NURSING: 2017

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Wednesday, 15 March 2017

Disaster preparedness synopsis

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA, BANGALORE.
PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR
DISSERTATION

1
NAME OF THE CANDIDATE
AND ADDRESS
MR. RAJEEV SHARMA
341/8 RATITALAI
BANSWARA, RALASTHAN
327001

2.
NAME OF THE INSTITUTION
M.S. RAMAIAH INSTITUTE OF
NURSING EDUCATION AND RESEARCH
M.S.R.I.T. POST
BANGALORE -54

3.
COURSE OF STUDY AND SUBJECT
IST YEAR M.SC. NURSING
COMMUNITY HEALTH NURSING
DISSERTATION PROTOCOL

4
DATE OF ADMISSION TO COURSE
31-05-07

5

TITLE OF THE TOPIC

ASSESSMENT OF THE ATTITUDE OF NURSING STUDENT TOWARDS VOLUNTEERING IN DISASTER MANAGEMENT, IN A VIEW TO PREPARE DISASTER PREPAREDNESS TEAM.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Be it an ‘act of God’ or act of man a mindboggling spectrum of disaster wreak havoc in the India subcontinent.

Disaster are either natural such as floods, draught, cyclones, and earthquakes or human made such as riots, conflicts, refuge situation and other like firs, epidemics industrial accident and environment fallouts. Emergencies, and disaster do not only affect health and well being of people, frequently, large number of people are displaced killed or injured or subjected to greater risk of epidemics. Considerable economic harm to the existing infrastructure and threaten the future of sustainable development.

Disaster as “Grave occurrence having ruinous result”. Disaster as a any occurrence that cause damage, economic distraction, loss of human life and deterioration in health and healthy services on a scale sufficient to warrant an extraordinary response from outside the affected community.1

In the modern world, the traditional view of natural disaster as punishments for human Wickedness has given way to scientific study of the causes of seemingly unpredictable acts of nature. In recent year, however, scholars have placent emphasis on the roles played by greed and indifference to potential human suffering in many seemingly “natural” disaster following is a selective list of natural and man made disaster that have occurred in the United States. It should be note disaster statistic is often approximation, at best. Not only do contemporary news accounts frequently differ, but the standards by which to judge whether death and injuries were directly caused by a cataclysmic.2
A report was given by the centre for research into the Epidemiology of disasters (CRED) In the decade 1988 -97, disasters in India affected on an average over 24 million people and killed 5, 116 each year, in 1988, disaster affected 34,112,566, people in India and killed 9,846, between 1985 and 1995 disaster caused an annual economic loss of about us$ 1,883.93 million. 3

In India damage due to natural calamities in 1998-99 total districts affected no. 290 villages affected -61,373, Area affected in million ha.10.010 population affected in million Ha. 51.318, damage to crop area in million 6.806, damage to House/Huts No. 19,77,861 Human lives lost No. 4,955 Animals lost 91,912.3

Damage due to natural calamities in 1988-99 in Karnataka due to Rains Floods Total district no.30, Districts affected no.27, villages affected in million Ha. 8.549 damage to crop Area in million Ha. 0.607 damage to House/ Huts. No.1, 28,902, Human lives lost No. 310, animals cost No. 9,562.3

A report given by DAS RA in sep. 1983, about circus fire disaster in 1981 at Bangalore, India. The Circus fire disaster claimed 92 live and 300 other were injured. In this incidence A total of 119 patient were treated in the Burns counter at Victoria Hospital. Forty two patients were treated as out patients and 77 cases were admitted. Fourteen patients with move then 80 percent burn of the body surface died within 48 hours of the disaster. Three patients out of the remaining 63 cases died in the course of treatment, 32 patients were operated by escharctomy and skin grafting flap procedure. According to them by proper medical assessment, early fluid therapy and respiratory care saved many critical patient. 4

6.1 NEED FOR THE STUDY

With a wide range of geography and climatic conditions. India is the highly disaster prone country in Asia pacific region with a average of 8 major natural calamities a year. While floods, cyclone, draught, earthquakes and epidemics are frequent from time to time, major accidents happen in railways mines, and factories causing extensive damage to human life and property.
A descriptive study was conducted to assess the knowledge of school nurses on Bio-terrorism and other disaster preparedness at U.S.A. A cluster random sampling technique was used to select the 125 school nurses in public and private school from three countries. The study results were found that eighty surveys were returned (24% response rate). Response were analyzed according to emergency preparedness

competencies and skills required to the management of emergency phases: mitigation, preparedness, response and recovery. Low confidence in preparedness capabilities were reported by all categories. High training was identified with 63% to 70% requesting additional education related to disaster management.5

According to Medical Education and Development Research Centre faculty to Medicine, University of Colombo, Sri Lanka, provided voluntary healthcare services during the aftermath of the 2004 tsunami. At that time the faculty recognized the need to prepare the health care system for future disaster by enhancing the capability of health care workers. The development and implementation of a disaster management course for healthcare workers was identified as a priority.6

A study was done by Stanley J.M (2005) on disaster competency development and integration in nursing education. Stated that nurses, because of their education and perspective practicing in multiple role and settings are uniquely qualified for mass casualty preparedness and response. Educating the current 2.7 million registered nurses and all future nursing graduates is daunting task. In their study they fill that nursing education must ensure that graduates are prepared with the necessary knowledge and skill for mass casualty incidents. This article examines the role each of there key entities play in the development of a nursing workforce prepared for mass casualty response.7

A study was carried out at the West Virginia University Hospitals, USA conducted by Manley WG. Furbee P.M (2006) stated disaster preparedness has always been an area of major concern for the medical community, but recent world events have prompted an increased interest. The health care system must respond to disaster of all types, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common area of preparedness must be explored.8

The individual are responsible for maintaining their well being, community members, resources, organizations, and administrations should be the cornerstone at an emergency preparedness programme. The reason of community preparedness is:

a. Member of the community have the most to lose from being vulnerable to disaster and the most to gain from an effective and appropriate emergency preparedness programme.
b. Those who first respond to an emergency come from within the community, when transport and communication are disrupted and an external emergency response may not arrive for days.
c. Resources are most easily pooled at the community level and every community possesses capabilities. Failure to exploit those capabilities is poor resources management.
d. Sustained development is best achieved by allowing emergency affected communities to design, manage, and implement internal and external assistance programme9.

The need that made the investigator select this topic for study was his own experience when he attended to manage rains, floods during his student period.

The study is aimed at assess the attitude of B.Sc. Nursing student towards voluntarily in disaster management in a view to disaster preparedness team. Nursing is a multi faceted profession and a professional is required to play. A variety of roles, unlike other profession a practitioner in nursing should have a positive attitude acceptable behaviour and interest which befits her role and responsibility to society.

6.2 REVIEW OF LITERATURE
The review of literature is traditionally considered as a systematic critical review of the most important published scholarly literature on a particular topic.

According to Polit and Hungler (1999) :
Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in context or to identified gaps and weakness in prior studies so as to justify a new investigation.

Literature review for the present study has been collected and presented under the following headings:
         ◦ Meaning and general information about disaster.
         ◦ Impact of Disaster.
         ◦ Need of Volunteering.
         ◦ Management of Disaster.

6.2.1 Meaning and general information about disaster

The unexpected event that cause terrific damage to lives and property of human being and animals it may either be made disaster like terrorist attack, bombs explosions, looting arson etc or natural ones like flood, earth quakes, cyclones, fires etc.

In the absence of official definitions, observations from the field suggest that disasters be classified under three broad categories: natural, Human-made, and other disasters. Amongst these, there are the major disasters and the minor disasters.

Natural Disasters
Major: Earthquake, Flood, Drought, Cyclone
Minor: Heat Wave, Cold Wave, Landslide, Avalanche, Tornadoes, Hailstorm.
Human Made Disasters:
Major: Communion Riots, Ethnic conflicts, Refugee situations.
Other Disasters:
Major: Epidemics, Industrial disasters, Fire, Policy induced disasters.
Minor: Transport – road, rail, railways, and water disasters.
Festival and pilgrimage – related disasters.
Food Poisoning, Alcohol/liquor tragedies.10

The major causes and influencing factors for increased disasters are inadequate physical infrastructure, environment degradation, poor management and use of lack of adoption of scientific and engineering advancements and rapid urbanization, inadequate planning, weak economic transion on one hand, climate change and variability on the other hand. So young adults need to know all the causes of disaster to prevent the disasters and its effects.

6.2.2 Impact of Disaster
Tan NT. Impact of the Indian ocean Tsunami on the well-being of children, This article provides an overview of the plight of the “tsunami Generation” detailing the social and physical conditions after the disaster. Children are most vulnerable and need protection and clear and sustained support for rehabilitation. The social, psychological recovery and protection of children are key concerns of child welfare and internal social service organization. Policy and programmes should build on the people’s resilience and provide the psychosocial and community support.11

An epidemiological study was undertaken to assess the severe cholera out break following floods at West Bengal. The sample was 88 subjects. The subjects were interviewed and examined clinically. An investigation was done to understand the epidemiological characteristics, identified the agents and rationalizes clinical management and suggests control measures. The results showed that during the period between August and October 1998, 16,500 cases were reported with 276 deaths, twenty one of 29 (22%) rectal swabs were positive. All the strains were sensitive to tetracycline, norfloxacin, and ciprofloxacin gentamycin but resistant to furazolidine, cotrimaxazole ampcillin. The study concluded that in the present study epidemiological and clinical deficiencies in the management of outbreak and recommended for its effective control of outbreak12.

BELGAUM: One person died and about 30 were injured when a boiler of the Riddhi-Siddhi Gluco-Biols Ltd in Gokak exploded on Friday night. The condition of about 20 of the injured — with 80% burns — is reported to be critical. Some 40 workers were inside the factory when the disaster occurred. The impact of the blast was so great that the roof of the factory blew off and fell 100 meters away. Everything in a 100-metre radius of the factory was destroyed.13

6.2.3 Need of Volunteering
Volunteering means to do something for some one.
Volunteering is a job, is something that you do with your hand and your knowledge. It’s a work necessary to do but it isn’t a paid job for or a full time job, part time is the common manner of volunteering.14

The volunteer is used for do something that can’t be made in other form. It means to work for a cause that really needs it. A Hospital or elderly homes that don’t have enough budget to pay personal has the only possibility for accomplish it’s mission with volunteers.14

By Roger Carr- volunteering a portion of our time is something we should do. There are reminders all around us, that our help is needed. Other people will significantly benefit from any time we contribute. But that is not the only reason to volunteer. According to them 18 reasons to volunteer some of your times.

1. To make new friends
2. To build personal and professional contacts
3. To build your self-esteem and self-confidence
4. To develop new job skills
5. To make a difference in the world
6. To increase personal satisfaction
7. To add experience to your resume
8. To develop people skills
9. To develop communication skills
10. To do something as a family
11. To explore career possibilities
12. To feel needed and appreciated
13. To share your skills with others
14. To be challenged
15. To do something different
16. To earn academic credit
17. To improve your health
18. To have fun

You will get more of your volunteer experience then you put into it. Don’t hesitate to identify and donate some of your time to a worthy volunteer opportunity you will be glade you did.14

6.2.4 Management of Disaster

Emergency preparedness is a programme of long term development activities whose goals are to strengthen the overall capacity and capability of a country to manage efficiency all types of emergency. It should bring about an orderly transition from relief through recovery, and back to sustained development.15

Disaster preparedness is an on going multisectoral activity. It forms an integral part of the national system responsible for developing plans and programmes for disaster management, prevention, mitigation, preparedness, response, rehabilitation and reconstruction. The system, known by a variety of names depending on the country depends on the coordination of a variety of sectors to carry out the following tasks.

→ Evaluate t he risk of the country or particular region to disaster.
→ Adopt standards and regulation.
→ Organize communication, information and warning systems.
→ Ensure coordination and response mechanisms.
→ Adopt measure to ensure that financial and other resources are available for
       increased readiness and can be mobilized in disaster situation.
→ Develop public education programmes.
→ Coordinate information sessions with news media
→Organize disaster simulation exercises that test response mechanisms.

The emergency prepared and emergency management do not exist in a vacuum. To succeed, emergency programmes must be appropriate to their context.15

A study was under taken to assess the management of a multi casualty event in and out of hospital phases including rescue, emergency service deployment and evaluation of casualties at Israel. Data were collected from 700 study subjects who were in the four emergency departments by referring medical files, telephones interviews and computerized information. The study results showed that 315 injured people, 43% were hospitalized. During the first hour 42 percent were evaluated by the volunteers and after seven hours scene was empty and at the hospitals about 1,300 staff members arrived immediately to give service to the victims.16

An evacuee evaluation center provides a convenient non-ED alternative for evacuees to address their non-emergent medical concerns and can be used to ease their transition to a new location.

According to Weiner EE, Trangenstein PA. Early informatics contributions to the emergency planning and response agenda have focused largely on surveillance of threat detection. A broader assessment of possible informatics contributions unveils that informatics can also contribute to increasing the efficiency in disaster response as well as providing a tale-presence for remote medical caregivers. This presentation will explore current and future roles of informatics in emergency preparedness and response. Special challenges for data management occur with every emergency or disaster. Tracking of victims, electronic health records, and supply inventory are a few of the contributions that informatics can play during disasters. Modeling of response resources can provide the parameters for more effective decision making. Public relations reporting can be made more accurate if given the information in a timely fashion. Databases provide the infrastructure for reporting of data that can be used to manage volunteers or later be mined to determine the effectiveness of planning and response efforts. As informaticists, we have a moral obligation to contribute to the emergency response agenda worldwide.17

6.3 STATEMENT OF THE PROBLEM
A descriptive study to assess the attitude of nursing student studying at MSRINER towards volunteering in disaster management, in a view to prepare disaster preparedness team.

6.3.1 OBJECTIVE OF THE STUDY:

         * To assess the attitude of nursing student studying at MSRINER
             towards volunteering in disaster management.
   * To find association between quality of attitude and selected socio demographic
     variable.
   * To prepare a disaster preparedness team.

6.4 OPERATIONAL DEFINITIONS.
6.4.1Attitude: refers to the feelings expressed by the students towards volunteering in disaster management in which will be assessed by using a structured attitude scale.
6.4.2 Nursing Student: Refers to the individual who are studying in M.S. Ramaiah Institute of Nursing Education And Research Bangalore.
6.4.3 Volunteering: Self interest of student to actively participate in any disaster management activity.
6.4.4 Disaster Management: Refers to the action to be taken during any sudden incident which is cause damage to human life and their property.
6.4.5 Disaster Preparedness Team: The group of student who is ready to face the Predictable and unpredictable emergency occurred due to disaster.

6.5 HYPOTHESIS.
H1 – There is significant association between the quality of attitude of nursing student and socio demographic variables.

7. MATERIAL AND METHODS:

7.1 Source of data      : Nursing student studying at MSRINER Bangalore.
7.2    Method of Data Collection: Data will be collected by administer structured
                                                  Attitude scale
7.2.1    Type of study    :         Descriptive study.

7.2.2    Research design        :        Non experimental descriptive research design.

7.2.3    Variables under study:
       Study variables    : Attitude of nursing student towards volunteering
                                                      in disaster management.
Attribute variables    : Personal characteristics which include age,
                                                      gender,course, year, religion, Place of residence,
Marital states

7.2.4    Sampling technique     :        Quota sampling technique.

7.2.5    Sample size    : 100 Nursing student.

7.2.6    Follow-up    : No follow up

7.2.7    Duration of study    : One month.

7.2.8 Inclusion criteria and exclusion criteria.
Inclusion criteria    : Student who are willing to participate in the
                                                      study.

       Exclusion criteria    : - Not available at the time of data collection.
                                                    - Those who are attended the synopsis
                                                        pesentation

7.2.9 Instruments
Section A              :             Socio Demographic Profile.
Section B              :              Attitude scale to assess the attitude towards
                                                                volunteering in disaster management

7.2.10 Data Collection Procedure.
1. After obtaining prior permission from the concerned authorities a brief introduction about self and the study will be given to the samples. After obtaining due consent from the subject the data collection tool will be administered.

7.2.11 Statistical method used.
Data obtained will be tabulated and analyzed in terms of objective of the study using descriptive and inferential statistics.

Descriptive statistics:
         ►   Frequency and percentage distribution will be used to assess the socio
            demographic variable and attitude of the nursing student.
        ►Mean and standard deviation will be used to assess the attitude regarding
            volunteer in disaster management

Inferential statistics:
        ►Chi square test will be used to determine the association between the
           quality of   attitude and the socio demographic variables.

7.3 Does study require any investigation/Intervention to be conducted on patient/Humans/ Animals?
Yes: Attitude of nursing student towards volunteering in disaster management
                    will be investigated by administering attitude scale.

7.4 Has ethical clearance obtained from Institution?
      Yes: Ethical clearance will be obtained from concerned authority and       consent will be obtained from the subject. Confidentiality and anonymity of subject will be maintained.

8. BIBLIOGRAPHY/REFERENCE
1. World Health Organisation : Strategy and approach to Humanitarian action.
   Coping with major emergencies Geneva. WHO j med. 2004 June 8.Page-11
2. Alexander, David. Confronting catastrophic: New perspective on natural
     Disasters. New York, Oxford University Press 2000.Page-78-82.
3. Centre for research into the Epidemiology of disaster (CRED); Available from http://www.punjabilok.com/india_disaster_resp/introduction/damage_ dueto.htjm.
4. DAS RA. Circus fire disaster in Bangalore, Finding causes, Management of
     Burn patient and possible presentation. Burns Incl Therm Ins. 1983 Sep: 10
    (1): 17-23 .Available from http://www.pubmed.com.
5. Weiss B, Clankson TW. Toxic.chemica school nurses on Bio-terrorism and
     other disaster preparedness at U.S.A.. Disaster Manage Response. 2006-Oct-
    Dec: 4 (4): (100-5). Available from www.pubmed.com
6. De Witt, James D Alegal Handbook for Non profit corporation Volunteers
    1997 Dec 7.Page 175-178
7. Stanley JM, Disaster Competency development and integration in nursing
   education.(Serial Online ) 2005 Sep; 40 (3) : 453-67 Available from
    Istanley @ aach.nche.edu.
8. Mayley WG, Furbee PM Realities of disaster preparedness in rural hospitals,
   disaster management response, 2006 sep 4(3): 80-7 Availabl from
    Manleyw@wvuh.com.
9. K.Park “ Preventive and social Medicine” 18th Edition Banarasides Bharat
    Publishers, Jabalpur 2006: Pg 602-603.
10. Bromberger Kar. ET. Disaster management team.2004 April 6. page 83-84
11. Tan NT : Impact of the Indian Ocean tsunami on the well being of children.
       2006: 5(6-7):68-72. : Reverside Ave South, 117570, Singapore,
       wktannat@nus.edu.sg
12. Melanie N.Smith, M.D., Ph.D. epidemiological study article Reviewer Info:
     [serial online] 2006; Feb. Available from : www.nwahs.sa.gov.au/repositories.
13. Vomsal F. The Impact of the blast. Times of India 2002 Feb 14; p.6-7.
     www.timesofindia.com

14. Roger Carr, Reason to volunteer. [ online ] 2005 [cited 2005 Sept 21]; Available from www.everydaygiving.com/ezine/21sept2005.html
15.K.Park “ Preventive and social Medicine” 18th Edition Banarasides Bharat
Publishers, Jabalpur 2006: Pg 603-604.
16.Irvin CB, Atas JG. Management of evacuees surge from a disaster area:
University School of Medicine, Detroit, Michigan, USA. cbi@123.net
17.Weiner EE, Trangenstein PA. Application of Knowledge management and the
intelligence contimuum for medical emergencies and disaster sceharios; Ann
Aead Med Singapore 2007 Sep; Page No.(100 – 5)

9.
SIGNATURE OF THE CANDIDATE

10.

REMARKS OF THE GUIDE It is very much need based, feasible and focused on the present problem and appropriate.

11.
NAME AND DESIGNATION OF:
(IN BLOCK LETTERS)
Mrs. Prof. GANGABAI.B KULKARNI
PROFESSOR AND HOD
COMMUNITY HEALTH NURSING
M.S.R.I.N.E.R, BANGALORE.

11.1

11.2
GUIDE

SIGNATURE

11.3

11.4
CO-GUIDE (if any)

SIGNATURE

11.5

11.6
HEAD OF THE DEPARTMENT

SIGNATURE
Mrs. Prof. GANGABAI.B KULKARNI

12

12.1
REMARKS OF THE CHAIRMAN AND PRINCIPAL

SIGNATURE The synopsis of the present study broadened to encompose the current trends of nursing issue so the study is genuine, relevant and feasible, individually benefited scientific, systematic methodology of research process.

Admission open

ADMISSIONS OPEN FOR 2017-19

MASTER OF MANAGEMENT STUDIES (HERITAGE MANAGEMENT)

Centre for Heritage Management (CHM), Ahmedabad University has announced opening of admissions process for its two -years Master of Management Studies (Heritage Management) programme, for 2017-2019 group, to commence from August 2017. The admission policy and application form are attached herewith, and are also available at the centre's website as well as at the Centre's office at Ahmedabad University.

1.Minimum required qualifications are a Bachelor's degree in any discipline (with a minimum of 50% marks) and an interest in heritage management. Students in the final year of their Bachelors degree studies may also apply if they are appearing for the final exams by June 2017, and the final results can be submitted by September 30, 2017.

2. A Statement of Purpose (SOP) outlining the candidate's interest in heritage management is required along with the application, and is a key evaluation component.

3. Applicants are required to submit their scores from any national level standard test - the test could be any recognized test in the respective discipline. Candidates with relevant heritage related work experience may submit a portfolio of their work in lieu of the test score.

4. Only selected candidates will be called for personal interview. Out of state candidates may be allowed for a tele-video conference if they are not able to come for personal interview (however, it is highly recommended). The admissions decision will be based on evaluations of standard test score or relevant experience,

For further information about the programme and admission policy, please visit our website.

The deadline for receiving the completed application form along with required documentation and application fee is April 15th, 2017. An online application process will also be available soon.

If you have any questions, please feel free to contact us:

Centre for Heritage Management

Ahmedabad University

Asmita Bhavan, Central Campus

Navrangapura, Ahmedabad- 380009

Gujarat

Website: ahduni.edu.in/chm

Contact No: + 91 079 61911552

Disaster preparedness

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Tuesday, 21 February 2017

Why nurses go unheard in India – even when they strike

India has more than 16 lakh nurses. But their complaints seem to be ignored repeatedly.

The indefinite strike by nurses that began on September 2 was short lived. The strike was called off after just two days following a meeting between the All India Government Nurses' Federation and health ministry officials at which the nurses were assured that their demands will be sent to the finance ministry by September 12.

However, the Delhi government had already invoked the Essential Services Management Act on Friday classifying the strike as illegal. It detained more than 20,000 nurses. Even though ESMA was declared only at 1.30 pm, nursing association leaders were arrested at 10.30 am that day. Two association leaders were even sent to Tihar Jail. Media reports focused on state health services affected by the nurses’ strike but not on the nurses demands.

The All India Government Nursing Federation has presented their demands to the government many times before. Their basic demand is for a better entry-level pay-scale, which they say has been due for correction since the Fifth Pay Commission in 1996. The nurses contend that while doctors have been given a salary hike of more than 14% in the Seventh Pay Commission, nurses have continued to be ignored.

Substandard working conditions

Most of India’s nurses work in private hospitals, which are largely unregulated and do not follow the norm of having nurse-patient ratios of one to every four. Nurses work nine- to 14-hour days, often doing double shifts. Their starting salaries are between Rs 3,000 and Rs 15,000. Many nurses are required to sign contractual bonds with their employers withholding their educational certificates as guarantee.

In the public sector, nurses are paid better than in private hospitals. But even here, nurse patient ratio are a far cry from the 1:4 norm. Nurses get promotions based on their management abilities and the number of years of experience they have. However, higher authority positions are occupied by physicians, with a nurse being restricted to one promotion in the course of her career. Many retire as staff nurses due to a lack of the higher positions and few opportunities for continuing education. Daily duties are also difficult with most hospitals not providing proper spaces for nurses to change or rest.

A World Health Report of 2006 reveals that 70% of the doctors are male and 70% nurses are female. In India, more than 90% of the nurses are women. In the rigid healthcare hierarchy, nurses are not considered independent professionals but are dominated by physicians and hospital managements.

Most health authorities, physicians and politicians acknowledge that nurses are the backbone of both health system and hospital but when nurses demand autonomy and legal recognition or even basic facilities like changing rooms, toilets and conducive work environments, they go unheard.

Protesting nurses are often punished, as has been reported many times. In December 2009, staff nurses of the Batra Hospital in New Delhi went on strike demanding basic facilities and minimum basic salary of between Rs 10,000 and Rs 15,000. They succeeded in getting the salary hike but those nurses at the forefront were fired on disciplinary grounds. In the public sector, nurses protesting working conditions are sometimes sent to difficult locations or may be refused leave.

A new dimension to nurses’ exploitation by the state is through contractual systems and recruitment outsourcing. The National Rural Health Mission recruits nurses on contractual basis with salaries from Rs 5,000 to Rs 11,000 but without offering any other conveniences. Even if they work for the same hospital, nurses with the same qualification and job description are paid differently depending on whether they are permanent and contract workers. These differences are in the range of Rs 15,000 to Rs 30,000.

India had more than 16 lakh nurses, according to a survey in December 2008. But their complaints seem to be ignored repeatedly. First, the government only set up nursing institutions in 2002, even though these were proposed in all five-year plans and other policy documents. Even here, a majority of nursing colleges were run by the private sector.

Few of states like West Bengal, Gujarat and Odisha have created a nursing director post but these are occupied by doctors. In Karnataka, which also has a nursing director position occupied by a doctor, the state government is merging nursing and paramedical boards.

Nursing movements

In the late 1970s and early 1980s, there were strong agitations by government nurses, who formed associations and unions. They made basic demands regarding uniforms and residence facilities. These associations were concentrated in the northern region and included the Delhi Nurses Union, the Maharashtra Government Nurses Federation, the Rajakiya Nurses Sangh in Uttar Pradesh , the Nursing Research Society of India and the All India Government Nurses Federation. Many of these are still active.

As nursing services have been commercialised over the past two decades, thousands of nursing institutes emerged between 2002 and 2005, especially in the southern states. Many young nurses formed associations such as the Indian Professional Nurses Association, Delhi Private Nurses Association, and the United Nurses Association to demand better working conditions. In May 2015, there was attempt to unite all nursing associations of India.

It's a difficult task. After all, a physician-dominated health system with men in the majority will not allow the advancement of professionals groups that have more women. However, healthcare needs teamwork: each member has to contribute, coordinate and cooperate for better outcomes. Uniting nurses and improving their conditions is essential to build a healthy nation.

I welcome your comments

Indian nursing council phd nursing candidates 2017-18

NATIONAL CONSORTIUM FOR Ph.D. IN NURSING
by
INDIAN NURSING COUNCIL
In collaboration with
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, Bangalore
* Admission for the Ph.D. in Nursing under National Consortium for the
following Candidates:
S. No. Registration No. Name of the Candidate
Community Health Nursing
1. 175B Ms.Salina S
2. 003B Ms.Sonia Karen Liz Sequera
3. 059B Ms.Saila Bala
4. 164D Ms.Krishnaveni.R
5. 140B Ms.Gomathi.A
6. 153D Ms.Mugda Devi Sharan Sharma
Medical Surgical Nursing
1. 057D Mr.Vijay V R
2. 037D Ms.Mamta Choudhary
3. 118B Ms.Anuja B.S
4. 016D Ms.Ajitha Datta Chaudhuri
5. 079B Ms.Sherin Susan Thomas
6. 177B Mr.Athar Javeth
OBG
1. 178B Ms.Manju SS
2. 035B Ms.Biji Jose
3. 029B Mr.Blaze Asheetha Maria Rosario
Pediatric Nursing
1. 090D Ms.Rupinder Deol
2. 018D Ms.Mohansundari.S.K
Psychiatric Nursing
1. 099B Mr.K.Jayakrishnan
2. 091D Ms.Xavier Belsiyal
3. 055D Ms.J.Manoranjini
National Consortium for Ph.D. in Nursing is not responsible for any inadvertent error that may
have crept in the results being published on website. The results published on the net is for
immediate information to the candidates.
* The last date for the admission is 15th March 2017 (upto 04:00 pm). The following documents
to be submitted to the Nodal Center in person:
I. Certificates of Qualification of M.Sc.(N), M.Phil (N).
II. Authentication from SNRC with regard to RN&RM Certificate.
III. Verification of Original Certificates & Documents by the Nodal Officer.

Monday, 20 February 2017

Martha Rogers - The Science of Unitary and Irreducible Human Beings The “Slinky”

Martha Rogers - The Science of Unitary and Irreducible Human Beings

The “Slinky”

Imagine the life process moving along the “Slinky” spirals with the human field occupying space along the spiral and extending out in all directions from any given location along a spiral. Each turn of the spiral exemplifies the rhythmical nature of life, while distortions of the spiral portray deviations from nature’s regularities. Variations in the speed of change through time may be perceived by narrowing or widening the distance between spirals.

Major Concepts

Human-unitary human beings

“Irreducible, indivisible, multidimensionality energy fields identified by pattern and manifesting characteristics that are specific to the whole and which cannot be predicted from the knowledge of the parts.”

Health

“Unitary human health signifies an irreducible human field manifestation. It cannot be measured by the parameters of biology or physics or of the social sciences.

Nursing

“The study of unitary, irreducible, indivisible human and environmental fields: people and their world.”
Scope of Nursing

Nursing aims to assist people in achieving their maximum health potential. Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompass the scope of nursing’s goals.

Nursing is concerned with people-all people-well and sick, rich and poor, young and old. The arenas of nursing’s services extend into all areas where there are people: at home, at school, at work, at play; in hospital, nursing home, and clinic; on this planet and now moving into outer space.

Environmental Field

“An irreducible, indivisible, pandimensional energy field indentified by pattern and integral with the human field.”

Energy Field

“The fundamental unit of the living and non-living. Field is a unifying concept. Energy signifies the dynamic nature of the field; a field is in continuous motion and is infinite.”

An energy field identifies the conceptual boundaries of man. This field is electrical in nature, is in continual state of flux, and varies continuously in its intensity, density, and extent. (Rogers, 1970)

Subconcepts

Openness

“Refers to qualities exhibited by open systems; human beings and their environment are open systems.”

Pandimensional

“A nonlinear domain without spatial or temporal attributes.”

Synergy is defined as the unique behavior of whole systems, unpredicted by any behaviors of their component functions taken separately.

Human behavior is synergistic.

Pattern

“The distinguishing characteristic of an energy field perceived as a single wave.”

Principles of Homeodynamics

Homeodynamics should be understood as a dynamic version of homeostasis (a relatively steady state of internal operation in the living system).

Principle of Reciprocy

Postulates the inseparability of man and environment and predicts that sequential changes in life process are continuous, probabilistic revisions occurring out of the interactions between man and environment.

Principle of Synchrony

This principle predicts that change in human behavior will be determined by the simultaneous interaction of the actual state of the human field and the actual state of the environmental field at any given point in space-time.

Principle of Integrality (Synchrony + Reciprocy)

Because of the inseparability of human beings and their environment, sequential changes in the life processes are continuous revisions occurring from the interactions between human beings and their environment.

Between the two entities, there is a constant mutual interaction and mutual change whereby simultaneous molding is taking place in both at the same time.

Principle of Resonancy

It speaks to the nature of the change occurring between human and environmental fields. The life process in human beings is a symphony of rhythmical vibrations oscillating at various frequencies.

It is the identification of the human field and the environmental field by wave patterns manifesting continuous change from longer waves of lower frequency to shorter waves of higher frequency.

Principle of Helicy

The human-environment field is a dynamic, open system in which change is continuous due to the constant interchange between the human and environment.

This change is also innovative. Because of constant interchange, an open system is never exactly the same at any two moments; rather, the system is continually new or different. (Rogers, 1970)

Assumptions

Man is a unified whole possessing his own integrity and manifesting characteristics that are more than and different from the sum of his parts.

Man and environment are continuously exchanging matter and energy with one another.

The life process evolves irreversibly and unidirectionally along the space-time continuum.

Pattern and organization identify man and reflect his innovative wholeness.

Man is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion. (Rogers, 1970)

Strengths/Weaknesses

Strengths:

Rogers’ concepts provide a worldview from which nurses may derive theories and hypotheses and propose relationships specific to different situations.

Rogers’ work is not directly testable due to lack of concrete hypotheses, but it is testable in principle.

Weaknesses:

It is an abstract, unified, and highly derived framework and does not define particular hypotheses or theories.

Concepts are not directly measurable thus testing the concepts’ validity is questionable.

It is difficult to comprehend because the concepts are extremely abstract.

Nurses’ roles were not clearly defined.

No concrete definition of health state.

Analysis

Apart from the usual way of other nurse theorists in defining the major concepts of a theory, Rogers’ gave much focus on how a nurse should view the patient. She developed principles which emphasizes that a nurse should view the client as a whole.

Application into Practice

Her statements remind every nurse practitioner that to retain the integrity of the individual, he or she should be viewed as one complex system interacting with the environment and care should not be fractionalized in different categories.

Conclusion

Being given with as wide range of principles and statements from Rogers, an aspiring nurse theorist can develop his or her own concepts guided with her work. Her assumptions are not confined with a specific nursing approach making it highly generalizable.

Models of nursing (conceptual framework) relation between models and theory model building in nursing

Models of nursing (conceptual framework) relation between models andtheory model building in nursing

Theory defined as a supposition or system of ideas that is proposed to explain a given
phenomenon. Or A theory is a sets of concepts & propositions that provides an orderly way
to view phenomena.
Nursing theory differentiates nursing from nursing from other disciplines and activities
that in that the purposes of describing, explaining, predicting and controlling desired
outcome of nursing care practices.
The purpose of theory: In scientific disciplines is to guide research to enhance the science
by supporting existing knowledge or generating new knowledge. A theory not only helps us
to organize our thoughts and ideas, but it may also help direct us in what to do and when
and how to do it. It supports the development of knowledge through thesis and
contestability. Theory not only explains and predicts outcome but also supports in decision
making.
The use of the term theory is not restricted to the scientific word, however. It is often used
in daily life and conversation.
All nursing theories have common concepts. Which are influence and determine nursing
practices are:
1. The person or client (individual, family, group or community)
2. Environment (Internal & external)
3. Health (the degree of wellness or wellbeing that the client experiences.)
4. Nursing, the attributes, characteristics and actions of the nurse providing care on
behalf of, or in conjunction with, the client.
A conceptual framework helps construct a "house" of relevant information. This house
explains, either graphically or in narrative form, the main things to be studied or taught
and the relationships among them. A conceptual framework for a thesis acts as a visual
outline to represent the concept or research idea ‐ the way the researcher shapes it
together. This framework expands upon the research problem as it associates to pertinent
literature research. Part of conceptual framework offers a synopsis of the study’s main
points. The framework shows the central factors influencing the relationship of the
primary variables/elements or constructs ‐‐ and how all relate to the stated hypothesis.
Or A conceptual Framework is group of related ideas, statements or concepts. For example
Freud’s structure of mind (Id, ego and superego) could be considered a conceptual
framework or model.
Nursing Theory and Model Relation Page 2
Models make precise assumptions about a limited set of parameters and variables.
Generally analysts use models to fix variables at specific settings and to explore the
outcomes produced.
Models allow analysts to test specific parts of theories.
For example
Situating models within theories and theories within frameworks keeps analysts honest,
supports the scientific enterprise and encourages the cumulation of knowledge. This ideal
is rarely met.
All good nursing theories are based on specific models for example Nightingale’s theory
based on Environmental Model, Peplau’s theory based on Interpersonal relationship model,
Orem’s theory based on Self‐care deficit theory, King’s theory based on Goal Attainment
Model, Roy’s Adaptation theory based on Adaptation model.
How is the term “theory” related to “model” and what else should these terms be related
to?
There are three of concerns about the usage of these terms. First, the terms “models”
And “theories… have been widely used as interchangeable in the profession”. Second
related Point is that, the term “theorist” usually means “model builder.” Third, a theory
involves more than technical/analytical desiderata:“Scientific culture understands theory
to entail requirements of importance and usefulness”
Nursing Theory and Model Relation Page 3
As a conclusion it said that “theory” has a higher normative status than “model.” Moreover,
few of Scientist believes that a theory does not require a “model” and a “model” is not
sufficient for a “theory.”
Notice that this set of requirements for a modelbased
theory has three characteristics:
First, “models” are theory wannabes. Only a really good model gets promoted to theory
status.
Second, the idea that “theory” might operate at a very general level, while “models” might
be specific applications of a theory (a theoretical framework) is missing.
Third, this usage makes no allowance for the possibility that models are sometimes (though
not always) a link between theory frameworks and the activities of empiricists.
References:
• Hart C. (1998): Doing a Literature Review.” London, Sage.
• Jennings G. (2001): Tourism Research. Australia, John Wiley and Sons.
• Maslow A (1954): “Motivation and Personality.” New York: Harper.
• Miles, M. B., & Huberman, M. A. (1994): “Qualitative Data Analysis: An Expanded
Sourcebook” (2nd edition). Beverley Hills, Sage.
• Rogers, E.M. (2003): “Diffusion of Innovations.” 5th Edition. London, Simon and
Schuster.
• Smyth R. (2004): “Exploring the Usefulness of a Conceptual Framework as a
Research Tool: A Researcher's Reflections.” Issues In Educational Research, Volume
14.
• Yin R. K. (1994): “Case Study Research: Design and Methods.” (2nd edition)
California, Sage.
• Leahy.j., Kizilay, P.(2005): Foundation of nursing practices; Nursing Process
Approach, New York, W.B. Saunders
• White, L (2001): Foundation of Nursing: Caring the whole person, New York,
Thomson Learning.
• Robert S. Goldfarb1 and Jon Ratner (2007): “Theory” and “Models”:Terminology
Through the Looking Glass
• Kozier & Erb’s (2009): Fundamentals of Nursing: Concepts, Process and Practices
(8th edition), Pearson

Basic Needs Nursing Theory “The nurse’s role is to “get inside the patient’s skin & supplement his strength, will, or knowledge according to his needs. . .”

Introduction of Virginia Henderson

Virginia A. Henderson, a Modern-Day Mother of Nursing, has earned the title "foremost nurse of the 20th century” or “The Nightingale of Modern Nursing”. Her contributions are compared to those of Florence Nightingale because of their far-reaching effects on the national and international nursing communities. She was born in Kansas City, Missouri, in 1897.

She did diploma in nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921.In 1923, she started teaching nursing at the Norfolk Protestant Hospital in Virginia. In 1929, she entered Teachers College at Columbia University for Bachelor’s Degree in 1932; Master’s Degree in 1934. She was recipient of numerous recognitions, well known nursing educator and a prolific author. An inspiration to nurses everywhere, she has influenced nursing practice, education, and research throughout the world. She has written several text books in nursing field. She died on March 19, 1996 at 99 years of age.

Theory Background

· She called her definition of nursing her “concept” (Henderson1991)

· She emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed (Henderson,1991)

· "Assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery" (Henderson, 1966).

· She categorized nursing activities into 14 components, based on human needs.

· She described the nurse's role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.

· Her definition of nursing was:

"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery, or to a peaceful death, that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible."1966

Assumptions of Henderson’s Basic Needs Nursing Theory

v Individuals have biological, psychological, social, & spiritual components or needs.

v Nursing activities are categorized into 14 components & are based on human needs.

v These components are closely paralleled to Maslow’s hierarchy of human needs.

v Health is the achievement of independence defined as the individual’s ability to function.

v Independence and dependence (due to illness) are on a continuum and it is the nurse’s role to assist the individual regain independence (see diagram)

v The nurse has 3 primary roles with the goal of working with the person to become as independent as possible.

v These roles are: Substitutive (doing for the person) Supplementary (helping the person) Complementary (working with the person)

The 14 components

· Breathe normally.

· Eat and drink adequately.

· Eliminate body wastes.

· Move and maintain desirable postures.

· Sleep and rest.

· Select suitable clothes-dress and undress.

· Maintain body temperature within normal range by adjusting clothing and modifying environment

· Keep the body clean and well groomed and protect the integument

· Avoid dangers in the environment and avoid injuring others.

· Communicate with others in expressing emotions, needs, fears, or opinions.

· Worship according to one’s faith.

· Work in such a way that there is a sense of accomplishment.

· Play or participate in various forms of recreation.

· Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

Comparison with Maslow's Hierarchy of Need

Maslow's	Henderson
Physiological needs	Breathe normally Eat and drink adequately Eliminate by all avenues of elimination Move and maintain desirable posture Sleep and rest Select suitable clothing Maintain body temperature Keep body clean and well groomed and protect the integument
Safety Needs	Avoid environmental dangers and avoid injuring other
Belongingness and love needs	Communicate with others worship according to one's faith
Esteem needs	Work at something providing a sense of accomplishment Play or participate in various forms of recreation Learn, discover, or satisfy curiosity

Henderson’s theory and the four major concepts

Major Concepts

Human or Individual

· Have basic needs that are component of health.

· Requiring assistance to achieve health and independence or a peaceful death.

· Mind and body are inseparable and interrelated.

· Considers the biological, psychological, sociological, and spiritual components.

· The theory presents the patient as a sum of parts with biopsychosocial needs.

· Society or Environment

Settings in which an individual learns unique pattern for living.

· All external conditions and influences that affect life and development.

· Individuals in relation to families

· Minimally discusses the impact of the community on the individual and family.

· society wants and expects the nurse’s service of acting for individuals who are unable to perform the 14 activities unaided

· She supports the tasks of private and public health agencies keeping people healthy.

Health

· Definition based on individual’s ability to function independently as outlined in the 14 components.

· Nurses need to stress promotion of health and prevention and cure of disease.

· Good health is a challenge -affected by age, cultural background, physical, and intellectual capacities, and emotional balance Is the individual’s ability to meet these needs independently.

·
Nursing

Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs.

· Assists and supports the individual in life activities and the attainment of independence.

· Nurse serves to make patient “complete” “whole", or "independent."

· The nurse is expected to carry out physician’s therapeutic plan Individualized care is the result of the nurse’s creativity in planning for care.

· “Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver.”

· In the Nature of Nursing Nurse role is,” to get inside the patient’s skin and supplement his strength will or knowledge according to his needs.”

Sub concepts

· 14 Activities for Client Assistance

Physiological
1. Breathe normally

2. Eat and drink adequately

3. Eliminate body wastes

4. Move and maintain desirable postures

5. Sleep and rest

6. Select suitable clothes – dress and undress

7. Maintain body temperature within normal range by adjusting clothing and modifying environment

8. Keep the body clean and well groomed and protect the integument

9. Avoid dangers in the environment and avoid injuring others

Psychological Aspects of Communicating and Learning

10. Communicate with others in expressing emotions, needs, fears, or opinions

14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities

Spiritual and Moral

11. Worship according to one’s faith

Sociologically Oriented to Occupation and Recreation

12. Work in such a way that there is sense of accomplishment

·
13. Play or participate in various forms of recreation

“It is equally important to realize that these needs are satisfied by infinitely varied pattern of living, no two of which are alike.” (Henderson, 1960)

Henderson’s and Nursing Process

”Summarization of the stages of the nursing process as applied to Henderson’s definition of nursing and to the 14 components of basic nursing care.

Nursing Process	Henderson’s 14 components and definition of nursing
Nursing Assessment	Henderson’s 14 components
Nursing Diagnosis	Analysis: Compare data to knowledge base of health and disease.
Nursing plan	Identify individual’s ability to meet own needs with or without assistance, taking into consideration strength, will or knowledge.
Nursing implementation	Document how the nurse can assist the individual, sick or well.
Nursing implementation	Assist the sick or well individual in to performance of activities in meeting human needs to maintain health, recover from illness, or to aid in peaceful death.
Nursing process	Implementation based on the physiological principles, age, cultural background, emotional balance, and physical and intellectual capacities. Carry out treatment prescribed by the physician.
Nursing evaluation	Henderson’s 14 components and definition of nursing Use the acceptable definition of; nursing and appropriate laws related to the practice of nursing. The quality of care is drastically affected by the preparation and native ability of the nursing personnel rather that the amount of hours of care. Successful outcomes of nursing care are based on the speed with which or degree to which the patient performs independently the activities of daily living

Strength and weakness of Henderson’s theory

Strength:

· There is interrelation of concepts.

· Concepts of fundamental human needs, biophysiology, culture, and interaction, communication are borrowed from other discipline. E.g. Maslow’s theory.

· Her definition and components are logical and the 14 components are a guide for the individual and nurse in reaching the chosen goal.

· Relatively simple yet generalizable.

· Applicable to the health of individuals of all ages.

· Can be the bases for hypotheses that can be tested.

· Assist in increasing the general body of knowledge within the discipline.

· Her ideas of nursing practice are well accepted.

· Can be utilized by practitioners to guide and improve their practice.

Weakness:

· A major shortcoming in her work is the lack of a conceptual linkage between physiological and other human characteristics.

Analysis

One cannot say that every individual who has similar needs indicated in the 14 activities by Henderson are the only things that human beings need in attaining health and for survival. With the progress of today’s time, there may be added needs that humans are entitled to be provided with by nurses.

The prioritization of the 14 Activities was not clearly explained whether the first one is prerequisite to the other. But still, it is remarkable that Henderson was able to specify and characterize some of the needs of individuals based on Abraham Maslow’s hierarchy of needs.

Some of the activities listed in Henderson’s concepts can only be applied to fully functional individuals indicating that there would always be patients who always require aided care which is in contrary to the goal of nursing indicated in the definition of nursing by Henderson.

Because of the absence of a conceptual diagram, interconnections between the concepts and sub concepts of Henderson’s principle are not clearly delineated.

Application to Practice

Current practice– cardiac step down unit specializing in heart failure. Goal of nursing care is to return the patient to his/her optimal self care ability via education on diet, medications, daily weights and follow up appointments to the physician

Challenges – due to co morbidities associated with heart failure, some patients may not have the desire or capability to return to their pre-admission state, therefore, the nurse must accept the patient’s perspective and definition of “wellness”

Research

Testability of the practice and outcomes of nursing. “Each of the 14 activities can be the basis for research” (Wills, 2007, p.140) Interpretation: quantitative and qualitative research has been beneficial in evaluating this theory due to the combination of actions (14 activities) and the assumed devotion of the nurse to his/her patients (affective evaluation)

Conclusion

Virginia believed that the function the nurse performs is primarily an independent one – that of acting for the patient when he lacks knowledge , physical strength, or the will to act for himself as he would ordinarily act in health, or in carrying out prescribed therapy. This function is seen as complex and creative, as offering unlimited opportunity for the application of the physical, biological, and social sciences and the development of skills based on them.

Henderson provides the essence of what she believes is a definition of nursing. Her definition of nursing and the 14 components of basic nursing care are uncomplicated and self-explanatory.

“The most FAMOUS NURSE of the 20^th century.

Miss Henderson gave our profession its identity.

Her work is the soul of Modern Nursing.” (McBride)

References

1. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange.

2. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book.

3. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins.

4. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott.

5. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott.

6. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006Jul; 27(6):605 15

Online References:

v http://currentnursing.com/nursing_theory/henderson

v http://nurses.info/nursing_theory_person_henderson_virginia

v http://www.nursinglibrary.org