Vital Signs And Mental Status As Per Nursing Assessment: Fill & Download for Free

Better patient outcomes are often achieved through effective surveillance, a primary function of nurses. The purpose of this paper is to define, operationalize, measure, and evaluate the nurse surveillance capacity of hospitals. Nurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. It includes a set of registered nurses (staffing, education, expertise, experience) and nurse practice environment characteristics.Empirical referents were extracted from existing survey data from 9,232 nurses in 174 hospitals. Using a ranking methodology, a Hospital Nurse Surveillance Capacity Profile was created for each hospital. Greater nurse surveillance capacity was significantly associated with a better quality of care and fewer adverse events. The profile may assist administrators to improve nurse surveillance and patient outcomes.Surveillance has multiple meanings in health care. The most familiar is population-based monitoring of health indicators, such as tracking infectious disease vectors or documenting increasing obesity rates in the general population. Nurses may be involved in population health surveillance through activities such as blood pressure and weight screenings at health fairs and in epidemiological studies.There is another less frequently used meaning of surveillance that involves the health care of individuals. Dougherty (1999) defined this type of surveillance as “the application of behavioral and cognitive processes in the systematic collection of information used to make judgments and predictions about a person’s health status”.In addition, in the Nursing Interventions Classification (NIC), surveillance is defined as “the purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision-making” (McCloskey & Bulechek, 1996).A conceptualization has not been developed, however, that captures the essence of nurse surveillance as a cumulative and temporal process, or describes a healthcare organization’s capacity for excellent nurse surveillance.The Quality Health Outcomes Model (QHOM; Mitchell, Ferketich, & Jennings, 1998) provided a theoretical base for framing the examination of nurse surveillance and nurse surveillance capacity. In the model, system and patient characteristics have a direct effect on outcomes; the effect of an intervention on outcomes is mediated by both system and patient characteristics. In the context of our study, nurse surveillance capacity has a direct effect on outcomes, and the effect of nurse surveillance on outcomes is mediated by nurse surveillance capacity and patient characteristics. The system characteristic in our study is nurse surveillance capacity (i.e., RN characteristics and the nurse practice environment) that influences the intervention of nurse surveillance. A direct measure of nurse surveillance is difficult to obtain; therefore our study does not show how the relationship between the nurse surveillance and outcomes could be mediated by system characteristics. Rather, the focus of this study was on the direct relationship between nurse surveillance capacity and outcomes, including quality of care. Patient characteristics, such as the severity of illness at admission, also are theorized to affect patient outcomes. However, the inclusion of patient characteristics was not possible because patient-level data were not collected in the survey.Nurse Surveillance: An InterventionNurse surveillance is a process through which nurses monitor, evaluate, and act upon emerging indicators of a patient’s change in status. The components of this process include ongoing observation and assessment, recognition, interpretation of clinical data, and decision-making.Ongoing observation and assessmentTemporality is a critical component in the examination of surveillance (Dougherty, 1999). According to Dougherty, surveillance differs from assessment in that surveillance is an ongoing practice that occurs over time, whereas assessment frequently is referred to as a one-time event. The process of ongoing observation and data collection in nursing includes physical and mental examinations, and vigilant watching for physiological or behavioral changes using sensory data, such as seeing and hearing, during interactions with patients (Zeitz, 2005).Technological devices, such as electronic monitors, may aid nurses in this function as well. Nurse surveillance also includes the ongoing monitoring of laboratory findings and medications, including side effects and drug interactions (Benson & Briscoe, 2003). As a consequence of surveillance, changes in patient status are identified either as presenting a risk or as evidence of desired responses to treatment.RecognitionAn integral piece of surveillance is the nurse’s ability to recognize patient conditions that deviate from baseline measurements or parameters of interest. The parameters of interest are established through the initial assessment of the patient (Dougherty, 1999). Several indicators serve as markers for recognizable change in patient status including vital signs, neurological and mental status, cardiac and respiratory functioning, and laboratory results (IOM, 2004). The ability to recognize and “read the situation” requires professional knowledge, expertise, and experience. This skill is facilitated by a nurse’s ability to recall previous experiences of similar situations and respond (Benner & Tanner, 1987).InterpretationAfter observing and recognizing an alteration, the nurse interprets and synthesizes this information in the context of the patient and the environment, relying heavily upon critical thinking and clinical judgment. Critical thinking entails an attitude of skeptical inquiry as well as intellectual ability (Kenney, 1995). Tanner, Benner, Chesla, and Gordon (1993) defined clinical judgment as to the application of formal knowledge and theory to nurses’ understanding of patients in the context of a given situation.Decision-makingAfter collecting and interpreting patient data, the nurse makes a decision to continue monitoring or act upon indicators of change in a patient’s status. Nurses act upon changes in a patient’s status by modifying the plan of care, communicating with other providers, or mobilizing resources. Multiple researchers (Kramer et al., 2007; Kramer & Schmalenberg, 2004a; Pearson et al., 2000) have cited the importance of nurses’ independent decision making to the quality of care that patients receive. Often, decisions may be influenced by organizational and environmental factors, such as resource availability and the practice environment.Cumulative and Temporal Aspects of SurveillanceAlthough surveillance is considered to be a nursing intervention provided by a single nurse on behalf of a single patient, in reality, individual patients are cared for in most contexts by multiple nurses over time. Thus, nurse surveillance as a nursing intervention has cumulative and temporal aspects.Associating the effectiveness of surveillance by an individual nurse with the outcomes of an individual patient in most contemporary health care settings is not possible because nurse surveillance is cumulative across nurses and overtime. Benner (1984, p. 126) illustrated this in her qualitative research reported in From Novice to Expert: a charge nurse making rounds enters a room and immediately observes a lidocaine intravenous drip using a macro- rather than a micro-drip. Nurses on two previous shifts, including a float nurse and a new graduate, had failed to associate the patient’s lethargy to over-medication. The charge nurse, whose surveillance was excellent, instituted a rescue attempt by turning the drip off, but the collective surveillance across multiple nurses over time contributed to the patient’s subsequent cardiac arrest and death. Thus, nurse surveillance is a collective effort of interventions delivered by multiple nurses over time, as well as interventions by individual nurses.It is equally difficult to measure individual and collective nurse surveillance. However, an organizational level indicator of nurse surveillance capacity across nurses and overtime would offer a metric with the potential to guide decisions that could improve surveillance, quality of care, and patient outcomes. A metric such as a nurse surveillance capacity also would be valuable to build research evidence for administrators.Nurse Surveillance CapacityNurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. Nurse surveillance capacity includes RN characteristics (staffing, education, clinical expertise, and years of experience), and the nurse practice environment. The concurrent evaluation of each of these characteristics comprises the Hospital Nurse Surveillance Capacity Profile.StaffingRegistered nurse staffing has been associated empirically with patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Mark, Harless, McCue, & Xu, 2004; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). For example, Aiken, Clarke, Sloane, Sochalski, et al (2002) found an increased risk of 30-day mortality, as well as an increased risk of failure-to-rescue, for surgical patients in hospitals with high patient-to-nurse ratios. Therefore, “the effectiveness of nurse surveillance is influenced by the number of registered nurses available to assess patients on an ongoing basis” (Aiken, Clarke, Sloane, Sochalski, et al., 2002, p. 1992).EducationIn addition to staffing, researchers have focused on the educational background of nurses as a predictor of patient outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et al., 2007). Aiken and colleagues (2003) found significantly lower rates of 30-day mortality and failure-to-rescue among surgical patients in hospitals with higher proportions of nurses who had earned at least a baccalaureate degree in nursing. Aiken’s findings were supported in two studies in Canada (Estabrooks et al.; Tourangeau et al., 2007). Researchers hypothesize that baccalaureate preparation has a positive association with nurses’ critical thinking and clinical judgment skills, which are essential to the surveillance of patients, both in terms of risk for adverse events and in the evaluation of therapies (Aiken et al., 2003; Young, Lehrer, & White, 1991).Clinical expertiseIn an influential work, Benner & Tanner (1987) explored the relationship between expertise and nurses’ practice style and demonstrated how expert nurses develop intuition - a powerful feature of the surveillance process. Intuition is defined as “understanding without rationale” (Benner & Tanner, p. 23). Expert nurses are able to recognize patterns and relate current clinical situations to past experience, integrate the knowledge of the patient’s disease with contextual knowledge about the patient, and are skilled in their specialty areas.Expert nurses also practice deliberative rationality-the capacity to view a clinical scenario from different perspectives; they also possess a sense of salience- the ability to identify the most pertinent observations in a complex assessment (Benner & Tanner). Therefore, expert nurses are able to immediately detect changes in a patient’s condition and intervene to prevent adverse occurrences (Christensen & Hewitt-Taylor, 2006; Houser, 2003).Years of experienceExperience is necessary for gaining expertise, but the two are not necessarily interchangeable (Christensen & Hewitt-Taylor, 2006; Houser, 2003). The number of years of experience, however, provides exposure to different patient conditions and clinical scenarios that contribute to the development of knowledge, technical skills, and critical thinking (Benner, 1984; Newman, 1990).Research that links experience to patient outcomes is scarce; however, existing findings are promising. For example, Tourangeau, Giovannetti, Tu, and Wood (2002) found that each additional year of nurse experience was associated with six fewer patient deaths for every 1000 patients discharged from urban community hospitals. In another study, units with more experienced nurses reported lower rates of medication errors and adverse events (Blegen, Vaughn, & Goode, 2001).Nurse practice environmentThe nurse practice environment is defined as “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). Several instruments have been developed to measure the nurse practice environment.One of these, the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002), is used to measure elements that are critical to nurse surveillance. Furthermore, the PES-NWI has been endorsed by the National Quality Forum (NQF) as a nursing-sensitive standard measure for inpatient care (NQF, 2004).The five domains of the PES-NWI are:Nurse Participation in Hospital Affairs;Nursing Foundations for Quality of Care;Nurse Manager Ability,Leadership and Support of Nurses;Staffing and Resource Adequacy; andCollegial Nurse-Physician Relations (Lake, 2002).Nurse participation in hospital affairs is not an obvious component of surveillance. However, in hospitals where nurses are able to influence administrative decisions and policies, nurses are likely to be more efficient in their practice (Aiken, Lake, Sochalski, & Sloane, 1997).Nursing foundations for quality care, such as patient assignments that promote continuity of care, are conducive to surveillance by enhancing the accumulation of knowledge about a patient. Job performance and productivity, including surveillance, depending on the support and ability of the nurse manager (Kramer, Schmalenberg, & Maguire, 2004).Nurses need the staffing support to have adequate time to spend with their patients to perform surveillance, as well as adequate resources available to them to implement necessary interventions (Laschinger & Lieter, 2006; McCusker, Dendukuri, Cardinal, Laplante, & Bambonye, 2004). Further, collegial relationships with physicians are essential to effective surveillance through the exchange of information vital to the patient’s clinical condition (Baggs et al., 1999; Kramer & Schmalenberg, 2004b).Nurse Surveillance and OutcomesBetter nurse surveillance is considered to be the link between better RN staffing/education and the prevention of mortality and failure-to-rescue in surgical patients (Aiken et al., 2003; Aiken, Clarke, Sloane, Sochalski, et al., 2002; Clarke & Aiken, 2003). With the elements of nurse surveillance capacity in place, nurses are better able to perform adequate surveillance of patients and initiate a timely response when a complication or adverse event is detected.Therefore, theoretically, multiple adverse outcomes may be used to assess the effectiveness of hospital nurse surveillance capacity, including mortality and failure-to-rescue. We posit that nurse surveillance capacity has the same relevance for all patient populations and non-mortality outcomes. Other outcomes of nurse surveillance capacity may include quality of care and adverse events, such as falls and nosocomial infections.Data SourceThis study was a secondary analysis of data derived from a 50% random sample survey of Pennsylvania RNs that was conducted in 1999. The survey response rate was 52%, for a total of 43,329 RNs (Aiken et al., 2001). The survey was developed to examine the relationships between nurse staffing, work environment, and patient outcomes (Aiken, Clarke, & Sloane, 2002). The survey contained questions about hospital work environments, workload, workplace safety, quality of care assessments, demographics, education, and experience. Data reflecting individual patient characteristics were not collected in the survey.SampleOf the 43,329 respondents, 13,204 nurses indicated they worked in one of the 210 acute care hospitals in the state. Nurses were included in the final sample for this study if they identified their primary position as a staff nurse working in acute care (excluding the emergency room). Hospitals were included in the sample that had a sufficient number of respondents to assure reliable aggregate values of surveillance capacity variables, as described elsewhere (Aiken, Clarke, Sloane, Sochalski, et al., 2002). An average of 60 nurse respondents from each hospital completed questionnaires. One-half of the hospitals had more than 50 nurse respondents and over 80% of the hospitals had more than 25 nurse respondents. The final sample for this analysis consisted of 9,232 RNs in 174 hospitals in the state of Pennsylvania.MeasuresEmpirical referents were extracted from the Pennsylvania nurse survey to operationalize nurse surveillance capacity. A Hospital Nurse Surveillance Capacity Profile was constructed for each hospital by ranking hospitals on a set of RN characteristics (staffing, education, clinical expertise, and years of experience) and the nurse practice environment. An aggregate measure of hospital nurse surveillance capacity was constructed by calculating a hospital’s average ranking across indicators. Nurse-assessed quality of care and two adverse event variables (nosocomial infections and patient falls with injuries) were the outcomes in this study.StaffingNurses were asked to provide the number of patients cared for on their last shift. The mean number of patients cared for was calculated across all staff nurses within a hospital who reported caring for at least 1 but no more than 20 patients on their last shift. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) considered this measure of staffing to be more accurate than administrative database sources. Harless and Mark (2006) discussed the bias introduced into staffing estimates when using administrative financial data to predict staffing allocation levels.EducationNurses were asked to provide their highest level of education in nursing. Respondents chose from diploma, associate degree, baccalaureate degree, master’s degree, or other. The education variable was operationalized as the proportion of staff nurse respondents within each hospital holding a baccalaureate degree or higher.Clinical expertiseNurses were asked to describe their clinical nursing expertise by choosing from one of the following response categories defined by Benner (1984): advanced beginner, competent, proficient, and expert. Responses were coded 1 to 4 respectively. The clinical expertise variable was calculated as the mean expertise of nurse respondents in each hospital.Years of experienceNurses were asked to provide the number of years they had worked as an RN. The experience variable was calculated at the hospital-level as the mean number of years of RN experience.Nurse practice environmentThe nurse practice environment was measured using the PES-NWI (Lake, 2002). The PES-NWI includes 31 items that use a 4-point Likert scale (strongly agree, somewhat agree, somewhat disagree, and strongly disagree) to assess nurses’ perceptions of the presence of organizational characteristics in their hospitals.A mean score for each of the five subscales was calculated at the hospital-level from the hospital mean of the individual items composing each subscale (Rousseau, 1985; Verran, Gerber, & Milton, 1995).The reliability of the five subscales was examined at the hospital-level by calculating the intraclass correlation coefficient (ICC (1, k)) across hospitals using a minimum criterion of .60 (Glick, 1985).All five subscales demonstrated acceptable reliability at the hospital-level with ICC (1, k)s ranging from a low of .67 for the Collegial Nurse-Physician Relations subscale to a high of .89 for the Participation in Hospital Affairs subscale. Internal consistency coefficients (Cronbach’s alphas) for the five subscales ranged from .78 to .85.Discriminate validity of the PES-NWI has been demonstrated by its ability to detect differences in the nurse practice environments of a magnet and non-magnet hospitals (Lake & Friese, 2006).Quality of careNurses were asked to rate the quality of nursing care delivered to patients on their unit using a 4-point Likert scale of excellent, good, fair, and poor. The reliability of the quality of care variable was examined at the aggregate level by calculating the ICC (1, k) across hospitals. The ICC (1, k) for quality of care was .73. Responses were collapsed into categories of poor/fair and good/excellent care to examine associations with the nurse surveillance capacity rankings.Adverse eventsNurses were asked to report how often two different adverse events, nosocomial infections, and patient falls with injuries, occurred involving their patients over the past year. The frequency of adverse events was measured using a 4-point Likert-type scale of never, rarely, occasionally, or frequently. The reliability of the adverse event measures at the aggregate level was examined by calculating the ICC (1, k) across hospitals.The ICC (1, k)s for nosocomial infections and patient falls with injuries were .73 and .71, respectively. Responses were collapsed into categories of never/rarely and occasionally/frequently to examine associations with the nurse surveillance capacity rankings.Data AnalysisThe purposes of the data analysis were to describe hospitals’ nurse surveillance capacity, to rank hospitals by nurse surveillance capacity, and to associate hospitals’ average ranking with quality of care indicators. Individual nurse responses were examined to assess demographics. Nurse responses were then aggregated to the hospital-level to create the nurse surveillance capacity indicators. Distributions for the aggregated variables were calculated.To create a Hospital Nurse Surveillance Capacity Profile, the hospitals first were ranked on each nurse surveillance capacity indicator so that they rank on each indicator reflected the hospital’s placement among all hospitals. A profile was developed to display hospital ranks by deciles for clarity of comparison, with 1 as the lowest and 10 as the highest decile. A Hospital Nurse Surveillance Capacity Profile was created for each of the 174 represented hospitals.Hospitals’ overall nurse surveillance capacity was then calculated as the mean ranking across all nine nurse surveillance capacity indicators. Finally, hospitals’ overall nurse surveillance capacities were ordered into deciles, with 1 as the lowest and 10 as the highest decile. One hospital profile from the overall highest decile and another from the lowest were selected to illustrate and to contrast a highly ranked hospital and its consistent performance across indicators with a low ranked hospital.To associate hospitals’ rankings with quality of care indicators, outcomes of hospitals in the highest and lowest deciles of overall nurse surveillance capacity ranking were compared. Nurse responses were aggregated to the hospital-level to create the outcome measures.Same-source bias was of concern as the nurse survey was used to measure the independent and dependent variables. Therefore, a split-sample approach was used to test the robustness of the estimates. In every hospital, a random half of the nurses’ responses were aggregated for the organizational measures. The other half was aggregated for the outcome measures, and the analysis was repeated.FindingsNurse Respondent DemographicsDemographics of the nurse respondents were examined. Nearly all respondents were female (94%). The average respondent was 39 years of age. The majority of the nurses worked on a medical/surgical unit (38%); about a quarter of the respondents (24%) worked in intensive care.Nurse Surveillance Capacity DistributionsAverage staffing across all hospitals was just over 5 patients per nurse. On average, one-third of the nurses within a hospital held at least a baccalaureate degree had over 13 years of experience as an RN and rated themselves as competent to proficient in their clinical expertise.A low proportion of hospitals (1 in10) had a majority of nurses who rated their practice as proficient or expert (average expertise ≥3.0). Hsubscale hospitals tended to score highest on the Nursing Foundations for Quality of Care of the PES-NWI; the lowest scored subscale was Staffing and Resource Adequacy. The Quality Health Outcomes Model (QHOM; Mitchell, Ferketich, & Jennings, 1998) provided a theoretical base for framing the examination of nurse surveillance and nurse surveillance capacity.In the model, system and patient characteristics have a direct effect on outcomes; the effect of an intervention on outcomes is mediated by both system and patient characteristics. In the context of our study, nurse surveillance capacity has a direct effect on outcomes, and the effect of nurse surveillance on outcomes is mediated by nurse surveillance capacity and patient characteristics. The system characteristic in our study is nurse surveillance capacity (i.e., RN characteristics and the nurse practice environment) that influences the intervention of nurse surveillance.A direct measure of nurse surveillance is difficult to obtain; therefore our study does not show how the relationship between the nurse surveillance and outcomes could be mediated by system characteristics. Rather, the focus of this study was on the direct relationship between nurse surveillance capacity and outcomes, including quality of care. Patient characteristics, such as the severity of illness at admission, also are theorized to affect patient outcomes. However, the inclusion of patient characteristics was not possible because patient-level data were not collected in the survey.Nurse Surveillance: An InterventionNurse surveillance is a process through which nurses monitor, evaluate, and act upon emerging indicators of a patient’s change in status. The components of this process include ongoing observation and assessment, recognition, interpretation of clinical data, and decision-making.Ongoing observation and assessmentTemporality is a critical component in the examination of surveillance (Dougherty, 1999). According to Dougherty, surveillance differs from assessment in that surveillance is an ongoing practice that occurs over time, whereas assessment frequently is referred to as a one-time event.The process of ongoing observation and data collection in nursing includes physical and mental examinations, and vigilant watching for physiological or behavioral changes using sensory data, such as seeing and hearing, during interactions with patients (Zeitz, 2005).Technological devices, such as electronic monitors, may aid nurses in this function as well. Nurse surveillance also includes the ongoing monitoring of laboratory findings and medications, including side effects and drug interactions (Benson & Briscoe, 2003). As a consequence of surveillance, changes in patient status are identified either as presenting a risk or as evidence of desired responses to treatment.RecognitionAn integral piece of surveillance is the nurse’s ability to recognize patient conditions that deviate from baseline measurements or parameters of interest. The parameters of interest are established through the initial assessment of the patient (Dougherty, 1999).Several indicators serve as markers for recognizable change in patient status including vital signs, neurological and mental status, cardiac and respiratory functioning, and laboratory results (IOM, 2004). The ability to recognize and “read the situation” requires professional knowledge, expertise, and experience. This skill is facilitated by a nurse’s ability to recall previous experiences of similar situations and respond (Benner & Tanner, 1987).InterpretationAfter observing and recognizing an alteration, the nurse interprets and synthesizes this information in the context of the patient and the environment, relying heavily upon critical thinking and clinical judgment.Critical thinking entails an attitude of skeptical inquiry as well as intellectual ability (Kenney, 1995). Tanner, Benner, Chesla, and Gordon (1993) defined clinical judgment as to the application of formal knowledge and theory to nurses’ understanding of patients in the context of a given situation.Decision-makingAfter collecting and interpreting patient data, the nurse makes a decision to continue monitoring or act upon indicators of change in a patient’s status. Nurses act upon changes in a patient’s status by modifying the plan of care, communicating with other providers, or mobilizing resources.Multiple researchers (Kramer et al., 2007; Kramer & Schmalenberg, 2004a; Pearson et al., 2000) have cited the importance of nurses’ independent decision making to the quality of care that patients receive. Often, decisions may be influenced by organizational and environmental factors, such as resource availability and the practice environment.Cumulative and Temporal Aspects of SurveillanceAlthough surveillance is considered to be a nursing intervention provided by a single nurse on behalf of a single patient, in reality, individual patients are cared for in most contexts by multiple nurses over time. Thus, nurse surveillance as a nursing intervention has cumulative and temporal aspects.Associating the effectiveness of surveillance by an individual nurse with the outcomes of an individual patient in most contemporary health care settings is not possible because nurse surveillance is cumulative across nurses and overtime. Benner (1984, p. 126) illustrated this in her qualitative research reported in From Novice to Expert: a charge nurse making rounds enters a room and immediately observes a lidocaine intravenous drip using a macro- rather than a micro-drip.d fai Nure the patient’s lethargy to over-medication.The charge nurse, whose on two previous shifts, including a float nurse and a new graduate, haled to associate surveillance was excellent, instituted a rescue attempt by turning the drip off, but the collective surveillance across multiple nurses over time contributed to the patient’s subsequent cardiac arrest and death. Thus, nurse surveillance is a collective effort of interventions delivered by multiple nurses over time, as well as interventions by individual nurses.It is equally difficult to measure individual and collective nurse surveillance. However, an organizational level indicator of nurse surveillance capacity across nurses and overtime would offer a metric with the potential to guide decisions that could improve surveillance, quality of care, and patient outcomes. A metric such as nurse surveillance capacity also would be valuable to build research evidence for administrators.Nurse Surveillance CapacityNurse surveillance capacity is defined as the organizational features that enhance or weaken nurse surveillance. Nurse surveillance capacity includes RN characteristics (staffing, education, clinical expertise, and years of experience), and the nurse practice environment. The concurrent evaluation of each of these characteristics comprises the Hospital Nurse Surveillance Capacity Profile.StaffingRegistered nurse staffing has been associated empirically with patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Mark, Harless, McCue, & Xu, 2004; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). For example, Aiken, Clarke, Sloane, Sochalski, et al (2002) found an increased risk of 30-day mortality, as well as an increased risk of failure-to-rescue, for surgical patients in hospitals with high patient-to-nurse ratios. Therefore, “the effectiveness of nurse surveillance is influenced by the number of registered nurses available to assess patients on an ongoing basis” (Aiken, Clarke, Sloane, Sochalski, et al., 2002, p. 1992).EducationIn addition to staffing, researchers have focused on the educational background of nurses as a predictor of patient outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Tourangeau et al., 2007). Aiken and colleagues (2003) found significantly lower rates of 30-day mortality and failure-to-rescue among surgical patients in hospitals with higher proportions of nurses who had earned at least a baccalaureate degree in nursing.Aiken’s findings were supported in two studies in Canada (Estabrooks et al.; Tourangeau et al., 2007). Researchers hypothesize that baccalaureate preparation has a positive association with nurses’ critical thinking and clinical judgment skills, which are essential to the surveillance of patients, both in terms of risk for adverse events and in the evaluation of therapies (Aiken et al., 2003; Young, Lehrer, & White, 1991).Clinical expertiseIn an influential work, Benner & Tanner (1987) explored the relationship between expertise and nurses’ practice style and demonstrated how expert nurses develop intuition - a powerful feature of the surveillance process. Intuition is defined as “understanding without rationale” (Benner & Tanner, p. 23).Expert nurses are able to recognize patterns and relate current clinical situations to past experience, integrate the knowledge of the patient’s disease with contextual knowledge about the patient, and are skilled in their specialty areas.Expert nurses also practice deliberative rationality-the capacity to view a clinical scenario from different perspectives; they also possess a sense of salience- the ability to identify the most pertinent observations in a complex assessment (Benner & Tanner). Therefore, expert nurses are able to immediately detect changes in a patient’s condition and intervene to prevent adverse occurrences (Christensen & Hewitt-Taylor, 2006; Houser, 2003).Years of experienceExperience is necessary for gaining expertise, but the two are not necessarily interchangeable (Christensen & Hewitt-Taylor, 2006; Houser, 2003). The number of years of experience, however, provides exposure to different patient conditions and clinical scenarios that contribute to the development of knowledge, technical skills, and critical thinking (Benner, 1984; Newman, 1990).Research that links experience to patient outcomes is scarce; however, existing findings are promising. For example, Tourangeau, Giovannetti, Tu, and Wood (2002) found that each additional year of nurse experience was associated with six fewer patient deaths for every 1000 patients discharged from urban community hospitals. In another study, units with more experienced nurses reported lower rates of medication errors and adverse events (Blegen, Vaughn, & Goode, 2001).Nurse practice environmentThe nurse practice environment is defined as “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). Several instruments have been developed to measure the nurse practice environment. One of these, the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002), is used to measure elements that are critical to nurse surveillance. Furthermore, the PES-NWI has been endorsed by the National Quality Forum (NQF) as a nursing-sensitive standard measure for inpatient care (NQF, 2004).The five domains of the PES-NWI are:Nurse Participation in Hospital Affairs;Nursing Foundations for Quality of Care;Nurse Manager Ability,Leadership and Support of Nurses;Staffing and Resource Adequacy; andCollegial Nurse-Physician Relations (Lake, 2002).Nurse participation in hospital affairs is not an obvious component of surveillance. However, in hospitals where nurses are able to influence administrative decisions and policies, nurses are likely to be more efficient in their practice (Aiken, Lake, Sochalski, & Sloane, 1997).Nursing foundations for quality care, such as patient assignments that promote continuity of care, are conducive to surveillance by enhancing the accumulation of knowledge about a patient.Job performance and productivity, including surveillance, depending on the support and ability of the nurse manager (Kramer, Schmalenberg, & Maguire, 2004).Nurses need the staffing support to have adequate time to spend with their patients to perform surveillance, as well as adequate resources available to them to implement necessary interventions (Laschinger & Lieter, 2006; McCusker, Dendukuri, Cardinal, Laplante, & Bambonye, 2004).Further, collegial relationships with physicians are essential to effective surveillance through the exchange of information vital to the patient’s clinical condition (Baggs et al., 1999; Kramer & Schmalenberg, 2004b).Nurse Surveillance and OutcomesBetter nurse surveillance is considered to be the link between better RN staffing/education and the prevention of mortality and failure-to-rescue in surgical patients (Aiken et al., 2003; Aiken, Clarke, Sloane, Sochalski, et al., 2002; Clarke & Aiken, 2003). With the elements of nurse surveillance capacity in place, nurses are better able to perform adequate surveillance of patients and initiate a timely response when a complication or adverse event is detected. Therefore, theoretically, multiple adverse outcomes may be used to assess the effectiveness of hospital nurse surveillance capacity, including mortality and failure-to-rescue. We posit that nurse surveillance capacity has the same relevance for all patient populations and non-mortality outcomes. Other outcomes of nurse surveillance capacity may include quality of care and adverse events, such as falls and nosocomial infections.MethodsData SourceThis study was a secondary analysis of data derived from a 50% random sample survey of Pennsylvania RNs that was conducted in 1999. The survey response rate was 52%, for a total of 43,329 RNs (Aiken et al., 2001). The survey was developed to examine the relationships between nurse staffing, work environment, and patient outcomes (Aiken, Clarke, & Sloane, 2002). The survey contained questions about hospital work environments, workload, workplace safety, quality of care assessments, demographics, education, and experience. Data reflecting individual patient characteristics were not collected in the survey.SampleOf the 43,329 respondents, 13,204 nurses indicated they worked in one of the 210 acute care hospitals in the state. Nurses were included in the final sample for this study if they identified their primary position as a staff nurse working in acute care (excluding the emergency room). Hospitals were included in the sample that had a sufficient number of respondents to assure reliable aggregate values of surveillance capacity variables, as described elsewhere (Aiken, Clarke, Sloane, Sochalski, et al., 2002). An average of 60 nurse respondents from each hospital completed questionnaires. One-half of the hospitals had more than 50 nurse respondents and over 80% of the hospitals had more than 25 nurse respondents. The final sample for this analysis consisted of 9,232 RNs in 174 hospitals in the state of Pennsylvania.MeasuresEmpirical referents were extracted from the Pennsylvania nurse survey to operationalize nurse surveillance capacity. A Hospital Nurse Surveillance Capacity Profile was constructed for each hospital by ranking hospitals on a set of RN characteristics (staffing, education, clinical expertise, and years of experience) and the nurse practice environment. An aggregate measure of hospital nurse surveillance capacity was constructed by calculating a hospital’s average ranking across indicators. Nurse-assessed quality of care and two adverse event variables (nosocomial infections and patient falls with injuries) were the outcomes in this study.StaffingNurses were asked to provide the number of patients cared for on their last shift. The mean number of patients cared for was calculated across all staff nurses within a hospital who reported caring for at least 1 but no more than 20 patients on their last shift. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) considered this measure of staffing to be more accurate than administrative database sources. Harless and Mark (2006) discussed the bias introduced into staffing estimates when using administrative financial data to predict staffing allocation levels.EducationNurses were asked to provide their highest level of education in nursing. Respondents chose from diploma, associate degree, baccalaureate degree, master’s degree, or other. The education variable was operationalized as the proportion of staff nurse respondents within each hospital holding a baccalaureate degree or higher.Clinical expertiseNurses were asked to describe their clinical nursing expertise by choosing from one of the following response categories defined by Benner (1984): advanced beginner, competent, proficient, and expert. Responses were coded 1 to 4 respectively. The clinical expertise variable was calculated as the mean expertise of nurse respondents in each hospital.Years of experienceNurses were asked to provide the number of years they had worked as an RN. The experience variable was calculated at the hospital-level as the mean number of years of RN experience.Nurse practice environmentThe nurse practice environment was measured using the PES-NWI (Lake, 2002). The PES-NWI includes 31 items that use a 4-point Likert scale (strongly agree, somewhat agree, somewhat disagree, and strongly disagree) to assess nurses’ perceptions of the presence of organizational characteristics in their hospitals.A mean score for each of the five subscales was calculated at the hospital-level from the hospital mean of the individual items composing each subscale (Rousseau, 1985; Verran, Gerber, & Milton, 1995).The reliability of the five subscales was examined at the hospital-level by calculating the intraclass correlation coefficient (ICC (1, k)) across hospitals using a minimum criterion of .60 (Glick, 1985).All five subscales demonstrated acceptable reliability at the hospital-level with ICC (1, k)s ranging from a low of .67 for the Collegial Nurse-Physician Relations subscale to a high of .89 for the Participation in Hospital Affairs subscale. Internal consistency coefficients (Cronbach’s alphas) for the five subscales ranged from .78 to .85.Discriminate validity of the PES-NWI has been demonstrated by its ability to detect differences in the nurse practice environments of a magnet and non-magnet hospitals (Lake & Friese, 2006).Quality of careNurses were asked to rate the quality of nursing care delivered to patients on their unit using a 4-point Likert scale of excellent, good, fair, and poor. The reliability of the quality of care variable was examined at the aggregate level by calculating the ICC (1, k) across hospitals. The ICC (1, k) for quality of care was .73. Responses were collapsed into categories of poor/fair and good/excellent care to examine associations with the nurse surveillance capacity rankings.Adverse eventsNurses were asked to report how often two different adverse events, nosocomial infections, and patient falls with injuries, occurred involving their patients over the past year.The frequency of adverse events was measured using a 4-point Likert-type scale of never, rarely, occasionally, or frequently. The reliability of the adverse event measures at the aggregate level was examined by calculating the ICC (1, k) across hospitals. The ICC (1, k)s for nosocomial infections and patient falls with injuries were .73 and .71, respectively. Responses were collapsed into categories of never/rarely and occasionally/frequently to examine associations with the nurse surveillance capacity rankings.Data AnalysisThe purposes of the data analysis were to describe hospitals’ nurse surveillance capacity, to rank hospitals by nurse surveillance capacity, and to associate hospitals’ average ranking with quality of care indicators. Individual nurse responses were examined to assess demographics. Nurse responses were then aggregated to the hospital-level to create the nurse surveillance capacity indicators.Distributions for the aggregated variables were calculated. To create a Hospital Nurse Surveillance Capacity Profile, the hospitals first were ranked on each nurse surveillance capacity indicator so that they rank on each indicator reflected the hospital’s placement among all hospitals.A profile was developed to display hospital ranks by deciles for clarity of comparison, with 1 as the lowest and 10 as the highest decile. A Hospital Nurse Surveillance Capacity Profile was created for each of the 174 represented hospitals.Hospitals’ overall nurse surveillance capacity was then calculated as the mean ranking across all nine nurse surveillance capacity indicators. Finally, hospitals’ overall nurse surveillance capacities were ordered into deciles, with 1 as the lowest and 10 as the highest decile. One hospital profile from the overall highest decile and another from the lowest were selected to illustrate and to contrast a highly ranked hospital and its consistent performance across indicators with a low ranked hospital.To associate hospitals’ rankings with quality of care indicators, outcomes of hospitals in the highest and lowest deciles of overall nurse surveillance capacity ranking were compared. Nurse responses were aggregated to the hospital-level to create the outcome measures. Same-source bias was of concern as the nurse survey was used to measure the independent and dependent variables. Therefore, a split sample approach was used to test the robustness of the estimates. In every hospital, a random half of the nurses’ responses was aggregated for the organizational measures. The other half was aggregated for the outcome measures, and the analysis was repeated.FindingsNurse Respondent DemographicsDemographics of the nurse respondents were examined. Nearly all respondents were female (94%). The average respondent was 39 years of age. The majority of the nurses worked on a medical/surgical unit (38%); about a quarter of the respondents (24%) worked in intensive care.Nurse Surveillance Capacity DistributionsDistributions for the nurse surveillance capacity variables for the 174 study hospitals are shown. Average staffing across all hospitals was just over 5 patients per nurse. On average, one-third of the nurses within a hospital held at least a baccalaureate degree had over 13 years of experience as an RN and rated themselves as competent to proficient in their clinical expertise.A low proportion of hospitals (1 in10) had a majority of nurses who rated their practice as proficient or expert (average expertise ≥3.0).Hospitals tended to score highest on the Nursing Foundations for Quality of Care subscale of the PES-NWI; the lowest scored subscale was Staffing and Resource Adequacy.Nurse Surveillance Capacity RankingsNine percent of hospitals ranked above the 50th percentile on all nurse surveillance capacity indicators. Nurses in the highest-ranked hospitals took care of approximately two fewer patients than nurses in the lowest decile of nurse surveillance capacity.Over 40% of the nurses in the highest-ranked hospitals had a bachelor’s degree as compared to 20% of nurses in the lowest decile. Nurses in the highest decile of nurse surveillance capacity also rated their clinical expertise higher than those in the lowest grouping.Hospitals in the top decile of nurse surveillance capacity also had more years of RN experience as compared to the bottom decile. Nurses in hospitals in the top decile of nurse surveillance capacity consistently evaluated the nurse practice environment more favorably as compared to nurses in the lowest decile. The differences in means across all five subscales of the PES-NWI were sizable. The largest difference between deciles was observed in the Staffing and Resource Adequacy subscale.Figure 1 illustrates the Hospital Nurse Surveillance Capacity Profile of two hospitals chosen from the highest and lowest deciles after average ranking across indicators. The figure compares the Hospital Nurse Surveillance Capacity Profile of a hospital with consistently high rankings, theoretically demonstrating a strong capacity for nurse surveillance, with a hospital in which the capacity for surveillance may be deficient based on the proposed conceptualization. Hospital values for each of the nine indicators are displayed to provide a more meaningful comparison.The nurse surveillance capacity of hospitals was examined in this study. Nurse surveillance capacity was operationalized as a set of organizational features derived from RN characteristics and reports of the nurse practice environment collectively referred to as the Hospital Nurse Surveillance Capacity Profile.The results of this study suggest that an organization composed of well educated, expert, and experienced nurses, with adequate staffing and a supportive practice environment, promotes quality of care and prevention of two adverse events—falls with injury and nosocomial infections. The hypothesized mechanism for this association is more effective surveillance across individual nurses and overtime.The findings from this study suggest that modifying organizational features to support surveillance is a promising strategy for reducing adverse patient outcomes and improving the quality of care.The analysis confirmed that the organizational characteristics that foster nurse surveillance are associated with a better quality of care and fewer falls with injury and nosocomial infections based on self-reports from nurses. Hospitals in the highest and lowest deciles of overall nurse surveillance capacity indicators were compared relative to the quality of care and adverse events.Nurses in the highest-ranked hospitals of nurse surveillance capacity reported better quality of care and less frequent nosocomial infections and patient falls with injuries.We operationalized nurse surveillance capacity in a way that the concept could be measured. Multiple literature syntheses have demonstrated the association between nurse staffing and patient outcomes, including mortality, complications, and length of stay (Kane et al., 2007; Lang, Hodge, & Olsen, 2004; Lankshear, Sheldon, & Maynard, 2005). In a comprehensive review of the literature, Kazanjian, Green, Wong, and Reid (2005) concluded that the hospital nursing environment affects patient outcomes; however, the need for additional research was highlighted. The IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004), cited all of the identified nurse surveillance capacity indicators as important factors to consider in the examination of patient care and safety.Management Applications of the ProfileIn this study, we translated the theoretical underpinnings of and organizational contributors to nurse surveillance that has been established in the literature into a measure of nurse surveillance capacity and organizational property that can be monitored and modified by nurse executives and hospital administrators.With this approach, administrators could profile their hospital’s surveillance capacity, benchmark that profile against peer hospitals with similar characteristics, and evaluate themselves over time. Benchmarking against similar hospitals with comparable macro characteristics, such as location, size, and teaching status, carries an additional advantage, as patient characteristics could be accounted for by proxy of hospital characteristics.Further, the NQF’s (2004) endorsement of the PES-NWI and the technical specifications prepared by The Joint Commission (JCAHO, 2005) allows hospitals to benchmark their institution against a broader range of hospitals. The Hospital Nurse Surveillance Capacity Profile can be used to detect weaknesses in the nurse surveillance system and highlight areas in which more attention and resource allocation are needed to ensure patient safety and quality care.The findings in this study demonstrate how the organizational capacity for nurse surveillance may be measured and evaluated. Institutions increasingly have the data to construct their own Hospital Nurse Surveillance Capacity Profiles.The Hospital Nurse Surveillance Capacity Profile could be added to a dashboard monitored by nurse executives and hospital administrators. Using the Hospital Nurse Surveillance Capacity Profile for benchmarking across like hospitals may only be possible through national databases, like the National Database of Nursing Quality Indicators (NDNQI), or health care systems that have multiple facilities, where data can be collected from and aggregated for a large number of facilities. For other facilities, the concept may be feasible for internal quality improvement at the nursing unit level. In addition to comparing similar units within hospitals, individual specialty units may follow their own surveillance capacity over time.Research ConsiderationsThis study is a secondary analysis of survey data. The use of survey data to describe organizations is challenged by the issues of respondent bias, response rate, and aggregation. The strengths of this survey data included a large number of respondents and hospitals and a research design that did not permit hospitals to opt-out.A limitation was deriving the data from nurses working in a single large state. The response rate of 52% is considered good by the current standards of social survey research (Asch, Jedrziewski, & Christakis, 1997). Individual respondents were similar to the Pennsylvania nurses in the National Sample Survey of Registered Nurses (Aiken, Clarke, Sloane, Sochalski, et al., 2002; U.S. Department of Health and Human Services, 2000). The survey data were compared previously with American Hospital Association (AHA) annual survey data and the findings revealed that the number of responding nurses from each hospital was directly proportional to the number of RNs in each hospital as reported by AHA (Aiken et al., 2003).The amount of same-source bias was likely to be reduced by the aggregation of our independent and dependent variables to the hospital-level (Rousseau, 1985; Verran et al., 1995). The effect sizes were equivalent in the split sample approach; therefore, the amount of same-source bias was negligible. Nurse informants responding to Likert-type scale items provided the outcomes in this study. The three outcome measures demonstrated reliable estimates using standard criteria. Recall bias is also a threat to the accuracy of these reports. However, nurses’ retrospective reports of adverse events have been substantiated by adverse event data collected prospectively (Aiken, Sloane, & Klocinski, 1997; Gerolamo, 2006).Although these data were collected in 1999, the concepts discussed in this study remain salient to current hospital executives (Donaldson, Brown, Aydin, Bolton, & Rutledge, 2005). Several study measures have been disseminated widely since 1999 through endorsement by the NQF (2004), the development of technical specifications byThe JCAHO (2005), and by inclusion in the annual RN Survey of the American Nurses Association-sponsored NDNQI, which was conducted in over 500 hospitals in 2007 (NDNQI, 2006; 2008).Future ResearchMethods to directly measure nurse surveillance present a challenge to the field. Nursing intervention classification systems’ measurement of nurse surveillance has been useful to begin to understand the process. However, these systems lack the specificity needed to construct a measure that accounts for each component of the surveillance process, and the organizational context in which nurses perform surveillance.To ensure the generalizability of these findings an important next research step would be to replicate and improve upon the current study using new data sets. Research on nurse surveillance capacity could expand to incorporate and evaluate patient characteristics and outcomes. By contrast to nurse reports, objective patient outcome data, including mortality, require patient-level risk-adjustment. To date, well-developed risk adjustment models exit only for surgical patient mortality using solely administrative data. Although efforts to risk-adjust mortality for medical and other patient populations have been made (Escobar, Greene, Scheirer, Gardner, Draper, et al., 2008; Tourangeau & Tu, 2003), these models need further development and refinement.Nurse surveillance capacity may be associated with other hospital structural characteristics, such as size, teaching status, and location. Opportunities to enhance nurse surveillance capacity, however, may be limited by hospital resource constraints.Additional research may reveal how units might be staffed to offset surveillance capacity inadequacies, such as insufficient RN staffing, few nurses with baccalaureate degrees, lower expertise, many new graduates, or unfavorable environments.We plan to examine this question in future work. The influence of physician workforce characteristics and technology status on the quality of surveillance will be important to consider. Moreover, information technology is a developing area, and its effectiveness on nurse surveillance remains unclear (Koppel et al., 2005).

Fewer Falklands War suicides than feared, study suggestsThe claim that more Falklands veterans have killed themselves since the war ended than died in action is not borne out by statistics, a study says.Some 255 UK personnel died in action, but a veterans group has said the suicide toll since 1982 exceeds that.However, the Ministry of Defence has found 95 deaths were recorded as suicides or open verdicts.The MoD said every suicide was a tragedy and urged veterans of any conflict needing support to seek help.In 2002, The South Atlantic Medal Association, which represents veterans, said it was "almost certain" the number of suicides exceeded the conflict death toll.It placed the blame predominantly on a lack of care for those suffering post traumatic stress disorderBut the MoD has now investigated the circumstances of 21,432 Falklands veterans three decades after the end of the conflict, and found that as of 31 December 2012, some 1,335 had died.That compares with an estimated 2,079 deaths that would have been expected among men of a similar age and background who did not serve in the forces, according to the MoD.Of those Falklands veterans, 7% of deaths - or 95 individuals - were due to "intentional self-harm and events of undetermined intent (suicides and open verdict deaths)".That finding means that on average across the whole 30-year period, veterans were actually 35% less likely to kill themselves than the equivalent group of British men with no military background.An MoD spokesman said: "Every suicide is a tragedy and our thoughts remain with the families and relatives of all those lost who bravely served in the Falklands conflict."He said the government had committed £7.2m to improving mental health support for military personnel, including creating a 24-hour helpline in conjunction with charity Combat Stress.The spokesman added: "We would encourage any Falklands veterans or serving personnel who need help to come forward to access the wide range of support available."The study also found:78% of veterans' deaths (1,046) were the result of disease, while 19% (247 deaths) were the result of external causes of injuryCancer was the primary cause of disease-related deaths, with 455 cases recordedBut veterans were 30% less likely to die from cancer and 40% less likely to die from disease in general than men with no military background over the period since 1982Of the 1,335 Falklands deaths, 140 occurred while the individual was still in service - the rest died after leaving the Armed ForcesThe MoD said military personnel were likely to have higher levels of fitness and lower levels of ill health than the general UK population, which could account for the lower incidence of death from disease observed by the study.The death toll of 255 from the Falklands War includes 237 UK servicemen, along with four personnel from the Royal Fleet Auxiliary, six from the Merchant Navy and eight Hong Kong sailors.Falklands suicides 'overestimated'2008 - Veterans Assistance in the UKDr. Eduardo C. GERDINGBulletin of the Naval Center Year 126-Vol. CXXVI-Nº 822-Oct-Dec 2008PrefaceThe medical care of war veterans is inserted, like that of the ordinary British citizen, in the so-called National Health Service (NHS ) which is comparable in its structure to our National Institute of Social Services for Retirees and Pensioners ( INSSJP ). There are population differences, given that the United Kingdom has a significant immigrant group from India, Pakistan, Somalia and the Philippines to the point that 21.9 percent of children born in Great Britain are to foreign mothers. On the other hand, his retirement system has been in trouble for a long time. ( BBC News, Pensions in Crisis- December 10, 2002). In 2003 total health spending per capita in the UK was US $ 2,317.There are serious healthcare problems in military hospitals. In March 2007, Selly Oak Hospital was charged with mistreating British war veterans returning from Iraq. ( BBC, March 11, 2007 ) The British government, arguing that military hospitals cannot provide the same level of care as NHS hospitals has been closing them since 1990. In fact, the Royal Naval Hospital in Haslar, dating from 1753, It is the last military hospital to close its doors in 2009 and the remaining military personnel ( 200 people ) will be transferred to a Ministry of Defense hospital unit located at Queen Alexandra Hospital in Cosham, Portsmouth.The National Health Service ( NHS )The NHS is the UK's public health service, serving 57 million people. England, Scotland, Wales and Northern Ireland each have their own NHS. The NHS budget in 2007 was £ 90 billion and is to be increased by 4 per cent by 2010. ( HealthInsider-10 Oct 2007 ).The Scottish doctor Archibald Joseph Cronin, author of the famous novel The Citadel, was the one who established the innovative ideas that gave rise not only to the NHS but to the triumph of the Labor Party in 1945. In primary care or First Level of the NHS the pillars are GPs ( General Practitioners ) or family doctors and RN ( Registered Nurses ) or Registered Nurses .Note:The General Practitioner (GP) or family doctor is the professional who provides primary or first level assistance. GPs treat acute and chronic illnesses, provide preventive measures, and offer health education to patients of both genders. The English word physician is generally reserved for physicians specializing in internal medicine. In hospitals, GPs can perform minor surgery and / or obstetrics practices. In the UK to receive a GP, you must complete 4 years of postgraduate studies at a Faculty of Medicine. According to the OECD (Organization for Economic Cooperation and Development) of which Great Britain is a part, in 2007 the number of doctors increased by 35 percent in the last 15 years, reaching 2.8 million.Structure of the British National Health System (NHS)To get an idea of ​​the size of the NHS let's say that in March 2005 it had 1,300,000 employees making up the third largest workforce in the world after the Chinese Army and the Indian Railways. Despite this, the figure dropped by 17,000 from 2005 to 2006 (The Independent-Alarm at significant drop in number of NHS workers, April 27, 2007).Seventy percent of NHS costs are to pay salaries and two-thirds of health expenditures go to patients over 60 years of age who have a growing demand for care. As in our country, medical equipment is becoming more sophisticated every day and the public demands treatments with new and expensive drugs. (Adam Smith Institute-Three quarters of NHS cash is needed just to stay still says think tank).The National Service Frameworks (NSFs) constitute long-term health strategies (eg, prevention of coronary heart disease) and are developed by health professionals and associated agencies. Strategic Health Authorities (SHAs) are They are also part of the NHS and are the ones that direct and execute the fiscal policies dictated by the Department of Health at the regional level. On April 12, 2006, Patricia Hewitt, Secretary of State for Health announced that there was going to be a reorganization and the SHAs would be reduced to 10. Each SHAs in turn contains several Trusts The National Institute for Health and Clinical Excellence (NICE) is the health authority of the NHS that publishes evaluations made on specific treatments based on cost / benefit.The TrustsThe First Level Trusts (PCTs) number 152 and comprise 29,000 family doctors (GPs) and 18,000 dentists. PCTs control 80 percent of the NHS budget. Ambulance Services Trusts comprise 290 organizations covering 1600 NHS hospitals. NHS Care Trusts provide Medical and Social care but do not exist in Scotland. The Mental Health Services Trusts provide psychiatric care but are not linked to the Combat Stress organization. Such is the case with the Oxfordshire and Buckinghamshire Mental Health Service NHS Trust. Foundation Trusts are intended to decentralize the NHS so that communities decide based on their wants and needs.However, UNISON, which is the union that groups all public service workers, thinks that this undermines the principles of public health services and sees this as a trend towards the privatization of public services.Monitor is an autonomous entity, independent from the government, which monitors the NHS Foundation Trusts by ensuring that they are well managed and financially sound.Note:A Trust is a group of companies under the same management whose purpose is to control the market for a specific product or sector.You criticize the UK's National Health ServiceBasically the British complain about the following points:Lack of access to medical benefitsPatients who do not conform to the resolutions dictated by the NHS must seek and pay for medical care in the private sphere.2. PoliticizationFiona Godlee, editor of the British Medical Journal, said on April 1, 2006 that ¨the National Health System needs a scheme that replaces political dogma with decisions based on clinical criteria, that replaces confrontation with consensus, lack of reliability with democracy and short-term decisions with long-term stability schemes.The NHS is too complex and vital to our future prosperity to be governed by interests of its own or of any specific party.The continuous use of the NHS as a theater of experimentation of management constitutes a waste ”.(BMJ 2006; 332: 1518 June 24)3 . Double paySometimes patients choose the private setting to be treated more quickly. So they are paying twice: one is withholding tax for the NHS (which they don't use) and the other is private consultation.4 . Long Waiting ListsAccording to the Daily Telegraph, the UK Health Department admitted that approximately 500,000 people in England suffer from shift expectations of a year or more. The worst first-rate care centers are in London, on the east and south coasts of England. The government's goal for 2008 is that no patient has to wait more than 18 weeks to be seen. (Daily Mail-500,000 wait over a year for NHS treatment- 7th June, 2007)5 .SupergermsHigh concentrations of antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile are considered to be the result of poor hygiene observed in NHS hospitals. Deaths linked to these two nosocomial infections have increased in one year by 59 percent. According to the Office of National Statistics, MRSA and Clostridium difficile caused more than 5,400 deaths in 2005. The highest peak in mortality (69 percent) according to death certificates were attributable to C. difficile. MRSA deaths increased 39 percent ( The Independent-Targets blamed as hospital infection deaths rised 59% -February 23, 2007 )6. ComputerizationIt is believed that an organization the size of the NHS should be able to meet the costs of developing and maintaining information systems.7. DentistryIn some areas there is reduced access to dental services and a tendency for these professionals to attend only private patients (BNN Online-March 1, 2006). In 2006 approximately 2000 dentists in England refused to sign a new type of contract introduced by the government according to which professionals would not charge from the NHS for treatment but would be assured an annual income of £ 80,000 for three years. The oral exam will be charged £ 15 and £ 40 will cover the repair of up to six cavities. (BNN Dentists ditch NHS, 8 April 2006 )8 . CoverageThe lack of accessibility to certain drugs in certain areas (due to the cost / benefit ratio) has led the British to jokingly nickname this "the postal code lottery"9 . DeficitsSome hospitals and trusts suffer from deficits and have incurred debt. A full report on this point and the allegations to the NHS can be found at BNN Online- NHS charges a complete mess, 18 July 200610 . Scandalsa) The scandal of the organs of Alder HeyIn December 1999 a team of researchers set about investigating the extraction of human organs that took place at the Royal Liverpool Children's Hospital NHS Trust.b) The Bristol Cardiac Surgery ScandalAn investigation was carried out on 290 children who died between 1984 and 1995 after having undergone cardiac surgery at the Bristol Royal Infirmary RegisteredNurses (RN)The history of nursing in the UK dates back to Florence Nightingale. On March 31, 2006 the number of nurses and midwives exceeded 682,000 making the Council of Nurses and Midwives or NMC the largest regulatory agent in the UK. There are approximately 400,000 nurses working for the NHS. The Royal College of Nursing (RCN), which has 395,000 members, was founded in 1916, in 1928 it received the Royal Charter and its patron was Queen Elizabeth II. The title of RN (Registered Nurse) is awarded only to those nurses endorsed by the Nurses, Midwives and Health Visitors Act of 1997. The bulk of them are dedicated to primary care. There are also Specialized Nurses, such as the Nurse Practitioner that complements the work of the GP,Registered Mental Health Nurses (RMN) are trained to care for the mentally ill, recognize symptoms, and even administer psychotropic drugs. In Trinidad Tobago, these nurses not only avoid unnecessary psychiatric hospitalizations but also provide prevention programs at the group level. (Health Sector Reform Program of Trinidad & Tobago)Registered nurses and their financial problemsNurses, policemen, teachers, ambulancemen and firefighters cannot afford housing in 65 per cent of British cities, whereas five years ago this was limited to only 24% of cities. (BNN Online-Key workers are priced out of homes-29 July 2006) During the course of the year, nurse Jusine Whitaker (37 years old) who, eight months ago was named Nurse of the Year, decided to resign from her job as nurse specialized in the treatment of lymphedema in protest at the permanent stress to which their peers are subjected by the constant health reforms. (The Independent, October 17, 2007). According to the RCN, during 2007 22,000 nursing positions were requested. (The Independent, April 5, 2007).The prescriptionsCancer drug prescriptions have placed a heavy burden on the NHS. Such has been the case with trastuzumab (Herceptin®). NICE recommends Herceptin® for women with early stages of breast cancer that are HER2 positive except when there are doubts about the patient's cardiac status. The NHS and NICE have approved the prescription in England and Wales of the so-called “smart drug” MabThera® (Rituximab). This drug is used for non-Hodgkin lymphomas. Rheumatoid arthritis affects 400,000 people in the UK (BBC News, 21 August 2007). However, the drug abatacept (Orencia®) was not approved. Orencia®, which costs £ 9,333 / year / patient could potentially benefit 12,000 patients in the UK alone (BBC News, 2 August 2007).The NHS offers financial assistance to those who cannot afford their treatments due to their low income. Patients who must receive chronic treatments can pay for their prescriptions through a prepaid certificate with considerable discounts. (Department of Health http: // www. Dh. Gov. Uk / en / Policyandguidance / Medicinespharmacyandindus try / Prescriptions /NHScosts/index.htm)Mental healthIt is estimated that 30 per cent of the world's population suffers from some type of mental disorder annually and at least two-thirds receive no care or receive inadequate treatment (The Independent-4 November 2007) .In the UK one in every six people suffer from chronic depression or anxiety and this affects one in three families. In most of Great Britain you have to wait nine months to receive sessions of Cognitive Therapy (CBT), (BNN-Therapy on NHS ¨must be increased¨, 18 June 2006).The impact on war veteransA study of 64 British Falklands war veterans revealed that half of them had some symptoms of post traumatic stress disorder (PTSD) and 22 percent had the full syndrome. (British Journal of Psychiatry (1991), 159, 135-141). 250 war veterans from the Malvinas, Northern Ireland, Bosnia, the Gulf War and other conflicts brought the Ministry of Defense to justice for not having been adequately treated by the PTSD upon their return, and another 1,600 were added to them. According to the South Atlantic Medal Association (SAMA) in the Malvinas Conflict 256 British combatants died but since then 264 have already committed suicide. (CMAJ-Suicide claiming more British Falkland veterans than fighting did-May 28, 2002). According to Roger Gabriel and Leigh A. Neal from the Gulf War Medical Assessment Program or MAP (a Veterans' Warfare Survey Program) at St. Thomas Hospital in London, any GP can diagnose a PTSD which will carry out the consultation with the psychiatrist as appropriate. (BMJ –Vol 324 -9 February 2002).Statue of the Abandoned SoldierThis statue, located in a Combat Stress, made by sculptor JamesNapier and modeled on Daniel Twiddy who wasseriously wounded in his face by splinters in Basra in 2003.The Combat Stress organization (Veterans Welfare Society)This society was founded in 1919 and is the only public welfare entity that provides assistance to war veterans who have suffered mental trauma as a result of combat. It has 13 regional centers and an experience based on 86 years of service. To date, more than 85,000 veterans and their families have been assisted and 8,000 veterans are currently registered. For hospitalizations (which cannot exceed six weeks a year) they have three centers: Hollybush House, Ayr (Scotland and Ireland) with 25 beds, Audley Court, Newport, Shropshire (England and North Wales) with 27 beds, and Tyrwitt House, Leatherhead, Surrey (England and South Wales) with 30 beds. They have a President, a Committee and an Executive Director on which report a Director of Clinical Services (a retired military psychiatrist), a Director of Finance and Administration (a civil accountant), a Director of Welfare and a Director in charge of collecting funds. The Director of Clinical Services controls Hollybush House, Tyrwitt House and Audley Court. There are no psychologists here but 15 registered nurses and two health assistants work. The clinical part is handled by the NHS GP. The patients have an average age of 44 years, have served 11 years, and on average it has been 13 years since they left active duty until they entered Combat Stress. 35 percent of applicants are rejected due to alcoholism or other severe addictions. According to the 2006 data, 80 percent belonged to the Army, 8, 7 percent to the Royal Air Force. 8 percent to the Royal Navy, 2.7 percent to the Royal Marines and 0.6 percent to the Merchant Navy. 10 percent of patients come from NHS referrals and 46 percent from friends or acquaintances.The so-called Comprehensive Care Plan (The Whole Person Care Plan) includes Cognitive Therapy (CBT), EMDR (Eye Movement Desensitization and Reprocessing). EMDR It is a method of desensitization and reprocessing of emotionally traumatic experiences through bilateral stimulation of the brain, education on Post Traumatic Stress, anxiety management, anger management, Creative Therapies, Relaxation Techniques , Sleep Hygiene, Occupational Therapy and Social Skills.Financial support for Combat Stress comes from the Ministry of Defense.The Robertson Truce, Seafarers UK, The Scottish Executive, The Officers´Association Scotland, The Corporation of Trinity House, The royal Army Chaplains Department, The Boughton Trust, Payroll Givers, Queen Mary´s Roehampton Trust, 51st Highland Division and Ross Bequest Trust , The Far East Prisoner-of-War Association, The Wates Foundation, and JP Getty Jr. Charitable Association. The day of admission to Combat Stress comes out £ 264 .. On March 31, 2007 they had received £ 2,732,000.The author at the Residential Treatment Center at Tyrwhitt House, Leatherhead, Surrey, England. The center provides the war veteran with a safe therapeutic environment in the company of their peers. Receive medical care that meets your needs with a team that seeks the most appropriate solutions.From right to left: Commodore Toby Elliott OBE RN (Executive Director ), Claire Evans (Head of Clinical Services) and Dr. Eduardo C.Gerding founder of the Nottingham-Malvinas Group. Photo taken atCombat Stress in Audley Court.The War Veteran's Personal FileEach War veteran has their own file which includes:a) The Medical History provided by their Family Physician (GP) and their Psychiatrist,b) A detailed report of their actual performance in combat made by an officer who was in charge andc) A final report made by a Welfare Officer.Files marked with a blue dot indicate new admissions.A neat bedroom in Audley Court. War veterans aregenerally reluctant to share the same. As theend of the year festivities approach many war veterans apply for admission due to amatter of loneliness.Veterans Recreation Activities at Audley Court. Thisincludes reflexology, relaxation techniques, Tai Chi, cookingclasses, computer classes, bowling, cycling, ping pong etc. On the rightMr. Jim Banks (Head Nurse).This painting was made by a Falklands War veteran interned at Audley Court. He himself had received a shot that destroyed his jaw. The image describes the intense pain suffered that he was not able to express in words. This constitutes part of the so-called Occupational Therapy. War veterans can also express their feelings through poetry, existing specialized therapists for them. (Arthur Lerner Ph.D ( Ed-Poetry in the Therapeutic Experience, 2nd edition )Special bathtub for disabled patientsThe War Pension SystemIn the UK, only war veterans who have been left with some degree of disability, widowers and orphans, receive a war pension. There are two systems: One for those affected before April 6, 2005 called the War Pensions Scheme and another for those who have suffered injuries after that date called the Armed Forces Compensation Scheme (AFCS). The latter does not prevent the veteran, if he wishes, from taking legal action against the Ministry of Defense .How War pensions are currently calculated according to the AFCSLevels from 1 to 15 are established depending on the severity of the injury.Level I correspWave to the most severe injuries and receive the largest amounts. Level 15 covers less severe injuries such as burns or knee dislocation. Those with Levels 1 to 11 receive a Guaranteed Income Payment GIP (Guaranteed Income for Life). This GIP is calculated by multiplying the pension payment by a factor that depends on the age on your last birthday. The younger the person, the greater the factor because the age that would normally be left to retire. The final GIP is a percentage of the rate that corresponds to you.The bands are as follows:Band A Levels 1 to 4 100%Band B Levels 5 to 6 75%Band C Levels 7 to 8 50%Band D Levels 9 to 11 30%Example:A 23-year-old soldier loses a foot as a result of a combat action. He is currently receiving a salary of £ 20,000. The corresponding factor is applied to a combatant of that age, which in this case is 0.878. The Guaranteed Income for Life (GIP) is calculated like this = Salary x Factor or £ 20,000 x 0.878 = £ 17,560. Since the injury is considered to correspond to Level 8, the person will receive 50% of their total GIP, meaning that they will receive £ 8,780 per year tax free.The case of the GurkhasLance Corporal Gyanendra Rai was seriously wounded by Argentine artillery at Bluff Cove during the Malvinas Conflict. Gyanendra Ray was discharged from the Army, receives no pension and was paid only £ 2,000 from the South Atlantic Fund. This Gurkha served 13 years in the British Army and not 15, which would have given him the right to collect a pension. ( Personal communication from Mike Seear )Apart from this, British immigration officials do not allow him to settle in Britain as they say that both Rai and other Gurkhas do not have "close ties to the United Kingdom". There is a provision stating that Gurkhas who retired before 1997 have no right to reside in the UK. An 84-year-old Gurkha named Tul Bahadur Pun who was awarded the Victoria Cross and was granted a visa called for justice for his peers. (BBC, 1 August 2007) http://www.cchero.co.ukLance Corporal Gyandendra RaiGyandendra Railost part of her backEl Grupo Malvinas-Nottingham

Fewer Falklands War suicides than feared, study suggestsThe claim that more Falklands veterans have killed themselves since the war ended than died in action is not borne out by statistics, a study says.Some 255 UK personnel died in action, but a veterans group has said the suicide toll since 1982 exceeds that.However, the Ministry of Defence has found 95 deaths were recorded as suicides or open verdicts.The MoD said every suicide was a tragedy and urged veterans of any conflict needing support to seek help.In 2002, The South Atlantic Medal Association, which represents veterans, said it was "almost certain" the number of suicides exceeded the conflict death toll.It placed the blame predominantly on a lack of care for those suffering post traumatic stress disorderBut the MoD has now investigated the circumstances of 21,432 Falklands veterans three decades after the end of the conflict, and found that as of 31 December 2012, some 1,335 had died.That compares with an estimated 2,079 deaths that would have been expected among men of a similar age and background who did not serve in the forces, according to the MoD.Of those Falklands veterans, 7% of deaths - or 95 individuals - were due to "intentional self-harm and events of undetermined intent (suicides and open verdict deaths)".That finding means that on average across the whole 30-year period, veterans were actually 35% less likely to kill themselves than the equivalent group of British men with no military background.An MoD spokesman said: "Every suicide is a tragedy and our thoughts remain with the families and relatives of all those lost who bravely served in the Falklands conflict."He said the government had committed £7.2m to improving mental health support for military personnel, including creating a 24-hour helpline in conjunction with charity Combat Stress.The spokesman added: "We would encourage any Falklands veterans or serving personnel who need help to come forward to access the wide range of support available."The study also found:78% of veterans' deaths (1,046) were the result of disease, while 19% (247 deaths) were the result of external causes of injuryCancer was the primary cause of disease-related deaths, with 455 cases recordedBut veterans were 30% less likely to die from cancer and 40% less likely to die from disease in general than men with no military background over the period since 1982Of the 1,335 Falklands deaths, 140 occurred while the individual was still in service - the rest died after leaving the Armed ForcesThe MoD said military personnel were likely to have higher levels of fitness and lower levels of ill health than the general UK population, which could account for the lower incidence of death from disease observed by the study.The death toll of 255 from the Falklands War includes 237 UK servicemen, along with four personnel from the Royal Fleet Auxiliary, six from the Merchant Navy and eight Hong Kong sailors.Falklands suicides 'overestimated'2008 - Veterans Assistance in the UKDr. Eduardo C. GERDINGBulletin of the Naval Center Year 126-Vol. CXXVI-Nº 822-Oct-Dec 2008PrefaceThe medical care of war veterans is inserted, like that of the ordinary British citizen, in the so-called National Health Service (NHS ) which is comparable in its structure to our National Institute of Social Services for Retirees and Pensioners ( INSSJP ). There are population differences, given that the United Kingdom has a significant immigrant group from India, Pakistan, Somalia and the Philippines to the point that 21.9 percent of children born in Great Britain are to foreign mothers. On the other hand, his retirement system has been in trouble for a long time. ( BBC News, Pensions in Crisis- December 10, 2002). In 2003 total health spending per capita in the UK was US $ 2,317.There are serious healthcare problems in military hospitals. In March 2007, Selly Oak Hospital was charged with mistreating British war veterans returning from Iraq. ( BBC, March 11, 2007 ) The British government, arguing that military hospitals cannot provide the same level of care as NHS hospitals has been closing them since 1990. In fact, the Royal Naval Hospital in Haslar, dating from 1753, It is the last military hospital to close its doors in 2009 and the remaining military personnel ( 200 people ) will be transferred to a Ministry of Defense hospital unit located at Queen Alexandra Hospital in Cosham, Portsmouth.The National Health Service ( NHS )The NHS is the UK's public health service, serving 57 million people. England, Scotland, Wales and Northern Ireland each have their own NHS. The NHS budget in 2007 was £ 90 billion and is to be increased by 4 per cent by 2010. ( HealthInsider-10 Oct 2007 ).The Scottish doctor Archibald Joseph Cronin, author of the famous novel The Citadel, was the one who established the innovative ideas that gave rise not only to the NHS but to the triumph of the Labor Party in 1945. In primary care or First Level of the NHS the pillars are GPs ( General Practitioners ) or family doctors and RN ( Registered Nurses ) or Registered Nurses .Note:The General Practitioner (GP) or family doctor is the professional who provides primary or first level assistance. GPs treat acute and chronic illnesses, provide preventive measures, and offer health education to patients of both genders. The English word physician is generally reserved for physicians specializing in internal medicine. In hospitals, GPs can perform minor surgery and / or obstetrics practices. In the UK to receive a GP, you must complete 4 years of postgraduate studies at a Faculty of Medicine. According to the OECD (Organization for Economic Cooperation and Development) of which Great Britain is a part, in 2007 the number of doctors increased by 35 percent in the last 15 years, reaching 2.8 million.Structure of the British National Health System (NHS)To get an idea of ​​the size of the NHS let's say that in March 2005 it had 1,300,000 employees making up the third largest workforce in the world after the Chinese Army and the Indian Railways. Despite this, the figure dropped by 17,000 from 2005 to 2006 (The Independent-Alarm at significant drop in number of NHS workers, April 27, 2007).Seventy percent of NHS costs are to pay salaries and two-thirds of health expenditures go to patients over 60 years of age who have a growing demand for care. As in our country, medical equipment is becoming more sophisticated every day and the public demands treatments with new and expensive drugs. (Adam Smith Institute-Three quarters of NHS cash is needed just to stay still says think tank).The National Service Frameworks (NSFs) constitute long-term health strategies (eg, prevention of coronary heart disease) and are developed by health professionals and associated agencies. Strategic Health Authorities (SHAs) are They are also part of the NHS and are the ones that direct and execute the fiscal policies dictated by the Department of Health at the regional level. On April 12, 2006, Patricia Hewitt, Secretary of State for Health announced that there was going to be a reorganization and the SHAs would be reduced to 10. Each SHAs in turn contains several Trusts The National Institute for Health and Clinical Excellence (NICE) is the health authority of the NHS that publishes evaluations made on specific treatments based on cost / benefit.The TrustsThe First Level Trusts (PCTs) number 152 and comprise 29,000 family doctors (GPs) and 18,000 dentists. PCTs control 80 percent of the NHS budget. Ambulance Services Trusts comprise 290 organizations covering 1600 NHS hospitals. NHS Care Trusts provide Medical and Social care but do not exist in Scotland. The Mental Health Services Trusts provide psychiatric care but are not linked to the Combat Stress organization. Such is the case with the Oxfordshire and Buckinghamshire Mental Health Service NHS Trust. Foundation Trusts are intended to decentralize the NHS so that communities decide based on their wants and needs.However, UNISON, which is the union that groups all public service workers, thinks that this undermines the principles of public health services and sees this as a trend towards the privatization of public services.Monitor is an autonomous entity, independent from the government, which monitors the NHS Foundation Trusts by ensuring that they are well managed and financially sound.Note:A Trust is a group of companies under the same management whose purpose is to control the market for a specific product or sector.You criticize the UK's National Health ServiceBasically the British complain about the following points:Lack of access to medical benefitsPatients who do not conform to the resolutions dictated by the NHS must seek and pay for medical care in the private sphere.2. PoliticizationFiona Godlee, editor of the British Medical Journal, said on April 1, 2006 that ¨the National Health System needs a scheme that replaces political dogma with decisions based on clinical criteria, that replaces confrontation with consensus, lack of reliability with democracy and short-term decisions with long-term stability schemes.The NHS is too complex and vital to our future prosperity to be governed by interests of its own or of any specific party.The continuous use of the NHS as a theater of experimentation of management constitutes a waste ”.(BMJ 2006; 332: 1518 June 24)3 . Double paySometimes patients choose the private setting to be treated more quickly. So they are paying twice: one is withholding tax for the NHS (which they don't use) and the other is private consultation.4 . Long Waiting ListsAccording to the Daily Telegraph, the UK Health Department admitted that approximately 500,000 people in England suffer from shift expectations of a year or more. The worst first-rate care centers are in London, on the east and south coasts of England. The government's goal for 2008 is that no patient has to wait more than 18 weeks to be seen. (Daily Mail-500,000 wait over a year for NHS treatment- 7th June, 2007)5 .SupergermsHigh concentrations of antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile are considered to be the result of poor hygiene observed in NHS hospitals. Deaths linked to these two nosocomial infections have increased in one year by 59 percent. According to the Office of National Statistics, MRSA and Clostridium difficile caused more than 5,400 deaths in 2005. The highest peak in mortality (69 percent) according to death certificates were attributable to C. difficile. MRSA deaths increased 39 percent ( The Independent-Targets blamed as hospital infection deaths rised 59% -February 23, 2007 )6. ComputerizationIt is believed that an organization the size of the NHS should be able to meet the costs of developing and maintaining information systems.7. DentistryIn some areas there is reduced access to dental services and a tendency for these professionals to attend only private patients (BNN Online-March 1, 2006). In 2006 approximately 2000 dentists in England refused to sign a new type of contract introduced by the government according to which professionals would not charge from the NHS for treatment but would be assured an annual income of £ 80,000 for three years. The oral exam will be charged £ 15 and £ 40 will cover the repair of up to six cavities. (BNN Dentists ditch NHS, 8 April 2006 )8 . CoverageThe lack of accessibility to certain drugs in certain areas (due to the cost / benefit ratio) has led the British to jokingly nickname this "the postal code lottery"9 . DeficitsSome hospitals and trusts suffer from deficits and have incurred debt. A full report on this point and the allegations to the NHS can be found at BNN Online- NHS charges a complete mess, 18 July 200610 . Scandalsa) The scandal of the organs of Alder HeyIn December 1999 a team of researchers set about investigating the extraction of human organs that took place at the Royal Liverpool Children's Hospital NHS Trust.b) The Bristol Cardiac Surgery ScandalAn investigation was carried out on 290 children who died between 1984 and 1995 after having undergone cardiac surgery at the Bristol Royal Infirmary RegisteredNurses (RN)The history of nursing in the UK dates back to Florence Nightingale. On March 31, 2006 the number of nurses and midwives exceeded 682,000 making the Council of Nurses and Midwives or NMC the largest regulatory agent in the UK. There are approximately 400,000 nurses working for the NHS. The Royal College of Nursing (RCN), which has 395,000 members, was founded in 1916, in 1928 it received the Royal Charter and its patron was Queen Elizabeth II. The title of RN (Registered Nurse) is awarded only to those nurses endorsed by the Nurses, Midwives and Health Visitors Act of 1997. The bulk of them are dedicated to primary care. There are also Specialized Nurses, such as the Nurse Practitioner that complements the work of the GP,Registered Mental Health Nurses (RMN) are trained to care for the mentally ill, recognize symptoms, and even administer psychotropic drugs. In Trinidad Tobago, these nurses not only avoid unnecessary psychiatric hospitalizations but also provide prevention programs at the group level. (Health Sector Reform Program of Trinidad & Tobago)Registered nurses and their financial problemsNurses, policemen, teachers, ambulancemen and firefighters cannot afford housing in 65 per cent of British cities, whereas five years ago this was limited to only 24% of cities. (BNN Online-Key workers are priced out of homes-29 July 2006) During the course of the year, nurse Jusine Whitaker (37 years old) who, eight months ago was named Nurse of the Year, decided to resign from her job as nurse specialized in the treatment of lymphedema in protest at the permanent stress to which their peers are subjected by the constant health reforms. (The Independent, October 17, 2007). According to the RCN, during 2007 22,000 nursing positions were requested. (The Independent, April 5, 2007).The prescriptionsCancer drug prescriptions have placed a heavy burden on the NHS. Such has been the case with trastuzumab (Herceptin®). NICE recommends Herceptin® for women with early stages of breast cancer that are HER2 positive except when there are doubts about the patient's cardiac status. The NHS and NICE have approved the prescription in England and Wales of the so-called “smart drug” MabThera® (Rituximab). This drug is used for non-Hodgkin lymphomas. Rheumatoid arthritis affects 400,000 people in the UK (BBC News, 21 August 2007). However, the drug abatacept (Orencia®) was not approved. Orencia®, which costs £ 9,333 / year / patient could potentially benefit 12,000 patients in the UK alone (BBC News, 2 August 2007).The NHS offers financial assistance to those who cannot afford their treatments due to their low income. Patients who must receive chronic treatments can pay for their prescriptions through a prepaid certificate with considerable discounts. (Department of Health http: // www. Dh. Gov. Uk / en / Policyandguidance / Medicinespharmacyandindus try / Prescriptions /NHScosts/index.htm)Mental healthIt is estimated that 30 per cent of the world's population suffers from some type of mental disorder annually and at least two-thirds receive no care or receive inadequate treatment (The Independent-4 November 2007) .In the UK one in every six people suffer from chronic depression or anxiety and this affects one in three families. In most of Great Britain you have to wait nine months to receive sessions of Cognitive Therapy (CBT), (BNN-Therapy on NHS ¨must be increased¨, 18 June 2006).The impact on war veteransA study of 64 British Falklands war veterans revealed that half of them had some symptoms of post traumatic stress disorder (PTSD) and 22 percent had the full syndrome. (British Journal of Psychiatry (1991), 159, 135-141). 250 war veterans from the Malvinas, Northern Ireland, Bosnia, the Gulf War and other conflicts brought the Ministry of Defense to justice for not having been adequately treated by the PTSD upon their return, and another 1,600 were added to them. According to the South Atlantic Medal Association (SAMA) in the Malvinas Conflict 256 British combatants died but since then 264 have already committed suicide. (CMAJ-Suicide claiming more British Falkland veterans than fighting did-May 28, 2002). According to Roger Gabriel and Leigh A. Neal from the Gulf War Medical Assessment Program or MAP (a Veterans' Warfare Survey Program) at St. Thomas Hospital in London, any GP can diagnose a PTSD which will carry out the consultation with the psychiatrist as appropriate. (BMJ –Vol 324 -9 February 2002).Statue of the Abandoned SoldierThis statue, located in a Combat Stress, made by sculptor JamesNapier and modeled on Daniel Twiddy who wasseriously wounded in his face by splinters in Basra in 2003.The Combat Stress organization (Veterans Welfare Society)This society was founded in 1919 and is the only public welfare entity that provides assistance to war veterans who have suffered mental trauma as a result of combat. It has 13 regional centers and an experience based on 86 years of service. To date, more than 85,000 veterans and their families have been assisted and 8,000 veterans are currently registered. For hospitalizations (which cannot exceed six weeks a year) they have three centers: Hollybush House, Ayr (Scotland and Ireland) with 25 beds, Audley Court, Newport, Shropshire (England and North Wales) with 27 beds, and Tyrwitt House, Leatherhead, Surrey (England and South Wales) with 30 beds. They have a President, a Committee and an Executive Director on which report a Director of Clinical Services (a retired military psychiatrist), a Director of Finance and Administration (a civil accountant), a Director of Welfare and a Director in charge of collecting funds. The Director of Clinical Services controls Hollybush House, Tyrwitt House and Audley Court. There are no psychologists here but 15 registered nurses and two health assistants work. The clinical part is handled by the NHS GP. The patients have an average age of 44 years, have served 11 years, and on average it has been 13 years since they left active duty until they entered Combat Stress. 35 percent of applicants are rejected due to alcoholism or other severe addictions. According to the 2006 data, 80 percent belonged to the Army, 8, 7 percent to the Royal Air Force. 8 percent to the Royal Navy, 2.7 percent to the Royal Marines and 0.6 percent to the Merchant Navy. 10 percent of patients come from NHS referrals and 46 percent from friends or acquaintances.The so-called Comprehensive Care Plan (The Whole Person Care Plan) includes Cognitive Therapy (CBT), EMDR (Eye Movement Desensitization and Reprocessing). EMDR It is a method of desensitization and reprocessing of emotionally traumatic experiences through bilateral stimulation of the brain, education on Post Traumatic Stress, anxiety management, anger management, Creative Therapies, Relaxation Techniques , Sleep Hygiene, Occupational Therapy and Social Skills.Financial support for Combat Stress comes from the Ministry of Defense.The Robertson Truce, Seafarers UK, The Scottish Executive, The Officers´Association Scotland, The Corporation of Trinity House, The royal Army Chaplains Department, The Boughton Trust, Payroll Givers, Queen Mary´s Roehampton Trust, 51st Highland Division and Ross Bequest Trust , The Far East Prisoner-of-War Association, The Wates Foundation, and JP Getty Jr. Charitable Association. The day of admission to Combat Stress comes out £ 264 .. On March 31, 2007 they had received £ 2,732,000.The author at the Residential Treatment Center at Tyrwhitt House, Leatherhead, Surrey, England. The center provides the war veteran with a safe therapeutic environment in the company of their peers. Receive medical care that meets your needs with a team that seeks the most appropriate solutions.From right to left: Commodore Toby Elliott OBE RN (Executive Director ), Claire Evans (Head of Clinical Services) and Dr. Eduardo C.Gerding founder of the Nottingham-Malvinas Group. Photo taken atCombat Stress in Audley Court.The War Veteran's Personal FileEach War veteran has their own file which includes:a) The Medical History provided by their Family Physician (GP) and their Psychiatrist,b) A detailed report of their actual performance in combat made by an officer who was in charge andc) A final report made by a Welfare Officer.Files marked with a blue dot indicate new admissions.A neat bedroom in Audley Court. War veterans aregenerally reluctant to share the same. As theend of the year festivities approach many war veterans apply for admission due to amatter of loneliness.Veterans Recreation Activities at Audley Court. Thisincludes reflexology, relaxation techniques, Tai Chi, cookingclasses, computer classes, bowling, cycling, ping pong etc. On the rightMr. Jim Banks (Head Nurse).This painting was made by a Falklands War veteran interned at Audley Court. He himself had received a shot that destroyed his jaw. The image describes the intense pain suffered that he was not able to express in words. This constitutes part of the so-called Occupational Therapy. War veterans can also express their feelings through poetry, existing specialized therapists for them. (Arthur Lerner Ph.D ( Ed-Poetry in the Therapeutic Experience, 2nd edition )Special bathtub for disabled patientsThe War Pension SystemIn the UK, only war veterans who have been left with some degree of disability, widowers and orphans, receive a war pension. There are two systems: One for those affected before April 6, 2005 called the War Pensions Scheme and another for those who have suffered injuries after that date called the Armed Forces Compensation Scheme (AFCS). The latter does not prevent the veteran, if he wishes, from taking legal action against the Ministry of Defense .How War pensions are currently calculated according to the AFCSLevels from 1 to 15 are established depending on the severity of the injury.Level I correspWave to the most severe injuries and receive the largest amounts. Level 15 covers less severe injuries such as burns or knee dislocation. Those with Levels 1 to 11 receive a Guaranteed Income Payment GIP (Guaranteed Income for Life). This GIP is calculated by multiplying the pension payment by a factor that depends on the age on your last birthday. The younger the person, the greater the factor because the age that would normally be left to retire. The final GIP is a percentage of the rate that corresponds to you.The bands are as follows:Band A Levels 1 to 4 100%Band B Levels 5 to 6 75%Band C Levels 7 to 8 50%Band D Levels 9 to 11 30%Example:A 23-year-old soldier loses a foot as a result of a combat action. He is currently receiving a salary of £ 20,000. The corresponding factor is applied to a combatant of that age, which in this case is 0.878. The Guaranteed Income for Life (GIP) is calculated like this = Salary x Factor or £ 20,000 x 0.878 = £ 17,560. Since the injury is considered to correspond to Level 8, the person will receive 50% of their total GIP, meaning that they will receive £ 8,780 per year tax free.The case of the GurkhasLance Corporal Gyanendra Rai was seriously wounded by Argentine artillery at Bluff Cove during the Malvinas Conflict. Gyanendra Ray was discharged from the Army, receives no pension and was paid only £ 2,000 from the South Atlantic Fund. This Gurkha served 13 years in the British Army and not 15, which would have given him the right to collect a pension. ( Personal communication from Mike Seear )Apart from this, British immigration officials do not allow him to settle in Britain as they say that both Rai and other Gurkhas do not have "close ties to the United Kingdom". There is a provision stating that Gurkhas who retired before 1997 have no right to reside in the UK. An 84-year-old Gurkha named Tul Bahadur Pun who was awarded the Victoria Cross and was granted a visa called for justice for his peers. (BBC, 1 August 2007) http://www.cchero.co.ukLance Corporal Gyandendra RaiGyandendra Railost part of her backEl Grupo Malvinas-Nottingham