Diversity Adaptation Inclusion Nursing Education

Diversity, Adaptation, and Inclusion in Nursing Education

This annotated bibliography will present analysis and review of some sources relating to adaptation, diversity, and inclusion in nursing education. Globalization has resulted in nursing schools experiencing diverse students’ population with learners who are culturally and linguistically diverse. The annotated bibliography will present measures that would enhance the adaptation of learners from culturally and linguistically diverse setting, challenges faced by these students and measures to improve the learning experience and performance. Also, the annotation will address diversity issues, policy implications and intervention measures for promoting workforce diversity through a diverse learning environment for nursing learners.

Gerrish, K. (2004). Integration of overseas Registered Nurses: Evaluation of an Adaptation Programme. Journal of Advanced Nursing, 45(6), 579–587.

Gerrish (2004) conducted a study to investigate adaptation program for nurses working oversea. These nurses normally experience challenges before adapting to new environment featured by different cultural setting and operational standards for nurses. With the current globalization trends, there has been increasing oversee nurse recruitment to address the significant staff shortage in United Kingdom healthcare sector that has resulted in theemergence of adaptation programs for nurses from other countries seeking experience and allow them to be acknowledged by the Nursing and Midwifery Council. Gerrish (2004) article collects data from different previous studies on independent evaluation of the adaptation programs for the overseas Registered Nurses who are offered by large acute healthcare facilities. Basing on the review, the study reported evaluation programs by focusing on objectives, overall success rate and outcomes from the stakeholders’ perspective.

Gerrish (2004) integrated a pluralist evaluation research model developed to facilitate the identification of the criteria that interested parties used in the judgment of success rate of adaptation programs. After identification of the success of the program, it is used in judging the program in question. Due to the nature of the study, a qualitative research method is applied to address the challenges faced in implementation of the program and measures to address the success of the program. A focus group approach is preferred in data collection where in-depth interviews were set to collect the data for analysis. Gerrish (2004) targeted oversea nurses, senior nurse managers, educators and ward managers. The study took a period of 12 months to complete data collection where the analysis was done through the development of principles for dimensional analysis. Criteria of success approach were crucial in identifying the views from the stakeholders that guided in the development of overall success of the adaptation program. After the analysis of data, results of the study were developed which helped in creating a holistic view of the adaptation programs in the United Kingdom.

The results indicated that five success meanings were developed comprising of gaining professional registration, reducing the nurse vacancy factor, fitness for practice, promoting the organizational culture that is based on diversity value and equality of opportunity. Gerrish (2004) also found that organizational context, features of their work environment and level of support influences the ease of gaining United Kingdom registration and their integration into the nursing workforce. From the article, Gerrish concluded that developed countries should take into account support for nurses sourced from the global market to facilitate their adaptation to environment featured by different social and cultural settings. This article is crucial in research involving nurses’ sourced from oversea by presenting challenges, opportunities and threats faced by the oversea nurses. The study provides crucial information relating to factors that are essential in enhancing the adaptation of these nurses through the provision of the necessary support. The article is also relevant in presenting different considerations that should be taken into accounting supporting adaptability of these nurses to the new environment.

Jeong, S. Y.-S., Hickey, N., Levett-Jones, T., Pitt, V., Hoffman, K., Norton, C. A., & Ohr, S. O. (2011). Understanding and enhancing the learning experiences of culturally and linguistically diverse nursing students in an Australian bachelor of nursing program. Nurse Education Today, 31, 238–244.

Jeong et al. (2011) conducted a study investigating measures of enhancing learning and performance of nursing students in a culturally and linguistically diverse environment.Nurses and nursing students are faced with the different cultural setting, which influences their adaptation and performance. The article review experience of nursing students in Australia who are from different cultural backgrounds. The challenges do affect not only the nursing learners but also the academic and clinical staff. A pilot study is conducted to review the perceptions from learners’ approach and another school academic and clinical staff perspective. This is crucial in identifying the challenges faced by clinical staff, academic staffs, and learners.

To attain the study objectives, Jeong et al. (2011) applied qualitative research methodology in collection and analysis of data. The article had its target as learners from culturally and linguistically diverse (CALD) backgrounds. The participants in the study comprised of learners classified as CALD who were attending their education in Australian universities. Academic staff who taught CALD learners were also integrated into the research. The study had a total of 18 participants comprising of 11 CALD students, four academic staff members, and three clinical facilitators. Qualitative research is appropriate when investigating aspects that require understanding the feelings and perception of the participants through a face to face interview where in-depth data is collected.

Jeong et al. (2011) developed interesting findings relating to measures that can address challenges faced by nursing students, clinical staff and educators with experience in learning or teaching in culturally and linguistically diverse environment. Focus groups were integrated into data collection process to enhance the quality of data collected. After the research Jeong et al. (2011) found that there were four themes crucial in addressing challenges under investigation. These themes comprise of English language competence level, isolation feelings and perception, limited opportunities in the learning process and inadequate of the university support. The effects of these challenges comprised of financial, social and intercultural contexts and political setting that learners experience. The article is significant when addressing the challenges faced by students from culturally and linguistically diverse backgrounds.

Additionally, the article utilizes an adequate number of participants which helps in identification of appropriate research data for analysis. The research is crucial to educators, clinical staff and policy makers relating to insights that facilitate the development of effective learners’ adaptation initiatives to promote an efficient environment for all culturally and linguistically diverse learners. The sample size for this article was efficient considering that qualitative studies require in-depth analysis, which is possible with a small sample of participants. The choice of research method in the article presents an opportunity for addressing challenges that students may suffer in silence, which would lower the productivity and performance of nursing students during practice. The article forms a foundation for further studies on the perspective of adaptation initiatives for learners in a cultural and linguistically diverse environment to aid both learners and academic staff.

Boughton, M. A., Halliday, L. E., & Brown, L. (2010). A tailored program of support for culturally and linguistically diverse (CALD) nursing students in a graduate entry Masters of Nursing course: A qualitative evaluation of outcomes. Nurse Education in Practice, 10, 355-360.

Boughton, Halliday, and Brown (2010)conducted a study investigating the significance of support programs for learners from culturally and linguistically diverse setting. The article defines the common support programs initiated to address the challenges faced by learners and teaching staff. Nursing learners enrolled for a program in culturally and linguistically different environment experience challenges that affect their learning outcomes and performance. The target population in the article were nursing students who were enrolled in 2-years accelerated Master of Nursing program from the faculty of nursing, University of Sydney. Also, the article aimed at examining the pedagogical aspects that affect the delivery of educators and nursing clinicians. The research identified gaps in the literature relating to the integration of CALD training in the learning process to improve the learning outcomes of learners from culturally and linguistically diverse environment.

Boughton, Halliday and Brown (2010) identified that learners from culturally and linguistically diverse settings are sometimes entitled to a program to facilitate their adaptation to the new environment. For the purpose of the article, the authors integrated their research into a program involving CALD interventions that took place during semester 1 in 2008 run by three academic staff members from series of workshops aimed at addressing challenges faced by learners from CALD setting. The article drew findings from both primary and secondary sources taking account evidence in existing literature. Selection of the research participants was on a voluntary basis where a total of 34 participants from different countries who were willing to join the program. A qualitative research method in collection and analysis of data allow the researcher to collect non-verbal feelings of the participants that help in the acquisition of crucial data regarding the participants. The qualitative method requires in-depth analysis that helps in establishing reality concerning the research aim and objectives. Positive results were collected relating to the impact that CALD program had on students’ adaptation to the Australian culture and language. To evaluate the impact, the researchers grouped the participants depending on the benefits that they got from the CALD program regarding enhancing their academic potential, students learning experience and clinical placement initial experience.

Diversity in Nursing Education
Diversity in Nursing Education

In the discussion, Boughton, Halliday and Brown (2010) integrated results from the primary data and critical analysis of existing studies. The in-depth literature review from the article helps in the acquisition of data that from secondary sources, which is crucial in the analysis. Integrating literature review to empirical evidence facilitates in identifying deviation of the primary results by using the previous studies as a datum. Additionally, qualitative studies involve in-depth analysis of data. This method was appropriate for this study to determine the significant impact that perception and feelings have on the research. Furthermore, the choice of the interview as data collection tool facilitates in seeking clarifications from the participants in case of an ambiguous answer and questions during the research process.

Bleich, M. R., Macwilliams, B. R., & Schmidt, B. J. (2015). Advancing Diversity Through Inclusive Excellence In Nursing Education.Journal of Professional Nursing, 31(2), 89–94.

Bleich, Macwilliams and Schmidt (2015)conducted a study investigating the measures of promoting diversity through enhancement of nursing education. With increased global movement of professionals in search of employment and nursing education, there is need to develop a diverse workforce that can serve employees from different cultural settings. However, only a few studies integrate the inclusion during recruitment and retention strategies for the improvement of academic learning outcome. The article addressed the organizational initiatives that promote diversity and inclusion in nursing education as supported by Association of American Colleges and Universities. The article addresses the inclusive excellence that builds an effective learning environment for diverse learners’ needs. There are six strategies for diversity and inclusion that are investigated basing on the authors’experiences, behavioral and structural concerns such as admission processes, community absence, invisibility, tokenism, promotion and tenure, and exclusion. The article was aiming at identifying behavioral and structural adaptations that are within the nursing education setting for the advancement of inclusion and diversity. Identifying different factors that inhibit or enhance an organization with diverse learners is significant in the current study.

The study integrates secondary data retrieved from previous studies in drawing the discussion and conclusions. In-depth analysis of the factors that influence diversity in the nursing education are analyzed. The study integrates step by step procedure of development an inclusive setting for nursing education. The study is crucial in presenting the step-to-step procedure of development of the effective framework for implementation of diversity in nursing education. Bleich, Macwilliams and Schmidt (2015) presented strategies for promoting diversity and inclusivity comprising of improving the admission process, reduction of the inevitability of the underrepresented cohorts, the establishment of support community, enhancing equity in the promotion and the tenure structures, and discouraging tokenism. These initiatives are drawn from different past studies that took into account the crucial elements of diversity.

Even though recent studies play a critical role in the research process, it should be accompanied by empirical results that improve the quality of data presented. Reliance on previous studies maybe misleading since the earlier studies could measure different elements that are not significant in the current study. Despite these challenges in the article, it present information that is crucial in the development of a foundation for more in-depth studies that incorporate primary sources of data. In studies relating to measures of enhancing diversity and principles in nursing education, the article by Bleich, Macwilliams and Schmidt (2015) is crucial in determining gaps in the previous studies that future research should address. In addition, the article could be effective in the presentation of effects of failing to integrate diversity principles in nursing education where diverse cultures are present. Strong self-awareness and self-esteem are crucial for learners within a diverse society to be incorporated into an efficient learning environment and demonstrate effective learning and productive environment.

American Association of Colleges of Nursing. (2015). The Changing Landscape: Nursing Student Diversity on the Rise. Washington, DC: American Association of Colleges of Nursing.

American Association of Colleges of Nursing(AACN) (2015) present review of policy on diversity in American nursing colleges. The report compiles evidence based on recent studies and available policies on the significance of cultural diversity understanding in the nursing workforce in the development of culturally sensitive patient care observing crucial patients’ safety and service quality. The data and analysis are dependent on the U.S. Census Bureau that classified differential cultural settings in the United States where groups that are racially underrepresented forms more than a third of the entire population. The report expresses the commitment of American Association of Colleges of Nursing in promoting diversity and inclusion in all nursing colleges.

The report presents a valuable source of data from primary sources like government websites relating to diversity in nursing education. To ensure the validity of data submitted, the AACN present results of previous reports from reliable sources that cite issues relating to diversity in American nursing colleges.

To address the initiatives by the government, AACN present two reports compiled by NAS in 2004 addressing measures to improve the diversity in the healthcare sector. Also, AACN also reviewed a report by NAS in 2010 on advancing nursing through enhancement of its leadership role through the development of the competent and diverse workforce. The research also presents the trends in changes in the level of diversity across learners undertaking Baccalaureate, Masters,Ph.D. and DNP programs in nursing for the period between 2011 and 2015. Also, the report presents diversity trends across all the states in the US. This helps the future studies in identifying the diversity trends across the American States diversity commitment in promoting the needs of all learners.

Apart from variations in diversity from 2011-2015 and regional diversity levels, ACCN report took into account variations in diversity across programs, which is crucial in informing researchers and policy makers on the degree of diversity in nursing education in the United States depending on the extent of learning. Furthermore, the report presents the diversity on gender-based variations. The report also illustrates the measures that the Federal and local governments would integrate into nursing schools to promote diversity in learning institutions for nurses. From 2006 to 2015, the research cites that there has been a drop in grant funding programs.  Understanding these challenges and opportunities relating to diversity in nursing education will enhance in effective decision-making regarding policy interventions appropriate to address the diversity issues in nursing education. This report is essential in developing valid arguments relating to interventions for diversity in American nursing education. The report presents a valuable source of information on trends based on annual grants allocation, gender, and level of study, which will guide the development of policy measures to encourage diversity in nursing education.

In conclusion, the five studies identify the nursing discipline as a complex profession that entails the harmonization of work culture, private life, societal obligations, and work schedule. Collectively, the authors concur that professional nurses and nursing students specialize in a demanding profession. The health care industry demands that the practitioners commit themselves to the responsibilities by preparing to work for extended hours under congested schedules. Therefore, the work environment prompts the governing institutions to consider improving expertise and the support infrastructure in order to enhance the efficacy of the healthcare service providers. In spite of the incongruousness in specific and general objectives, the studies converge into a common point of focus involving manipulating the parameters of interest to improve the performance of nurses. Jointly, the authors view the quality of nursing as a function of dedicated endeavors to establish support institutions, education programs, and cultural learning.

Nurses are mobile in nature as the occupation dictates. The interventions would enable the medical professionals to adapt new environments and avoid culture shock. New work environments expose the nurses to challenges in learning the ways of life of the inhabitants. The situation grows severe in workstations where the health care seekers subscribe to a foreign language. At this point, intervention programs and special education programs tailored to specific settings are vital to improving the performance of the personnel within the restrictive workplace. Additionally, the studies venture into using qualitative approaches to explore the parameters of interest. The commonality portrays a similarity in the five research works highlighting that most elements in nursing are non-quantitative.

As long as the authors agree on the complexity of the discipline, discrepancies emerge pertaining to the most suitable intervention strategies. The influence of the studies on the nursing practice significantly relies on an integrated method of implementing the findings. In other words, the observations made from each of the studies are solely dependent on the contributions of the rest. Furthermore, the authors base the studies on different scopes and parameters. Focusing on culture, education, and support programs exposes the incongruousness underlying the pursuit of knowledge. Through the principal areas of focus, the general objectives of the research works differ considerably from one study to another. The specialization undermines the view of mutual relationships in the rudiments of nursing.

The five articles are exclusively vital in enabling efficient nursing services. The diverse objectives pursued by the researchers present nursing practice as a multi-disciplinary subject comprising of equally important parameters. In a real sense, nursing profession describes a collection of medical subjects that equip the facilitators with immense knowledge essential for dealing with a myriad of scenarios in the healthcare industry. More important are the elements that the articles discuss as significant in enhancing nursing. Education denotes one of the traditional methods of knowledge acquisition. Training remains a viable approach to improve professionalism. Nursing professionals require excellent training to improve the quality of the service.

The education programs enhance the adaptation mechanisms of the medical personnel to various environments. As nurses move from one workstation to another, the environmental setting changes drastically prompting swift adjustment. Cultural learning denotes one of the most vital considerations since nurses interact with culturally diverse populations. The support institutions formulate and implement policies and programs aimed at enhancing the workplace for nursing professionals. Therefore, the articles discuss valuable factors essential for facilitating exemplary therapeutic services.


American Association of Colleges of Nursing. (2015). The Changing Landscape: Nursing Student Diversity on the Rise. Washington, DC: American Association of Colleges of Nursing.

Bleich, M. R., Macwilliams, B. R., & Schmidt, B. J. (2015). Advancing Diversity Through Inclusive Excellence In Nursing Education. Journal of Professional Nursing, 31(2), 89–94.

Boughton, M. A., Halliday, L. E., & Brown, L. (2010). A tailored program of support for culturally and li nguistically diverse (CALD) nursing students in a graduate entry Masters of Nursing course: A qualitative evaluation of outcomes. Nurse Education in Practice, 10, 355-360.

Gerrish, K. (2004). Integration of overseas Registered Nurses: evaluation of an adaptation programme. Journal of Advanced Nursing, 45(6), 579–587.

Jeong, S. Y.-S., Hickey, N., Levett-Jones, T., Pitt, V., Hoffman, K., Norton, C. A., & Ohr, S. O. (2011). Understanding and enhancing the learning experiences of culturally and linguistically diverse nursing students in an Australian bachelor of nursing program. Nurse Education Today, 31, 238–244.

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Nursing Dissertation Topics

Nursing Operating Budgets

Nursing Dissertation Topics

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Nursing Operating Budgets

Essay Nursing Operating Budgets


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.

Labor Budget

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.

Nursing Operating Budgets
Nursing Operating Budgets

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.
  • Scale.
  • 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;

  • Patient results.
  • Patient safety.
  • Diminishing the patient fall rates.
  • Clinical mistakes
  • Better nursing staff performance (Kalisch et al., 2011)


Bed Size

Units In Study

Age > 35   Years

Gender Female %

BSN> Educational   Level

Experience >   2 Years

Occupation  (%RN)

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;

  1. Ascertain the ratio of nursing staff classification to the nursing staff mix. Multiply the percentage of each nursing staff classification.
  2. Ascertain the cost of the nursing staff by entering the salary and benefits for each nursing classification.
  3. 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.
  4. 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

View Nursing Dissertations Here

Borderline Personality Disorder

Borderline Personality Disorder

According to DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) personality disorders are defined by maladaptive personality characteristics which begin during early years of life and have serious and consistent effects on functioning (Diagnostic and statistical manual of mental disorders, 2000). Borderline personality disorder (BPD) is a common reason to visit a psychiatrist (Skodol, Gunderson, Pfohl, Widiger, Livesley & Siever, 2002). BPD affects 2 percent of adults (mostly young women) (Swartz, Blazer, George & Winfield, 1990). Patients with BPD present a high rate of self-injury (without intent of suicide) and a significant rate of suicide attempts and completed suicide (Soloff, Lis, Kelly, Cornelius & Ulrich, 1994).

The patients of BPD are many times in need of mental health services and approximately 20 percent of hospitalizations in the psychiatric department are of BPD patients (Zanarini, Frankenburg, Khera &. Bleichmar, 2001). A patient with depression or bipolar disorder mostly endures the same mood for weeks while a patient with BPD may experience angers (intense bouts), anxiety and depression that may endure for only hours or at the most for a day (Zanarini, Frankenburg, DeLuca, Hennen, Khera & Gunderson, 1998). A study performed by Zanarini & Frankenburg (1997) showed that most of the patients with BPD report a history of neglect, separation (as young children) or abuse. Another study performed by Zanarini (2000) concluded that 40 % to 71% of Borderline Personality Disorder & Attachment Theory.

Origin of Borderline Personality Disorder

Children who have been exposed to psychological and physical neglect, sexual and physical abuse and maltreatment are at risk of developing BPD. The mental trauma faced by these children is due to neglect and abuse by a primary caregiver. This trauma disrupts the normal and healthy development of secure attachment. And as a result these children develop disorganized attachment (anxiety and depression). The children who are neglected are at risk of social rejection, incompetence feeling and social withdrawal. Neurobiological dysfunction can be caused because of abuse and neglect by primary caregiver. In order to develop a capacity of regulating emotions and developing a coherent sense of self the child has a requirement of attachment from the primary caregiver.

Attachment Theory and Borderline Personality Disorder

As per the ethological perspective of John Bowlby (1977, 1980, 1991) BPD can be considered as a condition of significant insecure attachment (with significant oscillations between detachment and attachment & between yearning and longing). The working models present in affect regulation and a lack of coherence (mainly in relationships with others) (Bowlby, 1973). The sorrow of detachment faced in early childhood negatively impacts the psychology of the person and this result in heightened sensitivity to loss and separation. It is also important to note here that since these feelings and thoughts are disconnected to the happenings in early childhood these individuals are unable to understand the reason behind their reaction. Research scholars (Melges & Swartz, 1989) have compared the fluctuations in the behaviour of BPD patients to prickly porcupines – they are of the opinion that patients with BPD are in need of someone but when someone comes close to them they drive themselves away as a result of fear. Thus BPD patients are looking for secure attachment but they fear rejection, anxiety and anger that could result (Bowlby, 1979). Melges and Swartz (1989) are also of the opinion that patients with BPD are preoccupied with regulating space. They do not feel the “invisible elastic” of attachment (Bowlby, 1969, p. 45). Also they are unable to protect themselves from anxiety of separation (Adler & Buie, 1979). The influence of certain types of experiences as related to family can be the cause of separation anxiety (Bowlby, 1988). John Bowlby’s “The seminal developmental theory” for treatment of BPD patients (Bowlby, 1969; Bowlby, 1973; Bowlby, 1980) has gained great attention. Bowlby proposed that human beings face pressures of natural selection in order to evolve behavioural patterns (example, clinging, smiling and proximity seeking ), that evoke in adults the caretaking behaviour (example, soothing, holding and touching).

These behaviours are reciprocal and encourage the development of an affective and enduring tie between caregiver and infant, which forms attachment. It is the result of these parental responses that internal models of the self and others are developed in infants which act as templates in the functioning of relationships later in life (Bowlby, 1973).

The Findings and Proposals of Bowlby the Following Is True In Case Of Attachment (Bowlby, 1973)

1. Model Of Self: The Internal Working Of It Is Related To The Degree Of Acceptance And Love One Has In The Eyes Of Primary Attachment Figures.

2. Model Of Others: The Internal Working Of It Is Related To How Available And Responsive Attachment Figures Are Expected To Be.

Attachment plays a very crucial role in the development of an external environment from which the child develops a safe and secure internal model of the self. Security on the grounds of attachment as perceived by the child results in his or her exploration of the world with confidence; this confidence springs by the availability of the caregiver. Security in attachment thus promises consistent, coherent and positive self-image. It also provides a feeling of being worthy of love and expectation that the important ones to him or her will be responsive and accepting. We here note that Bowlby has presented to the scientific mind the importance and need of attachment as essential to infants and children. Thus, attachment can be considered as an essential ingredient in the production of a psychologically healthy life. Now let us consider BPD patients, it is a case where the security in attachment is absent and there is a split and malevolent representation of self and others (Kernberg, 1967). In the life of BPD patients we usually observe angry, manipulative and needy relationships (Benjamin, 1993).

A number of scientific studies and intellectual thoughts have considered that intolerance of aloneness is the main defining characteristic of BPD and it is essential to note here that the descriptive criteria of DSM are also of the same opinion (Adler & Buie, 1979). Thus, the concepts and theories of attachment in many ways relate to DSM diagnostic criteria. Gunderson (1996) proposed that the early attachment failures actually constitute the cause of intolerance. He noted that in times of distress and sorrow patients with BPD are unable to invoke a “soothing interject” and this is due to unstable and inconsistent attachments to early caregivers. The above proposed scientific thoughts of Gunderson (1996) are same as that of Bowlby’s concept of insecure attachment.

The Scientific Observations Of Gunderson (1996) The Following Points Are True In Case Of Patients With Borderline Personality Disorder:

A Feeling of Insecurity on Grounds Of Attachment, Especially Pertinent To:

  • Plea for Attention
  • Pleas for Help
  • Checking For Proximity
  • Clinging

A Feeling of the Following in Borderline Personality Disorder Patients:

  • Denial Of
  • Dependency Needs
  • Fearfulness About

Based on the comparison of theories of object relations and attachment (Lyons-Ruth & Jacobvitz 1999) distinguished between normal processes (in early development) of separation individualization from the disorganized conflict behaviour (for attachment figures) by toddlers who are at significant risk for development of psychopathology. She identified that in infants the disorganized insecure attachment as a risk factor in the later development of BPD. Thus, we can state that as per the findings of Lycos-Ruth those infants who are victims of insecure attachments during the early years of life are at risk of developing BPD during later years of their life.

Borderline Personality Disorder
Borderline Personality Disorder

Attachment Therapy

In 1990, ATTACh (Association for Treatment and Training in the Attachment of children) was created in order to address the need of society and families to deal with critical attachment and bonding issues. ATTACh has cited important principles of attachment therapy and this includes the following:

1. Attachment therapy can be defined as a therapeutic process that is designed with the aim to define, develop and promote reciprocal attachment relationship and that which completely meets the criteria of that therapeutic process as defined and developed by ATTACh.

2. The aim of treatment by attachment therapy is to address the attachment problems and enable patients with healthy attachment relationships.

3. The emphasis in attachment therapy is laid on touch, physical and emotional closeness, reciprocal behaviours, empathy, atonement, communication, playfulness and humour. The attachment and bonding therapists are therefore required to treat with attention to the physical and psychological safety and wellbeing of the children and adults.

4. Family systems approach is of prime importance in attachment therapy. Thus there is need to correct child’s relationship with his or her primary caregiver.

5. It is essential to assess and study the following;

  • Psychological history
  • Educational history
  • Treatment history
  • Medical history
  • Attachment & Social history (including breaks in attachment)
  • Developmental history (including prenatal and birth)
  • Intellectual and Cognitive skills and deficits
  • Family functioning
  • Differential diagnosis (including DSM and ICD diagnoses)

6. Parents and children form the most active group of treatment regimen. Attempts are made to develop healthier patterns of interaction and communication.

7. To assist parents to develop parenting strategies in order to support positive attachments.

8. Description of any shortcomings attachment therapy might have for treating this issue and what else could be fused with attachment therapy to meet these needs.

Criticisms of Attachment Therapy

1) The application of attachment therapy for treatment of patients with BPD is equated with rebirthing or holding therapy and the techniques used to achieve the results are dangerous.

2) During the treatment of patients with BPD the attachment therapists make use of criteria that are even beyond those provided by the DSM-IV-TR (Zeanah 1996; Boris et al 2004). The strong correlation between insecure attachment and pathological parent-child interaction as shown by attachment therapy are beyond the symptoms listed in the DSM criteria (Bowlby 1944, 1973).

3) The attachment therapists many times over diagnose BPD.

  • Almost 87% to 96% of the children, who experience abuse, neglect or both, show an insecure attachment (Crittenden, 1988).
  • Between 50% and 80% of the adopted children have attachment disorder symptoms (Carlson, Cicchetti, Barnett & Braunwald, 1989).
  • Approximately 20% of children living in homeless shelter and nearly two thirds in foster care are identified with attachment disorders (Boris, Wheeler, Heller & Zeanah, 2000).

4) Attachment therapy is not supported with “empirical evidence” While attachment therapy can provide treatment of BPD, studies have revealed the effectiveness of other therapeutic methods as well. These methods have been briefly described below:

1. Psychotherapy

Randomized controlled studies have presented the efficacy of dialectical behaviour therapy and psychodynamic / psychoanalytic therapy (Bateman & Fonagy, 2001). The treatment provided in these trials comprises of three key features;

  • Meetings with an individual therapist (once a week)
  • Group sessions (one or more in a week)
  • Meetings of therapists for supervision or consultation

The psychotherapist’s approaches include a building of a strong therapeutic alliance and monitoring the suicidal or self-destructive behaviours. Other essential component of effective treatment plan for patients with BPD includes managing feelings, promoting reflection action (and not impulsive action), reducing patient’s splitting tendency, and limiting the behaviours related to self-destruction. There is some empirical data that supports individual psychodynamic psychotherapy.

2. Group Therapy

Group therapy for BPD patients is supported with research findings that indicate that it can be helpful (Greene & Cole 1991). Note: However, the benefit of family therapy in the treatment of BPD patients is not evaluated yet with research studies.

Descriptions of how dimensions of cultural context impact the issue you are discussing. How might this inform your treatment? I strongly believe that psychologists should not be racists. Today we are required to treat patients of different ethnic groups and countries during our clinical practice. Even an expression of detachment or neglect can hurt hard the patients with BPD. As discussed above the patients with BPD are in need of love and acceptance, care and attachment, understanding and touch, soothing approach and closeness. If a psychologist will distinguish on the grounds of colour, race, region and country then s/he won’t be able to perform well because for the treatment of BPD patients with attachment therapy it is essential to shower true attachment. Roentsch (1985) defines racism as: “Let there be no misunderstanding. A racist is anyone who accepts the existence of racial collectives”. Amongst doctors there is a belief in the a priori inferiority of non-white (Eysenck, 1990: pp. 215-220). The facts on racism reveal that we divide the world into ‘in-group and out-group’ or ‘us and them’ (Baron and Byrne, 1994: pp. 228-229). An important study first conducted by Clark and Clark (1947, in Baron and Byrne, 1994: 256) showed that a significant proportion of non-white children had internalized the attitudes of white racist. Thus the reaction of non-white adolescents towards white psychologists can be considered to be different from the reaction towards non-white psychologists. These racists’ feelings need to be addressed with maturity and patience. The dealings, behaviour and communication need to be such monitored that the feeling of racism is absent.

Self-issues that may impact a clinician’s conceptualization and treatment of this issue from an attachment perspective. How might one’s cultural context inform what they see and how they see it? What should clinicians be cautious of? Bonus points for examination of your own “self” in relation to treating this issue from an attachment perspective.

During my school times I lost my best friend because of racial differentiation attitude of a teacher. I was very much in harmony with my non-white friend. We had a high level of understanding and we loved spending time together. We were best friends for 3 years. However, my teacher did not like us being friends. She was white and disliked non-white people. Though she did not show it openly but it was obvious by some of her remarks at different times about non-white people. My teacher asked me to quit my friendship with the non-white girl. At first I was very much hurt by my teacher’s approach but then I agreed to it. This is because my teacher said that she will assure that I will get better grades in school if I agreed to what she said. My friend was very much hurt when I broke friendship with her. And after doing this I felt guilty for doing something really wrong. Even several years after quitting friendship with her, I feel sorry for my decision. Actually for some part of my life I had started thinking the way my teacher thought. I use to respect my teachers and had a feeling that they are always right. This is the reason why I started feeling that my teacher’s attitude towards non-white people was right. However, my thoughts have changed to good after leaving school. Now, I am equally friendly towards both non-white and white. I have both non-white and white as my friends. But sometimes the thought that I was once a racist makes me feel guilty. When I recollect that I was once a racist, I lose confidence in dealing with non-white people. I noted this when I was working on the treatment of a BPD patient who was non-white. I need to be more confident in my dealing with non-white people. I need to feel sure that I no more differentiate between non-white and white. I think I will gain this confidence when as a result of my sincere work several non-white BPD patients will get healed.

Describe what the early, middle and ending phases of therapy might look like for treating this issue based on what you have learned. Please also include some possible interventions and assessment methods. Attachment theory has been applied to both children and adults suffering from detachment. Bowlby (1969) formed a lifelong attachment behavioural system which encourages secure attachment. The attachment thus begins with the child’s requirement of secure attachment from the primary caregiver. The behaviour of attachment is organized and revolves around primary care giver. The feelings of attachment are elicited during the period of mental or physical discomfort or stress (1969). As per Bowlby’s (1969) perspective BPD can be considered as a condition of significant insecure attachment. There exists number of oscillations between detachment and attachment. The early childhood experiences of BPD patients are that of detachment, neglect, abuse, separation and loneliness. Thus the systems that mediate the feelings of attachment and positive behaviour are distorted and deactivated. In addition to this BPD patients have intense fear linked with loss and separation. However, since BPD patients do not remember their childhood time when they were neglected and abused they are unable to understand the reason behind their behaviour. I think a therapist is required to develop a secure and genuine attachment relationship with the BPD patients. The patient should feel completely secure in his or her relationship with the therapist. S/he should have no fear of loss or separation as related to relationship with the therapist. Development of a ‘secure’ attachment can help establish happiness in the life of the patient.

BPD patients are in need of love but the fear of loss and separation drives them away from people. It is therefore crucial that this fear of loss and separation should be dealt in the first phase of treatment. The patient with BPD should be counselled in such a manner that s/he starts gaining confidence in building secure relationships. The approach of the therapist should be driven by ‘attachment’ and ‘love’. Thus, while attempting to heal the BPD patient of the fear of separation, the therapist should try to build his or her own place in the heart of the patient. The approach should not only aim to heal the fear but also to open ways for love and attachment. The therapist should make the patient feel that s/he really cares for him. That it is not just a routine responsibility or duty to address the need of the patient. The therapist should show that s/he has started loving the patient and has become attached with him. S/he has started caring for the needs and essential requirements of the patient. A feeling of attachment should spring from within the heart of the therapist and should touch the emotions of the patient. Parents of the patient should be educated on the basics of attachment.

They should be taught the need of touch, eye contact, motion, love, compassion, care and attachment. The issues related to behaviour should be addressed and the pitfalls should be examined. The treatment should include a review of the attachment issues of the parents’. The parents should be educated on good ways to bring up the child. The attachment from parents and primary care taker are essential for answering the need of BPD patients. Gregory C. Keck states that holding the child or adolescent gives rise in an emotional response and intensity that cannot be achieved by any other medicine or therapeutic regimen. Therapist should educate the parents or the primary caretaker to hold the child or adolescent. The therapist should work to build in attachment between the child/adolescent and the parents/primary caretaker. Building of relationship and providing security and affection from parents or primary caretaker should be assured.

The therapist should also spend time to build in attachment between the child/adolescent and himself

The therapist should also work to repair the relationship that has been broken. S/he should try to develop more peaceful and lovable feelings between the child/adolescent and the parents/primary caretaker. The therapist can also do the holding of the child/adolescent and then s/he can transfer the responsibility to the parent or primary caretaker. The therapist is also required to make an important clinical judgment with regard to the suitability of the primary caretaker or parent for such an attachment. Guidance and education as related to the attachment should be provided by the therapist. In addition to holding ‘eye contact’ is an important part of attachment therapy. Eye contact opens the door to the heart of the person and builds attachment.

In conclusion, the therapist should believe in building relationships of attachment. A feeling of security should be the base of such attachments. Broken attachments should be repaired and new attachments should be built-in. The therapist should form attachment of the patient with himself or herself. In addition to this attachment should be built between the parent/primary caretaker and the child or adolescent. Education should be imparted on developing attachment. Today, in the modern days parents find little time for their children. Many times they forget to care for their own child. The child gets hurt each moment by a lot of anxiety, depression, neglect and loneliness. The child loses the charm of attachment and feels that s/he won’t get attachment from anyone. I believe that in order to begin with attachment therapy it is essential for the therapist to first build attachment between himself and the child/adolescent. Therapist should also build in attachment between himself and the parents of the child/adolescent. This is because the parents who feel attachment from the therapist will be more responsive and agreeable to treatment.

Attachment Can Create Wonders in the World of Therapy and Therapeutics

Attachment speaks to the heart and touches the emotions to bring forth a feeling of recovery. I strongly believe that attachment therapy is the best suit for patients with BPD. This is because attachment can repair the broken hearts, the fading hopes, the dying relationships and the detached home. I would strongly recommend attachment therapy as a method of choice for the treatment of patients with BPD. Children and adolescents want someone to speak to their heart, someone who understands their need of attachment and addresses to their requirement of love, touch, care and affection. During all the phases of treatment this should be kept in mind and should be reflected in approach and practice of the therapist.


Attachment theory is a good addition to the knowledge of psychology and its application can be beneficial for the treatment of BPD patients. While dealing with patients of BPD the psychologist should not have racist attitude and his or her approach should be confident.


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