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Discussion-ACHE leadership competencies

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Discussion-ACHE leadership competencies

Respond to at least two of your colleagues’ postings and continue the Discussion through Day 7. Expand on this Discussion by providing additional insights or alternative perspectives.

Discussion-ACHE leadership competencies

Peer posts 1

Jacquelyne Atakora 

Wk 4 Discussion

Meeting ACHE leadership competencies means having strategic management skills, which “involves building and allocating resources both to meet the needs of today and to fulfill the vision of the future” (Walston, 2018). Out of the five competencies, I have exceptional professionalism and communication skills that I have gained from overall work experience. Communication and relationship management mainly comes from having suitable customer service skills and knowing how to build appropriate, internal relationships for the betterment of the organization. Areas of weakness include “knowledge of the health care environment” and “business skills and knowledge”, which is based off of not gaining experience in these areas. I have no experience working in a health care, so I would need to get my foot in the door in that field. In order for any leader to effectively improve their weaknesses, they must be able to support change to encompass “encouraging individual growth and learning as well as organizational innovation” (Potthoff, 2004). Individual growth for me would mean building on my communication and relationship building skills to gain knowledge in health care and business. Networking, internships, and entry level positions are all ways in which I can gain proper knowledge to become a better leader. Speaking to the right individuals and getting my foot in the door at a proper business will help me put my strengths to use and continue to gain the knowledge I need to succeed.

Reference:

American College of Healthcare Executives. (2019). ACHE healthcare executive 2019 competencies assessment tool. Retrieved from https://www.ache.org/-/media/ache/career-resource-center/competencies_booklet.pdf

Potthoff, S. (2004). Leadership, measurement, and change in improving quality in healthcare. Frontiers Of Health Services Management, 20(3), 37–40.

Walston, S. L. (2018). Strategic healthcare management: Planning and execution (2nd ed.). Chicago, IL: Health Administration.

 

Peer Posts 2

Cornel Bedward 

Week 4 Discussion

When it comes to the ACHE leadership competencies building on the strengths and improving weaknesses is important to excel as a health care administrator and be successful. When it comes to communication and relationship management it is extremely important to execute this properly. Furthermore, leadership is essential with managing change and communicating the organizations mission and vision. Also, professionalism is a competency domain that meets up with the other domains. Continued education and planning is important to ensure that the role of the individual is being met for the benefit of the organization. Additionally, employees should have a good understanding of the health care environment. Unfortunately, this requires internal and external management constraints that the staff really only understand. If new employees do not understand the flow of the organization, it will be hard for them to grasp the routine and create issues. So ensuring that new employees are educated and understand the vision and mission of the organization is essential for the success of the employees and the organization.

Reference

American College of Healthcare Executives. (2016). ACHE healthcare executive 2016 competencies assessment tool. Retrieved from, https://www.ache.org/pdf/nonsecure/careers/competencies_booklet.pdf

 

SAMPLE ANSWER

PEER RESPONSES

Jacquelyne Atakora 

Hi Jacquelyne,

I enjoyed reading your post. It is good that you seem to have realized your strength and weaknesses. A good leader should try to know his or her weaknesses as much as knowing the strengths. Weaknesses can hold someone back and prevent them from achieving their dreams. However, when one realized and acknowledges the weaknesses, they will work on improving them. As Geil Browning notes, “to truly be a great leader, you can’t just take advantage of your strengths. You also have to recognize your weaknesses, and learn how to make them benefit your particular leadership style” (Browning, 2017). A leader should understand well their area of work and therefore, understanding the healthcare system is very important for you in order to become a leader in the sector. In addition, having skills and knowledge related to the healthcare field is important for one to lead others in a healthcare system. The willingness you have to improve in the areas is the first step that is required to achieve your goals.

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Reference

Browning, G. (2017). Excel at What Does Not Come Naturally: 7 Ways to Lead Better. Retrieved from https://www.inc.com/geil-browning/leadership-managing-identify-your-weaknesses-and-lead-effectively-because-of-them.html

 

Cornel Bedward 

Hi Cornel,

You brought our good insights in your discussion. One thing that I can agree with you is that continued education and planning is important especially in the healthcare setting. Continuing professional development is important because it ensures you continue to be competent in your profession. It is an ongoing process and continues throughout a professional’s career. Continuous professional development ensures that one stays relevant and up to date (Prince & Reichert, 2017). Thus, one is more aware of the changing trends and directions in the profession. There are many changes happening in the healthcare sector especially in terms of technology. Thus, if one stands still, they risk being left behind, as the knowledge and skills they have become outdated.

Discussion-ACHE leadership competencies

Reference

Prince, S. & Reichert, C. (2017). The Importance of Continuing ProfessionalDevelopment to Career Satisfaction and Patient Care:Meeting the Needs of Novice to Mid- to Late-CareerNurses throughout Their Career Span. Retrieved from https://res.mdpi.com/d_attachment/admsci/admsci-07-00017/article_deploy/admsci-07-00017.pdf

 

 

 

 

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Qualitative Research Critique and Ethical Considerations

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Qualitative Research Critique and Ethical Considerations

Write a critical appraisal that demonstrates comprehension of two qualitative research studies. Use the “Research Critique Guidelines – Part 1” document to organize your essay. Successful completion of this assignment requires that you provide rationale, include examples, and reference content from the studies in your responses.

Use the practice problem and two qualitative, peer-reviewed research article you identified in the Topic 1 assignment to complete this assignment.

In a 1,000–1,250 word essay, summarize two qualitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

SAMPLE ANSWER

Qualitative Research Critique and Ethical Considerations

Article 1

Johnson, J., Suwantarat, N., Colantuoni, E., Ross, T. L., Aucott, S. W., Carroll, K. C., & Milstone, A. M. (2019). The impact of chlorhexidine gluconate bathing on skin bacterial burden of neonates admitted to the Neonatal Intensive Care Unit. Journal of Perinatology, 39(1), 63. https://www.nature.com/articles/s41372-018-0231-7

Study Problem

Skin bacterial burden on the patients in the Neonatal Intensive Care Unit is a significant issue in the present world. The condition leads to high morbidity and mortality rates of patients in the ICU. Besides, the bacterial skin burden leads to extended stays in the hospital, which leads to increased healthcare costs for the patients. In the United States, more than 300 000 patients in the ICU are reported to have a bacterial skin burden (Johnson et al. 2019). Therefore, research needs to be done to solve the issues of Central-Line-Associated Stream Infection in the Neonatal Intensive Care Unit.

Qualitative Research Critique and Ethical Considerations

Significance of the study to the nursing practice

Antiseptic chlorhexidine gluconate is one of the primary measures that can be used to reduce bacterial infections in the central nervous and central line catheters. Chlorhexidine helps to prevent secondary and primary infections in patients because it has antibacterial activities which reduce pathogens in patient’s skin (Johnson et al. 2019). Therefore, nurses should consider the use of antiseptic chlorhexidine gluconate in the ICU since it is effective in preventing bacterial infections in patients as compared to regular soap and water bathing.

The objective of the study

The primary purpose of the study is to examine the effect of bathing with chlorhexidine gluconate on bacterial skin burden on patients admitted in the Neonatal Intensive Care Unit.

Research Question

Does bathing with chlorhexidine gluconate reduce bacterial skin burden in neonates admitted in the Neonatal Intensive Care Unit?

How does the article answer the PICOT question?

The PICOT question researches the comparison of the effects of bathing with Chlorhexidine and bathing with soap and water daily in decreasing the rate of central line-associated bloodstream infections in patients admitted in the Intensive Care Unit for one year. Therefore, the article helps answer the question by assessing the effectiveness of daily Chlorhexidine baths in reducing central line-associated bloodstream infections. The utilization of antiseptic chlorhexidine gluconate can be used as the primary intervention to fight bacterial load both in the central lines and central venous catheters. Therefore, chlorhexidine gluconate daily baths are imperative compared to regular baths using soap and water in the ICU unit.

How the intervention and comparison groups in the article compare with that one identified in the PICOT question

The PICOT question compares the effects of daily chlorhexidine baths and soap and water baths on the reduction of central line-associated bloodstream infections in patients admitted in the Intensive Care Unit. On the other hand, the article examines the effect of Chlorhexidine daily baths on central-line associated bloodstream infections by comparing the reduction level of central line-associated bloodstream infections between patients in the neonatal Intensive Care Unit who are exposed to Chlorhexidine and those who are not exposed.

 

Article 2

Savage, T., Hodge, D. E., Pickard, K., Myers, P., Powell, K., & Cayce, J. M. (2018). Sustained reduction and prevention of neonatal and pediatric central line-associated bloodstream infection following a nurse-driven quality improvement initiative in a pediatric facility. Journal of the Association for Vascular Access, 23(1), 30-41. Doi: 10.1016/j.java.2017.11.002

Study Problem

Central Line-Associated Blood Stream Infection (CLABSI) is a bloodstream infection that primarily leads to increased mortality and morbidity rates of patients in hospital. About 260,000 central line-associated bloodstream infections are reported in hospitals in the United States. Also, approximately 29,000 death cases related to the central line-associated bloodstream infections are reported every year. Nearly 29,000 US dollars are spent on treating each patient, which creates a burden of about 2.4 billion dollars on the US healthcare system every year.

Significance of the study to nursing

The suffering experienced by families and patients due to the central line-associated bloodstream infections acquired in the hospitals is immeasurable. Therefore, there is a need for nurses to focus on the prevention strategies for bloodstream infections in hospitals, especially in the Intensive Care Unit.

The objective of the study

Hospitals commit developing strategies to minimize the cases of central line-associated bloodstream infections which are the primary source of high costs of care by both patients and health institutions. Also, bloodstream infections are the leading causes of high mortality rates of patients admitted to hospitals. Therefore, the main objective of the study is to characterize the effectiveness and development of centralized Central Line-associated bloodstream infections prevention bundle in pediatric hospitals.

Qualitative Research Critique and Ethical Considerations

Research question

What is the effectiveness of centralized Central Line-Associated Bloodstream Infections prevention bundle in preventing CLABSI for patients in pediatric intensive care unit?

How does the article answer the PICOT question?

The PICOT question researches the comparison between the effects of daily baths with Chlorhexidine and with soap and water in reducing the rate of central line-associated bloodstream infections in patients in the Intensive Care Unit. The article answers the PICOT question by examining the effects of central line-associated bloodstream infections prevention bundle in reducing CLABSI in patients in the neonatal and Pediatric Intensive Care Unit. Therefore, the utilization of antiseptic chlorhexidine gluconate can be used as the primary intervention to fight bacterial load both in the central lines and central venous catheters. Chlorhexidine gluconate daily baths are imperative compared to regular baths using soap and water in the ICU unit.

How the intervention and comparison group in the article compare to those identified in the PICOT question

The PICOT question compares the effectiveness of two interventions, that is, daily baths with Chlorhexidine and regular baths with soap and water in reducing the rate of Central Line-Associated Bloodstream Infections for patients in the Intensive Care Unit. On the other hand, the article compares different interventions, that is, central CLABSI prevention bundles in reducing the rate of Central Line-Associated Bloodstream Infections in patients in the neonatal and pediatric intensive care unit.

Study methods used in each of the two articles and how different they are

The article by Johnson et al. (2019) used an observational study to determine the relationship between Chlorhexidine baths and Central Line-Associated Bloodstream infection prevention. The groin and arm skin bacterial growth were observed in non exposed patients, and 40 Chlorhexidine exposed patients in the Neonatal Intensive Care Unit. The exposed patients were given 2 % Chlorhexidine baths for Central Line-Associated Bloodstream infection prevention.

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On the other hand, the study By Savage, et al. (2018) used a research method where the researchers applied a retrospective time series to examine the effectiveness of various prevention bundles that were developed by nurses in infection control in neonatal and pediatric intensive care unit in 2006-2014. The research was subdivided in to post, peri, pre, and second peri-intervention periods depending on each bundles implementation status.

Results of the studies and their implications to nursing

The study by Johnson et al. (2019) indicated that the bacterial burden reduced after the patients took the first bath. However, the bacterial load returned to baseline after 72 hours. The concentration of residual CHG on the skin reduced with time as the bacterial burden increased.

Bathing with Chlorhexidine decreases the bacterial burden on the skin. However, the burden’s baseline returns after 72 hours. Nurses should be aware that CHG bathing twice a week may not be adequate in reducing the growth of bacterial skin burden in patients admitted in the neonatal Intensive care unit. Targeted interventions in the ICU such chlorhexidine gluconate daily baths can reduce the risk of CLABSI associated with using central lines and central nervous catheters. Thus, the study has shown the efficacy of chlorhexidine gluconate in intensive care patients and support is increasing in caring for non-ICU patients.

On the other hand, the study by Savage et al. (2018) showed that there was a significant reduction in unit Central Line-Associated Bloodstream Infection rates where all units were less than the corresponding National Healthcare Safety Network Central Line-Associated Bloodstream Infection rates after the study.

Prevention bundle for centralized Central Line-Associated Bloodstream Infection can be useful in universalizing central line care, improve and control the quality of care to help maintain low CLABSI rates in the hospital. Thus, the study has shown the efficacy of chlorhexidine gluconate daily baths in reducing the risk of CLABSI associated with the use of central lines and central nervous catheters in intensive care patients.

Ethical Considerations

When conducting research, it is vital to maintain the confidentiality of patient information. Secondly, the study should be supported and approved by the Institutional Review Board.  The Institutional Review Board approved the two articles. Besides, participants of the studies were chosen voluntarily, and their health information was confidentially maintained.

References

Johnson, J., Suwantarat, N., Colantuoni, E., Ross, T. L., Aucott, S. W., Carroll, K. C., & Milstone, A. M. (2019). The impact of chlorhexidine gluconate bathing on skin bacterial burden of neonates admitted to the Neonatal Intensive Care Unit. Journal of Perinatology, 39(1), 63. https://www.nature.com/articles/s41372-018-0231-7

Savage, T., Hodge, D. E., Pickard, K., Myers, P., Powell, K., & Cayce, J. M. (2018). Sustained reduction and prevention of neonatal and pediatric central line-associated bloodstream infection following a nurse-driven quality improvement initiative in a pediatric facility. Journal of the Association for Vascular Access, 23(1), 30-41. Doi: 10.1016/j.java.2017.11.002

 

 

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Week 3 Discussion_Strategic Plan

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Week 3 Discussion_Strategic Plan

2 peer responses to Group A and Group E. They are posted below.

 Peer responses By Day 7

Individually respond to at least two other teams in one or more of the following ways:

  • Provide recommendations for another team’s content.
  • Offer insights on how your team’s content supports another team’s content.

Group E, Week 3 Discussion

In the scenario presented regarding Millersville Regional Medical Center with a strategic plan requiring an evaluation, there are certain factors and components that need to be considered (Ginter, Duncan & Swayne, 2018). In the process of, the center needs to apply strategic controls, which are some of the factors to consider when looking at the center’s ability to optimize its strengths and opportunities. Premise control is used in order to help measure and determine outside environmental factors and this strategy can potentially be used in order to help the health care organization when it comes to determining influx of immigrants in the surrounding area (Clear Point Strategy, n.d.).  For example, the center’s ability to recruit more physicians and also retain the current workforce in the face of competition and better alternatives such as better pay and amenities for its workforce from its competitors.

Also, implementation control could possibly be used in order to help create and track an overall plan that can be used in order to help decrease wait times, increase funds, as well as increase the number of health care professionals.  It is because, at the implementation of the strategic plan, the center needs to ensure that in the event of unforeseen circumstances like the influx of patients, the strategic plan will not need any adjustments. These adjustments, in most cases, are costly, time-consuming, and may trigger loss of clients to competitors.

Week 3 Discussion_Strategic Plan

The third strategic control the organization should utilize is the special alert control. “A special alert control is the need to thoroughly, and often rapidly, reconsider the firm’s basis strategy based on a sudden, unexpected event” (Strategic Control, 2018). This strategic control would benefit the organization because the organization has seen an unexpected spike in the number of patients that visits the hospital.

It is vital for every strategic plan, even at its time of evaluation to put in place some monitoring tools. In this case of Millersville Regional Center, a monitoring tool such as the Gantt Chart, which is a bar chart used to monitor and show a project plan and its advancement or progress over time, is crucial in its strategy. It is because, in the moment of monitoring progress, the center would have set appropriate measures to prevent the depletion of its charitable care budget early in the year. The use of a balanced scorecard is essential because of its purpose in tracking and isolating four separate areas, also known as legs. These legs include learning and growing, business processes, customers, and finance (Cebeci, 2018). In the scenario, the strategic plan needs this tool to evaluate the center’s ability and capacity to handle some issues. These issues include the increase of patients, better pay, and amenities for its workforce through available resources. It will give the center an idea of where immediate or critical improvements are required or the need for additional resources. A dashboard would also help the center to focus on its mission and ensure that its strategy is effective.

Week 3 Discussion_Strategic Plan

Two tactical objectives the organization can use to address its operations requirements are to reach out to the nearest universities to create connections with nursing and healthcare students so that they may find interest in becoming employed at the facility when they graduate. By networking, the hospital can establish connections while also making students aware of the overall benefit of using their talents in rural communities. Another tactical objective the hospital should consider is involving staff members with their input on creative and innovative ways to improve the quality care and rewarding the employees for their involvement. Regardless of job title, all staff members may have ideas that could benefit the organization. Including staff also shows them that the organization cares about them and their ideas regarding the company.

References

Klipfolio. 2001. What is a data dashboard? Retrieved from https://www.klipfolio.com/resources/articles/what-is-data-dashboard

Strategic Control. 2018. Strategic Management: Formulation and Implementation. Retrieved from https://www.strategic-control.24xls.com/en143

S. Epstein. September 2013. Using the Internet in Your Job Search. Retrieved from https://career.fsu.edu/sites/g/files/imported/storage/original/application/27ba368e3cba4cc02d2931a2be2f4f3d.pdf

Clear Point Strategy. (n.d). Strategic control: Breaking down the process and techniques.Retrieved from https://www.clearpointstrategy.com/strategic-control-process/

Cebeci, U. (2018). Building hospital balanced scorecard by using decision support approach. IIOAB JOURNAL, 9(6), 42-47.

Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2018). The strategic management of health care organizations. John Wiley & Sons.

 

Group A Week 3 Discussion

Scenario:

The board of directors of Elite Healthcare formulated and implemented a strategic plan to address the city’s rapidly growing population (11% increase per month), which is demanding greater access to quality, innovative patient care. However, they failed to evaluate the implementation of the plan, and over time, many employees became overworked because of the increased demand for services, which has led to a higher percentage of work-related employee and patient injuries. The current work environment has adversely impacted employee morale and the organization’s ability to recruit new talent. Moreover, patients have started seeking care across town even though it is a much longer commute

Strategic controls, monitoring tools, and tactical objectives might be used to address date and tracking via medical records.  As an organization using tolls to monitor data from medical claims, pharmacy claims, and electronic medical records can impact millions of lives. Strategically leveraging this data to hone and train predictive models for population health management, fostering innovation and research across health care will also be impactful.  Although the size of the data assets would be impressive, it’s the enrichment and curation that makes most valuable to the health care industry. Also, there will be fewer negative consequences with expressed objectives and goals. Organizations are built with the goal of profitability through processes in mind. The organizational control approach incorporates goals and the strategy used to reach them.

Week 3 Discussion_Strategic Plan

As far as tactical objectives to leverage operational requirements the organization should revamp the scheduling process on the front line. Offer and request should be taken into consideration in scheduling surgeries and other non-life-threatening processes. Patients should be planned for such processes on days when owing to a busy night in the ED, the hospital is less likely to have a spike in patient volume. Consider alternative care delivery techniques. The organization can attempt to treat patients in different ways to alleviate the burden of heavy wait times. For patients with less severe problems with ED, telemedicine may be one option. The organization can also partner directly with neighboring emergency medical centers and other healthcare institutions to provide patients with an option for ED to reduce their waiting time. Incorporate the preferences of patients. Patients, not providers, should be the focus of scheduling. The organization must, therefore, reach out to find out what types of modifications would best suit the requirements of patients. Some clinics have provided patients with access to schemes where they can create their own ED appointments for less critical problems –or offer patients an estimated time to wait over the phone before arrival so they can make the appropriate arrangements. (White, 2015) These solutions should help with accommodating the imbalance of supply and demand that the organization is facing.

Monitoring tools used are data-driven tools, Epic, and good old fashion workgroups and meetings. We have weekly meetings with our vendor to ensure that the project is up to speed and this issue is being worked through. Monitoring this is no easy task but through communication and a strong project plan, we get it done. We rely on the data from the groups and their feedback to drive our conversations and push us.

Week 3 Discussion_Strategic Plan

In addition, we will use a balanced scorecard to align the daily work of all employees with the strategic plan aimed at increasing access to quality care and measure progress towards our strategic target (Walston, 2018). Taking the organization’s internal strengths and weaknesses into account, our objective of delivering quality care will lead us to the tactical goal of matching a reasonable patient-provider ratio that will prevent employee burnout. The balanced the scorecard will, at all times, help keep the patient-provider ratio proportionate to that determined in the strategic plan; a ratio that will prevent excessive workloads and employee burnouts.

One tactic used is meeting the NCQA standards for the health risk assessment to ensure that our organization meets the guidelines and requirements for reimbursements and the standards of care.  This is a necessary objective for all parties involved.

Another objective is weekly meetings to ensure that no other issues will arise and the project is on track. To me, nothing beats good old-fashioned meetings and face-to-face conversation. Meeting weekly increases the amount of communication and ensures that the project will get done. To me, this is very necessary and one of the strongest tasks. We go over project plans, updates, questions, concerns, and the timeline. We all count on this meeting to get our product done. Behrouzi, Shaharoun, and Ma’aram note this in their piece as a useful measure (Behrouzi, F., Shaharoun, A. M., & Ma’aram, A., 2014).

Diving deeper, an example within the workplace comes from work in an ICU as a respiratory therapist. One employee noticed that the balloon cuff on are vented patients was deflating between shifts causing patients not to get the exact volume they need to keep their lungs open while they were on the ventilator. Of course, this drives the nurses crazy when the ventilator is alarming. So the employees came up with a plan to do cuff checks at the beginning and end of our shifts.  Employees would check all patients that were vented at the end of the month as our milestone review and notice deflation was down. This allows vented patients to get the volume they needed to get their lungs healthier until they come off the ventilator.

Week 3 Discussion_Strategic Plan

Stepping further, with monitoring tools, these employees used a data dashboard tool to analyze the data from doing the cuff checks. They could track the average time when deflation started, average pressure that stayed in the cuff and us used that data to help to keep accurate pressure in the cuffs for our vented patients.

References

Walston, S. L. (2018). Strategic healthcare management: Planning and execution (2nd ed.). Chicago, IL: Health Administration.

Chapter 15, “Implementing, Monitoring, and Evaluating Strategy” (pp. 339-353)

Behrouzi, F., Shaharoun, A. M., & Ma’aram, A. (2014). Applications of the balanced scorecard for strategic management and performance measurement in the health sector. Australian Health Review, 38(2), 208–217.

Jakob Lauring, Jan Selmer and Annamaria Kubovcikova, Personality in context: effective traits for expatriate managers at different levels, The International Journal of Human Resource Management, 10.1080/09585192.2017.1381137, 30, 6, (1010-1035), (2017)

White, J. (July 6, 2015). 4 keys to reducing patient wait times. https://www.healthcarebusinesstech.com/reduce-patient-wait-times/ 

SAMPLE ANSWER

Group E, Week 3 Discussion

Having a strategic plan for a healthcare institution has become very imperative with the changing healthcare needs. Therefore, it is important for every healthcare institution to have its strategic plan for the future to ensure its success. A strategic plan helps the organization plan for the unknown. This is important to ensure that the healthcare organization can be able to deal with whatever may come along the way that was not expected. One of the most important consideration that needs to be done and planned for is financial requirements for running the organization. An organization should have objectives as well as goals that have been set to be achieved. In order to measure the implementation and success of the set goals, it is important to have a strategic plan. As you have mentioned, it is important for the healthcare organization to have a dashboard that would measure its performance overtime. The dashboard will help in evaluating which areas that may require improvement and which areas that needs to be maintained at the same level. Having a dashboard and a reward system within the healthcare organization can help in improving the efficiency of the organization.

Reference

Strategic Planning in Hospitals. Retrieved from https://www.stratadecision.com/healthcare-and-hospital-strategic-planning/

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Group A Week 3 Discussion

Strategic management is an important management practice in healthcare institutions. Nowadays, in order to achieve improved quality of health services, it is important to set a plan for the future by establishing sustainable processes through a strategic plan. A strategic plan outlines how an organization aims to progress from the current situation to the desire future situation. For the current case, it was important for the board of directors to have done a thorough strategic plan that could have helped them avoid the problems they are currently facing. This would have saved resources as well as costs that can be used to expand the facility. Due to the current situation, the quality of healthcare has been affected leading to patients seeking healthcare services elsewhere. It is important to look at the broad picture while making a strategic plan. This can help in identifying all the elements that can affect positively or negatively a healthcare organization in the future. Hospital performance evaluation is very important in order to determine the performance over time. This in turn would help in the development of a strategic plan.

Week 3 Discussion_Strategic Plan

Reference

Sadeghifar, J., Jafari, M., Tofighi, S., Ravaghi, H and Maleki M. (2015). Strategic Planning, Implementation, and Evaluation Processes in Hospital Systems: A Survey from Iran. Glob J Health Sci, 7(2): 56–65.

 

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Foundations of Evidence Based Practice

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Foundations of Evidence Based Practice

Write a 4 page APA paper addressing the following questions

1. Identify a project from a department at your place of employment that demonstrates a commitment to an improvement in patient care.  (Prefer pertaining to an inpatient PEDIATRIC UNIT)

2. Why is this project/study important?

3. What role would an APN play in this project?

4. Identify a PICOT question that you could use to guide the research of the identified problem.

5. Provide 5 databases that you might use for your research,and give a short description of each.

6. Provide 15 – 20 PEER reviewed references in APA format.

7. What barriers do you foresee in implementing this project?

Requirements for Paper:

  • APA Format, 6th
  • 4 pages in length, not including the title and reference page. (points will be deducted for papers over or under required length)

Note from teacher:   4 pages in length, not including the title and reference page. (points will be deducted for papers over or under required length)    PEER reviewed references do not go in the body of the paper but in the reference section.  That should give you enough space for the paper.  You do not have to incorporate all of the references into the paper. You just need to provide a list of appropriate references that you would use in researching the paper.

 

SAMPLE ANSWER

Foundations of Evidence Based Practice

Pediatric department of the health institution I currently work in has come up with a project to improve patient outcome through interventions in communication. The project management team will implement the plan through the use of a communication system that can put all the health caregivers on the same page (Berwick, 2016). The new communication system will include the use of whiteboards on the bedsides to indicate the daily objectives, the use of a dashboard for performance, and a note format for the daily progress of the residents (Lotz, Daxer,  Jox, Borasio, & Führer, 2017). The project will give families and patents who are excluded from rounds the courage to ask questions as well as express their concerns about the care plan.

Foundations of Evidence Based Practice

Why the Project is Important

Most of the breakdowns of teamwork and communication errors result in reduced patient outcome, increased costs, and prolonged losses in healthcare facilities. To solve these issues, the children’s department aims at improving communication to decrease medical errors during daily rounds (Katkin, et al. 2017). The project will begin by training healthcare workers on the rounds basics to help them conceptualize easily on its implementation (Gathara, et al. 2015). The project expectations are to increase the satisfaction of health care providers by more than 80 %. Besides, the project will be crucial in improving teamwork among health care providers, especially nurses, by reducing the number of nurses who multitask on bedsides during daily rounds (Hill, Knafl, &Santacroce, 2018). I will also reduce interruptions during presentations of the patients.

The role that an APN play in the project

Advanced Practice Nurses are those nurses with advanced certification and training with mostly a master’s degree and doctorates. Because of their advanced knowledge, APNs will play a crucial role in the implementation of the project. To begin with, the information on the bedside daily whiteboards will be verified by the APNs to ensure its high level of legitimacy in enhancing the highest quality of the patient outcome (Swan, Ferguson, Chang,  Larson&Smaldone, 2015).Besides, APNs will be involved in the project planning to ensure that the plan will be sound in meeting the goals and objectives of the project (Scotten, Manos,  Malicoat, & Paolo, 2015). APNs can work in the albescence of a doctor and other health practitioners because of their danced knowledge in nursing practice. Therefore, they will be useful in case of emergencies (Bryant‐Lukosius, et al. 2016). APNs will also have the role to educate and mentor other health practitioners on the best ways to implement the project primarily through teamwork and quality communication skills among healthcare professionals in the institution.

Foundations of Evidence Based Practice

PICOT question

Will the use of whiteboards on the bedsides to indicate the daily objectives, the use of a dashboard for performance and a note format for daily progress of the residents improve patient care within one year of project implementation?

Databases I might use for my research

  1. CINAHL Plus

CINAHL Plus is an advanced version of CINAHL index, and it provides a vast number of cited and full-text references and records. It includes nurse educators, nurses, researchers, students, and other health professionals with advanced literature in healthcare practice(Glanville, Dooley, Wisniewski, Foxlee, & Noel‐Storr, 2019). It provides easy access to high content that dates back to the late 1030s and a considerable number of healthcare journals. The database covers a wide variety of topics such as medicine, nursing, health sciences, biomedicine, complementary medicine, allied health disciplines, and consumer health, among others. The database would help conduct my search on how to improve communication to increase the quality of patient care.

Foundations of Evidence Based Practice

  1. Cochrane Library

Cochrane Library is an excellent source of quasi-randomized and randomized reports on controlled trails. It also provides other details such as the source, year of publication, and the author (English, Hillier & Lynch, 2017). However, they only give the summary of the report mostly through abstracts; that is, they do not provide the full text of the report. Cochrane Library will be a useful database for finding evidence-based information.

  • MEDLINE

MEDLINE is a library premier databases for medicine. The database provides the names of the authors and bibliographical citations and abstracts of the authors from about 4700 and above biomedical journals that are published in the United States and other countries (Duffy, de Kock, Misso, Noake, Ross, &Stirk, 2016). Some of the main topics covered in MEDLINE include nursing, medicine, veterinary, dentistry, pre-clinical sciences, and allied health. MEDLINE will be an accessible database when doing my research on the project to improve the quality of patient care.0

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  1. Nursing Reference Plus

Nursing Reference Plus is a database that is designed specifically for nurses. It educates nurses about nursing best practices and evidence-based practice(Oermann, et al. 2018). It mainly ensures that nurse educators, nurses, nursing students, and newly graduated nurses in the field have quick and easy access to the recent information in health practice to provide a maximum level of quality patient care.

  1. V) EMBASE

Embase is a pharmacological and biomedical database that contains more than 20 million articles and records that are published across the world (Bramer, Giustini,  Kleijnen, & Franco, 2018). It provides abstracts, citations, and indexing from peer-review journals and biomedical articles. Most of the quotes have summaries that are written by the authors. Some of the main topics covered by EMBASE include pediatrics, oncology, general clinical medicine, dermatology, and intensive care.

Barriers in implementing the project

Some of the barriers that may make the implementation of the project include; one, lack of full cooperation from the healthcare team members due to such factors as the conflict of interest or unwillingness to act according to the requirements of the project.

Foundations of Evidence Based Practice

Second, the costs involved incomplete implementation of the project may be higher, especially in redesigning the communication system in the institution. The administration of the institution may be reluctant in providing finances for designing bedside whiteboards and paying extra fees to the project management team (Friedman, Howard, Shaw, Cohen, Shahidi& Ferrante, 2016). This may hinder the successful implementation of the project.

Conclusion

Improving patient outcome through communication intervention is critical in the children’s department to improve communication among physicians and decrease medical errors during daily rounds. Developing and implementing a plan to facilitate communication between physicians and nurses will help reduce medical errors that result in reduced patient outcome, increased costs, and prolonged losses in healthcare facilities. APNs will play a crucial role in the implementation of the project, such as project planning and during education and mentoring program.  Databases such as CINAHL Plus, Cochrane Library, MEDLINE, Nursing Reference Plus, and EMBASE will provide more evidence on the interventional strategy including its application and importance. The major barriers during the implementation of the project will involve lack of full cooperation from the healthcare team members and the involved incomplete implementation of the project.

 

References

Berwick, D. M. (2016). Era 3 for medicine and health care. Jama, 315(13), 1329-1330.doi:

10.1001/jama.2016.1509.

Bramer, W. M., Giustini, D., Kleijnen, J., & Franco, O. H. (2018). Searching Embase and MEDLINE by using only major descriptors or title and abstract fields: a prospective exploratory study. Systematic reviews, 7(1), 200.doi: 10.1186/s13643-018-0864-9.

Bryant‐Lukosius, D., Spichiger, E., Martin, J., Stoll, H., Kellerhals, S. D., Fliedner, M., … & Schwendimann, R. (2016). Framework for evaluating the impact of advanced practice nursing roles. Journal of Nursing Scholarship, 48(2), 201-209.doi: 10.1111/jnu.12199.

Duffy, S., de Kock, S., Misso, K., Noake, C., Ross, J., & Stirk, L. (2016). Supplementary searches of PubMed to improve currency of MEDLINE and MEDLINE In-Process searches via Ovid. Journal of the Medical Library Association: JMLA, 016 Oct; 104(4): 309–312.doi: 10.3163/1536-5050.104.4.011

English, C., Hillier, S., & Lynch, E. (2017). Cochrane Corner. Stroke, 48, e275-e276. doi: 10.1002/14651858.CD007513.pub3.

Friedman, A., Howard, J., Shaw, E. K., Cohen, D. J., Shahidi, L., & Ferrante, J. M. (2016). Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators’ perspectives. The Journal of the American Board of Family Medicine, 29(1), 90-101.  doi: 10.3122/jabfm.2016.01.150175.

Gathara, D., Nyamai, R., Were, F., Mogoa, W., Karumbi, J., Kihuba, E., … & Todd, J. (2015). Moving towards routine evaluation of quality of inpatient pediatric care in Kenya. PloS one, 10(3), e0117048.doi: 10.1371/journal.pone.0117048.

Glanville, J., Dooley, G., Wisniewski, S., Foxlee, R., & Noel‐Storr, A. (2019). Development of a search filter to identify reports of controlled clinical trials within CINAHL Plus. Health Information & Libraries Journal, 36(1), 73-90.doi: 10.1111/hir.12251.

Lam, M. T., De Longhi, C., Turnbull, J., Lam, H. R., &Besa, R. (2018). Has Embase replaced MEDLINE since coverage expansion?. Journal of the Medical Library Association: JMLA, 106(2), 227. doi: 10.5195/jmla.2018.281.

Lotz, J. D., Daxer, M., Jox, R. J., Borasio, G. D., & Führer, M. (2017). “Hope for the best, prepare for the worst”: A qualitative interview study on parents’ needs and fears in pediatric advance care planning. Palliative medicine, 31(8), 764-771.doi: 10.1177/0269216316679913.

Katkin, J. P., Kressly, S. J., Edwards, A. R., Perrin, J. M., Kraft, C. A., Richerson, J. E., … & Wall, L. (2017). Guiding principles for team-based pediatric care. Pediatrics, 140(2), e20171489.doi: 10.1542/peds.2017-1489.

Oermann, M. H., Nicoll, L. H., Chinn, P. L., Ashton, K. S., Conklin, J. L., Edie, A. H., … & Williams, B. L. (2018). Quality of articles published in predatory nursing journals. Nursing Outlook, 66(1), 4-10. doi: 10.1016/j.outlook.2017.05.005.

Scotten, M., Manos, E. L., Malicoat, A., & Paolo, A. M. (2015). Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Education and Counseling, 98(7), 895-900.doi: 10.1016/j.pec.2015.03.009.

Swan, M., Ferguson, S., Chang, A., Larson, E., &Smaldone, A. (2015). Quality of primary care by advanced practice nurses: a systematic review. International Journal for Quality in Health Care, 27(5), 396-404. doi: 10.1093/intqhc/mzv054.

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NRS-433V-RS3: Quantitative Studies

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Quantitative Studies

Write a critical appraisal that demonstrates comprehension of two quantitative research studies. Use the “Research Critique Guidelines – Part II” document to organize your essay. Successful completion of this assignment requires that you provide a rationale, include examples, and reference content from the study in your responses.

Use the practice problem and two quantitative, peer-reviewed research articles you identified in the Topic 1 assignment to complete this assignment.

In a 1,000–1,250 word essay, summarize two quantitative studies, explain the ways in which the findings might be used in nursing practice, and address ethical considerations associated with the conduct of the study.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

 

SAMPLE ANSWER

NRS-433V-RS3: Quantitative Studies

Quantitative Research Article 1

Chiu, S., Bergeron, N., Williams, P. T., Bray, G. A., Sutherland, B., & Krauss, R. M. (2015). Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: A randomized controlled trial–3. The American journal of clinical nutrition, 103(2), 341-347. https://www.ncbi.nlm.nih.gov/pubmed/26718414

  1. Problem

The DASH diet emphasizes the consumption of vegetables, fruits, whole grains, and low-fat dairy foods to reduce blood pressure and the risks of cardiovascular diseases(Chiu et al.2016). According to the reports on the nursing studies, high-fat dairy products, fewer vegetables, and fruits are associated with a high risk of stroke, blood pressure, and diseases of the coronary artery.

NRS-433V-RS3: Quantitative Studies

  1. Significance to nursing

The extent of adherence to diet determines the effectiveness of the intervention of the DASH diet. Most people with the problem of following prescribed diets have difficulty if adhering to DASH diet. It is the responsibility of the nurses to create awareness and advice patients on how to follow prescribed diets to increase the effectiveness of DASH intervention. According to Chiu, et al. 2016, it is essential to include a variation in the composition of the macronutrients in the DASH diet while still enhancing the preservation to the benefits of lipid and blood pressure risk factors.

NRS-433V-RS3: Quantitative Studies

  • Purpose of the study

The main objective of the study was to assess the possible effects of switching to low-fat dairy foods contained in the DASH diet from full-fat foods. This was accompanied by a corresponding addition in fat and a decrease in sugar intake on plasma lipids, blood pressure, and lipoproteins.

  1. Research question

Does the DASH diet effectively lower blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol?

How the article answers the PICOT question

The article analysis the effects of the DASH diet, that is, the substitution of full-fat for low-fat dairy foods in the DASH diet with a reduction of sugar intake on the blood pressure, lipoproteins and plasma lipids.

How the intervention and comparison group in the article compares with those in the PICOT question

The report considers the DASH diet as a primary intervention to lower high blood pressure. The randomized trial takes place for three weeks. Similarly, the PICOT question includes the DASH diet as one of the responses in lowering blood pressure within the first five months.

 

Quantitative Research Article 2

Akita, S., Sacks, F. M., Svetkey, L. P., Conlin, P. R., & Kimura, G. (2003). Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the pressure-natriuresis relationship.  Hypertension, 42(1), 8-13. https://www.ncbi.nlm.nih.gov/pubmed/12756219

  1. Research problem

Blood pressure has become one of the leading causes of mortality rates across the globe. The Dietary Approaches to Stop Hypertension can act aa primary mechanism for lowering blood pressure through consumption of a diet with vegetables, fruits, and low-fat dairy foods.

NRS-433V-RS3: Quantitative Studies

  1. Significance to nursing

Nurses should consider Dietary Approaches to Stop Hypertension as one of the primary nonpharmacological approaches to stop high blood pressure.  The authors of the article theoretically describe that the blood pressure-lowering action can be analyzed on the pressure curve that is drawn through the use of data from the DASH-sodium trail.

  • The purpose of the study

The main objective of the study was to assess the effects of the DASH diet on the pressure-natriuresis relationship to identify its mechanisms of lowering blood pressure.

  1. Research question

What is the effect of the DASH diet on the pressure-natriuresis relationship in blood pressure lowering mechanism?

How the article answers the PICOT question

The report provides proof on whether the DASH diet lowers blood pressure within the first five months if intervention by testing its effects on pressure-natriuresis.

How the intervention and comparison group in the article compare to identified in the PICOT question

The article describes the effects of the DASH diet on the relationship of pressure-natriuresis to give clarity of its mechanism of lowering blood pressure. Similarly, the intervention in the PICOT question focuses on the blood pressure-lowering effect of the DASH diet.

Methods of the Two Studies

The report by Chiu, et al., 2016 used a randomized controlled trial where health men and women consumed a standard DASH diet, lower-fat and high fat carbohydrate modification of the DASH diet known as the HF-DASH diet for three weeks each separated by two weeks for washouts. The measurement in the laboratory included the concentration of lipoproteins articles which were determined by the mobility of ions. Statistical analysis for treatment differences was conducted through the use of ANOVA (Stata version 11) for a three-treatment cross over design.NRS-433V-RS3: Quantitative Studies

Similarly, the article on the Effects of the DASH diet on the Pressure-Natriuresis Relationship used a controlled trial method where DASH sodium trial and randomized feeding trial were used. However, the research design differed from the one conducted by Chiu et al. 2016 because it used a sample size of 412 who were 22 years and above(Akita, Sacks, Svetkey, Conlin & Kimura, 2003). Also, the participants were not healthy individuals as they had systolic blood pressure (SBP) ranging between 120 to 159 and Diastolic blood pressure ranging between 80-95 without blood pressure-lowering medication. Statistical analysis was conducted by comparing the x-intercept and the steepness of the curve of the pressure-natriuresis between DASH diets and the control diet as well as the subgroups and testing them by the use of Student t-test for the non-paired samples.

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Benefits and limitations of the methods used in the two research articles

Both articles used controlled trial methods. One benefits of the technique were that it was easy to produce accurate results which clearly showed the effects of the DASH diet on Blood pressure levels.

One limitation of the controlled trial methods used in the research articles was that it was difficult for the participants to strictly follow the prescribed diets, which made the research process tiresome.

Results of the two research studies and their implications to the nursing practice

Chiu et al. (2016) found that urinary potassium excretion was higher with the HF-DASH and DASH diets compared to control diets. The results of the DAH and H-F DASH DIETS did not differ where the mean for the DASH diet was 83.5, HF-DASH was 81.5, and that of the control diet was 50.5. The HF DASH and the DASH diets significantly lowered blood pressure as compared to the control diet. The implication of the study is that Nurses should emphasize the application of the DASH diet as a significant treatment of high blood pressure and create awareness among patients and members of the community. This would help effectively implement the use of the DASH diet as a nonpharmacological treatment of blood pressure.

NRS-433V-RS3: Quantitative Studies

Evaluation of the data obtained from the DASH-Sodium Trial through the use of pressure-natriuresis curve, the DASH increased the slope of the relationship (Akita, Sacks, Svetkey, Conlin & Kimura, 2003). This indicates that the DASH diet effectively lowered blood pressure groups though a diuretic action with high sensitivity of sodium. The implication of the study is that the DASH diet should be used as a primary nonpharmacological treatment of blood pressure. It also helps nurses understand the mechanism of the DASH diet in lowering BP, which makes it possible for them to speculate on patients and those situations it can be beneficial.

Outcomes comparison

The outcomes of the PICOT question included the lowering of blood pressure within the first five months of DASH diet intervention. The findings of the two articles showed a reduction of the blood pressure within less than five months as expected in the PICOT question.

 

References

Akita, S., Sacks, F. M., Svetkey, L. P., Conlin, P. R., & Kimura, G. (2003). Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on the pressure-natriuresis relationship.  Hypertension, 42(1), 8-13. https://www.ncbi.nlm.nih.gov/pubmed/12756219

Chiu, S., Bergeron, N., Williams, P. T., Bray, G. A., Sutherland, B., & Krauss, R. M. (2015). Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: A randomized controlled trial–3. The American journal of clinical nutrition, 103(2), 341-347. https://www.ncbi.nlm.nih.gov/pubmed/26718414

 

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Criteria for Impeaching the President

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Criteria for Impeaching the President

Please submit a paper that summarizes (in your own words) the “You are the Policymaker” feature titled “What Should be the Criteria for Impeaching the President?” and then give your opinion; what would you do if you were the policymaker? It must be a minimum of one page in length, typed and double-spaced.

FYI: (professor’s instructions)

Do not use outside sources. Do not quote from the book; I want you to paraphrase the feature (put it into your own words) so I can see that you understand the feature. The papers are to be doublespaced, Times New Roman, size 12 font. The papers must be at least one page in length.

 

SAMPLE ANSWER

What Should be the Criteria for Impeaching the President?

The article “What Should be the Criteria for Impeaching the President?” basically talks about the sex scandal that broke in 1998 between the then President Clinton and Monica Lewinsky. The article notes how President Clinton tried to obstruct justice when he was questioned about the affair with Lewinsky. President Clinton, as noted in the article, president Lewinsky to lie under oath. The President could not be put on trial because of his position and therefore the only way to be help accountable was through the House of Representatives as well as the senate where he faced a possible impeachment. An investigation report by an independent counsel recommended that the president should face 11 counts of possible impeachment offences. The president was accused of braking the law, betraying public trust and dishonoring the presidency.

President Clinton was forced to apologize to the nation. He, through the White House, argued that the mistake affected his personal life and not that of the presidency. The white house also accused the investigator of having personal vendetta against the president.

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The issue on whether the scandal had reached the threshold that could lead to the president’s impeachment then arose. An offense should be grave in order for it to be used to impeach a president. The case of President Clinton is compared to that of President Richard Nixon who was charged with obstructing justice, abusing power and failing to comply with congressional subpoenas. When enough evidence was gathered Nixon resigned in order to avoid being impeached. His impeachment majorly failed because of how the legislatures voted on party lines.

Nursing Paper Help

If I was a policy make, I could not have voted to impeach the president. This is because, while it is true that the president did a mistake by obstructing justice, he accepted the mistake and apologized. In addition, I do not think that his affair with Lewinsky affected his duties as a president in any way. I would consider the affair as a personal life and look at what he has been able to achieve through his presidency. I also do not think the case reaches the threshold for impeachment. The investigations by the legislature might not tell the truth of the matter and that is why the White House rejected the recommendation. Therefore, impeaching President Clinton could not have been the best solution for this case. I would therefore vote to retain President Clinton as the president.

 

 

 

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Simulation Technology

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Simulation technology has been transformative in nursing education. Through the use of simulation, nurses can repeatedly practice skills and gain clinical confidence in a risk-free environment. Simulation, however, is not just for health care professionals. How can nurses leverage simulation technology for patient and family education? Share your experiences and ideas for leveraging simulation technology for patient education.

 

SAMPLE ANSWER

Simulation technology has been critical in the nursing profession. The technology helped me throughout the time I was doing my associate nursing degree. The university I attended helped me to gain practical skills that gave me confidence when working with patients. The institution had a lab with all simulation technologies to help students present real-life situations and prepare them from the beautiful and stressful life in nursing profession. For example, my classmates and I were presented with a patient with the condition that we were to determine based on the signs and symptoms presented. Using the simulation technology, we were able to run a code that helped us to establish that the patient had a heart attack and the technology was so effective in reducing the risk of losing the patient. According to Foronda et al., (2017) it can increase student’s confidence and knowledge when caring for critical patients. Besides, it is estimated that simulation technology could eliminate about 50% of clinical time, without having any adverse effects on both patient care and learning outcomes (Hayden Padilha, Machado, Ribeiro, & Ramos, 2018).

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Patient education is also a critical element of simulation technology. Patients can benefit from simulation technology through education by helping them to understand clinical situations including, personal care, adherence to medication, and their outcome and wellbeing. Based on my experience when working with simulation technology, we were able to teach parents how to carry out CPR on their children during emergency.  We used a video about how CPR should be conducted on infants and asked them to explain and relay what they learned about performing CPR. It is therefore an excellent instructional strategy that can help nursing students to practice psychomotor skills, critical thinking, and clinical decision making without risking the life f a potential patient.

 

References

Foronda, C. L., Alfes, C. M., Dev, P., Kleinheksel, A. J., Nelson Jr, D. A., O’Donnell, J.

M., & Samosky, J. T. (2017). Virtually nursing: Emerging technologies in nursing education. Nurse Educator, 42(1), 14-17. doi: 10.1097/NNE.0000000000000295

Padilha, J. M., Machado, P. P., Ribeiro, A. L., & Ramos, J. L. (2018). Clinical virtual

simulation in nursing education. Clinical Simulation in Nursing, 15, 13-18. https://doi.org/10.1016/j.ecns.2017.09.005

 

 

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