CHAPTER 2

REVIEW OF RELATED LITERATURE AND STUDIES

Nursing Practice Student nurses often express a mix of excitement and apprehension, enthusiasm and reservation at what may lie ahead. Nursing courses are busy, demanding challenging and dynamic. The variety of practice experiences along with the education demands that you need to be recognized. (Schober & Ash, 2006) Nursing as a profession has made great strides in effecting federal and state health care legistration. The 1990s were filled with challenges as nurses were held accountable for quality nursing care amidst cutbacks in staffing patterns. Some of these challenges were settled by legislative outcomes such as determining nurse-client ratios in skilled nursing facilities and prohibiting acute care hospitals from assigning unlicensed personnel to perform nursing functions, in lieu of registered nurse. (Taylor & Piliae, 1998) For nursing students, learning occurs in various settings including the classroom, laboratory, and clinical area; that is hospital as well community sites. Teaching nursing requires facilitating a thoughtful engagement between the learner and the learners, who acquire the skills and knowledge for a relational practice. (Young & Paterson, 2007) In an attempt to recognize and control the practice of nursing, nurse practice acts, on a state-by-state basis, have established guidelines to ensure safe practice and to demonstrate accountability to society. The standards of care, as set forth in the practice acts, are based on the phases of the nursing process and require evidence of compliance by documentation. Nurses should be familiar with the practice acts and rules of the state in which they work. (Paniels, 2005)

The clinical experiences for nursing students exist not only to supplement the academic portion of the education but also to serve as an essential gateway into a practice profession. In fact, it is because of nursing practice profession that clinical practice may be even more important than classroom performance. (Towns, and Winks, 2005) The mastery and improvement of the students skills are also dependent on the cases that they will handle during hospital duties and independent actions that the institutions will allow. Restrictions and limited number of patients are factors that hinder the students to become skilled. Based on the studies of (Farkhondeh, 2005), the nursing students were not satisfied with the clinical component of their education. Gender Nursing is considered a predominantly female profession. History has pointed out that nurses are females and the doctors are males. The nursing profession is stereotyped as dominantly female. Florence Nightingale is considered a nursing icon. Florence gave birth to the stereotype of nurse which is a female. That is why only few males enter the field of nursing because of the stereotyping. According to men who enter the nursing profession faces a challenge wherein they must maintain their masculinity in a female-dominated profession. Men who work as a nurse has the fear of being viewed as unmanly, moreover there are structural barriers to males that cross over to a profession dominated by the opposite gender and the gender division exists greatly to men than women. Like in the case of young women that act as tomboys wherein it is acceptable, on the other hand, it is unacceptable for young boys to act and compromise their masculinity. Age

Young adulthood covers the period of early adulthood when people are exploring personal relationships. Erikson believe that a strong sense of personal identity is important to developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. The formal operational stage begins at approximately age twelve and lasts into adulthood. During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage. Piaget believed that deductive logic becomes important during the formal operational stage. Deductive logic requires the ability to use a general principle to determine a specific outcome. This type of thinking involves hypothetical situations and is often required in science and mathematics. The 11 Key Core Competency Based on a work by the Institute of Medicine (2003), leaders of the QSEN (Cronenwett, 2007) defined six competencies to guide professional development: PatientCentered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, and Safety and Informatics. Each competency has requisite Know ledge, Skills, and Attitudes. Simply stated, there are specific domains of knowledge that must be mastered, skills that must be developed, and attitudes that must be cultivated if a nurse is to deliver high-quality, safe, patient-centered care as a member of a health care team. The Quality Improvement Competency is defined as using "data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems". The knowledge that a clinician needs to meet this competency includes understanding variation and measurement to assess

quality of care, knowing strategies for learning about the outcomes of care related to one's practice (for example, knowing the wound infection rate in one's area of specialty), and designing approaches to decrease rates. This requires the clinician to have access to data about clinical outcomes, the ability to use data to benchmark with local and national databases to identify gaps in best practice, and how to use an improvement model to design, implement, and test changes in daily work. Safe and Quality Nursing Care Nurses are in a powerful position to improve the quality of care, the experience of patients, and health outcomes across health services. They identified that patients want to be treated well, to know that their nurse is knowledgeable that they are, skilled and competent, to have high quality care every time and that they want their nurses to have a caring and humane attitude, and make them feel safe and comfortable cared about as well as cared for. The attitude and approach of the nurse are the most important factor in securing this experience for patients, enabling them to be treated as a human being not a case with compassion, respect, empathy and by staff who are interested in YOU. (Daniels, 2005). Management of Resources and Environment Nurses have responsibility to assess for and provide for a safe client environment and anticipate areas of high risk (for both the client and the nurse). Client falls is one of the most prevalent reported injuries and with proper assessment these incidents could be drastically reduced. Always assess a clients environment relative to individual client, diagnosis, and administered medication. Reassess environment as needed. Remember: An

ounce of prevention is worth a pound of cure. (Gershon, Karkashian, Grosch & Murphy, 2000) Despite the documented substantial costs associated with nurse turnover (the cost of replacing a nurse is estimated to range from $US10000 to $US145000 (or up to 150 percent of the nurses annual compensation), depending upon the type of job, level of experience and clinical skills (Barney (2002), Contino (2002), only 20 percent of U.S. health care settings had nurse retention programs, and of these, only 10 percent were deemed to be effective (Barney 2002). A common program component of hospitals and health care settings that do have retention program is climate or culture surveys that can be used to gauge the perceptions of nurses, especially with regard to their unit culture and quality of work life (Coile, 2001), Gifford, 2002). Another effective method is simply, yet rare in its occurrence, having managers communicate directly, frequently, and respectfully with nursing staff. Studies of voluntary nursing turnover have found that reasons for leaving which were reported to third parties differed substantially from those reported to employers upon departure, suggesting nurse-administrator relationships were typified by a lack of trust and poor communication linkages (Cline, Reilly & Moore 2003). Furthermore, administrators need to understand that nurses, as trained professionals, expect to be provided with autonomy (Aiken et al. 2002) and the opportunity to provide input and recommendations on how to improve their work setting (Lacey & Ribelin, 2003). Health Education Health care education today, both patient education and nursing staff/student education are topics of utmost interest in every setting in which nurses practice. The current trends in health care are making it imperative that patient and their families be

prepared to assume responsibility for self-care management. Also, these make it essential that nurses in the workplace be accountable for the delivery of high-quality care. (Bartable, 2003). Nursing has often been maligned and criticized, both inside and outside of the profession, for its ability to understand and conduct effective health promotion and health education-related activities. In the absence of an expert-based consensus, nurses may find it difficult to progress beyond the current situation and this study seeks to fill that knowledgegap. An expert consensus was reached on 65 of the original 134 statements. While some minor contradiction was demonstrated, strong consensus emerged around the issues of defining health promotion and health education and the emergence of a wider health promotion and health education role for nursing. No consensus was reached on only one of the 13 identified topic categories - that of nurses working with other disciplines and agencies in a health education and health promotion role. This study provides a hitherto previously absent expert consensus on the current position of health promotion and health education in nursing and predictions for their future course. Its findings represent an important step for nurses as they seek to become increasingly active and influential within wider health promotion and health education arenas. Relevant to clinical practice, Delphis study does not necessarily offer indisputable fact. This study, however, with its strong consensus on the majority of original statements is a good indicator as to how nursing experts currently view health promotion and health education constructs. Expert consensus offers a useful form of measure against current and future clinical practice and helps to build a firm foundation for change. Nurses, then, are advised to refer to the findings

presented, that they remain contextually and conceptually clear, as they embark on current and future health promotion-related activities. (J Clin Nurs, 2008) Nursing education in the United States has undergone tremendous changes in recent years. Those providing care and teaching in schools of nursing are better prepared educationally than ever before, the science that underlies our practice is increasingly being built through scholarly efforts of nurses, and collaborative partnerships between nurses and other health care workers who continue to evolve. In addition, the opportunities for nurses to influence the health of people through their roles as nurse practitioners, nurse midwives, home care clinicians, managers and administrators, health educators, acute and long term care clinicians, and faculty are growing dramatically. Legal Responsibility Legal responsibility in nursing practice means the way in which nurses are obligated to obey the law in professional activities. The law is the final authority for regulating activities of all citizens including professional practitioner. Disobedience of the law results in punishment. (Fundamentals of Nursing, Basavanthappa, 2004) Nurses have to abide by laws and regulations when practicing nursing. All of the regulations and legal aspects of nursing are taught and explained to nurses throughout nursing school. Not abiding the code of ethics could cost the nurse his or her nursing license and result in a malpractice suit. (Taunda, 2009) Nurse Practice Act Every state has a Nurse Practice Act, which states all the guidelines and laws for the nurses who are licensed to practice in the state. The act includes the limitations and training specifications of each nurse. This means that each nurse has been trained in a

specific area of nursing, therefore, the nurse must practice in that area only. If a nurse is not trained to administer medication or treatment to a patient, the nurse is not permitted to do so. The nurse must consult with a physician or other nursing authority when a situation arises that the nurse is not certified to handle. Any wrongdoing is a violation of this act, and the nurse may lose his or her nursing license, as well as having a suit filed against him or her or the health care agency or hospital. Patient Advocate A nurse has the legal responsibility to be the advocate for the patient in all health care instances, including emergencies. The nurse will be the liaison between the physician and the patient. The nurse has the legal duty to monitor the patient and watch for any abnormalities or complications that may occur. If any occur, the nurse must access a physician to provide immediate care for the patient.

Administering Medication Any nurse who is certified to administer medication to a patient must do so accurately and timely. The nurse has the legal responsibility to interpret the charts and files of a patient and to understand what allergic reactions patients may or may not have to a certain medication. If a nurse does not administer the correct dosage or medication to a patient, the patient could suffer major health risks or even death. This is a ground for a malpractice suit against the nurse and health care facility. Patient Neglect The nurse will provide care for the patient he or she is monitoring at all times. If the patient needs assistance with any issues, such as hygiene, the nurse has the legal

responsibility to assist the patient. If a nurse does not monitor and provide care to the patient, this can be considered patient neglect, which is unethical and illegal. The patient may try to move and use the restroom on his or her own and may be physically injured in the process. Some patients may harm themselves while under the influence of medication, which should not happen if the nurse is paying proper attention to his or her patient. A nurse acting at par with professional standards while practicing many of these risks and dangers can be averted. Nurses must know the law that governs her profession to avoid law suits against her. The knowledge of legal responsibilities is integral with the expanding clinical role, and a logical application of the planned, systematic, and focused care, which should be the goal of Modern Nursing (Shaw, 1998). The Supreme Court has confirmed that the patients receiving deficient services from the medical practitioners and hospitals are entitled to claim damages under Consumer Protection Act 1986. (Yawad, 1996) For the implementation of high quality of nursing practice in the world of latest

medical and technological advances a good knowledge of legal responsibilities is a necessity. Objectives: 1. to assess the knowledge of legal responsibilities in patient care among nursing graduates; 2. to compare the knowledge of legal responsibilities in patient care among Diploma and B.Sc. Nursing graduates; 3. to find out the relationship of knowledge score of nursing graduates with the variables such as (a) age (b) academic education (c) work experience (d) exposure to In-service education.

Long past are the days when nurses have fulfilled their responsibilities by simply carrying out the orders of the treating physician. Nurses are fully recognized as professionals who are responsible for independent nursing care, involving activities of daily living, health education, health promotion, and counseling. Nurses are additionally being held accountable for providing a "check" of physicians, other nurses and ancillary health care providers as an essential aspect of their practice. Courts have remained consistent in supporting this role for nurses with no rulings since the landmark cases discussed in this paper. (Cavico & Cavico, 1995). Three reasons exist for imposing these responsibilities on nurses. First, because of the nurses' education and role in the delivery of health care, the nurse is in the best position to evaluate the entirety of care. While this does not mean that the nurse will be held to the expertise of a physician or other health care provider, the nurse will be required to use his/her best judgment in each situation using his/her own knowledge of past experiences, facility policy and national standards to evaluate care (Palmer, 1999). The second rationale for insisting on these responsibilities from nurses is that nurses are held to specific professional standards. These standards are determined from documents such as the American Nurses Association (ANA) Standards of Practice (ANA, 2004) or the Kentucky Nurse Practice Act (Kentucky Board of Nursing, 2004). Because of such standards, nurses are required to function as professionals with professional responsibility. While the nurse is not permitted to function outside his/her area of expertise, that nurse must not facilitate, permit nor carry out activities that are incorrect. The third reason for requiring this responsibility is that the nurse is an employee of his/her particular health care facility. As an employee of a health care facility, that facility

is liable for the conduct of its employees through the doctrine of respondent superior. Respondent superior in its simplest sense means that a principle (employer) is responsible for the actions of his/her agents (employees) in the course of employment. Ethico-Moral Responsibility As a profession, nursing has established standards of behavior that govern the practice. These standards are called codes of ethics. In the document governing ethical nursing practice, The ANA Code for Nurses identifies the goals and values of the profession. It includes interpretive statements that explain how each goal is realized in nursing practice. Not surprisingly, the code focuses on the protection of the client and the identification of standards for a nurses interactions with clients. (Daniels, 2005) This article summarizes the body of research about ethical conflicts described by nurses in various fields of practice and recommends direction for the use and extension of this information. Twenty-three studies that fit criteria for inclusion were located. As a group, studies use inconsistent terminology, pay little attention to measurement characteristics of the instruments used, and do not use explanatory theory about how and why ethical conflicts develop or are experienced. Several studies of nurses practicing in community and home care settings, in intensive care units, and in administrative roles show some common areas of ethical conflict. Studies of ethical conflicts can be used as a basis for improving practice. (Redman, 1997)

Personal and Professional Development Professional Development

Nurses are required to be compassionate, patient, skillful, and able to handle multiple tasks at once, responsive, efficient, intelligent, caring, and responsible. These are few of the qualities that a nurse must possess at the same time and also maintain critical thinking skills without making errors. Personal Development Health care institutions are progressively more aware of the need to respond to diverse patient populations and cultivate leaders to enrich the nursing profession both locally and globally. One response has been to establish international exchange programme for nursing students to give them experience of different cultures and health care systems. Nurses and the health care systems go hand in hand. The need for nurses is increasing on the professional front. The quality of leadership, caring and the healing touch expected of nurses forms a relationship-centered framework. Nurses need to follow a routine that involves care, health and hygiene. There are various programs that help nurses on a professional basis and provide education that is skill- based and evident in their approach. The professional development programs for nurses offer a number of courses that help them to learn and apply. They are taught how to manage stress and handle situations under pressure. A number of professional development institutions for nurses offer a diploma or degree course depending on the duration. There are online courses that offer job placement and help the nurses to work at reputed hospitals and enhance their skill. The benefit of taking up a professionally developed program is that the placements are good and the pay scale is higher than the other non-professional ones. The recognition acquired is internationally approved. There are several courses offered such as professional career enhancement and satisfaction, community building and networking. The courses

also include development of skills for clinical integration of complementary and alternative modalities and acknowledgment of the spiritual connection within healing work. In professionally developed courses, the nurses are given all the training necessary for the job requirement. These nurses are given advice on how to apply and give interviews and to answer all questions with tact. A fresher can also apply to a professional development institute for guidance on the selection of a job, part time or full time. There are a number of nurses who are trained professionally, through the programs, but are looking for jobs away their homes, in other states. The professional development organizations help such nurses to get the desired jobs (Morgan, 2005). Quality Improvement The basic goal of the health care system in the United States is to provide services that will optimize the overall the health of the resident population. The key to achieving this goal is the commitment to quality - assurance, monitoring evaluation, and improvement. They have published standards to help health care organizations continuously improve and meet this basic goal. (Kozier, Berman, & Snyder, 2004) Research As nurses we want to be able to give the very best care to our patient and clients. In order to do this we need to know what the best is and how to give it. Research findings and evidence can give us some of the knowledge to help us decide what is best and therefore, to deliver the highest standards of care possible. (Hek, Judd & Moule, 1996) Record Management In an attempt to recognize and control the practice of nursing, nurse practice acts, on a state-by-state basis, have established guidelines to ensure safe practice and to

demonstrate accountability to society. The standards of the case, as set forth in the practice acts, are based on the phases of the nursing process and require evidence of compliance by documentation. Nurses should be familiar with the practices acts and rules of the state in which they work. (Daniels, 2005) When patients are in hospital or sick at home and visited by a nurse, it is important that the care they receive is recorded properly. Nurses record a wide variety of information about a patients care and progress. For example, nurses would record a patients status while in ICU every hour or when and how pain medication should be given and when it was given, or the progress of a pregnant woman visiting a clinic. These nursing records are a way for nurses to share care information with other nurses, other health care professionals and sometimes with patients. These are information that can ensure patient care is consistent when staff changes shifts or information that can be used later as a history of previous care. But what is the best way to record and share this information? Is there a system or way of recording care information that is best? It has been suggested that there may be a difference in how nurses practice or how well a patient does with the use of one record system compared to another. A review of the effect of different nursing record systems was conducted after searching for all relevant studies. These studies compared nursing records filled out on paper with nursing records done on computer; nursing records that were held by patients themselves to records kept at a hospital or clinic; and nursing records which used different types of forms. The aim was to investigate whether perceptions of electronic nursing documentation and its performance differed because of primary health care management.

Success in leading people depends on the manager's personality, the context and the people who are led. Close proximity to clinical work, with manager and personnel sharing the same profession, promotes the authority to carry out changes. This study comprised a postal questionnaire to district nurses and an audit of nursing records from two primary health care organizations, one with a uniprofessional (nursing) organization, and one with multidisciplinary health care centres with general practitioners and/or another profession as managers. Uniprofessional nurse management increased district nurses' positive perceptions of nursing documentation but did not affect documentation performance, which was inadequate regardless of management type. Positive perceptions of nursing documentation are bases for further development to a nursing documentation including a holistic view of the patient. Communication Intimidating behaviour and deficient interpersonal skills create a culture of silence, where there can be a breakdown in team communications and an inability to collaborate and achieve high-quality outcomes. A study from Vital Smarts. Nurses must be as proficient in communication skills as they are in clinical skills. They articulated standards based on the interwoven concepts and relationships of the quality of work environment, excellent nursing practice, and patient care outcomes. The standards are evidence-based and founded on relationship-centered principles of professional performance, such as how healthcare professionals communicate, make decisions, and collaborate. Each standard is considered essential to the creation of a truly healthy work environment.

Using a semi structured interview script, the moderator guided six unit-based focus groups at a 220-bed, Roman Catholic, community hospital, and a recorder took field notes of the interactions. The sessions were audio taped for transcription and analysis. Level I coding was done by the moderator and recorder after each group. Level II coding was done with the transcripts and conferral of two of the researchers. A follow-up questionnaire with a 5-point Likert scale was used to validate the 13 categories of difficult communication derived from the focus groups. Five themes were identified: specific diagnoses and clinical situations, patient and family emotions, nurses' emotions, triangle of nurse-physicianpatient communication, and nurse coping behaviours with difficult communication. Emotion was the core variable that made communication more difficult. The groups described five major themes in difficult communication. They also identified the heavy emotional component of nurse-patient communication and the difficulties arising in work relationships that complicated communication. (Sheldon, Barrett, & Ellington, 2006). Collaboration and Teamwork In health care, as in most industries today, effective team performance and collaboration (a partnership in which all parties are valued for their contribution) is the norm. Today, nurses work in multidisciplinary teams that form, dissolve, and reform in matrix structures, as need requires. But simply bringing the best trained and most skilful people to the task at hand is often a futile and fruitfulness effort. (Daniels, 2005) Collaboration operates on a model of shared power. However, this does not mean equal formal power. Role status in hierarchical systems is an invisible structure that connotes a formal or dominant level of power, which creates a power imbalance between group members. To achieve collaboration, participants must have some form of mutual

exchange. It is the task of one negotiating in a conflict to increase his or her potential for success by actively structuring for a more even power base. (Gray, 1994) Teamwork and collaboration expands a traditional focus on the nursing team to include communication and negotiation skills required in coordinating care across disciplines. New visions of teamwork help providers develop skills for mutual respect, situation monitoring, and cross monitoring in sharing care tasks and responsibilities (King, Toomey, Salisbury, Webster, & Almeida, 2006). Teamwork and communication seek to create a clear common language for all members of the health care team. Situation, Background, Assessment and Recommendation (SBAR) is a primary strategy in improving patient care and is now taught across health professions to promote clear, concise communication (Haig, Sutton, & Whittington, 2006). Preceptor Perceptions of New Graduate Nurse Readiness for Practice According to Hickey, Mary T. EdD, RN, NP (2007)Preparing nursing graduates for entry into practice is a priority for academic and healthcare institutions. To effectively prepare competent entry-level practitioners, it is important to understand clinical agency expectations. Most clinical agencies utilize some form of a precepted orientation experience for new graduate nurses. The purpose of this study was to examine preceptors' perceptions of the competence of new graduate nurses. Data analysis indicated several areas of weakness in new graduate nurses' clinical skills. This information can be used by academic nursing programs to revise clinical experiences to better prepare graduates for entry into practice. Findings can also be utilized to assist healthcare institutions with designing orientation programs for new graduate nurses. Suggestions are provided to help train preceptors for their important role. It is essential, particularly in today's complex

healthcare environment, that strategies be explored to facilitate success of the emerging nursing workforce. Phil. Journal of Nursing Education
Phil. Journal of Nursing Education Vol.19 No. 1 October 2009).Significant differences were found in the ratings given by the respondents groups in all areas in research and quality improvement in the level of competency. Despites these differences, the nursing students were perceived to have performance the competency standards within an acceptable level and their clinical performance considered entry level of proficiency for a professional burse. The cases handles and the extent of the performance of competencies in the clinical areas showed a significant correlation between the two variables. This indicates throughout repetitive performance of the competencies the nursing students perceived themselves to have fully developed and enhanced their skills and experience in the clinical setting.

Influences on Compliance with Standard Precautions among Operating Room Nurses According to Sonya Osborne, RN, BSN (2004), Occupational exposures of health care workers occur because of inconsistent compliance with standard precautions. The purpose of this study was to develop national estimates of compliance with standard precautions and occupational exposure reporting among operating room nurses (specifically, scrub nurses) in Australia and to assess variables that influence compliance. These results have implications for the development of multifaceted perioperative infection control programs, including strategies for prevention, education, and policy development, to improve practices aimed at reducing occupational exposures among this high-risk group. Instrument Readiness: A Patient Safety Issue According to Patricia Ann Hercules, 2005) Operating room instrument and equipment readiness and availability are necessary to safeguard patient care. Using

available data and real-life stories, this article defines, gives an historical overview, and outlines the existing professional standards on this issue. It elaborates on contributing factors such as availability, substitutions, stress, and distractions. It concludes that the health care profession should take a closer look at this as a patient safety issue. Teaching Methods and Theory (in pedagogy: Foreknowledge About Students and Objectives; Particularly in the basic subjects of language and number, and to measuring intellectual ability in the form of reasoning power. There has been special emphasis on the idea of the students readiness at various ages to grasp concepts of concrete and formal thought. Numerous agencies produce test material for these purposes, and in many countries the idea has been widely applied to. Maturation and readiness theoriesReadiness theories of learning lean heavily on the concept of maturation in stages of biological and mental development. It is assumed that a child passes through all stages of development in reaching maturity. The teacher finds out what a child is ready for and then devises appropriate materials and methods. Much of the work on reading skills, for instance, makes use of the readiness concept, measurement of intelligence and adult learning. (Thorndike, 1928). Weingarten's Theory of Readiness States the When? How? Best Way To? of Readiness Weingarten's 2008 Theory of Readiness states the When? How? Best Way To? of readiness In its simplest form people "get ready" and become acclimated to changes in their lives in different ways. Some people dive right in and get used to the experience while they're muddling through it. Other people need to have all the elements in place before they can make a change or move. Many people make a change and then take a few steps back before

they jump right in again, and other people make a change before they're ready to live it and then act that out in different ways. Safe and Quality Nursing Care you must do the following steps: 1. Demonstrates knowledge based on the health/illness status of individual groups 2. Provides sound decision making in the care of individuals/groups.

3. Promotes wholeness and well-being including safety and comfort of patients. 4. Sets priorities in nursing care based on patients' need. 5. Ensures continuity of care 6. Administers medications and other health therapeutics. 7. Utilizes the nursing process as framework for nursing

8. Formulates a plan of care in collaboration with patients and other members of the health team. 9. Implements planned nursing care to achieve identified outcomes. 10. Evaluates progress toward expected outcomes. 11. Responds to the urgency of the patient's condition. Readiness Levels of Learners Readiness is often not the ideas and skills that will vary with readiness in a differentiated classroom, but rather the degree of difficulty or complexity in the way students interact with the ideas or skills. In other words all learners should work with the essential ideas and skills that build toward understanding the subject and proficiency in the subject. Some learners need to work with ideas and skills at a concrete level using manipulative, diagrams, or other devices that allow them to experience the idea in a clear,

specified, guided, and tangible way. Other learners are ready to work with the ideas and skills at a greater level of abstractness, in fuzzier problems, and with minimal guidance. Type of work to prepare for learners - respectful tasks The First type, All students should be offered tasks that encourage them to think at high levels of thinking. The second type, All students should have consistent opportunities to be active learners. The third type, all students work with a wide variety of peers over time. The fourth type all students should sometimes be teachers. Fifth type, all students should be involved with learning that is new to them. The sixth type, All students should be consistently pushed a bit beyond their comfort zone. Flexible grouping of students enables all learners to work in a wide variety of configurations and with the full range of peers, while targeting specific learning needs. needs. Students sometimes work with peers of similar readiness so that the teacher can target the complexity of the task to student needs or target task by similar interest and learning profile. At other times, students work in mixed readiness or interest groups with tasks that enable all students to play essential roles in the group's success. Sometimes the whole class works as a unit, or students work independently, or students make choices.

Local Studies

Identification of the Core Competencies of Board of Nursing Investigators According to Bitz, & Smith, 2009), the purpose of the current study was to establish an evidence-based tool that could be used in the recruitment, training, and evaluation of investigative staff. Core competencies for board of nursing investigators are the knowledge, skills, and abilities that one must have to be a competent professional in the process of conducting investigations in the regulatory arena. To identify core knowledge, skills, and abilities necessary for board of nursing investigators and the development of a tool that may be used for the recruitment and hiring of well-qualified candidates, orientation and training, and performance evaluation of board of nursing investigators, a series of studies on the core competences for board of nursing investigators was conducted. The values and usefulness of these competencies are directly related to performance measurement and outcomes. The tool identified 4 primary categories of core competencies

communication/interpersonal skills, behavioral traits/professional conduct, knowledge and application of regulatory statutes and rules, and knowledge and application of investigative techniques and processes. It is the researchers' intent that by establishing a uniform competency assessment tool for board investigators, the setting of standards can then be defined, and ultimately, an investigator training program can be developed and best practices will be identified in this segment of regulation. (Bitz, & Smith, 2009). Nursing Core Competency Performances Starting this 21st century, nursing profession had already manifested profound transformational changes, not just here in the Philippines but also in other foreign

countries. These changes affect the health care agencies since they have to adopt what has been changed to maintain and meet the national and international standards. Bellosillo, (2008) postulated that due to the foregoing, new expectations for contemporary nursing practice, competencies are emerging, which is heightened by the escalating complexity of globalization, the dynamics of health science and information technology, demographic changes, health care policy reforms and the increasing and more exacting demands from the consumers of health care. Moreover, the surge of overseas employment opportunities for Filipino nurses creates depletion in the reservoir of competent professional to serve the health needs of the country. These changes are spawned by the multitudes of forces converging in the national as well as international levels, which impact on the quality of nursing practice in the country. Accordingly, the Board of Nursing had created a committee which is responsible for developing competency standards for nursing practice in the country and this is called: Committee on Core Competency Standards Development (CCCSD) together with collaboration in the Commission on Higher Education Technical Committee on Nursing Education (CHED-TCNED). Furthermore, Bellosillo, (2008) elaborated that the

Committee was composed of leaders from nursing education, nursing practice and nursing regulation. The whole gamut of developing the standards were made possible through the participation of representatives of professional nursing organizations, consumers of nursing practice such as doctors, administrators and patients, senior nursing students and in consultation with nurse executives from regulatory authorities in three countries. Most health care providers begin their health profession education expecting to acquire the knowledge and skills needed to provide high-quality care. However, as they advance

through their education and begin their careers, they discover that health care systems are exceedingly complex, with a myriad of system issues that often make the provision of high-quality care difficulty. In addition, Bates (1995) discussed that nurses are uniquely positioned to serve as change agents within health systems. By partnering with other health care providers who share their vision for improving care and by linking with institutional quality professionals, the impact of nursing improvement efforts is heightened. As health care systems increasingly recognize the value of this work, nurses find that their contributions to care improvement lead not only to a sense of personal reward, but may lead to professional advancement. Investment in the development of skills in quality improvement provides a means for nurses to improve the lives of patients, build their own careers, and improve the joy they derive from their work. Since then, the Board of Nursing had released a Resolution No. 112 Series of 2005 which centers on A Resolution Adopting and Promulgating the Competency Standards for Nursing Practice in the Philippines which give emphasis that the 11 core competency areas of nursing should be utilized as a framework for the development of Instructional Standards in the Curriculum, the formulation of course syllabi and questions in the Integrated Comprehensive Nurse Licensure Examinations and the development of standards and performance evaluation in the practice of nursing (Bellosillo, 2008). After this resolution number had taken effect, different nursing schools in the Philippines had adopted the application and incorporation of the eleven nursing core competencies in their curriculum specifically in Nursing Care Management and Related Learning Experience. The Mindanao Sanitarium and Hospital College had already

followed and applied these eleven nursing core competencies as a model principle of nursing practice. The institution had incorporated this in the related learning experience and part of their teaching syllabi on the subject Nursing Care Management.

Standards of Professional Performance of Registered Nurses in Operating Room The entry into the professional operating room (OR) nursing as the clinical practice setting of choice is as a staff nurse. A staff nurse should have a degree in Nursing (Nursing) who has successfully passed the nursing licensure examination (registered nurse or RN). A registered nurse should be competent to provide nursing care for all surgical patients and to ensure a safe environment to achieve desired outcomes of surgical interventions. Eight standards of perioperative practice has been identified that may be used to measure professional performance of registered nurses (RNs) in the operating room (OR).
1. Quality of Care. The perioperative nurses are expected to systematically evaluate

the quality and appropriateness of nursing practice. It is anticipated that RNs in the OR should participate the quality assessment and improvement programs to promote a quality care.
2. Performance Appraisal. The practice of a perioperative nurse evaluates his or her

own performance in context with the professional practice standards and relevant statutes and regulations. Defining and evaluating professional practice behaviors is an ongoing process. To provide a framework for future growth and development

self-assessment and feedback from the health care team members should be gathered.
3. Education. The perioperative nurse acquires and maintains current knowledge in

the nursing practice.

4. Collegiality. It is expected that a perioperative nurse contribute to the professional

growth of his or her peers, colleagues and others by sharing knowledge and expertise through preceptor program, role modeling and mentorships. This assists the colleagues to attain a broader base knowledge.
5. Ethics. The decisions and the actions of a perioperative nurse on behalf of the

patients are determined by the governing ethical principles. Delivery of care and services should be within the practice parameter of not violating the basic rights of the clients.
6. Collaboration. It is a standard obligation of a perioperaive nurse to collaborate not

only with the patient but also with the significant others and health care providers in providing care. To attain the expected outcomes patient care should be a unified effort that is supported by internal and external forces that follows the same goal.
7. Research. The perioperative nurse uses research findings in carrying out his or her

practice.
8. Resource Use. In the planning and the implementation of the patient care the

perioperative nurse should consider factors relating to safety, effectiveness, efficiency, environment. Daisy Jane, RN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric,

Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

Synthesis The level III nursing Students in Operating room will enhance their skills if they apply the 11 core competency and knowing the standard procedures will enhance their readiness in the operating room.