. However, the health systems performance has been rather mediocre. Currently, a significant number of Indian people do not have access to vital healthcare services (Singh et al., 2020). In addition, health education has not been conducted properly, causing low health literacy rates (Thakur & Paika, 2018). In turn, TII is expected to be an entirely different program that is guaranteed to lead to positive results by increasing health literacy and providing active support and consultations to smokers. First and most important, it is expected that TIIs services in question will help to increase health literacy among Indian people and particularly, will provide education about the dangers of smoking as a tremendously harmful habit (Singh et al., 2020). It is expected that the introduction of the TII program into the target setting will reduce the levels of smoking by 40% within the first 6 months.

Stakeholders Positions and Attitudes

Presently, several stakeholders can be identified in the fight against the increasingly widespread phenomenon of tobacco use in Indian people. First, the citizens who smoke or are prone to developing the habit of excessive smoking are deemed as the primary stakeholders of the TII program. In the course of the program implementation, it is expected to help the target population to shape their attitudes toward the phenomenon of smoking by recognizing the arm that it does to their digestive system (primarily, their teeth), as well as the respiratory one, including the threat of developing lung cancer (Singh et al., 2020). Currently, the positions and attitudes of the specified stakeholders vary to an extent, yet mostly agree on the idea that smoking has a minimal effect on peoples health (Mishra et al., 2012). The specified opinion must be challenged so that a positive change could be introduced into the Indian community, encouraging the target demographic to abandon the habit of smoking and adopt healthier lifestyles.

The tobacco industry of India is another important stakeholder in this case. Being the supplier of the product that causes immense harm to Indian people, the companies working within the industry are highly unlikely to accept and acknowledge the adverse effects of their activities. Nevertheless, there are ways of reducing the effect that these companies have on changing the mindset of Indian people, particularly, the impressionable youth. For example, challenging the appeal that the current image of the industry has to the target population could be a possible solution (Gambhir et al., 2016). Namely, prohibiting organizations to promote their products in a way that glamourizes smoking could be a solution.

Additionally, dentists should be seen as key stakeholders in the described initiative. It is believed that dentists will benefit from the introduction of the TII initiative since it will invite the opportunity to share experiences. Moreover, insights about the means of managing dental issues in patients with a smoking habit will be discussed profusely.

IDA will also be affected by the TII initiative substantially. Namely, with the introduction of the initiative, IDA will gain an opportunity to bring awareness to the Indian population. Thus, the levels of public health, particularly, the efficacy o dental self-care, will rise, which is one of IDAs key concerns.

Finally, the government represents another key stakeholder in the described discourse. The TII initiative will provide the government with an opportunity to address a major public health issue, thus, ensuring the safety of Indian citizens. Therefore, TII will provide an opportunity for the Indian government to enhance the safety of the Indian population.

Health sector response, capacity and resources

In this section, the state-initiated campaigns, policies, and efforts to combat tobacco usage will be reviewed and assessed. It is believed that the response to be obtained from the health sector will be mostly positive. Specifically, health hazards faced by a significant percentage of the Indian population due to smoking have already attracted the attention of a large number of global entities and health organizations. For instance, the World Health Organization (WHO) has recently published a report declaring that Indian public health is under a significant threat due to the increase in smoking (World Health Organization, 2021). Outlining that the tobacco industry has been flourishing due to the presence of local traditions of smoking tobacco and its products such as khaini, zarda, gutkha, betel, and quid (World Health Organization, 2021). Moreover, the report highlights an increase in the number of deaths caused by the health issues occurring as a result of smoking to a total of 1% (World Health Organization, 2021). At first glance, the specified figures do not seem particularly threatening; however, after realizing that the current population of India constitutes around 1.4 billion people, one will discover that around 14 million people are, therefore, doomed to death due to the increase in the rates of smoking (World Health Organization, 2021). Therefore, the TII framework must address the issue immediately to avoid its further aggravation and the exponential growth in the number of victims. For this reason, partnering with the Indian health sector and eliciting a response from it in an attempt to improve the situation and address the current issue of overconsumption of tobacco must become an essential objective.

In addition, the issue of the health sector capacity needs to be addressed as one of the possible impediments to the TII implementation. Since active education of Indians that are currently at risk either due to smoking or due to exposure to the culture of smoking is needed, additional resources for providing consultations and maintaining active communication and connection with the target community must be utilized. According to the recent news regarding the Indian health sector, the industry has grown exponentially, having become one of the largest and most lucrative areas of business (Mishra et al., 2012). Therefore, it can be expected that the capacity of the sector will support the proposed program. At the same time, given the nature of the issue and the range of demographic that the campaign will need to embrace, it will be reasonable to consider outside sources of funding as well. Specifically, the opportunities for donations, as well as the use of investors support, should be examined as an option.

Finally, the issue of resources should be discussed as one of the main concerns. Although the current range of resources is quite large, there is a glaring absence of frameworks based on the use of innovative techniques and tools, particularly, the focus on social media and the power that it holds. Namely, given that the majority of the target population uses social networks actively, integrating the campaign into the social media context must be seen as a necessity. The development of media campaigns aimed at raising awareness and increasing the health literacy of Indian people who smoke or are at risk of developing the smoking habit will require exposure and extensive resources with which to supply the target population (Singh et al., 2020). Therefore, a catalog of web resources that the specified demographic will find helpful in their journey toward recovery will have to be included in the range of resources provided with the help of the TII. Additionally, a site for the target population to reach out to health experts in order to receive counseling and support must be created (Ladusingh et al., 2017). Thus, the chances to embrace as broad a range of the Indian population as possible will emerge. Furthermore, the range of resources to include in the catalog of the available tools must include materials for different ages and, therefore, has to be shaped accordingly, arranging the data according to age. Thus, children at risk of developing the habit of smoking will also be shielded from the threat.

SWOT Analysis

SWOT is one of the most widely accepted and used frameworks for project analysis. Tobacco Intervention Initiative and its main actor  the Indian Dental Association  were analyzed within the framework of SWOT to identify their strengths, weaknesses, possible threats and opportunities.

Key Findings

Situation analysis revealed a set of factors that have the greatest influence on tobacco usage in India. Tobacco usage was divided into three types  smoked tobacco, SLT, and dual usage  and for each type, the demographic and socio-economic factors were identified and measured.

Regarding peoples expectations and demands, the current trends in tobacco usage were assessed together with the attitudes and expectations of the local population. Additionally, the factors that encourage people to use tobacco and related products have been revealed. Specifically, a combination of peer pressure with the active promotion of smoking in media and the resulting early exposure of the target population to the subject matter has facilitated the epidemic scale of smoking in India (Singh et al., 2020). Counteracting the effects of the promotion campaign designed by the tobacco industry does not currently seem possible or reasonable given the fact that the specified branch of the Indian economy appears to be one of the most lucrative in the state. Therefore, minimizing its performance will not only take a tremendous amount of resources but also lead to a rise in the unemployment rates. Thus, a strategy aimed at building awareness in the target population and contributing to their understanding of the issue is required. Specifically, the target population will require access to healthcare consultations, materials, and respective services for addressing their smoking dependency.

Finally, the actions of the state and other stakeholders within the global anti-tobacco campaign were mentioned and evaluated. The research results indicate that the lack of initiative from the state has aggravated the situation, which is why further intervention is crucial (Ladusingh et al., 2017; World Health Organization, 2020). By promoting change within the target setting, one can build an environment in which people will be encouraged to accept healthy lifestyles.

Furthermore, Tobacco Intervention Initiative itself was evaluated within the framework of a SWOT analysis  its strengths, weaknesses, opportunities, and threats were listed to present a clear picture of the initiatives status-quo and its potential perspectives. Regarding the strengths that the TII possesses, they include the uniqueness of IDAs cessation program, and the expertise of IDAs participants (World Health Organization, 2020). On the other hand, IDA admits that issues with reaching out to the target population are still present, which calls for further improvements.

Recommendations

Based on the summary of findings from WHO situational analysis and SWOT analysis of TII, a set of recommendations for various actors were developed. Specifically, given the current levels of tobacco product consumption in Indian people, it is highly advisable to continue addressing the situation and promoting the development of healthy habits among Indian citizens (World Health Organization, 2020). Specifically, it is recommended that a health promotion program aimed at encouraging the development of awareness in the target population should be established as the groundwork for promoting more effective management of public health issues.

The program in question will strive to increase health literacy in Indian people in order to encourage them to abandon smoking and endorse a healthy lifestyle to the target population. Specifically, the program will include the production of health information materials and resources that the target audience will find helpful in gaining key background knowledge on the issue. Additionally, the campaign will involve a foray into social media, particularly, social networks where the target population typically communicates (Kostygina et al., 2020). These will include Facebook, Instagram, and Twitter, among others. With the help of the networks in question, a massive health literacy campaign will be held as a part of TII, offering the target demographic evidence from the existing cases and peer-reviewed resources. Additionally, tools for diagnosing respiratory issues and the relevant conditions that the excessive use of tobacco products causes will be provided. Thus, every Indian citizen will be able to check their health status and receive the necessary help if needed. Finally, healthcare support tools including medications and other resources for abandoning the habit of smoking and mitigating the consequences, including problems with the respiratory system, will be offered in the TII.

The TII program will take place on the statewide level and will be implemented on the statewide level. It is believed that the program will allow bolstering the levels of health awareness in Indian people regarding the dangers of smoking, specifically, and regarding the necessity to maintain good health by leading a healthy lifestyle, in general.

Critical Reflection

Concrete Experience. The experiment involved studying the factors affecting tobacco use in India. Therefore, in the course of the study, the understanding of the culture-specific experiences of Indian consumers of tobacco, as well as the opportunity to model the actual environment of the Indian community within the TII framework, could be seen as concrete experiences that have added to the understanding of the subject matter. Namely, the ability to create a model of the target setting with the key factors affecting the participants choices being included was a vital experience that has expanded the range of my skills and knowledge.

Reflective Observation. Reflecting on the experience described above, I should note that its key effects included the identification of the key factors encouraging the Indian population to smoke and the evaluation of the current strategies, particularly, the problems in their implementation. Conducting the study required collecting quite a vast range of data, yet most of it pointed to the same concerns associated with health availability and the problem of awareness in the target community (Daily News and Analysis, 2016). The fact that peer pressure and social conditioning defined the decision to succumb to smoking in most Indian citizens proves that the social component must lie at the core of the further analysis and the development of an intervention (Ladusingh et al., 2017). In addition, it was highly informative to apply the process of modeling to reveal that the approximation of the observed data has helped in condensing the obtained information while retaining critical data and key variables affecting the development of smoking habits in the target population. Therefore, the process of research and the development of the TII initiative has led to an array of discoveries regarding the direction for my personal development as a researcher and the strengths and weaknesses that I must take into account when implementing the TII.

Abstract Conceptualization. The observations above have led to some important conclusions. Specifically, by considering what forces Indian people to accept the habit of smoking despite the detrimental health outcomes that it causes, one could conceptualize the obtained results based on the nature of these forces and the extent of their impact. Namely, the first concept to be addressed is the issue of peer pressure. Being the most common factor in coercing young people and children into developing the habit of smoking, it has a tremendous impact due to the instinctual need for appreciation and acceptance within a community (Singh, 2020). Therefore, I gained an important insight into the role of social factors such as the phenomenon of peer pressure in the development of the habit of smoking. The understanding of the sociocultural influences was essential to my development as a professional and the changes that were made to the program

Conceptualizing the issue further, I will need to point to the phenomenon of health literacy. Particularly, the discovery of its drastically low rates among the target demographic has inspired the idea of developing a TII program aimed at increasing the levels of health awareness and health education among Indian citizens, particularly, in regard to smoking and its adverse effects. Therefore, conceptualizing the issue further, one must connect the presence of a health threat to the problem of poor health literacy. In conjunction, the phenomenon of resource availability should be included as the next concept to be addressed. Understanding the significance of the specified concept was vital to me in determining the constituents of the health program to be implemented in the Indian setting (Gambhir et al., 2016). Specifically, it helped me to realize how nurse-patient connection can be promoted via social networks and how counseling services can be offered to customers with the help of digital technologies along with personal communication.

Active Experimentation

The concepts listed above have guided me directly to the development of the intervention plan for the smoking Indian demographic, which can be considered a prime example of active experimentation. Namely, in the course of the experimentation process, I managed to develop a new strategy for creating a communication channel for the target Indian population to use when striving to overcome the harmful habit of smoking. I realized that, based on active support and nurse-patient communication, including the option of counseling, the TII program can be considered the outcome of the active experimentation carried out in order to improve the quality of Indian peoples lives. The further stage of active experimentation will require refining the proposed approach to promoting change in the Indian healthcare context, particularly, the management of the needs of people with an addiction to smoking (Ladusingh, 2017). Nevertheless, the platform prepared so far appears to be quite functional, which is why further actions must be made in order to advance it and introduce the target population to the essentials of health management and the importance of leading a healthy lifestyle. Thus, I have made major professional and personal progress in understanding what factors shaped the success of the program aimed at helping the smoking Indian demographic to quit.

References

Daily News and Analysis. (2016). Since 1998, the number of Indian male smokers increased by 36%: New study. Web.

Gambhir, R.S., Kaur, A., Singh, A., Sandhu, A.R.S., & Dhaliwal, A.P.S. (2016). Dental public health in India: An insight. Journal of Family Medicine and Prime Care, 5(4), 747-751.

Guindon, G. E., Fatima, T., Li, D. X., Joukova, A., Sudhir, J., Mishra, S., Chaloupka, F. J., & Jha, P. (2019). Visualizing data: Trends in smoking tobacco prices and taxes in India. Gates open research, 3, 8. Web.

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Introduction

Congestive heart failure, which is often abbreviated as CHF, is a condition that ones heart is not able to pump sufficient blood to the other parts of the body (Kinchin 204). The condition can happen in a gradual process or a in a rapid process. The CHF conditions can be aggravated by a wide range of related conditions like high blood pressure, the coronary heart diseases and other diseases that are related to the heart (Kinchin 204).

Previous studies (Heerdink 995; Burke 206) have indicated that approximately two million people living in the United States alone become victims of the congestive heart failure (CHF), while an average of 500 000 admissions of new cases are witnessed every year. In previous studies conducted in Italy, a statistics of 200 000 patients were suspected or confirmed to be victims of CHF in the cardiology units. In all those reported cases, 40% of the entire patients population was reported to be in need of admissions in the hospitals (Heerdink 95). There are various new therapeutic measures that have been laid down, in an attempt to bring down the statistics of the CHF cases. Despite all these efforts, a very recent study indicated that the occurrence of the CHF cases has not changed much. This study can be backed up by the observable diminishing fatality chances from the status of acute cardiovascular occurrences that later result in a large statistics of those who are at risk of being infected with CHF. In the contrary, it is indicated that regardless of the condition remaining in a stable condition, the occurrence of the CHF condition is stipulated to be on the rise. This is as a result of aging in the general population and the related consequence that that comes along with the condition in the health care facilities which is probably increasing (Heerdink 188; Burke 206).

Cardiovascular heart failure has been considered a very lethal and fatal syndrome, with its rates of mortality being referred to that of the fatal forms of cancerous cases. The CHF condition has been considered a very dangerous condition with its occurrence to be constantly in the increase, in the contrary it is worth wondering why the cases of the condition that receive admissions in the hospitals has been on the increase over the years. The increase has been revealed on very steady escalating rates that produce a very steep graph. In the United States, CHF is now considered the most renowned cause of hospital admissions, with majority of the patients being 67 years and above (Porche 56; Demetrius 200).

Problem Statement

CHF is an issue affecting many people and public health systems in different countries across the world. More than 20 million people worldwide are affected by CHF while 2% of prevalent patients are reported in developed countries. Nasi and Alahmad (2004) note that the American Heart Association has reported that there are 5.3 million Americans suffering from the CHF condition with 660,000 new patients being reported annually. The occurrence of the condition is about 10 people per 1000 persons in the U.S. population. Due to health implications brought about by the CHF condition, about 287,000 people die every year. In spite of increased infection rates of CHF, the success rate of treating the conditions has also increased (Georgiou, et al. 2001). On the contrary, the problem remains high in rural settings that are characterized by high readmissions of CHF patients. Therefore, this study investigates reasons for high CHF patient readmission in a local setting (Jong, et al., 2002).

Hypothesis Statement

The research will satisfy the following questions.

1. Does the month of January register the highest number of CHF admission and readmission?
2. Is non compliance the major reason for CHF readmission?
3. Can a case management strategy be used to mitigate the rising number of cases of admission and readmission of CHF patients?

Rationale and significance

Cardiovascular heart failure has always caused a major strain on many health care facilities such as in the cardiology units and the general departments related to medicines, which takes initiatives in caring for CHF patients (Porche 56; Demetrius 200). Most importantly, intervention measures should be identified to ensure improvements of the prognosis and in the implementation of strategies that are aimed at reducing the cost incurred in the treatments (Porche 56; Demetrius 200). Consequently, it is worth identifying the factors that act as the predictors of a long time hospitalization and which may result in hospital mortality.

Summary

There are a number of factors that are attributed to CHF conditions. These risk factors which expose individuals to the risk of contracting the CHF condition include alcohol intake, smoking, lack of PCP follow up, non compliance to medication and lack of community follow ups. In addition, other medical conditions that can increase the risk of CHF conditions includes overweight or obese, diabetes, hyperthyroidism and other heart related diseases (Heerdink 195; Burke 206). This paper aims at identifying the relationships between such risk factors and the patients who are hospitalized with CHF condition.

Literature review

Cardiovascular cases have been associated with a variety of factors such as age and sex. The age and sex factors have been considered a health risk to the condition (Marantz 175; Tobin 65; Derby 199). Despite cardiovascular diseases being the greatest health challenges in the current centaury, the condition is found to be popular among those aged 65 years and above (Porche 48, Demetrius 202). It is reported by (WHO 205) that over 1.6 million cases were observed globally. The cardiovascular conditions have always been used to investigate and evaluate the potential impacts and effects of the secondary diagnosis and other related contributing factors. Several studies have also revealed that more men are prone to the condition compared to females. Relevant surveys have also indicated a positive relationship between low to moderate physical activities because men are more statistically observed to suffer from contributing medical conditions such as diabetes, or high blood pressure. Other factor that can contribute to the CHF condition is lifestyles of people. CHF condition is significantly observed in the elderly because they are less physically active in comparison with active children and youths (Porche 17; Demetrius 200). It has been observed that successful maintenance of health to avoid CHF condition is to lose excessive weight through involving in regular and vigorous activities. Sporting have always been associated with a positive impact in promoting of health-there is a positive effect on the CHF factors in the maintenance of a good health through sporting activities (Porche 134; Demetrius 44).

CHF conditions are the fifth ranked leading global cause of death. A report by WHO (201) indicated a high rate of global morbidity and mortality in over 2.8 million people of adults. CHF conditions have been reported to accounts for 44% of global diabetes mortality, 23% of global ischemic heart related diseases mortality and an average of 7% and 41% of high blood pressure conditions mortality. All these related diseases are casual etiologies that enhance mortality rates with the association of CHF conditions (Dryden-Edwards 210; Marantz 234; Tobin 78; Derby 94).

United States has been identified as a CHF condition holoendemic country, with obesity as the primary manifestation of the situation as the contributing factors (McMurray 200). The country is large enough with many mainlands as its components. The country has a large population, of which around 200 million people is the population of the Caucasian community in the country (Heerdink 87; Marantz 67; Tobin 45). The large immigrants who come from different countries from all over the world have attributed the very diverse cultures experienced in the country. Only 2.4% of the population in United States is the indigenous people population.

The economy of a country can be associated with that of Western-style capitalist, which can be attributed to the Western influence in the country with the immigrants from the Western worlds. Modernizations in most countries seem to follow the Western cultures, and this could be a major factor as well. According to the recent studies, the country has diverted an average of $8500 million on the health and care of CHF conditions treatments and medications. In the United States society, overweight is as a common phenomenon. More men than women have been surfer from overweight, with a 48% and 30% respectively from the population. In addition, the number of women who suffer from obesity exceeds the number of men who suffer from the CHF, with an observed average of 19% and 22% respectively from the population. The study also noted and documented CHF conditions in both the children and adults as victims of CHF conditions. United States is no exception in the global trend towards the increased cases of CHF conditions as seen in other many countries (Heerdink 199; Marantz 45; Tobin 94). The trend can be associated with change of the way of life and customs and modernization as a major factor contributing to the conditions.

The observed increase in the trend can be attributed to the kind of lifestyle that is associated with the people in the environment. This lifestyle can be described as a sedentary life, where many people do not involve themselves in physical activities. This lifestyle exposes the patients to a lifestyle with very many predisposing factors. This kind of life is common in both developed and developing countries (Heerdink 95; Marantz 67; Tobin 199). Making changes in the dietary methods can help in lowering the CHF risk factors. It is indicated that high consumption of sodium components can help in the maintenance of the body liquids, and as a result, the heart becomes overworked, which eases breathing.

It is thus advisable to take a limited amount of sodium on daily basis. These factors are associated with the increase in CHF conditions in the United States and the rest of the world (McMurray 213). The change of dietary in the society is a force to reckon with, as it has been observed as the major cause of body CHF conditions. The intake of junk foods is also associated with overweight and obesity, which is a major risk factors in the CHF conditions. The intake of junk foods has been on the increase in the developed and developing countries (Marantz 234; Tobin 94).

CHF has been associated with various diseases which are related to cardiovascular diseases, which has a very high mortality rate in many parts of the world. The cardiovascular diseases alone claim an average of 50,000 lives annually (Heerdink 195; Marantz 78; Tobin 14). Cardiovascular diseases are very common with the diabetic cases, which also affects various aspects of life, such as reducing the sufferers life expectancy by about 15 years (Porche 52). CHF conditions have been observed to be related to a number of complications such as many muscular-skeletal diseases, which leads to muscles wastage, and joints degenerations.CHF conditions complications involve cancerous conditions, in addition to psychosocial problems. Reports have shown that approximately 1.7 billion adults were CHF victims and at least 400 million people were diagnosed (WHO 200). The prevalence of the cases of the CHF conditions has continued to be on the rise regardless of medical measures that have been laid down to control the situation. Apparently, weight loss and weight maintenance as well as observance of a healthy diet is an ideal intervention for this particular condition.

Substance use and smoking is also a major factor in the CHF conditions. Studies have revealed that smocking damages the blood vessels. This causes a reduction in the amount of oxygen that is in circulation in the blood, a condition that results burdening of the heart (McMurray 28). The ultimate solution to this would be stoppage of smoking habits. Excess consumption of alcohol can also lead to weakening of the heart muscles. Weakened heart muscles are often characterized with abnormal heart rhythms. Individuals should avoid the excess consumption of alcohol in order to maintain healthy heart coordination (Dryden-Edwards 201; Marantz 65; Derby199).

Some information of great significance and relevance to statistics by Premier Beattie indicated that the total population of the world consists of specific groups. For every three patients, two are males. Half of the total population of female is CHF positive. Surprisingly, one out of every four of the children in United States is overweight (McMurray 213), and one out of three overweight people are literally obese cases. This evidence shows that a very large population is subjected to the cardiovascular diseases.

Cardiovascular diseases is a highly characterized complication of obesity disorder, with approximately 7000 people in United States dying annually of cardiovascular mediated diseases. In addition, an average of 20 people dies every day in relation to weight problems. From the observed statistics in studies, it is worth concluding that there is a crisis. This crisis is constantly on the rise with the cardiovascular diseases problems in the country. In the contrary, according to the Premier, about 1% annually, there is a 50% increase in the rates of CHF conditions and obesity cases in a period of 2 decades, which can be translated to a 5% annual increase of CHF conditions (Dryden-Edwards 201; Marantz 45; Tobin 266; and Derby 199). General, CHF condition is a troubling issue that affects many societies, particularly because its remedy is not forthcoming. Score of nations population have succumbed to CHF conditions as a result of poor eating habits. In addition, lack of adequate physical exercises has contributed to the escalation of CHF conditions (Dryden-Edwards 200; Marantz 143; Tobin 64; Derby 1594).

Studies conducted in the University of Queensland indicated that one out of every five adults in Queensland is obese or suffering from CHF condition (McMurray 188). Elsewhere, a survey by the Healthy Kids Queensland and Physical Activity was carried out for Queensland health strategies and nutrition tendencies. The study investigated the effects of physical fitness and weight management among children as well as between the ages of 50 years and above. The studies indicated that out of the total adults, 21% of them are struggling with CHF conditions. 19.5% of this population facing CHF conditions was males, while 22.7% were females. This statistics shows that obese and CHF conditions among males and females continue to be on the increase in Queensland. The population in Queensland has been observed to engage in a sedentary lifestyle. Actual values indicate that one male out six males are following the national guidelines of one of the moderate unhealthy dietary on daily basis. This trend has been observed in one out of every five female. In addition, one out of every four children in Queensland is found to be suffering from CHF conditions (McMurray 63).

High blood pressure is another factor that contributes significantly to the CHF conditions. Those who experience poor blood pressure are at experiences high risk of CHF conditions (Porche 14; Demetrius 24). Those who have poorly maintained blood pressure stand at a high risk of getting CHF conditions compared to those with normal blood pressure (Smith 26). High blood pressure causes the heart to be engaged in excessive work; hence straining the heart muscles. In order to put up with the increased work load, the heart muscles can increase in their width measurement and eventually lead to weakening of the heart muscles while gradually dilating (Demetrius, 20). The increased heart pressure and the changes that take place in the whole system may finally lead to heart failure.

Martensson et al. (25) maintained that patients with CHF may suffer depression as a result of frequent readmission, environmental changes, and increased financial demands. Consequently, the patients may hesitate from seeking timely medical checkup which worsens the condition. The perception that that the patient holds to the particular illness is therefore worth understanding, as it may influence the choice of intervention. This means that home care can as well be preferable as compared to hospital care, if at all it can cut on costs. Martensson et al. (56) found home care of CHF patients coupled with nursing follow up, to be a very effective way of managing this condition. This is particularly because the patients felt more secure and emotionally stable while living closer to their families. Consequently, the patients are likely to recover fast and hence reducing readmission rate. Furthermore, support and motivation from family members and friends while at him keeps them free from depression and mental disillusionment.

Methodology

Introduction

The research technique that shall be used is quantitative technique, whereby the data collected shall be graphically analyzed to draw some conclusion. The participants will be those the patients diagnosed with CHF condition, but must fall under the targeted age group. Economic and social status shall not count in the identification of sample group. Lawrence Hospital which has a bed capacity of 300 has been identified as the study environment. The study will basically rely on medical records alone, for data collection.

Research Design

The research will use quantitative descriptive design by doing retrospective chart review of cases diagnosed with congestive heart failure admitted in the local hospital. The data will be gathered between dates of January 2010 up to March 2011 period. Regardless of sex, number of admissions, ages sixty five years and above, either from other facility or from home admits. Also highlighted in this research are the indicators of re admission such as diet, medication, smoking, drinking, sedentary lifestyle, or no support from the community program.

The number of admission data will be presented as linear graph. The reasons for admission will be gathered and graphed for presentation. The study will start by obtaining permission to access the medical records department for chart review study on CHF cases admissions. Once obtained, charts will be gathered and screened with the inclusion criteria such as patients must be 65 years old and above, diagnosed with CHF, admitted during the study period of January 2010 to March 2011. Obtaining data by doing chart review will exhaust an estimated time of 4 days, 4 hours a day that will be split to 2 hrs in the morning and 2 hours in the afternoon. This will cover the 15 months of CHF admission charts. Tabulating and putting into graphs will take 3 days to finalize the input and findings. Due to time constraints, this chart review was opted to speed up the study process and meeting the deadline. The admission case will be graphed in linear form that will highlight the highest and lowest month/year of the admission. The reasons for admission will be in linear graph as well, that will be presented and followed by discussion of findings.

Setting

The study will be conducted in Lawrence Hospital, a community hospital with 300 bed capacity, in the suburb of Bronxville, New York. The target audience in this study was patients that were diagnosed with CHF when admitted or readmitted in the hospital from January 2010 to March 2011. Participants were 65 years old and above, regardless of sex, gender, marital status, socio economic status, and race. The population of elderly will be considered either admitted from home or any nursing skilled facilities, and rehabilitation center. Regardless of mental capacity or physical disability as long as patient admitted with CHF and falls on age category will be sampled. The patients ethnicity and cultural background will not be a problem in this study since this is only a chart review. Patients coming from different area in the local community will be sampled as well.

Study Participants

The community hospital has record of all the patients being admitted and coded the diagnosis. The study will be conducted in the local community hospital. The sampling technique will be used is the non probability purposive sampling. Target population of the study will be patients admitted with CHF ages 65 years old and above, regardless of sex, gender, race, and economic status. The main source of information will be the medical records of the patient in the hospital. The constraints of the study might be the process in obtaining access to the patients medical records. The study will gather cases of congestive heart failure admitted from January 2010 to March 2011. Reviewing charts with readmission of CHF cases between the months of January 2010 and March 2011.

Data Collection

Data to be collected

The data will be gathered are as follows;

1. Diagnosis of CHF
2. Patient 65 years old and above
3. Reasons for admissions that includes non compliance to medications, no diet modification, alcohol intake, smoking, no follow up to PCP (primary care provider), lack of community support
4. Admitted between dates of January 2010 and March 2011

The four data mentioned above plays the major part of the study. This research will not use questionnaire, interview, tests, survey, or actual patient interaction. This research will only use the medical records of the patients admission data and course in the hospital.

Procedure

The research will use quantitative descriptive design by doing retrospective chart review of cases diagnosed with congestive heart failure admitted in the local hospital. The data will be gathered between dates of January 2010 up to March 2011 period. Regardless of sex, number of admissions, ages sixty five years and above, either from other facility or from home admits. Also highlighted in this research are the indicators of re admission such as diet, medication, smoking, drinking, sedentary lifestyle, or no support from the community program. The number of admission data will be presented as linear graph. The reasons for admission will be gathered and graphed for presentation.

The study will start by obtaining permission to access the medical records department for chart review study on CHF cases admissions. Once obtained, charts will be gathered and screened with the inclusion criteria such as patients must be 65 years old and above, diagnosed with CHF, admitted during the study period of January 2010 to March 2011. Obtaining data by doing chart review will exhaust an estimated time of 4 days, 4 hours a day that will be split to 2 hrs in the morning and 2 hours in the afternoon. This will cover the 15 months of CHF admission charts. Tabulating and putting into graphs will take 3 days to finalize the input and findings. Due to time constraints this chart review was opted to speed up the study process and meeting the deadline.The admission case will be graphed in linear form that will highlight the highest and lowest month/year of the admission. The reasons for admission will be in linear graph, which will be presented and used for discussion and findings.

Survey Tool

The data collection tool used in this study was a research designed spread sheet. A spreadsheet is designed with 2 columns to include months/year and the number of admission. The second spread sheet includes the indicators for admission and comprises seven columns that includes the following date( month/year) and reasons for admission (non compliance to medication, no follow up to primary care provider, drinking alcohol, smoking, and lack/no support from community). Data from the study were collected from the chart where patient been admitted and discharged. Permission for access to the records was granted by the Medical Records Department head and the Hospital Director.

Interpretation of Analysis Result

The findings of the study indicate that the level of CHF patients in the rural setting fluctuated over the period from January 2010 to March 2011. The patients were as high as 17 in January 2010 (Piepoli et al., 2004). They declined to a low level of 5 patients during the month of May 2010 before beginning to increase gradually to 16 patients during the month of March 2011 as indicated in the figure below.

The increase in the level of CHF readmissions was attributed to be various factors such as non-compliance to medication, smoking, drinking alcohol and lack of diet modification as illustrated and explained below.

Summary

Figure I shows total number of patients who were admitted in the hospital on monthly basis for the whole 15-month period. Figure II illustrates the prevalence of medication non-compliance, no diet modification, no follow-ups PCP alcohol intake smocking lack of community follow-ups. The second table showed the patients. According to figure II, most admissions of patients were victims of CHF conditions whose cases were aggravated by the excessive intake of alcohol. Some 83 patients throughout the population study represented this. This was the highest number confirmed so far in relation to the CHF risk factors. The second popular risk factor among the patients was the non-modifications of diets, which was represented by 80 patients out of the possible 194 patients who took part in the study.

The third largest risk factor was due to lack of community follow up activities by the community. This was probably due to negligence by the community to carry out follow up activities on those who were already previously suffering from CHF condition. This was followed by a non-compliance of medication, which contributed, to a population of 66. Lack of follow-ups for PCP came to the second last risk factors according to the risk factors that were of study, with a population of 65. Lastly, the contributing factor that was recorded with the least number of patients was smocking. From the results, it can be deduced as to which factors puts one at more risk than the other.

Results Findings

Overview

According to the study, the predisposing factor or the risk factors have different pathogenicity while some factors are found to be more common among the patients than the other factors. From the study, it is noted that those patients who got involved in alcohol intake were the majority of the patients in the hospital at all seasons of the study. Alcohol intake has always been associated with the damaging of the heart by infecting the heart cells. Due to damages on the heart cells, the heart fails to contract sufficiently due to the weakening of the heart muscles, as a result, the CHF condition develops. This condition can be termed cardiomyopathy (Porche 12; Demetrius 222). Lack of diet modification was also featured as a leading factor. Consumption of food with high contents of cholesterol congests in the arteries that supply the heart with blood. This accumulation narrows the blood. As a result, this causes a reduction in supply of oxygen in the heart, which can result to cardiac arrest. In the extremes, heart failure occurs.

. The community non follow-ups and non-medical compliance were significant factors in the study- which contributed greatly to the aggravation of the CHF condition. Failure to comply with medical requirements impacts negatively on health status of patients. When the ventricles are damaged and fail to receive sufficient medication, they fail to function properly. This condition is known as systolic failure (McMurray 203). These conditions need to be diagnosed as they have different treatment mechanisms. These are some of the conditions that can result from failure to comply with medical requirements.

Analysis of the Data

Does the month of January register the highest number of CHF admission and readmission?

Although the month of January is not characteristically the only one that registers very high number of CHF condition, it is clear that substantial numbers of admissions are experienced at this particular month. Indeed, the highest value at 18 was recorded in the first January while the subsequent January still recorded relatively high level at 12. The trend also shows that the numbers of admission drops drastically after January, and also increases after December. From the analysis, it has been established that lifestyles and behaviors of individuals; such as alcohol intake are some of the leading CHF risk factors. Perhaps, it can go without saying that alcohol indulgencies and related behaviors during the month of December, which is a festive season has significantly contributed to the high number of admissions in January.

Is non compliance the major reason for CHF readmission?

None compliance to medical instructions is not the major reason for CHF readmission. It comes after no community follow ups, alcohol consumption and lack of dietary modification. Even though, an important risk factor that cannot be overlooked, some other risk factors seems to take a center stage. This shows that most patients are keen to comply with medication requirements, but some other factors such as alcohol intake results to readmission.

Can a case management strategy be used to mitigate the rising number of cases of admission and readmission of CHF patients?

Apparently, the study shows that there are some common patterns behind CHF admission and readmission. For instance, there is very high level of admission on January, and alcohol intake has been found to be a major risk factor. This case can be used as a strategy to mitigate the escalating number of CHF admission and readmission.

Result and Interpretation

Several risk factors of CHF have been identified, but some seems to have more impact than others. Alcohol has been found to be the leading risk factor leading to CHF condition. In addition, some periods such as January have registered very high level of CHF admission and readmission, something that can be attributed to behavioral indulgencies such as alcohol intake during the festive season of December.

Summary

In summary, the risk of CHF is basically contributed by behavioral factors, which can be adjusted if proper care is given to the patients. Nurses should follow up on CHF patients to ensure that they do not expose themselves in activities such as smoking, alcoholism, poor dieting habits among many others. They should also ensure that they adequately follow medical godliness to avoid readmission on similar cases.

Discussion and Conclusion

Overview

CHF is a frequent in hospital admissions and can be fatal if adequate care is not taken. A variety of risk factors have been found to contribute to the conditions. Managing CHF requires a coordinated and a well thought strategy in order to avoid hospital readmission. To achieve this, different factors that lead to hospital admissions and readmission should be studied and analyzed so as to take collective measures. This study has revealed that factors such as a

Abstract

A meta-analysis targeting the studies that investigated the associations that exist between several dyads on self report on pain ratings. The child and parent, parent and nurse and the relationship between the nurse and the child were among those investigated. Online databases were preferred in this study due to the ease of accessibility and large pool of information available. The study utilized systematic methodologies that ensured that the results were feasible and offered statistically significance. The findings are imperative in informing the policy development in nursing practice since they offer the best available evidence on the pain assessment. The meta-analysis on pain reporting has great implications to the nursing practice and education since it dwells mainly on patient care, particularly for the in-patients. With the input of the meta-analysis, the nurses are better placed to improve and offer satisfactory services and care to recovering patients especially in post-operative. The study is crucial since it recommends the application of more efficient pain assessment tools in order to achieve the precise ratings with regard to the pain experienced thereby informing the practice.

Introduction

The availability of a large volume of statistical information on certain fields of interest has occasioned the development of meta-analysis and systematic reviews. Meta-analysis is a study conducted with the aim of combining the results from a pool of studied thereby resulting in a common position that integrates the findings (Whitehead, 2002, p. 1). Meta-analysis provides the researchers with similar methodological rigor imperative in the literature review required from the holistic study of experimental study. In line with this, meta-analysis generally refers to the development of a report of the available primary research by utilization of statistical methodology achieved through the assistance of computer based databases and to a large extent on statistical software. The development of meta-analysis was occasioned by the shortcomings in the narrative reviews. The narrative reviews failed to take into account the variation in the characteristics of the primary studies. The fact that the meta-analysis is informed by the observation of laid down guidelines makes its findings more valid and viable than the narrative reviews (Beck, 1995, pp. 14). This paper will review a meta-analysis with particular interest in critiquing it using the Whitmore criteria while also discussing it in the context of the nursing practice.

Locating the materials is demanding task owing to the immense information found on the academic databases. However, this is crucial and helpful since it helps the researcher to narrow down the search to a specific field. The selection of the databases was carried out in October 2007, targeting the studies carried out from the year 2000 and 2007. The meta-analysis targeted the studies that investigated the associations that existed between several dyads on self report on pain ratings. The child and parent, parent and nurse and the relationship between the nurse and the child were among those investigated. Online databases were preferred in this study due to the ease of accessibility and large pool of information available. In particular, medical databases employing the English language such as CINAHL, Ovid, psycINFO & Medline were preferred since they provided the most consistent primary research materials and meta-analysis in the western world. More importantly, some technical terms such as meta-analysis on children pain ratings were utilized as the reference terms during the search. The article was chosen for meeting the few requirements such as publication was done using English language and consistency and statistical significance was clearly explained. The article was selected from among 10 meta-analyses due to the fact that the primary research articles employed statistical methodologies and in particular reported Pearsons r as part of the outcome measure.

The selection of this meta-analysis was achieved through application of stringent statistical procedures. The current nature of the article influenced its selection since it contained the most recent information on the topic. In addition, the methodology utilized in coming up with the meta-analysis showed a lot of consistency and therefore was instrumental in imparting its choice. Moreover, my interest in understanding and improving pain management especially in children made the article important for me. The fact that there are a lot of conflicting studies that dwell on the topic but fall short in their methodologies and in producing convincing findings made the meta-analysis the best option since it contained a review of the conflicting findings (Bero et al, 1998, p. 467). The meta-analysis also acts as a foundation for my future research studies owing to the fact that I have great interests in pain management.

Stringent procedures in the methodology were utilized in coming up with the twelve articles that formed the basis of the meta-analysis. The target population of the meta-analysis was children suffering from illnesses that occasioned their admission into hospitals where they underwent surgical procedures or any other procedures that contributed to their pain. Data collection encompassed the interviewing of the admitted patients for a period not less than three weeks to help remove bias. The age of the participants ranged from birth and stretched up to late adolescence. More importantly the studies that utilized the Pearsons statistical analysis as the main measure for the outcome were useful in the determination of the articles. The studies also ensure that the articles selected were published in English with the publication dates ranging from 1990 and 2007.

Meta-analysis usually offers the best alternative for effecting far reaching changes in the areas of education, practice and administration (Anello & Fleiss, 1995, p. 112). The fact that it provides a review of the latest trends in certain fields of interest makes it provide a basis for introducing policy and administrative changes in the nursing practice. The meta-analysis on pain reporting has great implications to the nursing practice and education since it focuses mainly on patient care, particularly for the in-patients. The practice is therefore well informed on the attitudes of the patients with regard to the care given to them. With the input of the meta-analysis, the nurses are better placed to improve and offer satisfactory services and care to recovering patients especially in the post-operative wards. The study is crucial since it recommends the application of more efficient pain assessment tools in order to achieve the precise ratings with regard to the pain experienced thereby informing the practice.

Whitmore criteria

The lack of criteria for the evaluation of the various forms of reviews and meta-analysis necessitated the development of the Whitmore tool in 2005. A rise in the number of integrated reviews and the need for concrete findings vital in directing the nursing practice saw the initiation of efforts aimed at improving the application of evidence based practice. Data abstraction, literature search, statistical techniques and the publication form the criteria employed in the evaluation of the presented findings. The purpose of the study and sampling play a major role in directing the researchers in the development and process of meta-analysis. It is therefore worth noting that the synthesis of the results must follow a systematic method to minimize the occurrence of bias and also boost the confidence needed for the results to be applied in the nursing practice and education.

The meta-analysis on pain reporting utilized studies published in some of the leading English databases. The fact that the literature search involved the review of the database means that little input on the meta-analysis was received from unpublished studies. The meta-analysis has also provided the key words such as children/adolescents and pain assessments that played a major role in the literature search. Usage of the key terms ensured that the study met one of the condition set by the Whitmore criteria. The inclusion and exclusion criteria applied are also provided by the researchers. Initially, the researchers identified twenty studies that were relevant to the study topic. Six studies were eventually excluded due to their failure to provide for the Pearsons correlation coefficients that play a significant role in ensuring outcome measures are useful in calculation of the effect size. The study also excluded other studies that had ages of the sample population outside the desired range of 1-18 years. Abstraction was achieved through standardized procedures that explained in depth the procedures employed in the achievement of high quality information that met the set criteria regarding statistical significance and effect size model. The correlation aspect of majority of the studies enhanced the application of the raw data from the Pearrson correlation coefficient in setting the foundation of the estimation of the effect size. As stated in the Whitmore criterion, the study applied the fixed effect model due to the small size of the sample and the similarity in the effect size parameter. The utilization of parameters that relied heavily on the effect sizes with involvement of other distribution model such as fisher-z transformation makes the analysis more statistically significant. The results were collected from studies undertaken on different groups of people thereby minimizing overlapping and duplication (Sweet, 2004, p. 45-46). More importantly, the results were inclusive of raw data and correlation coefficients that enhanced the analysis and also served to reveal any existing and undetected discrepancies. The application of the fixed effect model meant that a summary statistic for the effect of the intervention was provided. It also helped in deducing whether the study had any impact on the development of the nursing practice particularly in the area of pain management in children. The statistical test for homogeneity also showed that some homogeneity existed among the 12 studies thereby making the combination of the results feasible.

The meta-analysis employed literature search that entailed English databases and also referenced materials that failed to get published. This enhanced the minimization of publication, although to a small extent. The assessment was undertaken through a funnel plot that showed a relative distribution of the effect sizes from the vertical base line. From this assessment, the publication bias was found to be minimal and hence did not pose concern with regard to the integrity of the analysis. The publication bias was also minimized through the inclusion of those studies that had clear effect sizes. The results of the meta-analysis has great impact on nursing practice since it affects the lives of children recovering from surgical operations. Considering that children form a sizeable population of the in-patients, the meta-analysis offers a foundation for informing the care and the policy development (Sweet, 2004, p. 45-46).

Potential use of meta-analysis study in health policy development

Sound research coupled with concrete evidence based practice has always formed the backbone of improvements in the healthcare particularly in the United States. The incorporation of research in the delivery of healthcare services has resulted in an overall positive impact on the general treatment outcome in the patient. While the utilization of evidence based practice has received wide application in nursing practice, the policy makers and the decision makers are faced with a difficult task of selecting the most appropriate evidence. In addition, the cost effectiveness and the sustainability of the measures are some of the factors that hinder the application in nursing practice and education. However, a great shift has occurred in research and practice with increased improvement on curriculum aimed at integrating new evidence into practice. In the case of this meta-analysis, its implications on the management on the post-operative care of patients will strengthen the laid down guidelines especially on the assessment of pain in children.

The assessment of pain in surgical patients is an essential task that enhances the proper management while ensuring that the children enjoy optimum comfort during their stay in the hospital and recovery period in the community. Dickson & Flynn (2005, p.20) noted that the fact that nurses spend considerable time with the patients, makes them carry the burden of implementing policy changes that will enhance the achievement of better patient outcomes. The continued reliance on ineffective scales for assessing pain in patients may have contributed to dire consequences for the patients since they fail to bring out the feelings of the children. The advantages conferred by self-report over observational and physiological methods have led to an immense push for it to be considered for application in major hospitals in the United States (Kingdon, 2003, p. 128).

It is therefore worth noting that the study can help hospitals to initiate pain management reforms by incorporating self-report combined with observational method as a standard for assessing pain in children. The nurse should also be informed that the perception of pain given by the parent or fellow nurse forms an estimate rather than an expression of the actual pain. Policy development aimed at allowing the patient to self-report the pain should be encouraged in order to ensure the patients receive the best care (Dickson & Flynn, 2005, p.22).

The meta-analysis is also imperative to the management since its offers a foundation for future research. The institutions can therefore set aside funds to boost studies that would help shed more light on the association of the various dyads. The study further informs the institution policy makers since it calls for the initiation and development of training sessions for nurses to enhance their capability in the management of pain. Policy makers would therefore insist on re-training of new nurse entrants on assessment and management of pain in the patients as part of the measures to alleviate the problem. The policy makers could go a step further and propose the integration of the programme into the curriculum of medical training institutions so that all graduates are overly acquainted with the new developments. Furthermore, the accreditation and regulatory authorities would find it useful particularly when issuing certification and conducting monitoring and evaluation. Making the pain management as one of the areas in patient care would serve as a big boost to the children. The healthcare institutions would be compelled to observe certain measures such as training the nurses on pain management and also the application of more effective pain assessment tools. The introduction of age appropriate assessment tools is also important in ensuring there are improved outcomes in the children. The policy makers and the accreditation institutions would require the institutions to lay down quality improvement strategies for implementing advanced pain assessment guidelines that take into account the ages of the children.

Treadwell, Franck & Vichinsky (2002 p.39) asserted that significant improvements have been reported by patients, nurses and family members when strict adherence to the guidelines is observed. The study further observed that the nurses and patients reported increased satisfaction on the advanced tools and on the services offered respectively (Treadwell, Franck & Vichinsky, 2002, p. 39). However, care should be taken when applying the procedures since the tools might not have the same effect in all patients. Franck & Bruce noted that there is need to understand the effectiveness and the genesis of the assessment tools before embracing them. Overall, the meta-analysis on pain offers ample evidence to inform the development of policy measures aimed at introducing advanced pain assessment tools and quality improvement strategies in nursing practice (Manchikanti, 2008, p. 161).

Steps needed to incorporate the meta-analysis study into health policy

Healthcare faces broad influences from external and internal forces that eventually lead to policy changes especially in nursing practice and patient care. The evidence from meta-analysis and systematic reviews has greatly informed the development of clinical guidelines and assessment tools (Treadwell, Franck & Vichinsky, 2002, p. 51). The rigorous processes and the systematic approaches that are characteristic of meta-analysis and reviews have endeared them to policymakers unlike the inconsistencies that exist in available primary research articles and expert recommendations.

Whilst there are different approaches to implement the research evidence into nursing practice, the applicability of the evidence into the nursing setting and sustainability of the practice must always take first priority. The systematic application of research evidence into practice enhances the delivery of quality care. The existence of a problem is instrumental in making the policy makers and other stakeholders to seek the best available evidence. The existence of a problem is important since it brings out the need for change to be instituted in the nursing practice. Communication by the affected stakeholders such as the nurses also aid in the spotting of the problem or shortcoming in the delivery of healthcare services. After the selection of the knowledge, the stakeholders embark on a journey whereby it is analysed to ascertain its applicability and in the nursing setting (Lavis, Oxman, Moynihan & Paulsen, 2008, p. 53). The shortcomings in the practice are usually linked with interventions while ensuring that the outcomes have positive bearing to the patients and the staff. Designing of the change practice is initiated whereby round table discussion involving several stakeholders are held with the aim of exploring strategies of implementing the intervention (Rosswurm & Larrabee, 1999, p. 317). This allows for the step to step application of the evidence into the clinical and nursing practice. With time, the application of the research finding is up scaled particularly when the pilot application bears positive fruits.

The stakeholders are obliged to put monitoring measures to enhance its success. At this point, the expansion of the intervention requires the development of health policy so that its utilization can have a major effect or outcome on the practice (Steinberg et al, 1997, p. 921-922). The evaluation of the implementation of the evidence into practice forms the basis for the development of the health policy from the findings in the meta-analysis. In this regard, success in the implementation stage plays a major role in influencing the incorporation of the interventions in the health policy by the relevant government authorities. The achievement of the health policy is also pegged on the ability of the health systems to maintain the change practice. More importantly, the policy is imperative since it helps in the setting of guidelines to be followed when implementing the intervention (Sackett, Straus, Richardson, Rosenberg & Haynes, 2000, p. 16)

Incorporation of the research evidence into practice requires collaboration and working closely with other interested partners or organisation. Collaboration enhances the pooling of immense ideas and initiatives that allow the generation of a solid framework and foundation for sound health policies. The establishment of strong links with stakeholders and to a larger extent with the policymakers will add more technical expertise required during the development of the policy. A clear framework must be set up so that disputes and conflicts within the group or external forces can be solved amicably without bringing undue pressure on the team (Steinberg et al, 1997, p. 922). Furthermore, the stakeholders must be encouraged to work as a team in order to enhance efficiency while bolstering the chances of coming up with a concrete policy that will promote quality patient care. The policy must be accompanied with technical capacity in terms of the workforce, hence the need to train the stakeholders on the processes involved in the development of the policy in pediatrics.

The development of a successful health policy must rely on solid evidence that has the ability to persuade the stakeholders to shift from one approach to another. The regular and continuous monitoring of prior implementation of the desired strategies must be carried out so that its limitations and benefits can be understood.

Role and impact of nursing research on policy development and nursing profession

Research in nursing has continued to play major role in the development of the nursing profession particularly in the last three decades. The fact that majority of policies are developed due to availability of better and improved strategies calls for radical changes in the functioning of the nursing. Evidence based practice has helped improve the working conditions of the nursing working while ensuring that the patients receive the best available care. Moreover, the incorporation of evidence in policy has caused paradigm shift in the delivery of healthcare and the management of the healthcare institutions. Of particular importance, is the role played by the nursing research in enhancing the accreditation of healthcare organization into magnet status.

For the last few decades, nurses have benefited immensely from research based evidence carried out in their area of operation. For instance, the introduction of technology in hospitals and use of sophisticated medical devices has brought forward the need for the nurses to undergo training on information communication technology. The successful completion of this course has helped them access the latest information and evidence on the nursing field. Effective utilization the available research evidence and systematic reviews has made it possible to deliver timely and quality patient care. The nurses are also better equipped to persuade and explain to the patients the reasons why they chose to utilize a certain treatment method. Information on the efficacy of the various regimens is overly available while wastage of time is minimized due to the simplicity offered by the technology. Tracing of health and patient records becomes easier thereby improving the diagnosis and treatment procedures in the hospitals.

Nursing research has led to the achievement of magnet status, which is the highest recognition received by hospitals that achieve high standards in nursing care, due to the promotion of best practices in the functioning of the nurses (Kitson & Antrobus, 1999, p. 750). For a centre to achieve magnet status, nursing practices that lead to optimum patient outcomes, job satisfaction and minimal turnover of the nurses, and effective mechanisms to address grievances. This means that magnet hospitals and leaders are more interested in working with the nurses. Achievement of magnet status ensures the nurses enjoy transformational leadership, exemplary professional practice, research and evidence based practice. Nursing research helps in the improvement of the policies in the hospitals. This is mainly evident in hospitals with magnet status where all nurses are provided with a safe environment to conduct their daily duties. Exposures to different environments help them to make changes in the staffing and encouraging the collaborations between the nurses and the other professionals working in the institutions. Evidence based practice is used in improving the diagnostic process and the management of patient care (Ward, House & Hamer, 2009, p. 158-159).It basically utilizes the most current evidence in informing the care givers decisions on the delivery of patient care. Since it is an approach that integrates the clinical appraisal with the clinical experiences, it tends to put into consideration the preferences and values of the patient. Evaluation of the practice is important to ascertain its effectiveness. It is practiced in order to enhance the achievement of good results and benefits such as professional development. Professional development has been embraced in nursing since it allows the nurses to gain the desired knowledge that is vital in the selection of the best components to be incorporated in patient care. This is through helping them to assess the viability and usefulness of each element of the professionalism.

Evidence based practice is taken as the only avenue that an institution makes improvement in delivery of patient care. Professional development is therefore important to instill the needed confidence and knowledge to help the nurses in explaining the processes involved in patient management. Their interventions are always supposed to offer better and cost effective results and outcomes. The ability to take accurate data from the patients is also enhanced thus the nurse is able to assess whether there is need for change or not. The nurse is well equipped to link the knowledge about the problem with the possible interventions. A consideration for relevant outcomes through the review of the available evidence helps the nurses to come up with the design of an ideal nursing practice. Continuing education is also pivotal in bringing change in the health care institutions since new knowledge on cost effective and efficient methods in patient are learnt. Nursing research also ensures evaluation and monitoring of change practice take place thereby providing the required impetus for nurses to advance their professionalism in specific areas of nursing. Professional development has also helped the nursing fraternity to embrace the relevant knowledge and skills in research (Happell, Johnston & hill, 2003, pp. 255-256).

Nursing research has also imparted on bridging the gap that exist in application of knowledge nursing practice. Application of current knowledge in evidence based practice helps in minimizing the barriers to its application. Professional development on current nursing practices has resulted in effective patient care that has helped address the problem of acute shortage of nurses in the hospitals. Evidence based practice also benefits largely from the efforts made by the scholars who are tirelessly carrying research studies on ways of bettering the practice by addressing the barriers and problems plaguing the sector (Grol, 2001, p. 1149). The care providers are also equipped with the requisite knowledge that enhances their critical thinking and evaluation of available nursing practices. Their ability to utilize data which is imperative in making decisions on clinical interventions is improved.

Moreover, the proper utilization of this knowledge helps the nurses to meet the patient needs while taking into considerations the trends in healthcare (Centre for Nursing Studies and the Institute for the Advancement of Public Policy, 2001, para. 2-3). The retention of nurses in health facilities is also boosted thus creating a solid foundation for developing evidence based practices. Providing advanced training on research methodology to lecturers has played a major role in improving professional development in nurses. This is because the professional become more research oriented and recognize the positive impacts of utilizing the findings in practice (Titler, 2007, p.26-31). Exposure to research results leads to enhanced applicability of cost effective and quality care improvements in areas such as diabetes care.

Conclusion

The meta-analysis offers useful information on the association of pain assessment in the three dyads. The study utilized systematic methodologies that ensured that the results were feasible and offered statistically significance. The findings are imperative in informing the policy development in nursing practice since they offer the best available evidence on the pain assessment. The study met most of the criteria set by Whittemore thereby adding credibility to the findings and boosting their applicability in policy development. Findings in the study indicate that designing of age appropriate assessment tools for pain is imperative, meaning that there is need to develop policy that encourages the utilization of self-reports as the main assessment tool. The incorporation of the meta-analysis findings on the policy development has enhanced the advancement of nursing profession through professionalism observed in nurses in terms of career advancement and utilization of research into practice. Evidence should be integrated into practice and in policy development in order to ensure that the patients receive quality care in the hospitals.

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Sweet, M. (2004

Introduction

As Tate points out, senior nurses are likely to engage in a range of leadership activities in their daily routine and some may find the concept hard to understand (34). Leadership in nursing is an art that involves quality delivery of care and facilitating positive nursing growth among other nurses. Leadership skills and capabilities among nurses can be judged by their ability to manage time, organize the team under them, and maintain professional ethics. It is also judged on the basis of how well they can solve problems and make decisions in the face of a crisis. As a nurse, adhering to professional ethics and acting with integrity is critical in developing leadership skills.

Senior nurses should adopt an effective leadership style that allows them to exercise basic leadership duties such as offering proper instructions to the junior nurses and the teams they work with. Senior nurses responsibilities include coordinating the day/night shifts of their team and supporting them by giving directions. It is also their responsibility to help the new nurses fit into the system and grow their careers through effective training. However, they need to realize that an effective leader needs more than the ability to give instructions and supervise those under them. It is for this reason that this study is significant.

Leadership skills in the nursing industry are categorized into different classes. They include organizational management, creation and vision, communication and strategy. The first step towards being a good leader is realizing that leadership roles are different from management functions (Nagelkerk and Diane, 14). By realizing this, a good leader is willing to stay in touch and in line with the management and follow the hospitals policies and regulations. Every leader must work on being more visionary and equip themselves with the required strategies. Such qualities will help them direct their teams and services to a better future in the industry. To be an effective leader, they should also work on their problem-solving skills and develop their groups.

Background of the problem

The healthcare industry is today faced with many challenges that make it hard to deliver quality and do it consistently. Key among these challenges is leadership. There are constant disputes over roles and responsibilities between nurses, physicians and other medical experts. These disputes are largely blamed on the lack of good leadership capable of offering proper guidelines on roles and mandates of the different medical experts. Shortages that rock the nursing industry have made it even harder to resolve these existing challenges (Rogolosi, 55). The complexity of the medical professional further makes it hard for governments to intervene wherever leadership challenges arise.

The Gallup Organization, established that nurses had the highest standards of honesty and ethics in that year (2). Ten years later, the nursing industry faces major challenges as far as ethics and discipline are concerned. The industry is faced with challenges that come with the constant changes happening in the industry. Furthermore, medical needs are constantly changing, a factor that calls for flexible policies, models and leadership. More cases of questionable conduct are filed each day and ethical concerns and issues are still evident.

Regulations, policies and expectations from customers may sometimes be hard to keep up (Marquis and Carol, 67). In order to ensure that nurses still hold that position they held a few years back, it is necessary that they have initiatives and someone to help them mold these characteristics. Good leadership is also paramount. This paper seeks to understand the role of leadership professional development. It will seek to explore effective leadership skills to motivate and empower nursing facility. Leadership development in this paper will address its role in administering medical services, having proper professional ethics, and nurses being able to execute professional duties in a skilled manner.

Aim

Explore effective leadership skills to motivate and empower nursing faculty in nursing colleges

Objectives

• Understand the role of leadership in the nursing colleges
• Conduct a literature review to evaluate the impact of leadership on professional development for young nurses
• Understand current challenges facing leadership in nursing colleges
• Explore possible solutions to these challenges
• To evaluate how leadership can participate in nursing professional development.

Rationale

This research has specific practical value. Having considered the results, it will be possible to state whether leadership plays a vital role in motivating and empowering nursing faculty in nursing colleges. The answers will explain different responsibilities of leaders and how they contribute to the nursing colleges development. The influence of leadership is evident in its role in training, coaching and development.

Significance of the study

This study is relevant in understanding the role of good leadership in nursing schools, especially in the current economic climate. As the needs of patients become more diverse, nursing schools need to be empowered and motivated to fully equip nurses for the market. The final product offered by nurses is therefore highly dependent on their foundation which starts in colleges. Information gathered in the final paper will be focused on improving staff retention focusing on managers, improving standards of teaching, increasing staff faculty satisfaction levels.

Literature review

Leadership

It is evident that leadership in nursing is of supreme importance at all times (OBrien, 113). As the author further explains, the outcome of all the challenges facing nursing colleges and the nursing industry will depend in large measure on the kind of leadership right from colleges. The number of nurses leaving the profession in the recent past due to stress, bullying and disempowerment is alarming. Analysts argue that these issues affect them so much due to lack of preparation right from an early stage of their profession which is back in college. Myrick and Olive explain that nursing, education and the profession have an unparalleled opportunity and capability to address the critical issues that face the industry (221).

Leadership plays a critical role on the way policies are formulated as well as the way they are implemented. In nursing colleges, policies on recruitment of tutors, intake of students and programs ran in each faculty is largely dependent on their leadership. What nursing students are taught, examining and qualification criteria is also influenced by leadership. These processes all affect the quality of nurses a nursing faculty produces and what it equips its students with.

The role of leadership

Traditionally, the role of leaders and managers has been to serve as the systematizing, policing arm of executive management (Saarikoski, 260). Today, leaders are strategic partners, employees advocates, change champions and business advisers on several issues affecting their area of operation. The principle function of leadership in nursing colleges is recruiting the right teams which include the tutors as well as the students. A fundamental role played by leaders in the introduction and implementation of skill development is handling pressure from all the relevant stakeholders.

Today, nursing colleges are faced with tussles arising from racial biases, poor school performance, gender discrimination and ethical issues, among others. Other than these there are common legal challenges which the health care sector is constantly faced with. These issues need to be addressed right from college by ensuring nursing faculties have comprehensive syllabus that covers all the possible challenges in the field. When assignment and responsibilities are not well defined in any industry, challenges may arise. This is a critical area and a point of big consideration when choosing a leadership team in a nursing college.

Leadership is a key organ in nursing colleges when it comes to expansion of the skill mix strategies or implementation of new strategies (Chen, 374). This happens through managing students performance and facilitating better training. Other leadership roles in developing skills include job designs, accountability, division of labor, training and development, just to mention a few. According to Lambersen the main priority of a nursing colleges strategy and strategic management should be to secure a long-term future of good quality (117). This research will be used to establish whether leadership strategies in the nursing sector vary to suit different objectives. However, there are common fundamental strategies in the industry today, and ensuring quality is one of them. Training allows leadership to deal with constantly changing demands for skills. Being constantly aware of the needs in the markets is therefore a critical role of leadership in nursing colleges.

Good leaders create and motivate leadership among the students that go through their colleges. The nursing faculty is motivated to produce better nurse leaders through training and coaching. It is for this reason that leaders have to be trained on delegation, authority and responsibility (Marion, 113). Recruitment and admission processes, which the leaders have to be trained on, play a major role in determining the future leaders of the sector. For a skill diversified industry such as the nursing sector, understanding and integrating skills with different cultural and management styles is a hard task left to the leaders in nursing colleges (Christian, 108).

For the sector to successfully implement good leadership and reap maximum benefits from it, human resource managers have to do a good job in information management (Furlong, 1060). Information management is the collection, distribution and conversion of information to knowledge (Furlong, 1064). It is also evident that nursing practices and the development of nursing faculties in the healthcare sector are influenced by both internal and external factors. Internal factors include labor policies, training and support policy, shareholders and the labor market. External factors include government policies, legal factors, patients needs and technology (Cohen, 30). However, it is notable that leadership has a role to play in all of these factors. This is evidence enough that leadership plays a significant role in the motivation and empowerment of nursing faculties in nursing and medical colleges.

As the American Nurses Association argues, successful industries are becoming more adaptable, resilient, quick to change directions, and customer-centered (44). The nursing sector today is constantly changing and demands strategic planning and organization. Technological innovations such as Human Resource Management Systems have made it easy for sector to handle information related to skills, knowledge, training and development. If these skills are not implemented at the college level, it is hard for nursing colleges to produce what is expected in the markets. The rate at which they embrace and develop such agendas is influenced by the flexibility and vision of the colleges leadership.

Leadership key issues

As Christian explains, it constitutes the professional reward aspect which incorporates processes and procedures for tracking new skills, measuring job values, designing and maintaining results structures, creating performance and ensuring benefits (108). However, it is important to note that leadership is not just about skill. It is also about quality performances which boost confidence in the nursing colleges, and improve nursing students confidence as well as motivation. Key issues to address in leadership in nursing colleges are;

• How to ensure external and internal competitiveness and equity
• How to train nursing students as individuals and promote team work as well
• Which leadership processes are appropriate for the healthcare sector training
• How to devolve power and ensure nursing students can manage their own skill mix strategies while staying within the sectors policies
• How to motivate nursing students who have to reached the highest level of career possible when they start practicing
• How to ensure leadership initiatives translate to improved performance
• How to structure and design leadership skills and evaluate present schemes
• How to ensure nursing students are prepared for both their inputs and outputs
• How to make nursing students recognize and appreciate skill development as a positive technique in the healthcare sector

In todays scenario, there are various leadership trends available for the nursing training facilities (Gebbie, 316). As Armstrong explains more industries today choose to develop increased awareness of the need to treat training measurement as a process for managing relatives, which, as necessary, has to adapt to new organizational environments and much greater role flexibility (30). Others choose leadership structures that cover every student regardless of their performance or area of training. Team development is a common trend in any industry trying to introduce new initiatives in their sector (Aiken and Sean, 997). Other trends include performance awards and more sensitivity to functional markets to enable the industry retains talented students.

Role of motivation, satisfaction and retention

Today, human resource environments are characterized by constant changes, stiff competition and changing skill preferences. It is also evident that human resource management is crucial in any organizations success. Retention today poses as the biggest challenge for human resource managers. The situation is not different for the nursing sector where nursing colleges have to work on motivating and retaining the best managers. A part of the literature review will cover the impact of reward management on retaining the best managers to empower nursing faculties in nursing schools. It will also look at retention and how nursing faculties can use retain their best managers to motivate end empower it.

Several theories attempt to explain the role of motivation in managing human resources. Process theories explain how workers meet their needs by selecting only those behavioral actions that suit them. One of these theories is the equity theory, which argues that workers compare the reward potential to the effort they must expend (Armstrong, 20). The author further explains that employees not only consider their own rewards, but those of others as well. When an employee feels his/her reward is inferior compared to that of others, the issue of inequality arises. This may be a real concern in nursing schools where the rewards of those graduating from the faculty have bigger rewards and level of recognition that those teaching them.

Expectancy theory explains how managers drive to perform and exert effort, is influenced by their beliefs that their efforts will be recognized, appreciated and rewarded. The theory argues that the most influential factor in motivation is learning how to relate effort, performance and rewards. Goal satisfaction is highly dependent on the level of expectancy and the attractiveness of the reward, an area that would be significant in nursing colleges as far as the academic nursing managers are concerned.

Another significant theory of motivation is reinforcement theory which examines how behavior and consequences relate. The theory argues that an employee behavior can be influenced using different techniques. These techniques are positive reinforcement, extinction, avoidance and punishment. Other theories include the goal-setting theory which views goals as a major source of motivation. When the colleges help managers achieve their goals, they are then motivated to set new and higher goals and work towards achieving them. These theories will be explored and their application in nursing faculties in nursing schools discussed. Managers

Employee retention is a critical factor in developing good leadership skills in any organization. An organization cannot have good leaders if it is not able to train, build and retain the best talent it has. For nursing schools to develop the best leaders, they need to have a retention program which recognizes the importance of mutual respect between the institutions and the leaders, reward senior employees appropriately, and motivate its leaders. Employee retention and increased performance of employees has a huge payoff which is often underestimated by many organizations. It increases productivity, improves employees morale, increases turnover as a result of reduced costs of recruitment and training, and trains a business to effectively address employee-related problems. Retaining its best managers will allow nursing faculties in nursing schools to reap the outlined benefits, as well as having the best team in leadership positions.

Job satisfaction and motivation are two different and directly linked factors, which play a significant role in the ability to have the best leadership team. Job satisfaction for leaders in nursing faculties can be measured through collection of data and holding forums with managers to discuss their level of satisfaction as well as air their complaints. Many at times, retention is considered a responsibility of the human resource department when the truth is employee retention is everyones responsibility and is totally dependent on satisfaction. This means that the management and other concerned stakeholders in nursing schools must take time to understand their managers satisfaction levels by ensuring that their views and suggestions are heard.

Managers value opportunities which are a core value of satisfaction. The management should hold meetings with them to routinely discuss their career paths and provide developing opportunities for those whose interests and skills allow. Nursing faculties in nursing schools should start working with managers and help them identify as well as achieve reasonable career objectives. Through such initiatives, they will have managers who can convert their satisfaction to desirable results in their jobs.

Skill mix in leadership

The issue of skill mix in the leadership of nursing colleges is a topic that attracts a lot of interest and debates. The pursuit of leadership from people outside the nursing profession in nursing colleges has sometimes divided managers and stakeholders in the nursing industry (Armstrong, 112). Opponents argue that if it was to be adopted fully, the threat of losing quality in the sector would be more real. Such a measure would also lead to the erosion of value for quality. Those in support of such strategies argue that leadership by someone outside the nursing profession will allow policies and strategies that address other issues outside the nursing profession which still affects nurses.

Proponents argue that skill mix will allow the nursing students in the colleges to develop different skills through skill transferability from their leaders and other procedures. The debate over the issue of skill mix continues to heighten and more issues keep arising. For example medical professionals argue that decisions on whether to implement such initiatives should be entirely left to them since the government does not understand the complexities of the profession (Chabeli, 40).

In the context of nursing colleges, skill mix can be used as a skill transferability initiative. According to Chabeli, skill-mix changes may involve a variety of developments including enhancements of skills among a particular group of staff substitution between different groups and innovation of roles (40). The sector will many times take the option of hiring and working with unqualified personnel than spend money on conducting further training on nurses. At its best, however, careful consideration of skill mix offers much in terms of aligning services more effectively and more appropriately to the health needs of local populations (Tate, 45).

Methodology

Introduction

Research methodologies to be used in this research project will include the study of books, academic journals, online articles, past projects by different authors, statistics from government and non-governmental organizations on skill in the healthcare sector. It will also involve a study of various academic works and research papers on leadership and its role in motivating and empowering nursing faculties in nursing colleges. From books, different academic articles and online articles already reviewed, it is clear that the nursing industry is among those suffering increased need for leadership and a diminishing capacity to satisfy what the market requires. To prevent such challenges, the industry starting from the colleges has realized that the most important factor in developing skills and professionalism is proper leadership. This is best achieved through different initiatives such as skill mix, motivation, and appreciation. As a result, a lot of attention is being put on leadership in nursing colleges.

Primary data used in this research project will be collected by from a survey conducted on several people from the sector. The survey will be conducted in cooperation with organizations and staff federations in the nursing industry. It will be open to different stakeholders in the nursing. The survey will be aimed at informing the various discussions on leadership in nursing colleges, as well as its role in motivating and empowering the nursing faculty. Involving nursing faculties, already graduated nurses and academic managers in the faculty will ensure that the survey collects comprehensive information representing a number of stakeholders in the nursing industry.

The initial findings of the data will be focused on three main questions:

1. What is good leadership and is it an important aspect in nursing colleges
2. The role of leadership in motivating nursing faculties
3. The role of leadership in empowering nursing faculties in nursing colleges

The survey will target 100 participants. Such a high number demonstrates the level of importance of the topic, and ensures that views collected are wide and comprehensive.

Another source of information will be from an interview with five experts and scholars in the healthcare industry. Participants will be chosen from their level of experience and understanding of the structures of nursing colleges. The interview will be aimed at understanding how the culture of good leadership is appreciated in nursing colleges, by studying how colleges are able to provide quality leadership in the nursing faculty. The interviews will further discuss the need for professional development and training among leaders, teachers and trainers in nursing faculties. The interviews will be used to understand the role of policies and labor markets expectations in ensuring good leadership is established and maintained in nursing colleges.

Data analysis and discussions will be written from the findings in different academic resources, the survey and the interview. It will review and classify findings from different statistics and the situation in nursing faculties in several colleges. It will also present statistics and information collected from the outlined sources to get a professional understanding of the topic. The findings will be used to structure an argument and different discussions. The position and capability of nursing colleges to develop good leadership will also be reviewed, discussed and evidence presented. The results will be interpreted and a more detailed examination given.

Participants

To collect comprehensive data and information, this study will be conducted on 100 participants. It will be open to nursing faculties, academic managers and graduate nurses. The survey will encourage participants from all categories and locations in the area of study to ensure equal representation. It will target 100 participants. The big number of participants signifies the level of importance of the topic. The interviews will have five participants. The interviewees are expected to have a good understanding of the role of leadership in nursing colleges, as well as its role in motivating and empowering the nursing faculty.

Academic managers will account for 50% of the participants. Half of these are expected to have had practiced nursing and have adequate experience in management. The remaining 50% of the participants will include already graduated nurses and other staffs in nursing faculties. To ensure gender balance in the study, 50% of the participants will be female, while the remaining percentage will be male. There will be an age limit of 25 years to ensure information is only collected from experienced participants. The questionnaires will be accessible to the participants for a period of three months to ensure participants fill them at their own time without pressure.

Recruitment

Recruitment will be done by using social network and online forums to reach out to targeted participants. The snowball technique will also be used to reach the targeted number of participants required for the study. From Orchers definition snowball sampling is a non-probability sampling technique where existing study subjects recruit future subjects from among their acquaintances (154). In this technique, people familiar with the study will be used to reach out to more people who will then be directed to the researchs weblink. For the interviews, specific people will be contacted on the phone by fetching their numbers from directories. All participants will be presented with adequate explanations and guidelines for the study. All participants will also be required to fill and sign a consent form agreeing to voluntary participation.

Case design

The case design will involve a comprehensive literature review addressing all the topics and theories relevant in the paper. It will also comprise a task to collect data and statistics from past projects, government data sources and relevant statistics from various nursing schools and organizations working with them. Data gathered from these tasks and sources will be divided into primary and secondary data. Every task will be comprehensive and complete enough, to allow stakeholders understand and utilize the information in decision-making easily, whether they were part of the research team or not. These stakeholders include student nurses, practicing nurses, other medical professionals, government officials, and other stakeholders. Reviewing the case design will be critical to ensure its validity and applicability. Cross-comparing the case design and its outcome, with similar research projects conducted in the past, will help this research to highlight commonalities and identify areas where the results need to be strengthened.

Justification of the methods

Appreciative inquiry

Appreciative inquiry is based on the assertion that problems are often the result of our own perspectives and perceptions of phenomena (Orcher, 20). The approach will be applicable when identifying what has worked well in the past and applying it in the current situation. This proved the most applicable methods when researching on the healthcare sectors development and strategic planning. The method will prove particularly relevant when gathering information that will help the sector develop their development plan.

Case study design

According to Fink (111), case studies are particularly useful in depicting a holistic portrayal of a clients experiences and results regarding a program. In order to implement any leadership initiatives, nursing colleges will need to confirm the effectiveness of its programs and processes. This entails evaluating their strengths, weaknesses and threats. A case design in this research will include arranging a wide range of information from different sources and similar projects in the past by the nursing sector or other stakeholders. Comparing the results and patterns of past project will then help this research make relevant conclusions and recommendations. Evaluation will include both straightforward comparison and in-depth analysis.

Interviews

Interviews are a brilliant way to pursue in-depth information about a project. They are particularly helpful when a case needs follow-up, and when answers are required from a particular person (Fink, 113). The best way to get information during interviews is to ask open-ended questions. Preparing for interviews will involve choosing settings with the least level of distraction, explaining the purpose of the interview to the interviewees, explaining the purpose of the interview to them, and recording it for reference purposes. This method of research will be beneficial when trying to understand the concept of leadership and its role in empowering as well as motivating nursing faculties in nursing colleges.

Questionnaires

Questionnaires will be the most convenient and easy way to collect data from a large population. They are easy to design, and since they do not require a lot of time, it is easy to have respondents to cooperate. Their disadvantages include the fact that they do not allow the researcher to examine complex issues. Since the target group in this research project will be 100 people, questionnaires are considered the most efficient way of gathering information and opinions from them.

Data collection and analysis

Primary data collection will be done by administering questionnaires and doing interviews. Secondary data will be collected from past research projects, government and non-governmental statistics and other relevant sources. Data analysis tools and software will be beneficial when sorting out data and identifying patterns. As Fink argues, data analysis techniques can help gain greater insight into trends being investigated (20).

Orcher defines data analysis as the process of inspecting, cleaning, transforming, and modeling data with the goal of highlighting useful information, suggesting conclusions, and supporting decision-making (112). Data analysis comprises of diverse techniques depending with the type of data, and expected outcomes. When conducting a leadership study, data mining is an indispensable technique since it involves discovering knowledge, as opposed to describing it.

In any study focusing on attitudes and perception, the importance of primary data cannot be over-emphasized (Orcher, 233). In such a project, it is expected that at least 90% of the questionnaires distributed will be returned and filled correctly. Interviews will be scheduled early to guarantee enough time for preparation by participants. Secondary data will be extremely valuable and will be collected to augment the research. Before any data is collected, permission will be sought from different authorities such as the relevant ministries and colleges the survey will be conducted. An initial visit to these institutions will be crucial for introductory purpose, familiarization as well as seeking consent for the research project.

Data analysis tools and software will be beneficial when sorting out data and identifying patterns. As Fink argues, data analysis techniques can help virtually any research project gain greater insigh

Introduction

In the world today millions of people are suffering from severe and complex diseases that are terminal or chronic in nature. The aftermath of these diseases is normally pain, distress, suffering, early death and grief to the people affected. Some of these diseases are cancer that is chronic, terminal ailments, progressive pulmonary disorders, fetal heart failure, AIDS, and to some extent progressive neurological conditions. (Jones, 2002) These conditions have become wide spread of late affecting mainly the young and elderly persons bringing about grief, loss and suffering at end of life. Diseases of this nature have triggered measures to be put in place for care giving and comforting purposes. The measures for curbing these situations are in the employment of hospice and palliative care for the people suffering from these ailments together with their families.

Palliative care is any kind of care that lessens symptoms improves the quality of life of an ailing individual together with his/her family and provides physical, psychological and professional support. (Eagan &Labyak 2001) On the other hand hospice care is a kind of care that centers upon palliating symptoms in critically ill individuals. (Eagan & Labyak 2001) Hospice care again includes palliative care for the incurably ill given in institutions such as hospitals or nursing homes but also care provided to those who would rather die in their own homes (Worden, 2002)

Nurses are highly recommended to carry out palliative and hospice care. This is because they are professionally trained to handle such situations; they can offer better care giving services needed in the day to day activities of the patients and to some extend offer psychological support. The issue of employing nurses is again supported by the American Association of Colleges of Nursing (1998) in their recommended competencies and curricular guidelines for end of life nursing care. Competency #11 states that nurses are to Assist the patient, family and colleagues to cope with suffering, grief, loss, and bereavement in end of life care. Therefore this paper will be focusing on loss of life, suffering, grief and bereavement experienced by families, patients and care givers at end of life. The paper will discuss on the type of care to be administered in these situations (Palliative & hospice care), talk about two cases studied and finally conclude by showing how to effectively deal with this issue.

Palliative Care

Palliative care in the home environment is gaining attention due to the high quality of services it provides as well as the costs and efforts with regard to the personnel it requires. Current research in this area is focusing on various drugs, devices, ethical and moral issues related to death and dying. This is an evidence of a constant effort to improve the quality of care in the palliative home care setting.

In the past, the most common method of caring for dying patients was to admit them to a hospital or nursing home. While this method may have relieved some burden of family members and care givers, patients may not have been satisfied (Jacobson, 1998). Most patients at end of life would prefer to be surrounded by familiarity and with family members. Therefore, it is not surprising that many of them ask for home palliative care. In many cases, living at home until end of life is possible, and therefore home palliative care does take place.

Another reason why palliative care has become important especially in the American health care system is that, many Americans die of chronic and terminal diseases. The cost of medical care for these patients has increased considerably when care is to be provided in a hospital. Therefore, palliative caring at this stage becomes essential (Blakemore, 1998).

There has been a lack of development in the palliative care sector in the medical field. In the past, policy makers did not consider it as an important subject. However, with the aging baby boomer population and the increase in life expectancies, palliative care is becoming a large and important part of medical care. Mostly, chronic complications begin at around the age of forty prompting this kind of care which continues until death of the patient. The question in this regard is how well the American health care system is equipped to provide health care to older generations and what arrangements it has made to serve the increasing aging population.

Palliative care is very different from routine care provided to patients either in hospitals or at home within the traditional home care environment. The codes that acknowledge the responsibilities of palliative care differ considerably from other routine methods. For example, it is of utmost importance to consider not only the patient, but also the family members and the caregivers. This kind of setting addresses the family problems and needs as adequately as the needs of the patient. Therefore, coping therapies, counseling and bereavement becomes a fundamental part of the total care exercise (Mathews, 2002). Patient autonomy and confidentiality must also be maintained; consequently a thorough evaluation of the patient from all aspects must be carried out and taken care of accordingly. This encompasses physical, mentally, spiritually and ethically needs.

End Stages of Life and Palliative Hospice Care

The patients in the end stages of life may require more understanding and humane communication, therefore, relevant people should be ready to provide the necessary attention and devotion. As noted by Peschel (1997) suggested domains for measuring quality at end of life should include the patient and family satisfaction, family burden, including financial and emotional burden. Finally, any symptom that the patient has must be addressed immediately and professionally. A team approach and proper planning towards a patients welfare helps in avoiding confusion and coordinates better outcomes. (Faull, Cater & Daniels, 2005)

In most cases predicting the stages at end of life are not difficult, as almost all follow a similar pattern with some variability. Cancer patients usually show a decline that may range from weeks to months. While these declines may be predicted, the lack of reserve due to multiple organ failure is indicative of an unpredictable time of death. The type of disease and its progression is very indicative of the time it will take for the person to die (Strang, 2004). The severity of the condition also dictates the length of stay and how it will affect the family members or care givers. Hospice has become a larger sector of palliative care, and this can include a variety of settings. Hospice may be the home of the patient, an assisted living facility, long term care facility, or a hospice residence of some kind (Radulovic & Person, 2004). This concept was embraced when doctors came to realize that in the end stages of life, patients preferred to be at home instead of a hospital setting. There are genuine reasons for such wishes, for example a hospital makes the patient feel more vulnerable and depressed. Being in comfortable surroundings helps the patient to cope better with the inevitable.

In this kind of setting caregivers are often given the tremendous task of caring for a patient who is nearing death. Even if this is individual effort, a team effort is highly recommended in providing a good care at this dying stage. Palliative care is related to a lot of concerns; one of them is medical care, where the patient must be given relief from various pain and anxiety issues. Another one is the moral and ethical principles that require attention throughout the processes. Clinicians highlight the basic concerns in this care to be, preventing and treating pain and other symptoms, supporting the family or those who are caring for the patients, ensuring continuity, making informed decisions, attending to emotional well being which may include ethical, religious and spiritual areas and sustaining functions. (Lorenz, 2008)

While medical care is an essential tool for the care of dying patients, many of these patients undergo depression. The five stages of dying, and depression is another important element in the palliative care of the patient. Non pharmacological therapies usually involve individual and group therapies for the patients as well as their families. These include, Education, cognitive and non cognitive group behavior therapy, informational interventions and individual and group support (Lorenz, 2008).

Hospice care in this regard is considered a very good option for those who are aware of their terminal conditions and do not wish to receive any more treatments. Hospice care at home may in fact help reduce the degree of depression, because the patient is in his/her own comfort zone. This care helps patients feel somewhat in control of their situation. Other interventions are also being incorporated in this care to improve outcomes by decreasing complications and death approaches. Involving all stakeholders has also shown to increase outcomes and improve end of life care (Lovell, & Cordeaux, 1998).

Trends in Palliative Care

In the past, family and care givers were kept at bay when medical care was being administered. This resulted in increased complications and early death. The care givers and family members felt cut off, in the event medical personnel were suddenly without information about the mental state or psychological aspect of the patient. In short, the physician focused on the patient, leaving behind the family which could help in improving the outcomes. Such methods in the past were considered professional, but now they are being questioned. Currently the medical personnel are realizing the importance of family, the ethical and ethnical variations and the need of the patients psychological needs in the complete palliative care. The palliative care team believes in order to improve outcomes and avoid any confusion; the family or relevant persons must be involved in the end of life plan. It is said that among the many trends that may have taken place in palliative care, perhaps the most significant one was the inclusion of family in the various decision making process of the patient. (Lorenz, 2008)

With clearer understanding about the needs of dying patients, home based palliative care systems are now increasing to address this issue. There are now specific practices and protocols being developed to standardize the provision of palliative care in the home environment. The utilization of nurses in the provision of care is also paramount.

It is again important to understand the hospice concept from the patients point of view. Patients during their final days wish to spend their last moments at home and die there. In this regard, the role of the primary care setting is important in providing the patients with their wish. This is however not an easy task to conduct, as caring in the home is far more difficult than giving care in a hospital. The care takers or family members may possibly be unprofessional and therefore, may not understand the importance of various signs and symptoms of the patient. (Faull, Cater & Daniels, 2005)

Among the various factors that encourage the patients to prefer hospice care include being close to the family and other care givers, adequate nursing care and familiar surroundings. The disadvantages of hospice care to the family may be disruption of normal activities, financial strains, and providing intensive support multiple times a day. (Faull, Cater & Daniels, 2005) Home based palliative care program is a very ethical method of providing adequate care while respecting the patients wishes though. Such programs are useful in reducing costs, because emergency care and hospitalization are considerably reduced. With rising costs of health care, home based palliative care programs are very good options for near death patients. (Brumley, 2002)

Development of the Hospice System

During the last 30 years, there have been a lot of efforts placed on increasing awareness among the public on the hospice option. The increased support in various forms led to its evolution and growth. Not only has the number increased in current hospice settings, but the organizational complexity has also been achieved. Now there are many palliative care service providers. With the improvements in the care provided, many patients prefer to remain at home with hospice care (Seymour, 2004).

Palliative Care and Its Advantages

Currently individuals are shifting from hospital based care to home based palliative care program. These program aims to integrate palliative care earlier than did previous programs. Attempts to blend these two different fields and kinds of care are often difficult and therefore, training of professionals to ensure a smooth transition is important. Again the benefit of such a program is twofold. It helps the patients remain with their primary physician, which many patients prefer, while getting regular visits from the palliative care team and physician. (Brumley, 2002) Contrary to the initial methods of care, where the patient was not included in the decision making process, the current programs aim to support the patients by making them active participants in various interventions and actions that take place.

Programs such as ours are very flexible intended to help ease the difficulties encountered in palliative care, including the medico legal ones. The program has very flexible guidelines, and helps to include even those patients who may have less or more than six months to live. The program also supports and encourages curative care alongside palliative care.

The program follows five main rules in carrying out palliative care. It works by a team effort, which is responsible to constantly monitor various needs of the patients, and monitors various signs and symptoms. The team conducts numerous home visits, which provide nursing, personal care, support and education to the patients and care givers. Ongoing care management and telephone support is given around the clock to improve outcomes. The program is aimed at encouraging patients into accepting hospice care instead of hospitalization. The program also helps the patient in staying at home in the final days of life. This program has resulted in higher patient satisfaction, with many patients dying at home rather than in the hospital. The other advantage is in its cost effectiveness. The program has considerably reduced the number of emergency room and hospital visits as well as costs for specialized and professional care. The only cost factor is an increase in the number of team visits to the home.

Current increases in the number of older patients and the aging baby boomer population requires a comprehensive care program for the provision of palliative care. As much as they are destined to death, it is important to note that life of these patients does not stop abruptly. In this regard the introduction of hospice is important as well as a prudent and cost saving option. This care makes sure the patient is allocated a care giver who will call the doctor when; the patient experiences a lot of pain, when he/she is having difficulties breathing, has difficulty passing urine or is constipated, is depressed and wants to harm him/herself, when he/she will not take the medications prescribed and when the caregiver does not know how to handle a situation (Whiteman, 2000).

Therefore, as shown in this paper, improvements in the service provision as well as in the making of policies can help improve the outcomes for the dying patients. Hospices can become the centers for palliative care and therefore more expertise and concentration is required to make them better places for care. Hospice care also makes it possible for families and caregivers of these patients to ensure that there is an efficient pain and depression management, there is enough discussions regarding the aftermath of the illness, the patients wishes are honored, all decisions made are in the favor of the patient and lastly the family makes sure that all important goals are completed (Green, 2003). When this is done the patient and the family at large would not feel the harsh effects of grief, loss, suffering and end of life.

SWOT Analyisis of Nicholas

A personal analysis of a patient is very difficult because of strong factors of judgment, empathy, routine, societal perception, as well as individual and psychological aspects. Therefore, the analysis can be carried out from both the patients perspective as well as the medical management perspective.

Strengths

The strength of this case may be taken in the form of experiences that Nicholas had. A positive experience reduces tension, and fears that many patients experience and may even help in their compliance. When it become evident that Nicholas was deteriorating he was admitted to the hospice program where he had already established a good relationship with the team. Nicholas received a great deal of support and love from his mom, sisters and the extended family as well as a faith community. His physician from the cancer centre where he was treated called on a weekly basis and made sure she was available to both the patients mom as well as the hospice staff. At times when Nicholas felt well, his family took advantage of this allowing him to attend Camp Hole in the Wall. This gave him an opportunity to interact with other children.

The provision of nursing and social services in the initial stages of treatment was a good plan to help the family adjust to various stages that lay ahead of them. During this stage helping the patient stay at home with his family was good for everybodys mental and psychological state. Through social support, the family was taken care of by being given the necessary guidance and help regarding the patients care and mental preparations for the impending death.

Weaknesses

From the patients perspective, the situation did not work well. Discharge from hospice was something to be happy about, but the readmission and continued decline of the patients state pointed out the physical inability of the body to respond to the cancer treatments. Such slow decline in the patients condition often causes anxiety and depression as well as fear, especially in a pediatric patient such as Nicholas. Nicholas presented his fear especially of being isolated, secluded, and the fear of being alone.

Another weakness identified is the support system which had provided Nick with his emotional and psychological needs all through his illness was not part of his end of life care. Nick lived a distance from the large cancer centre and essentially all communication, except with his primary treating oncologist ceased. The psychological support that Nick and his family had received from the empathetic and understanding physicians and nurses as well as social workers at the treatment centre stopped. Children as well as adults have a difficult time understanding the changes taking place around them, which may also cause fear, and decreased confidence. Nicholas and his family received their end of life care from a dedicated skilled hospice team but clearly all were aware that this meant the future looked bleak.

The gradual decline in his physical condition meant more reliance on others and realization of the fact that death was near. This proved to be fearsome for this nine year old boy and his family. Nicks mom continued to work and care for his sisters which meant that she was out of the house for extended periods of time each day. His grandparents provided supervision and some care to him but it was clear that nick wanted his mom to be always present. The whole issue of Nicks care was difficult to come to terms with. Nicks family needed him home but they also had other responsibilities which prevented them from being together as a family at all times. Nicks sisters were fearful and began spending time around his frail declining body. The hospice social worker and bereavement counselor spent significant amounts of time each week discussing the girls fears and helping them develop coping mechanisms.

Opportunities

Strategies should be explored and developed to consider separate funding for the care of pediatric hospice patients that would be designed in a way to provide 24 hour care and supervision that some of these patients and families so desperately need. Various programs have been introduced in recent years that promote the palliative care of children and are trying to rid the various loop holes in the US Health care system. Among these is the introduction of the Essential Care Program or ECP. This program has been at work since 1988 and is providing in house care along side of hospice care. As in the case of Nicholas the initial decision of the family to have him receive care at home was efficient. The ECP tries to provide just that to families in order to minimize the anxiety associated with admission to hospital. This program includes among other things, counseling and various kinds of support for both the patient and the family. (Field and Behrman, 2003)

Threats

The biggest threat to the palliative care system is the lack of care providers relevant to the field. Many of the providers in this area are general health care providers. There is also lack of understanding on how palliative care is different from normal medical care. The doctors and nurses may have to put more time and energy, not only from the medical and professional aspect but also to the human side of their nature of duty, which is the prime need of the patient. The lack of health care specialists in this area is therefore the biggest threat that exists. With increased trends towards palliative care the need for such individuals is greater. Another big threat that causes complications for many palliative care patients is the six month until death regulation. (Field & Behrman, 2003) The waiver of this policy is essential to improve the quality of palliative care. However the replacement of the regulation was based on the anticipation that palliative care is more expensive than normal programs that are used for children with life threatening conditions.

SWOT Analyisis of Joe

Strengths

Hospice care programs are especially ideal for cases such as Joes, whose family members may not be able to provide required care at all times. In his debilitating state, Joe required constant care. With physical limitations Joe received the help he required from trained nurses, social workers, chaplains as well as volunteers. He received the equipment required, drugs for symptoms management as well as the home health personal care and homemaking aid. Various therapies such as respiratory, physical and occupational were also administered. With patients like Joe who are isolated for most of the day, anxiety levels are increased considerably. In such cases, they should not be left alone for long periods of time. The kind of care that Joe received was important as it reduced his anxiety. Joe also complained about lack of motor coordination, which meant that for his daily tasks such as eating and bathing he needed help. Family members were not able to provide that kind of assistance in this case therefore; the hospice care was a good option for Joe. Hospice care allows for patients such as Joe to be maintained in their own home, surrounded by people and things that mean most to them.

Weakness

Joe had difficulties in expressing himself orally which proved to be a big weakness. Joe would have benefitted from 24 hour care supervision but his wife worked therefore she was away most of the time. Although the hospice staff, including several volunteers, provided a great deal of care and supervision to Joe, the staff felt more supervision was required. Joe was declining physically and his ability to provide any self care changed considerably. He was also at risk when alone as he would not have been able to leave the home on his own in an emergency. While the staff worked very hard to maintain Joes autonomy, the evaluation from both a physical and psychological standpoint had to be closely evaluated and taken care of accordingly.

Opportunities

There is an opportunity to better organize in more formalized ways, how care is coordinated with various organizations throughout the country. Through better coordination of care perhaps we could start to get a grip on hospice associated with healthcare. Creating partnerships in care through collaboration and cooperative efforts we effectively address and assess local needs which could lead to a more comprehensive approach. Patients with motor decline are in more need of constant care since they are unable to fend for themselves. An inpatient setting therefore would be an ideal situation where nurses and other health care providers are present to provide round the clock comfort and care to patients. Hospice inpatient should be encouraged to provide long term care as an ethical manner of care provision. By giving the field of palliative care autonomy, palliative and hospice care can work according to what I seen as fit for the provision of good cost effective and ethically fulfilling option over expensive hospital stays and admissions. (Cassel & Demel, 2001)

Threats

The limited reimbursement provided for home hospice appears to be the greatest threat for this kind of care. The lack of funding in this sector is also a major problem. Other threats include the loss of key personnel, retention of key staff, limited resources and lack of funding and availability of 24 hour care (Portnoy & Bruera, 2001). Another problematic issue is the lack of health care providers for palliative care. Introduction of many acts related to palliative care is also increasing the complexity of these issues.

Planning for Educational Inclusion in Palliative Care Programs

Palliative care programs could be enhanced by formal education programs during orientation periods as well as ongoing scheduled educational requirements. These would include establishing continuous quality improvement committees responsible for end of life care, collecting data as a catalyst for change, reviewing existing outcome measures and data sources and experimenting with new ones. (Field and Behrman, 2003)

Recent studies have shown that there are certain areas which patients and families feel are important to address when administering palliative care. In each case, the patient needs to be treated with dignity, demands honesty, confidentiality and appreciates being treated as a person rather than a patient. The sense of self respect increases as the patient nears death and therefore, providing the patient with such is a very positive influence during this crucial time. (Field and Behrman, 2003)

Critically ill patients are in more need of physical comfort than any other patient. In palliative care, the provision of this particular need to the patient is basic and all else is secondary. The patients in palliative care are generally in need of effective and consistent management of their pain. Psychological support is required extensively by the patients and the patients need to be with their family members requiring constant attention and care (Marita & Kashiwagi, 2003). The family is the most common need for such patients, along with friends, peers and medical staff. The accessibility of these services to the family of an inpatient is also another factor that patients claim they require. (Field & Behrman, 2003)

The four priorities of a palliative care currently are to carry out clinical interventions including symptom management, methods that improve decision making and communication, arrangements that improve the quality of care and introducing different strategies to bereavement care (Field and Behrman, 2003)

The patient and family are in constant need of staff compassionate feelings to the patient. Now nursing articles and texts are focusing on palliative care. Various monographs and other publications are also being introduced to increase competency of nurses in these fields.

Educational programs must provide sensitization about the various stages of palliative care and the biological mechanisms that accompany it pertaining to the age and condition of the patient. Since pain is the most common symptom experienced by the patient, an understanding about the pain mechanism and how it affects the emotional and psychological status of the patient should be understood. Both pharmacological and non pharmacological case management must be learned, and various tools that help assess the patients symptoms must be mastered. For nurses, the ability to coordinate the various aspects of palliative care practice with other health care professionals is another important area requiring mastery. Finally, an understanding of the potentials and limitations of the various life sustaining procedures and treatment should be learned alongside the ability to make informed decisions about prognosis. (Field & Behrman, 2003)

Palliative care providers must also learn to not only master the professional aspects but be able to provide competent compassionate care to the patient and family while trying to minimize severity of the emotional stress that affects the parties. They must be able to gently convey any difficult or bad news to the patient or family members, keep them up to date on developments, anticipate the type of response that the family and patient may have and manage it accordingly. Sharing goals, responsibilities and decisions with family members before carrying out any decisions is again recommended. (Field & Behrman, 2003)

Conclusion

Current increase in the number of older patients and the aging baby boomer population requires a comprehensive care. In this regard the introduction of palliative care programs is a prudent cost saving option. With increased awareness about palliative care programs as good alternatives, there is a swelling interest in diverting to these services. Improvements in the service provision as well as policy making can help develop care giving outcomes. However more expertise is needed to make palliative care programs better options. Palliative care provision is a relatively new field with lack of specialties as well as lack of proper educational resources. Identifying these challenges and managing them is important for future provision of palliative health care.

Nurses form an important component of palliative care and therefore must be adequately educated in this area. Their competency in the field is essential for smooth function of the entire program, since they are the most important stakeholders in this field. Nurses are usually the first people who are approached by the family of the patient and therefore the right compassionate and competent attitude ensures confidence for the family. These and many more interventions are required before palliative care can be embraced and considered an advanced and efficient care provision specialty.

References

American Association of collages of Nursing. (1998) Recommended competencies and curricular guidelines for end of life nursing care. Boston: Houghton Mifflin.

Blakemore, K. (1998) Importance of Palliative care (1^st ed.). Philadelphia: Open University Press.

Brumley, R. (2002) The Palliative Care program. The Permanente Journal, 7(2), pp. 54-74.

Cassel, K., & Demel, B. (2001) Remembering Death: Public policy in the USA. Journal of Royal society of medicine, 94 (9), pp. 433-436.

Eagan, K.A., & Labyak, M. J. (2001) Hospice Palliative Care: A model for quality end of Life care. New York, NY: Oxford University Press.

Faull, C., Carter, Y., & Daniels, L. (2005) Handbook of palliative care. Blackwell Publishers.

Field, M., & Behrman, R. (2003) When Children Die: Improving Palliative and End life Car