Dissertation – A Critical Evaluation of the Effectiveness of Cognitive Behaviour Therapies for Children and Adolescents with Anxiety Disorders
Research into the effectiveness of cognitive behavioural therapy for anxiety disorders has previously mainly focused on adults. However, there has been an increase of research into the effectiveness of cognitive behaviour therapy for children and adolescents, albeit studies remain scarce. This dissertation aims to examine the effectiveness of cognitive behavioural therapies available to children and adolescents with anxiety disorders.
This critical literature review analyses the available literature, offering a critical evaluation of the most used forms of cognitive behaviour therapy: group and family cognitive behavioural therapy, individual cognitive behavioural therapy and computerised cognitive behavioural therapy.
Cognitive Behaviour Therapy
Furthermore, this research outlines a range of key findings, identifying numerous difficulties found in treating children and adolescents with anxiety disorders as well as considering what is needed for cognitive behaviour therapy to be effective. Some of the issues found to affect the overall effectiveness of cognitive behaviour therapy include non-compliance, parental involvement, drop-out and the strength of the therapeutic relationship. The main conclusions propose that cognitive behavioural therapies for children and adolescents with anxiety disorders are effective from the outset, but upon further analysis, may not be as effective as many professionals suggest.
The aim of this dissertation is to examine the effectiveness of cognitive behavioural therapy (CBT) in children and adolescents with anxiety disorders. Through carrying out an extensive literature review using secondary data, this piece of research will gather and critically analyse evidence for and against the effectiveness of cognitive behaviour therapy for children and young people with anxiety disorders.
More specifically, this dissertation will critically analyse the effectiveness of the most widely used forms of CBT: family and group based cognitive behaviour therapy, individual cognitive behaviour therapy and computerised cognitive behaviour therapy. A comparison between approaches will be made in the discussion whereby suggestions will be made upon which form of CBT is the most effective for children and adolescents with anxiety disorders.
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This paper considers the treatments that work most effectively for teaching people with dyslexia how to read confidently. I will begin by reviewing the background of dyslexia. Relying heavily on sources I surveyed, I will briefly explore the benefits of early intervention while providing hope of treatment for those the system already failed. Finally, I will examine treatments that successfully aid young dyslexics in conquering their disease and suggest implementing these in all kindergarten classes.
Introduction and Diagnosis
Dyslexia is a major problem for many children who desire to read but cannot break the reading code. Peer pressure that results from the inability to decipher words into speech can even lead third graders to contemplate suicide (Berninger, 2000, p 183). Yet, Shaywitz estimates twenty percent of all school age children have the disorder. Sadly, in the same experiment she discovered only one-third of these children were in special education programs (Shaywitz, 2004, p 30). Every child who desires to read has the right to learn; however, many children on the edge of reading disabilities never receive remedial treatment until they fail multiple times. While the older dyslexic has the ability to conquer the disease, intervention at earlier ages is more effective and saves the child from stigmatization.
Although early diagnosis is a key factor in recovery, many disagree on how to identify children with the disability (Scruggs, T., Mastropieri, M., 2002; Stanovich, K., 2005). This delays treatment, reducing the chances of remediating the child to fluent reading. Intelligence tests and multiple years of academic failure are the most widely used methods of diagnosing dyslexia, but lead to widespread over- and under- diagnosis (Scruggs, T., Mastropieri, M., 2002). Genetic research is more accurate, but it is an expensive method of identification. However, researchers have not identified all the genes responsible for dyslexia. Additionally, while genetic influence exists (Taipale, M., Kaminen, N., Nopola-Hemmi, J., Haltia, T., Hannula-Jouppi, K., Kere, J., 2003), twin studies show it is not a determining factor as to whether or not a child will develop dyslexia (Shaywitz, 2004, p 99), and children without any genetic markers develop the disease from poor instruction.
MRI imaging is one of the most accurate diagnostic tools, but it also is costly and only available to researchers. It allows one to see which areas of the brain are active during language processing. The pictures clearly show the difference between those who have broken the code, dyslexics and dyslexics that have compensated for the disease. However, the benefit of an accurate diagnosis does not outweigh the cost in time and money of performing the test.
When children are unruly in class or difficult to teach, teachers often refer them for testing. Shaywitz points out the large percentage of boys diagnosed with dyslexia while very few girls receive this identification. Her reassessment of children in several schools found the number of boys was actually equal to the number of girls (Shaywitz, 2004, p 32). This creates more of a problem by placing children in classes where they will bore easily or by leaving children in classes that do not meet their needs.
In addition to under- and over- diagnosis, one also finds the problems of late diagnosis and not seeing the need for diagnosis. Some believe students must be over the age of eight before a proper identification of dyslexia is possible. Shaywitz argues that between four and five are the ideal ages for intervention. Conflicts arise over whether the learning disabled label will brand the child for life with a negative image, or whether the child will be allowed to fall through the cracks once labeled as dyslexic.
The school told the mother of a girl I once tutored that she should not have her child tested to eliminate the possibility of the child being stuck with the label. Additionally, because dyslexics and average readers learn on the same curve, some in education still assert children outgrow the disease or that there is no reason to change the child’s current reading program. While it is true that the curve is similar and dyslexics even make a slight gain on their peers, dyslexics always score far below good readers (Shaywitz, 2004, p 34).
Before addressing the question of how to solve the problems of diagnosis and treatment, we must first explore some terms common in dyslexia. The term as defined by the International Dyslexia Association is:
Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge (August, 2002).
The phoneme is “the smallest unit of speech that distinguishes one word forms another” (Shaywitz, 2004, p 41). The phonological module is “the functional part of the brain where sounds of language are put together to form words and where words are broken down into their elemental sounds” (Shaywitz, 2004, p 40). Because the major problem with dyslexia is a breakdown in the ability to recognize phonemes contained in words, these terms are all important to any discussion of the disease.
If dyslexia is a breakdown in the ability to distinguish phonemes, it logically follows that increasing the amount and quality of phonemic instruction will aid the child in overcoming the disease. Parents and educators must realize the need for intervention and actively pursue it. Important to consider are the dyslexic’s developmental age at the time they begin supplemental instruction. Equally as important is to develop a program that focuses on the child’s strengths and interests.
To begin to aid a child in understanding the relationship between sounds and words, one must introduce the child to the sounds of language. Books filled with rhyme and alliteration such as Chicka Chicka Boom Boom or One Fish, Two Fish, Red Fish, Blue Fish are excellent choices (Shaywitz, 2004, p177 – 182). After spending time reading these books for pleasure, it is important for the teacher or parent to draw attention to which words rhyme and what rhyme is. They should have the child think of other words that begin or end in the same way. Children need to realize that words are related through sound before identifying that those sounds are represented alphabetically. All elementary teachers should spend time each day reading to their students just as parents should spend time each day reading to their children. Connecting words we speak to the phonemes that create them is essential to all readers.
Once the child can rhyme, the program must begin to help the child break words into all their sounds. Beginning with two sound words like key, bee, or it, the educator can teach the child to break the words into their respective phonemic units. Introductory work on syllables can begin. After the child realizes that words separate into smaller parts, the adult may teach three sound words like cat, seat, or call. At the same time, it will be useful to reinforce what the child already learned by asking questions like “What do you get if you put the /s/ sound in front of the word key?” or “What does /m/… /o/ …/m/ make?” All these things build phonemic awareness and are useful to all children learning to read.
Once the child has a basic understanding of phonemes, the instructor should introduce decodable texts that use relatively few phonemes to create stories. These books, such as the “Bob Book” series, slowly build confidence in the child’s reading ability. As the child begins to enjoy their ability to read, new books and sight words should be introduced. Sight words must be memorized. Children can make their own flashcards with words like is, are, was, one, and two. This allows them to read and write the word.
The child must practice writing to build legible handwriting and further establish phonemic awareness. Practice is the only way to learn. The more a child practices making letters correctly and sounding out words on paper, the better the child will become at it. All children should be given many chances even at the beginning of kindergarten to practice writing. Word cards with tracing paper clipped to them will aid in early instruction. In writing, having the child practice forming the letters correctly should be stressed. Allowing children to write four pages of a’s (for example) backward is not as useful as having the child trace one page of the letters correctly.
By the end of kindergarten, children should be practicing spelling skills. While children at this level should not be expected to spell well, invented spelling is an important step on the road to recognizing the phonemic roots of words. The more chances children are given to attempt to sound words out for themselves, the more they will master breaking words apart into their letters, and in return, the better ability they will have to decode written words.
As with all kindergarten children, teachers need to read enjoyable books and surround children with literacy. When children recognize the joy of reading, they desire to read. When teachers and parents read to children, they encourage larger vocabularies. Children who know the meaning of words like “ink” will have a better time decoding it when they come across it in texts they are reading (Shaywitz, 2004, p192).
Finally, it is important for children to develop self-confidence. Children should make progress as they go through an intensive phonics program. Tests can be performed to make sure they understand what was taught, but tests are teaching tools that evaluate teachers not students. When a student does not understand something, it should cue the teacher to reintroduce it in a new way. Additionally, children should not repeat a grade if they have failed to decode reading by the end of kindergarten (Shaywitz, 2004, p196).
Many teachers will look at the plan for educating dyslexic kindergarteners and think, “That is what I do for my class already.” This is because what Shaywitz proposes is an intensive phonics program. Others like Beringer (2000) utilize the same style of reading program to teach dyslexics. The two major differences between intervention reading and a standard kindergarten program are that many kindergarten programs try rushing phonics training and that intervention work is created around a theme of interest among the students.
Implementing this program for all kindergarten students would not lower the education they receive. However, if all schools focused on intensive phonics training for their kindergarten students, dyslexia could be conquered without extensive testing to discover which children have the disorder. When schools use tests to evaluate what they need to teach instead of how well students are learning, they can resolve many learning issues. Some may argue that children without learning disabilities will become bored with intensive learning, but often the children that learn to read too quickly develop other learning problems later on that could be corrected by skills learned from intensive phoneme training (Shaywitz, 2004, p196).
While dyslexia is a major problem that needs to be addressed, it can easily be eliminated from the classroom. Shaywitz and others have show through MRI’s that even dyslexics can conquer the disease and rewire their brains if they are instructed in intensive phonemic awareness. Because of the difficulty in recognizing the disease early and intervening, it is imperative schools adapt an aggressive stance on this learning disorder.
Berninger, V.W. (2000). Dyslexia the Invisible, Treatable Disorder: The Story of Einstein’s Ninja Turtles. Learning Disability Quarterly, 23(3), 175-195
Glenn, H.W. (1975). The Myth of the Label Learning Disabled Child. The Elementary School Journal, 75(6), 357-361
Lyon, G.R. (August 2002). International Dyslexic Association. Washington, D.C.
Scruggs, T.E., Mastropieri, M.A. (2002). On Babies and Bathwater: Addressing the Problems of Identification of Learning Disabilities. Learning Disability Quarterly, 25(3), 155-168.
Shaywitz, S. (2003). Overcoming Dyslexia. New York: Knopf. Qtd. Lyon
Stanovich, K.E. (2005). The Future of a Mistake: Will Discrepancy Measurement Continue to Make the Learning Disabilities Field a Pseudoscience? Learning Disability Quarterly, 28(2), 103-106.
H., Muller, K., Kaaranen, M., Lindsberg, P.J., Hannula-Jouppi, K., Kere, J. (2003). A Candidate Gene for Developmental Dyslexia Encodes a Nuclear Tetratricopeptide Repeat Domain Protein Dynamically Regulated in Brain. Proceedings of the National Academy of Sciences of the United States of America, 100(20), 11553-11558.
Temple, E., Deutsch, G.K., Poldrack, R.A., Miller, S.L., Taillal, P., Merzenich, M.M., Gabrieli, J.D.E. (2003). Neural Deficits in Children with Dyslexia Ameliorated by Behavior Remediation: Evidence from Functional MRI. Proceedings of the National Academy of Sciences of the United States of America, 100(5), 2860-2865
Torgesen, J.K., Wagner, R.K., Simmons, K., Laughon, P. (1990). Identifying Phonological Coding Problems in Disabled Readers: Namin, Counting, or Span Measures? Learning Disability Quarterly, 13(4), 236-243
Health Studies Dissertation Examination of Eating Habits That Affect Adult BMI
The dissertation will determine whether or not there is a close relationship between the identified dependent (i.e. the adult students’ actual BMI level) and independent variables (i.e. the habit of eating in fast food restaurants, adult students’ wealth or disposable income, and heavy marketing activities and advertisements on fast food logo/brand).
The dissertation accurately determine whether or not there a close relationship between the identified dependent (i.e. the adult students’ actual BMI level) and independent variables (i.e. habit of eating in fast food restaurants, the adult students’ disposable income or wealth, and heavy marketing activities and advertisements on fast food logo/brand), a total of 50 adult students will be invited to participate in the actual quantitative research study.
After requiring each of the 50 research participants to complete the research survey questionnaire, the researcher will gather and analyse the gathered data. As such, a regression analysis was performed in this study. Some of the quantitative data was analysed based on multiple regression, R Square (R2), t stat, P-values, and significance F values. Regression analysis result shows no direct relationship between increase in the adult students’ BMI level and factors such as the habit of eating in fast food restaurants, the adult students’ wealth or disposable income, and heavy marketing activities and advertisements on fast food logo or brand.
The main objective of this study is to examine the perception of students with regards to the relationship between the identified dependent and independent variables. In this study, independent variables include habit of eating in fast food restaurants, adult students’ wealth or disposable income, and heavy marketing activities and advertisements on fast food logo or brand whereas dependent variable is the adult students’ actual BMI. Based on the students’ perception, is there a close relationship between the identified dependent and independent variables? As such, this study will focus on testing the following research hypotheses:
H1 = There is a relationship between the students’ actual BMI and the adult students’ wealth or disposable income
H2 = There is a relationship between the students’ actual BMI and heavy marketing activities and advertisements on fast food logo or brand
H3 = There is a relationship between the students’ actual BMI and the habit of eating in fast food restaurants.
Becoming overweight and obese can lead to the development of controllable diseases. Therefore, it is necessary to continuously examine and identify all factors that can contribute the increase in the student’s weight and adult BMI level. The adult students’ increase in adult BMI level is highly dependent on so many factors. Poor eating habits, sedentary lifestyle, and poor socio-economic factors such as low income could increase a person’s risks of becoming obese.
It appears that the coupling between energy intake and energy expenditure is at the heart of the obesity epidemic, both of which are greatly influenced by psycho-social factors and the environment in which we live and work. Currently the evidence points to changes in the level of physical activity and food system, which is producing more processed, affordable, and effectively marketed high-energy food. These changes in my opinion have led to a positive energy balance causing the obesity epidemic. Policies that encourage and promote physical activities and a change towards healthier food are needed to reverse the epidemic.
1 – Introduction
Background on Obesity and BMI
Statement of the Problem
Purpose of the Proposed Investigation
Research Questions and Hypotheses
2 – Literature Review
General Information about BMI
Significance of Race and Ethnicity in the Accuracy of BMI
Impact of Fast Food on BMI
Other Factors that Can Affect Changes in a Person’s BMI
3 – Research Methodology
Primary Research Study Design
Data Collection Tools
Sample and Population of Research Participants
4 – Research Findings and Discussion
Demographic Profile of Research Respondents
Eating Health and Well-Balanced Food
Lifestyle and Physical Activities
Budget Allocation for Fast Food Restaurants
Common Reasons for Eating in Fast Food Restaurants
Adult Students’ Perception of the Given Statements
Relationship between Dependent and Independent Variables
5 – Conclusion and Recommendations
Recommendations for Future Research Study
I do hope you enjoyed reading this post on eating habits and how it affects adult BMI. There are many other titles available in the health studies dissertation collection that should be of interest to construction management students and building professionals. There are many dissertation titles that relate to other aspects of health and nursing such as project management within the NHS, midwifery, nursing techniques and treatment of mental health to name a few. It took a lot of time to write this post and I would be grateful if you could share this post via Facebook and Twitter. Feel free to add your thoughts in the comments section. Thank you.
A person may never realise of his/her gift unless he/she sees a person who lacks a certain normal ability. Autism is an in-born condition that can occur to any child. Autism refers a group of complex disorders associated with brain development (Heather, 2010). The main characterizations of these disorders are difficulties in social interaction, communication (both verbal and nonverbal) and repetitive behaviours. Autism has many sub-types that are closely associated with Autism Spectrum Disorder (Jeri, 2009). Autism Spectrum Disorder is associated with intellectual disabilities and motor coordination difficulties. Autism Spectrum Disorder has also been associated with some cases of gastrointestinal and sleep disturbances. This paper is dedicated to exploring all aspects of this disorder.
A few years ago it was not well known about the causes of this condition. This prompted the need for research, and consequently a logical explanation can be given at the causes of this condition. Generally, there is no cause of autism. Genetic studies have revealed that in autistic people, there are rare genes changes, simply mutant genes. The number of these genes in an individual determines the extent of autism in that person. It is the combination of these genes and environmental factors that are responsible for causing most cases of this disorder. It is usually during early brain development that environmental factors are able to impact largely on the condition and this makes autistic people resistant to change.
In addition to environmental factors, non-genetic stresses also appear to contribute to the risk of a child’s autism. Factors such as the parents’ advanced age, birth difficulties particularly those that deprive oxygen to the brain and mother’s illness during pregnancy may contribute to some degree. These factors do not pose the threat of autism. It is the presence of the mutant genes in the presence of these factors that are responsible for higher risks of autism (Heather, 2010). A recent research showed that birth of autistic children can be reduced by administering prenatal vitamins that contain folic acid or the woman should eat at least 600mcg of folic acid in diet during the preconception and post conception period (Jeri, 2009).
Autism varies among different individuals and each case is unique. Majority of those on the autism spectrum have shown remarkable abilities in academic skills, visual skills and music. About 40 percent of autistics have less than 70 score in IQ, and as such they can be termed as intellectually disabled (Simon and Patrick, 1993). Many people on the spectrum are proud of the extraordinary abilities and normal perspective of viewing world issues. Others experience high levels of autism and they are unable to leave on their own. About a quarter of all autistics are unable to speak, but they can learn by subjecting to the necessary medications and therapies (Simon and Patrick, 1993).
Autism is one of the largest disabilities to affect children, and it is estimated that five in every ten thousand births are autistic. Autistics vary in different ways and degrees. The condition is noticeable by age 3 even though from birth a child may indicate signs of autism. An autistic child may show discomfort when being held, resists affection and arches back more than a normal child. Most of The autistic children are easy to parent until they start showing difficulties in social skills and communication that the parents realize the variation (Simon and Patrick, 1993).
In diagnosing the condition, the DSM-IV (the Diagnostic and Statistical Manual of Mental Disorder-4th Edition) is used (Simon and Patrick, 1993). This is a text that is psychologically tailored to identify the varying degrees of autism. I mainly focus on pervasive developmental disorders also has autism. In the autism diagnosis, six symptoms from three key areas: social skills, communication and repetitive behaviours must be noticeable before age 3 (Heather, 2010). There must be at least 2 symptoms associated with social skills and at least one in communication and repetitive behaviour.
Characteristics of people with autism may include resistance to touching, pain insensitivity, cold and heat insensitivity, self-induced behaviours, unexplained reactions such as weeping or laughing for no reason and emotional unawareness. Autistic people may do what a normal person fears such as diving in a cold pool of water. Self-induced behaviours are defined as repetitive movements of an object. These behaviours can be divided into five senses. A person with autism finds it hard to understand other people’s feelings. Their ability to empathize with others is feeble than that of normal people. Autistics conversation is not engaging. Of course, a person may talk about an idea or thought, but there is less exchanging than if the conversation was held between two normal people (Simon and Patrick, 1993).
Visual self-stimulatory is the first sense, and individuals tend to stare at lights and flapping hands. Flapping of hands, in most cases results in self-injuries behaviour or injurious behaviour towards other people. It should be noted that behaviours vary and that hand flapping does not necessarily precede violence. Auditory behaviours vary from tapping of the ears to making of senseless noises (Allison). The most common of this is the vocal noises made by autistics during times of extreme excitement of fear. Tactile stimulation is also common in autistics, and it is common to find autistics scratching, rubbing objects with hands and even rubbing skin (Allison). Most of these behaviours are performed for pleasure or to overcome cases of anxiety or excitement. It may be difficult to differentiate between self-stimulatory and self-injurious behaviours since the two may overlap. Self-injurious behaviours include head-banging, scratching to the point of bleeding and hand-biting. Since some of the autistic people may be insensitive to the pain, they may injure themselves in the process of trying to calm themselves from anxiety or excitement. Autism characteristics are universal but differ among individuals. However, the diagnosis guidelines are different across the globe depending on the country.
There are treatments that have shown success in dealing with the disorder. Since the condition varies among individuals, medicines prescribed for one individual may fail to work for a different person. Therapies such as Anti-yeast therapy, food supplements and Dimethyglycine aid in healing of the disorder. These are administered to help modify the behaviour of an autistic. There is also a Japanese program that focuses on the individuals around an autistic person and the roles that they should play to moderate his or her behaviour. Other therapies include Facilitated Communication and Mega-Vitamin Theory (Jeri, 2009).
Dr. Bernard Rimland conducted a research on the effect of vitamins in dealing with the condition, and he concluded that vitamin B6 was effective in dealing with over forty percent of the cases. This is after parents to autistic children noted that some foods made a difference in their children. The vitamin generally improves behaviours in speech, decreases self-stimulatory behaviours, sleeping patterns and attention span. This treatment takes two to three months for any observable changes. It has been noted that after application of the vitamin, children who previously could not pay attention during an address by either teachers or parents they are able to listen keenly and even follow instructions (Jeri, 2009).
Facilitated communication involves giving help to an autistic individual to express him/herself via some object such as typewriter or board once given physical support to an arm or a finger. Even though there is a facilitator, it is the autistic individual who types since he or she is intelligent. Autistic individuals may express anger through this means since they may be aware of all that is happening to them, but they cannot express their feelings and thoughts. This method is tailored to enables autistic individuals to emotionally and cognitively bring out them.
Since this condition has no sound cause, varying characteristics and varying medications, it is still a mystery to many people.
Myths about Autism
Autism can be cured. All the above named therapies help autistics develop social, and communication skills, but they cannot treat the core symptoms of the disorder. All they do is reducing problematic behaviours such injurious behaviours.
Autism is caused by vaccines. There is no scientific link between vaccines and autism. This perception came about after a scientific paper wrongly linked vaccines and autism, but there is no evidence of this claim. Childhood immunizations are meant to help reduce the risks of conducting childhood diseases such as Polio.
Unfriendly parents may cause autism. It is true that non-genetic factors and environmental factors may contribute to the degree of autism, but these on their own cannot cause the condition. The condition is as genetic mutation.
Occurrence of an Autism Epidemic
The current high numbers of autistics may be attributed to the increased public awareness or even redefinition of the term autism. As such, one cannot claim that there is an epidemic related to this disorder.
Autism leads to improved math ability and memorization. Stories about autistic individuals being highly gifted in memory are untrue and baseless. Autistics do not show extraordinary math ability however children with Autism Spectrum Disorder may exhibit intense interests in a particular subject and as a result has a lot of information regarding that subject.
Autistics have no emotions. This is quite untrue as the condition is characterized by the inability to express thoughts and feelings, and so it should not be assumed that they don’t have emotions (Myths about Autism, 2013).
Autism is a developmental and lifelong disability. The characteristics of the disorder vary among different individuals. There is no single identified cause for autism, and this makes this disorder a mystery. The theoretical causes that include genetic mutation prove that this disorder may truly be a disability. With available treatments, it has been shown those that suffer from this condition may be modified but not cured. High doses of vitamin B6 and other therapies such as Facilitated Communication may allow autistic individuals a chance to express themselves without frustration due to the inability to communicate. Autistic individuals as well as parents to autistic children need to be supported and accorded help as they really need it. This is due to the fact that for every individual born normal, it is by chance, and there is no guarantee for normal birth.
Baron-Cohen, Simon, and Patrick Bolton (1993) Autism: The Facts. Oxford: Oxford University Press.
Freedman, Jeri. Autism Spectrum Disorder (2009) New York, NY: Rosen Pub.
Heather B. Autism. (2010) New York, NY: Chelsea House.
Child Mind Institute (2013) “Myths about Autism Spectrum Disorder” Oxford.
The capital budget will be defined. The non-labor operating budget will be explored. The labor budget for a thirty bed telemetry unit with a nurse to patient ratio of 1.6: 1 will be examined. Line items on a capital budget, non-labor operating budget and labor budget will be examined. The elements which compose a staffing mix will be examined. The ramifications of operating with a marginal staff will be examined.
Research has demonstrated that increased levels of patient staffing are directly related to improved teamwork in health care facilities. Increased levels of staffing are a causal attribution of the quality of care and lower staff turnover. Lower vacancy rates and staff turnover have been linked to increased levels of patient staffing. Nursing teamwork is directly related to the physical characteristics of the health care facility such as number of beds, case mix index and nurse staffing. The type and level of nurse staffing is related to patient outcomes .The relationships which will be demonstrated in this research paper are the relationship to nurse staffing, nurse teamwork, staff confidence, team orientation, back up, a collective mental model and effective team orientation (Kalisch et al., 2011).
In budgets, the labor costs for a thirty bed telemetry unit, 1.15 FTEs are allocated per nurse staffing personnel. A thirty bed telemetry unit and a 1.6:1 nurse to patient ratio would require thirty RNs, eighteen nursing assistants, one director of nursing and unit secretary. The salary staffing mix is 70% RN, 25% nursing assistants. The shifts would be 60% with rotating shifts (Kalisch et al., 2011).
The approximate salary for a director of nursing is $140,000 per year. The director of nursing is required to have five years of experience in nursing administration, a BSN and critical nursing experience (ihirenursing.com, 2013). The total salary for a registered nurse is between $40, 157 and $79, 759 per year. The duties of RN care are the following: teacher, healer, administrator and counselor. A nimble mind is required in addition to an associate’s degree, a diploma or a bachelor’s degree. Registered nurses with BSN degrees are offered the opportunity to move into management and augment their salary (payscale.com). The annual salary of a nursing assistant is $18,995- $31, 719. The nursing assistant composes approximately 25% of the labor budget for a thirty bed telemetry unit (payscale.com). Unit secretaries and directors of nursing compose approximately 5% of the staffing mix. The unit secretary salary is between $20, 164- $36,362.
Calculating the Labor Budget
In calculating the nursing budget, we must analyze the average daily census (ADC). The ADC is calculated by totaling the number of patients in a year and dividing by the number of days in a year. The ADC is multiplied by the Average Nursing hours per patient day (NHPPD). This gives us the average NHPPD per year. The average total nursing staff direct care FTEs divided per 2080 hours gives the number of nursing staff direct care FTEs. 2080 divided by the number of productive hours of each FTE gives the percentage of productive hours per FTE. 2080 divided by the number of productive hours gives the actual number of FTEs. Two week vacation which total eighty hours, ten sick days which total eighty hours, eight holidays which total forty eight hours and two education days must be included. The total staffing budget for a thirty bed telemetry unit, including director of nursing, unit secretary is $2,446,000 (see attached spreadsheet line 8). An example of a line item in the thirty bed telemetry unit nursing budget is benefits for the nursing staff is $611, 500. This is another example of a labor budget line item (hrsonline.org).
Nurse staffing is very important because of the influence that it has upon patient safety and patient perceptions of quality care. Urinary tract infections, shock, upper gastro intestinal hemorrhage and pneumonia are very sensitive to nursing care. The majority of the negative patient outcomes have been documented due to the premise that a negative patient outcome is more likely to be recorded. Lower nurse to patient ratios have been linked to higher incidences of non-fatal adverse patient outcomes. This research has not d3emonstrated that lower nurse staffing levels are associated with increased mortality. Higher nurse staffing is related to a 2% decrease in adverse patient outcomes. Research has demonstrated that a 21% increase in hospital patient acuity between 1991 and 1996. A decline of 14.2% in the ratio of licensed nursing staff to acuity related patient day of care has been realized within the five years from 1991 to 1996. Research has also demonstrated that;
40 % of nursing professionals are unhappy with their working conditions.
35.7 % of nursing professionals classified the quality of care in their health care facility as outstanding.
44.8% of nursing professionals have noticed a decrease in the quality of care at their health care facility.
83 % of nursing professionals reported an increase in the average daily census (ADC).
34.4% of nursing professionals perceive that there is enough RN to supply high quality care.
33.4% believed that their health care facility has enough staff to accomplish the assigned tasks (Stanton, 2012)
A Markov cohort simulation is applied in determining the cost effectiveness of suggested staffing versus median staffing in patients requiring acuity based treatments. The cost effectiveness of suggested staffing versus median staffing is $321,000 per discounted quality of life year gained. This aspect is especially important in patients who require acuity based treatments from the health care facility (Ganz et al., 2005).
Various budgets are applied by health care organizations. These budgets are implemented in order to coordinate the situation of a program or initiative. The operating budget is implemented in order to coordinate to the daily transactions over an accounting period (Danna, 2011). An example of a line item in an operating budget is revenue. A salary operating budget would contain benefits as a line item. Capital budgeting is the method by which the finance team decides whether or not to invest capital resources in particular projects or assets. An example of a capital budget line item is clinical furnishings (hrs.online.org)
The elements of a capital budget decide which capital equipment will be purchased and which facilities will be renovated, constructed, or rented. These components enable the finance management team to ascertain the depreciation costs which will need to be included in the following accounting period. Depreciation costs compose part of the operating budget. Capital budgeting decisions will be realized before the operating budget finalization. Items which are included in the capital budget are major pieces of clinical and office furnishing. These items include but are not limited to office equipment, X-ray machines, magnetic resonance imaging (MRI), computerized topographical devices (CT scanners) and positron emission tomography scanners (PET scanners). The facility and fixed improvements (i.e., plumbing and wiring) are also elements of the capital budget (gehealthcare.com).
The operating budget includes the expenses related to equipment (i.e., capital equipment maintenance and financing). Labor and staffing expenditures are also part of the operating budget; In addition, education supplies, medications and printing supplies are elements of the operating budget.
In the strategic planning process, the quantity of capital equipment will be decided. Details which must be considered are the depreciation expense which remains on existing equipment and the objective of the health care facility in its development. The primary purpose of the capital budget is to classify the capital items to be procured in the following accounting period. These items require a capital proposal which must be received six to twelve months prior to acquisition. The department administrator will usually compose the initial draft of the request. This draft will be refined and submitted to the finance managers for viability. The elements of the capital budget are the following;
Specifications of the item which requires capital funding.
Conditions which require the acquisition and implementation of the capital item.
The financial influence of the acquisition on the target market, unit, patients and nursing personnel.
Initial price estimates.
Decision making standards which approach the strategic mission and objective of the health care organization (gehealthcare.com)
The annual capital and operating budget required by a thirty bed telemetry unit with a nurse to patient ratio of 1.6: 1 can be classified into the capital budget which considers equipment, building and other initiating expenses and the operational budget which will provide for continuing expenses. These continuing expenses may include medical supplies, salary and benefit expense. The establishment of a twenty four hour, seven day a week should include the following line items as capital expenditures. This is an example of a justification of a line item in the nursing capital budget: The cost of thirty beds is $212,000. In order to justify the expense of the beds, the following must be considered;
Increase in nursing efficiency.
Decrease the application of specialty beds.
Decrease the number of accidents.
The beds which are to be incorporated in the thirty bed telemetry unit must have the following:
Exit notification system.
Inflatable and deflate mattresses.
Ability to be adjusted to a ninety degree sitting position.
Ability to be raised and lowered from the floor.
Ability to automatically disengage the headboard in order to facilitate the administration of CPR.
In a thirty bed telemetry unit, the savings of acquiring thirty beds is $12,645.00. The benefits of this acquisition result in the elimination of two specialty beds which cost $23,400.00. The acquisition of the thirty beds will also result in the reduction of injury to staff and patients (Hardy, 2004).
The expense of new hospital construction programs vary from $900,000.00 to $1,300,000.00 per bed. This strategy must be well considered in order not to bring the health care organization to bankruptcy. If these changes are well implemented, the project is designed to improve the facility’s ability to attract patients, increase long term operational performance and to realize a return on the capital expense (Rich & Hosking, 2013).
Research has demonstrated that increased levels of patient staffing are related to improved teamwork in health care facilities. Increased levels of patient staffing are also related to the quality of care and staff turnover. Lower staff turnover and a lower vacancy rate have been linked to increased levels of patient staffing. Nursing physical teamwork is related to the characteristics of the health care facility. These physical characteristics are: the number of beds, case mix index and nurse staffing. The level and type of patient staffing is directly related to the following;
Diminishing the patient fall rates.
Better nursing staff performance (Kalisch et al., 2011)
Units In Study
Age > 35 Years
Gender Female %
BSN> Educational Level
Experience > 2 Years
Full Time (%)
Rotating Shift (%)
The HPPD rates for which the units participated in the survey varied from 6.27 to 21.30. The average was 11.02. The average RN rate was 8.91 with values varying from 3.75 to 20.89. The average skill mix is 0.79 with values varying from 0.53 to 1.00. The average case mix index (CMI) was 2.28 with values varying from 0.83 to 6.93. A positive relationship between the number of hospital beds and the nursing teamwork ratings was established. The higher the level of HPPD, RN HPPD and skill mix, the higher the level of nursing teamwork (Kalisch et al., 2011)
The concept of assisted living is defined as a philosophy which is different from other types of residential care. This system supports autonomy, privacy and respect. Many health care facilities divide their beds into wars or designated areas. The Nursing Home Reform Act is also known as the Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987). This legislative act requires that a health care facility supply a level of care which facilitates the patient “to attain and maintain the highest practicable physical, mental and social wellbeing”. As defined by these legislative acts, the number of square feet required per bed is sixty square feet.
The number of direct care FTEs multiplied by the actual FTEs;
Ascertain the ratio of nursing staff classification to the nursing staff mix. Multiply the percentage of each nursing staff classification.
Ascertain the cost of the nursing staff by entering the salary and benefits for each nursing classification.
Ascertain the ratio of the staff that would be appropriate by shift. Divide this ratio of the staff required by each shift to ascertain the FTEs in each nursing classification.
Ascertain the percentage of full time staff compared to the part time staff. Divide this ratio by the number of FTEs by the full time or part time percentage.
The elements of a capital budget determine which capital equipment will be purchased, which facilities will be renovated, rented or constructed. These components will enable the finance management team to ascertain which capital budget decisions will be made before the operating budget finalization. Items which are included in the capital budget as line items are major clinical furnishings, including office equipment. The facility and fixed improvements are elements of the capital budget (gehealthcare.com). The non-labor operating budget includes the expenses related to equipment, labor and staffing expenditure. Educational supplies, medications, medical supplies and printing supplies compose the operating budget (see lines 10 – 19 on spreadsheet). The annual operating budget includes RNs (70%), technicians (25%) and support staff (5%). In calculating the budget 1.15 FTEs is allocated to each registered nurse (hrsonline.org). Research has demonstrated that increased staffing levels are related to improved teamwork in health care facilities. Increased staffing levels are directly related to the quality of patient care and lower staff turnover. Nursing teamwork is related to the physical characteristics of the health care facility. These characteristics include the number of beds, case mix index and nurse staffing (Kalisch et al., 2011). A Markov- cohort simulation is applied in determining the cost effectiveness of suggested staffing versus median staffing in patients requiring acuity based care. The cost effectiveness of suggested staffing versus median staffing is $321,000.00 per discounted quality of life years gained. This aspect is especially important in patients who require acuity based treatments from the health care facility (Ganz et al., 2005).
Assisted Living Facilities. Encyclopedia of Everyday Law (2013)
Danna, D. (2011) Learning and Mastering the Operating Budget Strategies for Nurse Managers.com.
Dunham- Taylor, J. (2009) Financial Management for Nurse Managers. Merging the Heart with the Dollar. Jones and Bartlett Publishers
Ganz, D. (2005) Cost effectiveness of recommended nurse staffing levels for short stay skilled nursing facility patients BMC Health Serv Res 5:35
GE Health Care Financial Service (n.d.) Capital Analysis Self Tutorial Module 1. How Decisions are Made
Hardy, P. (2004) The impact of nursing care and other health care attributes on hospitalized patient Satisfaction and behavioral intentions Journal of Health Care Management May, 2004
Heart Rhythm Society (2012) Education Women’s Leadership
I Hire Nursing (2013) Director of Nursing Oakland, CA
Kalisch, B. (2011) Nurse Staffing Levels and Teamwork: A cross Sectional Study of Patient Care Units in Acute Care Hospitals Journal of Nursing Scholarship, Vol. 43(1)
Rich, D & Hosking A (2013) First the strategy, then the bricks, 3rd Edition
Stanton, M. (2012) Hospital Nurse Staffing and Quality of Care Research in Action 14 March 2012