Red Robin Restaurant Evaluation Essay Example for Free

Red Robin Restaurant Evaluation Essay The theme for all Red Robin restaurants is â€Å"Red Robin†¦. Yum! † When thinking about this statement you really have to think about all that encompasses. What makes the food so good? Does the atmosphere make the yum factor even better? What about the staff how do they contribute to the yum factor of the food? For this evaluation I would like to explore this yum factor and truly understand what makes the Red Robin chain of restaurants stick with yum as a marketing tool to entice customers to come in. Firstly we will explore the atmosphere of the Red Robin restaurants and how the atmosphere adds to the yum factor. When you first walk into a Red Robin restaurant you are greeted by a friendly hostess who joyfully takes you and your party to your table. Once you are seated your server comes over to greet you and take your drink order. This is great for the yum factor because no one like to eat food in the mist of negativity, when you are in a place where the atmosphere is negative it just makes your whole entire experience bad. The one down side to this is that at times if you have children, you are still in the process of settling in; you are not quite ready for your server to come by and take your drink order because you have not even looked at the menu. Secondly we must discuss the staff and how they add to the yum factor for Red Robin restaurants. The staff at Red Robin is for about 95% of the time the friendliest and warm restaurant staff you will encounter. The staffs at Red Robin restaurants are very accommodating for anyone who needs to place a special order. They are also good about getting food to children first, especially if it is later in the evening and they are hungry. This ability to get what I desire to eat the way that I desire it without having to be reprimanded for substituting this for that or adding this or that, makes the yum factor so much better because it is truly what I want. However, the one con that I have seen of the Red Robin staff is that, they are not prepared for last minute large parties. There have been times when a group of friends have decided to just go and have a great time eating together, the staff takes about thirty minutes to get their selves together to be able to accommodate the crew. Lastly, we must discuss what makes the food so good and how it makes the yum factor. The food at Red Robin consists of burgers, French fries, select chicken products, salads and sandwich wraps. The burgers are considered gourmet because they have more than just your typical bacon, cheese, ketchup and mustard. The food theme for Red Robin is classic comfort with a twist of class to heighten your taste buds. On the other hand when it comes to the food some may find that the classiness of some of the items is too much for them. Some people just want a simple cheeseburger with no muss or fuss, and with all the gourmet burgers this may be a turnoff to those people. The uniqueness of the food is what gives Red Robin the yum factor, the food is comforting and the flavors are bold. In conclusion you can clearly understand how the staff, atmosphere and food at Red Robin restaurants live up you their motto â€Å"Red Robin†¦Yum! † When you have a great atmosphere, great staff, and food that delivers’ on the taste, you have a great recipe for the yum factor. When you are choosing a place to eat you want to choose a place where you have the full yum factor effect. Some restaurants may just have one or two elements of the yum factor, but if you are looking for a place with all three yum factors, then Red Robin is the restaurant for you.

Educational Mobility Essay Example for Free

Educational Mobility Essay The journal article is basically a report on the first study to longitudinally examine educational mobility among nurses. The reason for the study is that schools of nursing cite a lack of qualified nursing faculty as a primary barrier to program expansion. The main objective of the study therefore is to identify patterns in how nurses’ entry-level degrees and other individual characteristics correlate with the timing and achievement of subsequent advanced nursing education. The researchers used longitudinal analysis of data gathered as part of North Carolina’s licensing renewal process. They studied the educational mobility of newly graduated RNs with a variety of entry degrees in this state. They followed cohorts of new graduates who were licensed in 1984, 1994 and a special group in 2004, which is basically a longitudinal study of three decades. The results suggest among others that, more than 80% of all nurses in either cohort who attained a master’s degree in nursing or a doctorate in any field began their nursing career with a bachelor’s degree. Younger age at entry into nursing, male sex, and belonging to a racial or ethnic minority were associated with being more likely to pursue higher academic degrees. Based on their findings, they concluded that increasing the number of graduates with a bachelor of science in nursing degree, especially those who are men or members of a racial or ethnic minority will have the most immediate effect on increasing the potential nursing faculty pool. A Critique of the Research Process and Paper The hypothesis or research question was clearly articulated in the article when the authors introduced the issue of the lack of qualified faculty by schools of nursing as a primary barrier to program expansion. The researchers realized that an examination of the data could offer a much better understanding of how patterns in educational mobility have led to the current shortage, as well as some insight into how to address it. Since it was a longitudinal study of three decades, the literature review must not just be current, but also pertinent in order to address the research problem. In this study, the researchers used only two sources of data: cohort data from the North Carolina Center for Nursing database and data on national graduates from the National League for Nursing Division of Research: Nursing Data Book, 1984; Nursing Data Review, 1994; and Nursing Data Review, 2003. In terms of research design the researchers used longitudinal analysis (which is done over time) to explore patterns of educational mobility among RNs in North Carolina. In this type of research, longitudinal analysis is valuable and relevant because it profiles actual behavior and does not rely upon intentions or recall as in other types of conventional research such as cross-sectional research. However, as the authors admitted a disadvantage of this approach is that over time the nature of educational opportunity and access change so that what was true for nurses starting their career at a specific point in time may not be true for those starting in another time. In terms of selecting the sample and adequacy of the sample size, it was done in accordance to the sampling requirements of the longitudinal study. The first cohort initially consisted of all RNs who graduated from an entry-level program in North Carolina in 1983 or 1984 and were licensed in 1984. A second cohort initially consisted of all RNs who graduated from an entry-level program in North Carolina in 1993 or 1994 and were licensed in 1994. They also collected demographic data on a third cohort of 5,400 RNs who graduated from an entry-level program in 2003 or 2004 and were licensed in North Carolina in 2004. Using the database from the North Carolina Center for Nursing (NCCN) to get the raw data, the researchers were confident that as the first state agency dedicated to nurse workforce planning, the NCCN has 20 years of longitudinal data, including educational information, on the state’s nursing workforce. As far as ethical issues are concerned, there is no point or period in the study article that would suggest of any ethical issue raised by respondents. However, as longitudinal researches take a long time to finish, certain privacy may be raised by some respondents who do not want their past information to be dug up by researchers. For statistical analysis the researchers basically used descriptive statistics such as frequency, means, and certain non-parametric tests (chi-square) for testing significant differences between means computed from the data. Because of the relative characteristic of the statistical tests, the power of the non-parametric test is comparatively lower to that of parametric test. So it is difficult to determine why the authors decided to use non-parametric tests in this case. The findings of the authors do well in identifying the behavior and characteristics of nurses who will most likely fill the gap in terms of the shortage of qualified nursing faculty. Their data also suggests that the nursing shortage will not be remedied without having sufficient nursing faculty in place. While the number of RNs has increased in the past decade, their findings suggest that the demand for nursing faculty is not being met. This research is a longitudinal study only of a specific groups or groups of respondents. This study cannot be generalized and duplicated in other states or locale because of such study’s background. The presentation and style of presenting the research article to the average reader might be a bit overwhelming considering that, although a descriptive study, certain areas are complicated and have heavy technical descriptions. The figures such as charts, tables and graphs are also readable and accurate, albeit it takes time for an average reader to understand them. The articles is useful to nursing practice since it tries to address the issue of shortage of nurses due to the lack of qualified nursing faculty who hold master’s or doctorate degrees. The authors themselves tried to encourage all nurses to understand the value of an advanced formal education and the expectation to pursue it. The authors believe that the fastest way to increase the ranks of faculty nurses is to encourage more nurses to enter practice at the baccalaureate level as this academic route has been shown to make advancement for master’s and doctorate degrees more rapidly.

Quakers Are Known As The Society Of Friends Religion Essay

Quakers Are Known As The Society Of Friends Religion Essay The Quakers, also known as the Society of Friends, are a group of Christians that are tolerant of other religions. They do not believe in sexism, racism, or war. As a society they preach love, truth, and tolerance. They believe in treating every person as a best friend, yet this peaceful group of Christians was viewed as one of the largest threats to Christianity and the Puritan way of life during the mid-17th century. They were persecuted, whipped, and hung by the Puritans in the Early American Colonies. Why would the peaceful Society of Friends be so greatly feared that it would drive the Puritans to persecute them so? Were the Quakers that large of a threat, or was this just another example of antagonism that existed between other Christian bodies in the past? This paper will argue that the Quakers were feared only because they had a different religious view than the Puritans and that throughout history Christians, having a different view points on Christianity has led to persecut ions. First I will cover a short history of how the Quakers and Puritans came to New England. Next I will cover some of the similarities and differences between the Quakers and Puritans. Then I will detail some of the persecutions that the Quakers endured from the Puritans in New England. Finally I will compare the hostility that the Puritans held towards the Quakers, with hostilities that other Christians and groups of Christians faced throughout history. The Puritans started out as a group of Christians who sought to purify the Church of England, during the early 17th century. They felt that the Church should be separate from the rule of the King. The Puritans wanted to be free to worship God how they saw fit, without the King of England telling them how they should worship (Woodman 22). The Puritans also wanted to correct certain practices and ceremonies of the Church of England, which they viewed as Anti-Christian. They wanted to return the Church back to how it was during the apostolic times, before the Church adopted practices that they felt strayed from Gods glory. Unfortunately the Puritans did not have much luck in purifying the Church of England, instead they had stiff opposition to any changes and the Anglican Church ended up passing laws against them (Sweet 18). Since the Puritans were persecuted and unable to change the Church of England, they instead went to the New World in order to create a pure Church that was not controlled by any kind of government (Abbott 232). They viewed New England as a place where they could create their perfect church. They wanted to build a Church that warned against pleasures of the flesh, one that was very plain so as not to detract from the glory of God, and one that promoted a very strict way in which to live. They also wanted to ensure that the government would not be able to control their Church. This would allow them to worship as they saw fit, without government interference. The Puritans thought by doing this that they would be able to live their simple life that was completely devoted to God in every aspect without the fear of persecution (Sweet 21). The Quakers, like the Puritans, also saw the Church of England as being corrupt. They believed that the Anglican Church had strayed from the correct path of God and that it needed changes. They also felt that the church should not be controlled by the King. The Quakers also met stiff resistance, just like the Puritans, and were persecuted for standing up to the King and the Church of England. Laws were quickly passed to try and suppress them, their meeting houses (similar churches) were burned, and the jails were quickly filled with Quakers. Despite this opposition the Quakers were not deterred, instead they continued to preach in England despite the fact that they were constantly persecuted and the Church refused to change (Woodman 22). The Quakers felt the urge to spread their religion around the world, so unlike the Puritans, they did not come to New England to start a new church nor to escape persecution. Instead they traveled to New England in order to spread their religious beliefs. They went to New England as missionaries, but instead of being accepted with open arms by the Puritans, they were immediately thrown in jail. The Puritans then burned the Quaker missionarys books and arranged for their deportation shortly after (Hamm 23). A short time after the first two Quakers were deported, more Quakers began to arrive and the Puritans felt they must stop the Quaker invasion immediately. Soon the Puritans passed laws to fine the ships captains that brought any Quakers to New England. The Quakers soon found it very hard to get a ship to take them to New England. Instead of being deterred, the Quakers simply built their own ship to take them to New England. The Puritans continued to persecute the Quakers as they would arrive. They would whip, brand, and sometimes even mutilate the Quakers who came to Massachusetts. Then the Quakers would be banished and all of their property confiscated by the Puritans. When the Quakers were departing New England, the Puritans would give them a strict warning that promised the Quakers death if they ever returned again. Despite these strict warnings and punishments, the Quakers still continued to return to New England (Hamm 23). What could have caused the Puritans to act so violently towards the Quakers? After all, there were many similarities between the Puritans and the Quakers. They both had suffered persecutions from the Anglican Church and the King of England. They both believed that the government should not control the church and they both thought that the Church of England was had become corrupt and needed to be fixed. Also both the Puritans and Quakers believed that people should avoid the natural pleasures of the world and the pleasures of the flesh, as well as any fashions or customs that could lead to pride and/or selfishness. They both believed in having a simple church so as not to detract from the glory of god and they both disliked the idea that a priest was needed to communicate with God (Jones xx). Despite these similarities between the Puritans and Quakers, there were also many differences. The Puritans, like many religions, had a minister to lead the church services, whereas the Quakers had no ministers or priests (Abbott 232-233). The Quakers believed that every Christian could be a minister in his or her own way and that the Holy Spirit could move any person, whether man, woman, rich, poor, royalty, or peasant, to speak on Gods behalf. For their church services, instead of a person leading the sermon, the Quakers would gather together and wait in silence until the Holy Spirit would move through a person. That person would then be compelled by God to speak for God and to reveal new revelations. Another difference was that the Puritans believed that only a select few were selected by God, whereas the Quakers believed that every individual had an inner light in themselves. This inner light could show every person the way to salvation. It could illuminate sin and show how to avoid anything that was contrary to what God would want a person to do. This inner light also allowed each person to communicate directly with God, without the need for a minister or priest (Hamm 21). The Puritans also believed that reading the Bible was the best way to understand what God wanted. The Puritans believed that the Bible was the inspired word of God and that it held all of Gods truths (Sweet 98). They stressed that studying the Bible was of the utmost importance. The Quakers on the other hand, believed that following the inner light was of the utmost importance, with the Bible coming in second. The Quakers still believed that the Bible was Gods word, but they also believed that God could reveal new things to each person through their individual inner light that may not have been revealed through the Bible (Jones xxi xxii). The Puritans also viewed the sacraments as outward signs of Gods invisible grace, while the Quakers view of the sacraments is purely spiritual. For example, the Quakers do not have baptisms or take Holy Communion. Instead they believed that true communion was gathering together to worship Christ. Also, they believed that the only true baptism was when a person was baptized with the Holy Spirit moving through them. The Quakers then viewed Gods grace not as a visible sign, but one that you could not see. It was a sign that went directly into a persons heart and only that person could sense that they had Gods grace (Abbott 252 Hamm 21). Another difference was equality. The Puritans had a very strict social order, but the Quakers, believing that all men and women were equal, did not have a social hierarchy. The Puritans believed that women should not have public roles, but the Quakers would often give women public roles and allow women to play important roles within their Church (Hamm 23). Also the Quakers viewed every person as if he was a beloved brother. They believe that all life is a sign of Gods grace and every person should be treated as if they were your best friend. This meant that the Quakers did not view any person as outranking another person, even if that person happened to be a King or a Bishop (Woodman185). Persecution of the Quakers in New England Before the arrival of the first Quakers to New England, the Puritans had received anti-Quaker pamphlets. These pamphlets led the Puritans to believe that the Quakers may be a threat to their way of life. Because the Puritans believed that they had set up a perfect society and church in Gods eyes, they did not want anyone to threaten their way of life. Therefore the Puritans viewed all other religions as a potential threat (Sweet 144). When the Quakers did arrive, they immediately viewed them as a potential threat for civil disorder. Because the Quakers did not believe in authority, but that every person was equal, the Puritans viewed this as contempt and disorder in their society. This in turn allowed the Puritans to use state laws to punish Quakers. When the first Quakers came to New England, the Puritans claimed that the Quakers were creating civil unrest and immediately had them arrested and thrown in jail (Chu 6-7). After the first deportation of the very first two Quakers to arrive in New England, the Puritans thought they may have stopped the problem. However when more and more Quakers began to arrive, the Puritans felt threatened by the change the Quakers were trying to bring. The Puritans decided they had to put an immediate stop to anymore Quakers coming to New England. This led to the fines on ships captains for bringing Quakers to New England, but the Quakers continued to arrive and spread their religion. This led to the Puritans fining anyone who even possessed any of the Quakers books or pamphlets. In fact the Puritans were so protective of their society that these fines were not limited to only Quaker books, but to any material from a religion other than the Puritan religion (Wills 19). Despite these fines, the Quakers continued to come and spread their religious beliefs, even though it meant building their own ship to get from England to New England. This constant influx of Quakers only helped to convince the Puritans that Quakerism was definitely one of the greatest threats to their society. They were revolted by the Quakers views on the Bible, direct revelation, giving women public roles, the sacraments, their opposition to taking oaths, and the fact that the Quakers seemed compelled to go where they were not wanted. To the Puritans it seemed as if the Quakers must surely be possessed by demons and that they were out to destroy the Puritans way of life (Hamm 23). They could not fathom anyone in their right mind who would keep going where they were not welcome. The Quakers however, were stubborn. They, like the Puritans, believed that their religion was the correct religion and that God was on their side. At first the Puritans felt that the fines, jail time, and banishment would stop the Quakers from coming, but the Quakers continued to return again and again. When these punishments failed, the Puritans then set up stricter laws to try and keep the Quakers out. They declared that if a male Quaker returned after being banished, he would have his ear cropped. Then if he returned again, the other ear would be cropped. After a third return, the Quaker would have his tongue bored through with a hot iron. For women Quakers, they would be whipped for the first two times they returned and then they would have their tongues bored through for the third offense. When these punishments proved to be ineffective, the Puritans felt that they must set up the death penalty to try and deter the Quakers from coming (Sweet 146). Still the Quakers would kept coming back to try and spread their religion. They would claim that visions and dreams urged them to go to New England and to spread the good word of their religion. Because the Quakers were so persistent on going to New England, despite the punishments inflicted upon them, many more people converted to Quakerism. Once people would see how devoted the Quakers were to their religion and that they would willingly die for what they believed in, it end up drawing many more people to the Quaker religion. This led to the Quaker religion spreading fast and far (Fox 34). Other Christian Persecutions These hostilities between the Quakers and Puritans werent just an isolated incident between these two religions. It has been going on for centuries between Christians and non-Christians, as well as between Christian groups that have different beliefs. Christianitys history is littered with persecutions and individuals who have died for their faith and beliefs. When Christianity was first starting, the Roman Empire had persecuted Christians on and off over the first few centuries. Starting with Jesus who was viewed as a threat to the Empire and therefore was persecuted and eventually killed for his beliefs. Then his followers were also persecuted for following him. For example Paul the apostle, who was a big influence in spreading early Christianity, was persecuted, thrown in jail, tortured, and driven out of towns for spreading the Christian faith. Then in 64 C.E. the Roman Emperor, Nero, blamed Christians for burning the city of Rome, to which he ended up persecuting many more Christians. Many Christians were also persecuted for refusing to pay homage to the Roman Emperors genius or divine spirit. These Christians had viewed paying homage to the emperors genius as idol worship and refused to participate in the act. Christians were also persecuted by the Roman Empire for refusing to perform sacrifices. These Christians were often executed by fire, wild animals, or gladiators in public arenas, in order to send a message to other Christians that they should comply with the rules of the empire (Moore 58-59). The early Christians were persecuted because they had different beliefs than many of the Romans and therefore were viewed as a threat even though they may have been peaceful. This however, did not keep them from persecuting others as time went on. Other groups of Christians that also faced opposition and hostilities, during the first couple of centuries that Christianity came into existence, were the Ebionites, Gnostics, and the Marcionites. These three groups were Christians that had different views on Christianity than the proto-orthodox Christians. For this they were persecuted and completely destroyed by the proto-orthodox Christianity. For example, the Ebionites believed that in order to be Christian a person must be Jewish and follow all of the Jewish traditions from eating a kosher diet to circumcisions. They also believed that Jesus was the adopted son of God and did not result from a virgin birth. Because of these beliefs the Ebionites were not popular with other Christians that wanted to get away from the Jewish traditions, which led to them being persecuted and eventually their religion was wiped out (Ehrman 100-102). The Marcionites were also considered heretics and persecuted for having different beliefs than the proto-orthodox Christians. They were seen as a significant threat and even had five volumes of books written against them in order to attack their beliefs. Their beliefs differed because they believed in two Gods, one was the evil Old Testament God and one was the good New Testament God. They also believed that Jesus was not actually human, which greatly contrasted with proto-orthodox Christianity. (Ehrman 103-108). The Gnostics also had different views than the proto-orthodox Christians, which led to them being harassed and persecuted. The Gnostics believed that Jesus wasnt actually human, that the material world was completely evil and the spirit world was good, that there were multiple Gods, and that only certain people had a divine spark in them that would allow them to go to heaven. These ideas caused the Gnostics to be considered heretics and another threat to Christianity. Christians were even warned on how to spot possible Gnostics in order to try and drive them out of the proto-orthodox Christian churches (Ehrman, The New Testament 197-201). Persecutions among different Christian orders continued, but persecutions even occurred within the same Christian order. Whenever there was a split in beliefs, Christians would often argue over who was right and who was wrong. This would often lead to more persecutions. One such example was around the 8th century when there was a huge conflict over icons of Christ, the Virgin Mary, and the saints. Christianity split into two groups, each of who thought their views were correct. One group was the iconoclasts, who believed that all icons should be destroyed, and the other group was the iconodules, who believed that icons where just simple glimpses of what heaven may be like. This difference in beliefs led to violent conflicts over who was right and who was wrong. Constantine V, Emperor Leo IIIs son, had some of the greatest and harshest persecutions of this time. He had hundreds of iconodule monks tortured by gouging out their eyes, cutting off their tongues and noses, setting their be ards on fire, and even executing those that stood against his iconoclast view. These hostilities between the iconoclasts and iconodules lasted from 726 until 787 C.E. (Nystrom 134-235). Another example of hostilities between Christian orders was between the Protestants and the Catholic Church. The Protestants were persecuted because they interpreted the Bible differently than the Catholics. The Protestants then used these new interpretations of the Bible to try and change the Catholic Church. Some of the changes they wanted were to eliminate indulgences, reduce the sacraments from the seven to only baptisms and communion, and to use scripture alone as the primary guide for faith. The Catholic Church on the other hand wanted to keep indulgences, all seven sacraments, and to continue using scripture in conjunction with church teachings as the ultimate authority for faith (Moore 182-183). These differences led to an irreparable split between the two Christianities, with the Catholic Church declaring that the Protestants were. Conclusion In conclusion, these hostilities between Christian groups and between Christians and Non-Christians were very similar to the hostilities between the Puritans and Quakers. All of the hostilities had to do with different views on Christianity resulting in persecution of one of the Christian groups. These persecutions ranged from imprisonment, to excommunication, to banishment, or even to death. The Quakers had very different views on Christianity than the Puritans. Because the Puritans felt threatened by these differences, they persecuted the Quakers. This was very similar to many other persecutions throughout the history of Christianity. Christians when they were first forming had different viewpoints than non-Christians. Then as Christianity grew, factions of Christians separated because they had different viewpoints on how Christianity should be. This in turn led to the new groups of Christians, with the new viewpoints, who were often persecuted by the original group of Christians. While it may seem that the Puritans were especially harsh on the Quakers, it is obvious that they were not the only ones to use death and punishment to deter what they viewed as a threat to their way of life. When two groups of Christians have opposing viewpoints, and they both believe very strongly that they are right and the other group is wrong, this inevitably leads to hostilities between the two groups. If the hostilities are strong enough, there were likely to be punishments and maybe even death to deter and stop the spread of the opposing groups beliefs. These hostilities are likely to continue in the future as new revelations come about over what Christianity should be and what practices should be followed. Only time will tell what new Christianities will branch off of the vast array of Christian orders that are already established, but it is almost certain that new branches of Christianity will meet opposition and persecution from one or another of the already established br anches of Christianity.

Spike Lee :: essays papers

Spike Lee In 1995 I considered Spike Lee's gritty CLOCKERS one of the year's best films; recently I spotted its video in a clearance bin and picked it up. Upon re-viewing, I am struck again by its complexity. It is the first urban drama to depict inner-city race relations with the intricacy such a pervasive cultural issue demands. On the surface it resembles a whodunit, but its main concern is how drugs and violence contaminate entire communities, dramatized in the collapse of one African-American youth's life. (He chokes up blood the way some of us sweat.) This process is observed by a predominantly white police force that makes hollow attempts to keep order, and refuses to intervene with the community's gradual decline. Instead of characters with overt prejudices and plain racial allegiances-characters that are sterile symbols of bigotry rather than credible humans guilty of it-Lee gives us characters of casual racism. Most representative of this is Harvey Keitel's Rocco Klein, a white detective who cannot understand the culture surrounding him, which is a culture of narcotics, violence, and black-on-black crime. On his beat, drugs are less a problem than a lifestyle, murder resolves the tiniest of disagreements, and young mothers valiantly but vainly battle the influence young dealers have on their sons. Klein views the inner-city with contempt, but deep down he knows all the whores and dealers are human beings, too. Klein is introduced at the scene of a homicide, where the police handle the gruesome death with a clinical sense of detachment, cracking bad jokes and asking the bloodied corpse questions. Is it just a job, or is it racism?

A Critical Study of Media Reaction to September 11 Essay example -- Se

September 11, 2001: A DAY OF INFAMY.  Ã‚   So it was vehemently proclaimed in Time Magazine ¹s special issue dedicated to one of the most tragic events in American History and arguably one of the most brutal acts of terrorism to date.   America, in the spasms of a few hours, has become a changed country.   Perhaps in an attempt to understand this change and come to grips with the ensuing crisis, more and more people are turning to the media for answers.   Now more than ever, the media, namely television, radio, newspapers, and the internet, have become the most powerful tools in disseminating information relevant to this event.   This is a truth we cannot escape.     Ã‚  Ã‚  Ã‚   It would of course be naà ¯ve to say that this information is always reliable and accurate.   Beneath the surface there may be underlying messages which can serve to manipulate the public.   We as individuals need to be aware of this reality.   We need to be discerning with the information we take in, be able to critically analyze it, and eventually make intelligent and informed judgements.   Hence, to do a critical study of media culture with reference to the events transpiring after the September 11 attack, we need Cultural Studies.   Ã‚  Ã‚  Ã‚   Cultural Studies gives us the methods for analyzing the media.   It gives us the pedagogical tools necessary to critically interpret the media.   It enables us to read cultural text  ³against the grain ² by deconstructing it.   In other words, it allows us to decode the encoded messages.   An example of an encoded message could be the ubiquitous NBC Peacock icon which has changed its rainbow colored wings to red, white and blue.   Prior to this change, the constant presence of the logo at the bottom of the screen had made it almost invisible  ... ...ake a quick buck ² by flaunting the flag on everything from a pin to clothing to various other patriotic paraphernalia.   In many such cases the flag serves as a spectacle.   Many billboards across town are an entire picture of the flag with no caption, thus creating a polysemic visual image evoking endless emotions and feelings in the viewer.     Ã‚  Ã‚  Ã‚   From a cultural studies point of view, if one is to derive a  ³lesson ² from all of this, it would be that we need to be educated in media literacy so that we can discern and discriminate between good media and bad.   We should not be so naà ¯ve as to blindly accept the subliminal or even sometimes overt messages conveyed through media.   Instead, we need to critically decipher media messages and understand their overwhelming impact on our culture.   Only then will we be empowered to make intelligent and informed judgements.

An Analysis of Baldwins, Sonnys Blues :: Sonnys Blues Essays

An Analysis of Baldwin's, Sonny's Blues Sipiora identifies the critcal issues in Sonny's Blues with the character giving his self-reflections. Sipiora also says that literary characters sometimes perceive or not perceive the relationships or circumstances. We also have to judge characters in how they react to other characters whether they acted in good faith or not in good faith. We have to ask ourselves when we read literature if the character is being objective looking for personal qualities in a character when they come in contact with another character or is the character looking at another character in a judgemental, stereotypical, or preconceived way of thinking. Also is the character allowed the opportunity to share the similar things that are in common with another character or characters in the story. The main thing in reading literature in an Ethical Criticism is to take note on how a character interacts with another character or characters in a story. Also, take note on relationships of one character with anothe r character. In Sonny's Blues, the narrator is self-reflecting his experiences with various family members such as his mother and his younger brother, Sonny. Sonny and the narrator are brothers with a 7 year difference between them. The narrator was disappointed with Sonny at first due to his interest in becoming a musician. He thought it was a phase he was Sonny was going through and maybe it would pass. The older brother patronized Sonny with his insincere interest in music at first until it angered Sonny and he told his brother "don't do me no favors"(82). The narrator had a judgemental, stereotype, predetermined way of thinking when it came to his past. The narrator's thoughts and feelings were cruel and hard for the drug addict childhood friend of Sonny's when he told him he did not want to hear his "sad story"(81). Yet, he realized they both have something in common. The narrator has Sonny's drug addiction and the friend has his own addiction to deal with. The narrator realized that everyone has a sad story. When Sonny was trying to express how he felt on the inside and reveal his drug abuse, the narrator did not want to accept his younger brother's drug abuse and he 'kept putting them away. I told myself that Sonny was wild, but he wasn't crazy"(79). Just as Sonny felt alone and helpless, he could not talk about it to anyone.

Organizational Systems and Quality Leadership Essay

A. Complete a root cause analysis that takes into consideration causative factors that led to the sentinel event. (This patient’s outcome) The terms failure analysis, incident investigation, and root cause analysis are used by organizations when referring to their problem solving approach. Regardless of what it’s called there are three basic questions to every investigation: 1. What’s the problem(s)? 2. Why did it happen? (the causes) 3. What specifically should be done to prevent it? (Galley, n.d., ∂ 1) In the case of Mr. J, these were multiple issues that led to and contributed to his unexpected demise after what is usually considered a routinely performed procedure in an emergency department setting. The JCHAO (Joint Commission on Accreditation of Healthcare) defines a sentinel event as â€Å"an unexpected occurrence involving death or serious physical or psychological injury†, (Frain, Murphy, Dash, & Kassai, ∂ 1) and in the case of Mr. B, his death would be considered a sentinel event which would warrant a review by a team of interdisciplinary members of the hospital. In this particular case members of the team would include one or more ED physicians, the RN in the scenario and the LPN, a respiratory therapist, a nursing supervisor, a hospital administrator, the ED nurse manager, a hospital pharmacist, and a risk manager. More staff nurses from the ER could also be involved. A credible and successful root cause analysis will identify all of the elements that contribu ted to the event, an action plan will be developed to prevent the event from reoccurring and ensure that those actions are completed. Action plans should be based on best practices and appropriate standards. (Frain et al., ∂ 10) The scenario presented starts out as what  appears to be an average afternoon shift in a small 6 bed emergency department in a rural hospital. Staffing consisted of one emergency room physician, one registered nurse (RN), on licensed practical nurse (LPN) and a secretary. Due to the size of this particular ER, there appears to be limited staffing and therefore limited resources to handle large volumes of patients and or critical patients. There are two patients already being worked up in the department at the time of Mr. B’s arrival and they are stable, have already been evaluated and they are awaiting further treatment or orders. Mr. B is brought to the ED by private vehicle complaining of left leg and hip pain after losing his balance and falling over his dog. The triage nurse noted that other than the patient displaying tachypnea, his vital signs were otherwise within norm al limits. The patient states his pain level is severe, a â€Å"ten out of ten†, and physical examination finds a shortened left lower extremity with calf swelling and ecchymosis. In triage it is noted that the patients leg is stabilized and he is subsequently moved into a patient room where the admitting RN, Nurse J, takes over and gets a more thorough history of this patient, noting impaired glucose tolerance, prostate cancer and chronic back pain. Mr. B regular medications include Atorvastatin and also Oxycodone for his chronic back pain. The doses and how often he takes these mediations is not provided. Although there is no mention of any radiology studies being performed on Mr. B after his arrival, it is assumed that this was performed before the ER physician completed his evaluation and ordered 5 mg intravenous diazepam to sedate the patient to perform a manual reduction of a dislocated hip. After waiting for 5 minutes, the physician then instructed the RN to administer 2mg of hydr omorphone, a powerful narcotic analgesic. The staff waits five more minutes, after which the physician then instructs the RN to repeat both doses of diazepam and hydromorphone because he is not satisfied with the patient’s level of sedation. It is after these medications are administered that the physician notes patient’s weight and history of opiate use. Five minutes after the last dose of medication is administered a successful reduction of the left hip takes place and the patient remains sedated. The reduction procedure, which initially began at approximately 16:05, ended at 16:30. Although Nurse J is monitoring this patient, she is alerted that EMS (Emergency Medical Services) is bringing in an elderly patient with reported acute  respiratory distress. Nurse J, an experienced critical care nurse, elects to place Mr. J on an automatic blood pressure machine with a pulse oximeter. Although not stated, it is likely that this is a portable machine and is not hooked up to any wall monitors. It does not have continuous EKG monitoring. It does not have end tidal CO2 monitoring. Nurse J then elects to leave the patient in the company of his son with a blood pressure of 110/62 and an oxygen saturation of 92% on the portable machine. The patient is breathing room air and does not have any other monitoring. The ambulance patient has arrived to the department and both the RN and LPN are involved in stabilizing this new arrival and discharging the previous patients as the lobby is now becoming congested with more patients seeking care. There is no mention of anyone suggesting that additional staff should be brought in to help with the load. During this time the pulse oximeter alarm fires off in Mr. B’s room showing at saturation of 85%. The LPN enters the room and resets the alarm and repeats a blood pressure, but there is no mention of the LPN assessing the patient’s respiratory and or mental status. At 16:43, almost forty minutes after Mr. B’s procedure had begun, the son who is at the bedside with him states the monitor is alarming. Nurse J finds a Mr. B in respiratory arrest and a stat code is called. A code team arrives and the patient is connected to a cardiac monitor for the first time. The patient is in ventricular fibrillation, CPR is begun, and according to this scenario he is intubated before he is defibrillated. After thirty minutes of interventions, this patient is resuscitated to a normal sinus rhythm with pulses, but is unable to breathe without a ventilator. He has fixed and dilated pupils and no spontaneous movements. Most likely due to the facility being a small rural hospital, they must transport this patient to a higher level of care, and he is flown out to another facility where the patient was ultimately determined to have brain death and was taken off of life support. A-1 Discuss the errors or hazards in the care in this scenario Causative factors in this scenario appear to include poor staffing to patient ratios, inadequate adherence to hospital policy for moderate sedation, and an obvious lack of communication between peers /coworkers. The human factors point to failure of staff to follow an established protocol, possible  fatigue, possible inability to focus on the task, and a lack of utilizing critical thinking skills. There did not appear to be any equipment problems other than the fact that the appropriate equipment that was available was not accessed. The environmental nature of emergency medicine lends itself to hazards in the fact that a department can go from being quiet and mellow in one moment, to being volatile and hectic the next moment. It is an environment of unpredictability and bestows care to a wider population of patients than any other department in the hospital. Common environmental issues to all emergency rooms can include poor location and accessibility of equipment, overhead paging systems that no one hears, security risks, lighting and space issues, lack of privacy due to patients being placed in hallways and other open areas not designated as patient care areas. Organizational factors may include budgeting limitations, staffing to patient ratios and contingency problems. Dealing with unexpected sick calls, inability to fill those calls, power outages and electronic documentation systems that fail, external environmental disasters, rapid influxes of unexpected patients and the media are all common factors that can disrupt hospital care. Well written policies are a must to guide staff in continuing to provide quality care while minimizing errors and hopefully avoiding sentinel events. Potential hazards and errors can be avoided by learning from the literature and past experiences of other emergency departments. Specific protocols for procedures performed in the ER are developed for this very reason. In the given scenario there is the issue of proper staffing which posed a hazard to the patient who eventually expired. Nurse to patient ratios in this scenario were inappropriate due to the fact that a patient who had received moderate sedation was not closely monitored and ideally should have received one on one nursing care for the duration of his procedure and until he met discharge criteria. This would have been possible had the RN asked for back up which was apparently available. Looking back on the scenario, it was noted that immediately after the joint reduction of Mr. B had been performed, a critically ill ambulance patient had arrived and the RN was responsible for that patient as well. In the emergency department, or any department for that matter, nurses are continually subject to frequent interruptions, the need to multi-task, and reliance on â€Å"work-arounds† because of inadequate systems  support. (Cherry & Jacob, 2011, p. 473) In the case of nurse J, she may have been fixated on completing other tasks, such as stabilizing the ambulance patient, thus distracting her from the ongoing developments with Mr. B. who appeared to be resting comfortably with his son at the bedside. Assuming the patient was safe with a family member, the RN missed the opportunity to reverse the downslide of events that unfolded. Not anticipating the need for additional help is a hazard when staff become overwhelmed but continue to proceed as if help is not needed, because they may be accustomed to being understaffed and working only with what they have. Therefore, this presents the issue of the culture of safety, or lack thereof. It did not appear that there was any organized culture of safety and the communication between staff members appeared to be minimal. Possibly there was an environment of distrust between coworkers, or an intimidating environment in which the RN was afraid to speak up to the ERMD regarding the management of the patient’s pain and sedation. Perhaps the LPN was intimidated by the RN and did not chose to inform the RN of the abnormal vital signs. It appears that inconsistent or absent communication skills among the staff present that day contributed overall to a hazardous situation. And lastly, possible poor training and education of staff creates a hazardous environment and the lack of critical thinking skills demonstrated in this scenario suggests that this is an area that needs to be examined closely at this hospital. There is no mention of what the LPN’s responsibility is in assessing the patient but it is difficult to comprehend how an experienced health care worker in an ER would not investigate a poor pulse oximetry reading further than simply resetting the monitor. Educational requirements and experience of the staff needs to be reviewed and revised by the interdisciplinary team as part of the improvement plan. Errors made in this scenario that contributed to this sentinel event include the fact that there was a specific protocol for conscious sedation and it was ignored. Although Nurse J was ACLS (advanced cardiac life support) certified, and she had completed the hospital’s training module, she did not follow the guidelines in the written protocol which more than likely would have prevented any of this event from happening. Perhaps she did not understand the protocol, perhaps she was accustomed to taking short cuts, or perhaps she was drug or alcohol  impaired. Another possibility is that the nurse was not able to find the online protocol on the hospital portal. Perhaps the portal was difficult to navigate and the policy was difficult to locate. Being under time constraint, a nurse might decide to forgo looking up the policy because it is too time consuming to look for it. Only Nurse J. would be able to provide us with this critical information. It is not clear as to why an experienced critical care nurse with no history of negligence did not follow proper procedure. Other errors include the fact that sufficient monitoring equipment was available and not utilized, including use of supplemental oxygen and possible end tidal CO2 monitoring. Furthermore, no one in the department called for any back up, such as a nursing supervisor or a respiratory therapist to help manage the patient. The ER physician who ordered the medications did not communicate with the nurse before the procedure about the risks associated with this patient, including the patient’s home use of opiates for his chronic pain. Polypharmacy, possible use of supplements, adherence issues, and the potential for adverse drug events all posed potential hazards that needed to be addressed. (Williams, 2002, ∂ 1) The RN did not question the physician about the orders and the physician in turn, did not question the nurse if she had any concerns. There was no â€Å"time-out† procedure performed by the staff, which would have given staff members the opportunity to voice concerns. The doctor also failed to notice that the patient was not being appropriately monitored, and along with the rest of the staff he did not appear to display a teamwork mentality. The key to a successful root cause analysis is to search for answers as to what system errors and failures need to be corrected, and not to pursue blame on any one individual. Individual blame centers around forgetfulness, inattention, or moral weakness. It is punitive. A systems approach examines the conditions under which health care workers work and sets up defenses to avert errors or mitigate their effects. (Cherry & Jacob, 2011, p. 473) The goal is to bring staff together to design and implement processes that provide uniform standards of treatment and care and provide safety to all involved and minimize the likelihood of harm or a sentinel event. B. Improvement Plan By requiring the staff of the emergency department to reexamine its actions on that day, a dialogue is created that hopefully will create a strong motivation to seek out better and newer ways to handle patients that require sedation and monitoring. If the participation is not there, then the motivation will not be created and change will not occur. One way of developing an improvement plan would be to apply the theories of change developed by physicist and social scientist Kurt Lewin in the 1950s. His change management model, known as Unfreeze-Change-Refreeze, refers to a three stage process of transitioning through change. Lewin believed that to begin any successful change process, one must first understand why the change must take place, and this is where the motivation for change begins. He stated that one must be helped to re-examine many cherished assumptions about oneself and one’s relations to others. This is the stage known as â€Å"unfreezing†. (Thompson, n.d., p. 1) In the case of the emergency department, the entire team needs to be compelled to change the way sedation procedures are performed, as well as how patients are handled before and after the procedure. In addition to reviewing the procedural sedation protocol, the team needs to look at overall hospital care of those receiving any medications that cause respiratory depression. This should not be too difficult to promote since the procedure performed that fateful day resulted in harm and subsequent death of a patient. Not only was the patient and his family harmed, the entire organization was harmed and is liable for this incident. The hospital and its emergency department’s community reputation is going to suffer. Knowing that the staff that day is probably emotionally traumatized and possibly fearful of the consequences, the environment is ripe for change and the unfreezing stage can begin with a review of the sedation policy and why it was not followed. Each individual there and staff that were not there that day need to be made aware and can meet one on one with the department manager to voice their concerns and questions. Barriers hopefully will be identified as to why the sedation protocol was not followed that day. The hospital already provides an electronic educational module on conscious sedation procedures which would have a required date for staff to complete. This module should be reviewed for any inconsistencies  and updated and it should be made easily accessible on the computer portal. The actual written policy should also be easily accessible on the portal as well as in print form in a binder at the nurses station, should staff not have access to the computer. An analgesic protocol could be developed in which there would be a minimum time lapse between opioid doses (for instance 10 minutes versus 5) and the use of a hospital approved sedation scoring system should be in place. Patients in addition to requiring continuous pulse-oximetry monitoring should also be on continuous end tidal CO2 monitoring as well, long considered a more effective way of measuring effective ventilatory status. A new electronic training module on the use of end tidal CO2 monitoring would be mandatory for nursing staff to complete and equipment in the ED would be upgraded to provide for this type of monitoring. A representative could come and demonstrate the use of this type of monitoring and sign off employees for a mini-education module. Although many emergency departments have upgraded their documentation to all electronic, it might be helpful for staff nurses who are continuously monitoring patients at the bedside to use paper forms to document the pre procedure requirements including consents, time-outs, intra procedure medications and response to those meds and vital signs as well as post procedure Aldrete scores and recovery notes. This would be advantageous for simply the reason that not every bed has access to a computer. Health care providers certified in Advanced Cardiac Life Support (ACLS) must be in direct attendance with the patient throughout the entire course of the sedation and until the patient is fully recovered. Their primary responsibility is to monitor the vital signs including heart rate and rhythm, blood pressures, respiratory rate and oxygen saturation, as well as the patency of the patient’s airway. The RN managing the patient should never leave the patient unattended or engage in tasks that would compromise this continuous monitoring. The RN is responsible for taking the leading role in assuring that the care provided is safe. Proper airway equipment and drug reversal agents should be at the bedside and this must be documented. In order to unfreeze the staff and help them to change their behaviors, the ED could hold mock sedation procedures to practice their skills in managing a sedated patient. Annual skills days should be held with  review of the policy and equipment used. Staff would be signed off annually on this module. Certifications for BLS(basic life support), ACLS, PALS(pediatric advanced life support) and possibly TNCC (trauma nurse core curriculum), should be up to date and the hospital should offer these courses on campus to make it easier for their employees to maintain their certifications. Staff members whose scope of practice do not require them to practice ACLS or PALS should be reeducated on what normal vital signs are, how to set parameters on the cardiac monitors, how to take vital signs on the cardiac monitor and they need to review basic BLS skills by attending their own skills day. Teaching should include basics on what normal vital signs are for different age groups, and how medications can alter these vital signs. If the hospital has the funds to open a simulation lab, all nurses and allied health personal could practice simulated scenarios on mannequins and even videotape them. This would be a huge asset for the staff of all the patient care departments. Another part of the improvement plan would include classes for staff on communication and critical conversations. Learning how to communicate as a team and voice concerns about patient safety is a skill that requires practice, confidence and no fear of retribution or intimidation. Staff members who deal in stressful and hectic environments may at times be uncertain when they see behaviors that are unsafe and therefore may elect to say nothing when they believe the care of a patient may be compromised. In the case of the LPN who turned off the SPO2 alarm, I would wonder if perhaps there was a communication barrier between her and the RN and or the MD, or was it simply a knowledge deficit. An action plan needs to be in place for a saturated emergency department in which additional staff can be called in with a less than 30 minute wait time, or perhaps float other available qualified staff from other departments, such as the critical care unit or the telemetry floor. Because critical care nurses are accustomed to working in a 1:1 environment with their patients, it would have been ideal to float a CCU nurse to the department when Nurse J realized she could not take care of the rest of the department without leaving Mr. B unattended. Of course this may not have  been feasible since we do not know the census in the CCU. Chart reviews are also an invaluable tool for improvement. The manager will assign nurse in the ED to perform a monthly audit of all sedation charts with checklists of what was done correctly and what was not. These audits are important for providing data on how the ED needs to improve its performance and safety measures. This data will be provided not only at ED staff meetings but at quality improvement meetings involving the nursing director and hospital administration. If there is a problem convincing the hospital to provide safe staffing levels, the ED must provide strong data in order to show administration that there is a need to provide additional nursing. After the uncertainty of the unfreeze stage has occurred, change then begins to take place. Staff will start to believe and act in ways that support the new growth of the department. The transition will not happen rapidly as people take time to learn and embrace new ways of doing things and for each individual the rate of change is personal. In order to accept the new change and contribute to its success, staff will need to understand how the changes will benefit them and not every person will feel this way. Most healthcare workers probably feel that if healthcare delivery is made safer and better for their patients, then they will buy in to the need for changes and produce those changes. Unfortunately some of these people may feel harmed by change, and it is possible to notice some folks not participating in meetings, outside events, or educational updates. They may voice discontent with the whole process and complain that the changes are unnecessary. They may feel the status quo is being challenged and are threatened if they are unable to adapt to the changes. They may eventually leave the department or even the hospital environment as a whole. These are the people who may require the most encouragement and handholding to get them through the transition. Time and communication are of utmost importance and as staff gains understanding of the changes, they also need to feel connectedness to the organization throughout the transition period. (Thompson, n.d., p. 3) Lewin’s third stage of change, or Refreezing, takes place when the organization has identified the barriers to sustain the changes made, and when it has identified what makes the changes work. Employees feel  confident and comfortable using new communication techniques, they participated in learning the new procedures and feel supported by their peers and leadership. There is an established feedback system for employees to participate in regarding their education and training, in which they can voice what works and what doesn’t. Changes are now used all of the time and are incorporated into the normal day to day operations in the ED. If the changes are not used regularly and not anchored in to the culture of the ED, the refreezing state cannot occur and employees may get caught in a â€Å"transition state† where each person is not sure how things should be done and there is no consistency for policies and procedures being followed. For the refreezing states to be successful, the department should celebrate its success with the change. Employees will need to have a sense of closure and management needs to help them feel appreciated for enduring an uncertain and uncomfortable time. It is important to encourage staff to believe that the contributions they have made have made the changes a success. (Thompson, n.d., p. 4) Continuing to provide support and transparency keeps employees informed and motivated to preserve the new changes in place. Allowing staff to voice their opinions and participate in how changes are rolled out is part of this process. Overall, a team approach to care is of utmost importance in the ED and each individual should be encouraged and reminded regularly how important their contributions are to the whole. Reward systems to encourage pride and enthusiasm for work well done can be included at monthly staff meetings. One or two employees might receive a gift or a trophy for hard work, these recipients would be nominated by their peers who anonymously write a nice note about someone who did something nice for a patient or a staff member or just did a particularly great job that day. Team building activities can also include an organized activity outside of the ED where employees and their family members can socialize together and relax. Nursing leaders and managers should strive to build environments that are conducive to friendships, facilitating and promoting good communication and respectful communication between nurses, physicians and administrators. (Blosky & Spegman, 2015, p. 34) Trust is the cornerstone of good communication, which was sorely lacking in the ED that day. C. Use a failure mode and effects analysis to project the likelihood that the  process improvement plan you suggest would not fail. (Identify the members of the interdisciplinary team who will be included in the RCAS and the FMEA) FMEA is a step by step process used to identify all possible failures in a design , a manufacturing or assembly process or a product or a service. FMEA was started by the US military in the 1940s, and was further developed by the aerospace and automotive industries. (American Society for Quality [ASQ], n.d., p. 1) It has been adopted by the healthcare industry successfully as a tool to identify areas of healthcare processes tat may fail, in order to prevent harm or sentinel events before they occur. â€Å"Failure modes† are the ways, or modes in which something may fail. Failures are errors or hazards, which affect the customer and in healthcare the customer is usually the patient. These errors or hazards can be actual, or potential. Effects analysis is the study of consequences of those failures. Failures are prioritized in order of how severe the consequences are, their frequency of occurrence, and their ease of detection. The purpose of the FMEA is to eliminate or reduce the percentage of failures, starting with the highest priority areas. (ASQ, n.d., p. 1) In the scenario of Mr. B, unfortunately the FMEA cannot change the outcome, but it will be a proactive method of developing a new policy and procedure for how sedation cases are handled in the emergency room setting. The FMEA will be used to evaluate the new protocol for sedation procedures as well as staffing protocols related to monitoring 1:1 patients. This evaluation will occur before the actual implementation and will be used to assess its impact on the existing protocols.(IHI, 2015, p. 1) The process that needs to be evaluated and improved specifically to the case of Mr. B, would be the moderate sedation policy and its specifics to requirements of staff during the procedure and the recovery period. Some of the failure modes that may occur or have the potential to occur would be staff resistance to change, inexperienced nurses or practitioners with lack of education, inadequate ability to staff the ED appropriately during influx of patients, sick calls, or inadequate equipment or equipment failure. (Study Mode, 2014, p. 12) The key to a successful FMEA will be the involvement of a interdisciplinary  team, which would most likely consist of the some of the same members of the RCA. An emergency room physician, preferably the director, director of respiratory therapy, the hospital pharmacist, the ED nursing director, a risk manager, a head administrator who can lead the group in decision making, one or two ACLS certified staff nurses from the ED that perform sedation procedures, head of anesthesiology, and possibly even members from other departments where moderate sedation is performed. The team will need to meet regularly and be committed to providing continuing support during the course of implementation. C1: Interventions With the unfortunate scenario of Mr.B, it is now up the the interdisciplinary team to begin testing interventions that will or may be integrated in to the new plan for management of moderate sedation patients, with the goal of improving safety and eliminating adverse events. Once the established team has focused their aim, their next step would be to test a change or a few changes in the ED. This would be done with subsequent procedural sedation procedures which are commonplace in the ED. A small but major change to test would be the mandatory presence of an ACLS certified RN in 1:1 care of the patient from the beginning of the procedure and throughout it to discharge. The goal of this change is to prevent adverse events from respiratory depression in 100% of all patients receiving sedation in the following 6 month period. Performing this test several times will enable the team to see if the staff is actually complying with the new protocol and what barriers there are to prevent it from being successful. Staff will give feedback later as to what is working and what is not, and what they think needs to be done to make the changes work. An effective way to implement testing would be to utilize a PDSA cycle. The Plan-Do-Study-Act (PDSA) cycle is known as shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. (Institute for Healthcare Improvement [IHI], 2015, p. 1) According to the Institute for Healthcare Improvement, the reasons to teats changes are as follows: To increase ones belief that the changes will result in improvement To decide which of several proposed changes will lead to the  desired improvement To evaluate how much improvement can be expected from the change To decide whether the proposed change will work in the actual environment To decide which combinations of changes will have the desired effects on the important measures of quality To evaluate costs, social impact, and side effects from a proposed change To minimize resistance upon implementation The Institute for Health Improvement lists these steps in the PDSA cycle to include: Step 1: Plan Plan the test or observation, including a plan to collect the data State the objective of the test: â€Å"Minimize or eliminate adverse events from respiratory depression while being monitored in the ED under conscious sedation† Make predictions about what will happen and why Develop a plan to test the change (Who, what, when where? What data needs to be collected?) Step 2: Do Try out the test on a small scale: maybe only perform the test in a 3 week period, on sedation procedures performed between the busiest times of the ED, for example between noon to 6pm. In a 6 bed rural ED, this might actually be the busiest time period. Carry out the test Document problems and observations, unexpected and expected Begin analysis of the data Step 3: Study Set aside time to analyze the data and study the results, for example: a biweekly or monthly meeting of the FMEA team. Complete the analysis of the data Summarize and reflect on what was learned Step 4: Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for next test, probably on a larger scale. For example, test all sedations over a month , for actual 24 hour periods in the ED. In addition to performing the PDSA cycles, the ED could appoint a volunteer or volunteers from the department to form a safety committee with a leader being the liaison who would have the authority to come up with quick solutions to certain problems that are encountered in the department on a daily basis. The liaison would take care of fixing broken equipment or replacing it, ordering new equipment and providing user training, communicating with staff about safety concerns and bringing these concerns to management and the FMEA team. The safety liaison would be trained in Human Factors Engineering, the science of why people make mistakes. The staff will need to be reassured that this person is their ally and not an informant or disciplinarian. (Institute for Healthcare Improvement [IHI], 2015, ∂ 1) This is a person they should feel comfortable reporting their concerns to. This person could take an active role in the PDSA testing and collect data as which could be added to the monthly chart audits of all the conscious sedation procedures performed since that fateful day with Mr. B. C2: Presteps: Discuss the pre-steps for preparing for the FMEA. Step one in preparing for the FMEA in regards to revising the sedation protocol involves selecting a specific process to evaluate. While there were many factors that contributed overall to the sentinel event that occurred , the FMEA should be focused on a sub process. Conducting an FMEA on a combination of the sedation protocol, the staffing ratio issues, the communication problems between staff members, knowledge deficits of staff and equipment issues would be an overwhelming task, so instead we will consider individual analysis of each variant. In this case, we are going to focus on creating a better defined policy on how to safely perform conscious sedation in the emergency room setting in order to prevent further sentinel events. We want to define in the policy what licensed and certified personnel is to be present and performing the procedure, and step by step spell out what is required of those team members from the time of informed consent to the time the patient is discharged from the ED. The policy needs to be easily accessible and there needs to be a standard way of making sure staff has read the policy and understands how to follow it. The goal is to make sure that the patient has 1:1 care at all times with qualified  personnel and leaves the ED in stable, improved condition. The second pre-step is to recruit the multidisciplinary team, including everyone who is involved at any point in the process. Be clear that not all people need to be included on the team throughout the entire process, but should be part of the discussions in which they are or did participate in the process. For example, In the case o f Mr. B, radiology was probably at the bedside performing pre and post reduction films, in which the RN clearly would not have remained at the bedside unless he or she was wearing a lead apron. Pharmacy may have become involved if they had to mix any post resuscitation drips for the patient after he returned to a sinus rhythm from ventricular fibrillation. The secretary was involved in calling a rapid response team, and members of that team may be able to provide valuable insight as well. The third pre-step is to have the team meet together to create a list of all of the steps in the process. Every step should be numbered and be as detailed as possible. Note that this may take numerous meetings to complete this portion, due to all of the variables and complexities. Using flowcharts helps team members to visualize the processes more clearly and create a more understandable outline of the steps. There needs to be a group consensus that the outlined steps of the FMEA correctly show the process. By creating a step by step flow sheet the team will be able to visualize the scenario in detail and begin the process of elimination of what does and does not work and move on to pre-step 4. The team will now begin to list all of the possible failure modes. Possible failure modes include absolutely anything that could go wrong, such as the following: Staff not trained in protocol Staff not knowing how to properly use equipment Monitor not connected to patient Equipment not plugged in Medications not reconciled Communication problems between peers Assessments not completed Ancillary staff not educated IV fluids not running Patient experienced respiratory arrest These are just of the few of the possible failure modes that could be listed. For each of these failure modes, the team must list a cause. For example, in the case of Mr. B, he was never connected to a cardiac monitor until he went unresponsive, so the team must try and explain the cause of this. Prestep #5 , for each failure mode, the team will need to assign a numeric value which is called the Risk Priority Number or RPN. The RPN is a measurementof three variables: the likelihood of the failure occurring, of it being detected, and its severity. This is a scoring method that assists the team in determining what areas need the most most focus on improvement. C3 Three Steps: Once again, assigning numeric values to three separate variables assists the team in determining the issues which should be prioritized in order of importance, or the need for improvement. The three topics are as follows:( IHI, 2015, p. 4) the likelihood of occurrence: In other words, how likely is it that this failure mode will happen† A score between 1 and 10, with 1 meaning â€Å"very unlikely to occur† and 10 being â€Å"very likely to occur†. In the case of Mr. B, had a FMEA already been in place prior to his visit to the ED, the likelihood of his demise would have been much more unlikely to occur. But the system had failed him and due to all of the multiple mistakes that did occur that day, the likelihood of what happened was higher up on the numeric scale. the likelihood of detection: If this failure mode does happen, how likely is it that it will be detected? † A score between 1 and 10, with 1 meaning â€Å"very likely to be detected† and 10 being â€Å"very unlikely to be detected.† On the day of Mr. B’s demise, there were multiple opportunities for the staff to detect that there was a potential problem, but they did not. No one noted the lack of staff, communication was poor, and proper equipment was not utilized. So, this question goes back to the Root Cause Analysis and in the FMEA the team will need to determine how the staff can detect these failures before harm occurs again to someone else. the severity: If the failure mode happens, what is the likelihood that the patient will be harmed? † A score between 1 and 10, with 1 meaning â€Å"very unlikely that harm will occur† and 10 being â€Å"very likely that severe harm will occur†. According to the IHI, a score of 10 often means death. In Mr. B’s case, the consequence that resulted from the  failures in the ED that day was his untimely death. So the severity rating for that particular day would be a 10. D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities: The professional nurse plays a critical role in hospital quality improvement, since nurses are the primary caregivers in the system of healthcare. They are pivotal in improving the processes in which care is provided. According to Cynthia Barnard, MBA, the role of the professional nurse in quality improvement is two-fold: to carry out interdisciplinary processes to meet organizational QI goals, as well as measuring, improving and controlling nursing sensitive indicators affecting patient outcomes specific to nursing practices. She states that all levels of nurses, from the direct care at the bedside, to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization. (HCpro, 2010, p. 1) Ms. Barnard lists the following levels of nursing and their professional responsibilities: The CNO: The CNO sets the tone for the nursing departments participation in QI. As an administrator, the CNO is responsible for integrating nursing practices in to the organizational goals for excellence in patient outcomes by communicating the strategic goals to all the levels of staff. The nurse manager (NM) or nursing director: The NM or director is responsible for communicating and operationalizing the organization’s QI goals and processes to the bedside nurse. The NM identifies specific nursing sensitive indicators that need improvement according to the organization’s specific patient population and coordinates QI processes to improve these at the unit level. The direct care nurse: The bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care. Important to this provision of quality care is the fact that professional nursing leaders are the key factor in setting the tone and providing an environment in which all health care staff feel empowered to uphold these expectations. If nursing leadership and administration feel that they have less than adequate engagement of staff, it may be simply because the staff may not always understand the rationale and momentum  behind particular quality improvement initiatives. For nurses to be involved in delivering high quality care, it is imperative that leadership allows the participation of staff nurses into the design and implementation of processes by continuously educating and informing them, instead of simply telling nurses what they are supposed to do. A hospital culture that encourages quality as everyone’s responsibility is most likely to achieve sustained and noticeable improvement. Because nursing practice occurs in the context of a larger team, the impact of other departments and practitioners must be included in leadership’s efforts to improve quality. (Draper, Felland, Liebhaber, & Melichar, 2008, p. 4) By having every staff member engaged, including the other members of clinical staff, ie; physicans, respiratory therapy, even housekeeping and dietary management, accountability for patient safety and quality becomes a group effort and does not rest mainly on the shoulders of the nursing population. References American Society for Quality (n.d.). Failure Mode Effects Analysis (FMEA). Retrieved July 3, 2015, from http://asq.org/learn-about-quality/process-analysis-tools/overview/fmea.html Blosky, M. A., & Spegman, A. (2015). Communication and a healthy work environment. Nursing Management, 46(6), 32-38. Cherry, B., & Jacob, S. R. (2011). Contemporary nursing; issues, trends and management. Available from https://online.vitalsource.com/#/books/978-0-323-06953-3/pages/52165015 Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The rrole of nurses in hospital quality improvement. Retrieved July 3, 2015, from http://www.hschange.org/CONTENT/972 Frain, J., Murphy, D., Dash, G., & Kassai, M. (n.d.). . Retrieved, from Galley, M. (n.d.). Basic elements of a comprehensive root cause investigation; three steps and three tools that organize and improve your problem solving capability. Retrieved June 29, 2015, from rootcauseanalysis.info HCpro (2010). Ask the expert: Understanding nur sing roles in quality improvement. Retrieved July 6, 2015, from www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles-in-quality-improvment.html Institute for Healthcare Improvement (2015). Failure modes and effects analysis. Retrieved July 3, 2015, from