Nursing Shortage in the United States

Nursing Shortage in the United States NURSING LABOUR FORCE IN THE U.S. HEALTH CARE SYSTEM Abstract The well-anticipated demographic change attributed to the ageing of the baby boomer population in the USA will led to a significant demand on the healthcare industry in the long run. Important resources such as the nurse work force will be required to provide quality health care services to the population. This research paper will provide a brief description and statistics of the nurse labor force in the USA, the educational requirement needed to be a nurse, the challenges face by the nurses in the healthcare system. The last part of the paper identifies the nursing shortage and the solutions for the short and long run, the recommendations and finally, the conclusion. LABOR FORCE IN THE U.S. HEALTHCARE SYSTEM The healthcare system in America is a complex and unique setting comparing to the other 34 countries in the Organization for Economic Co-Operation and Development (OECD). In 2016, The United States spent $3.3 trillion on health care benefits, or 10,348 per person annually, which represents17.9 % of the total GDP and remained at top of all OECD countries for the healthcare expenditures. About 30% of the cost was spent on hospital care, 20% on physician and clinical services, 10% on prescription drugs and 5% on nursing care. However, the life expectancy is 78.6 years which ranked 22nd of the OECD countries (Medicare & Services, 2015). Meanwhile, problems such as growing population, aging and shortage of physicians and nurses are causing the increasing demand for healthcare benefits (Levit & Patlak, 2009). In 2016, there were 5,534 registered hospitals including 4,840 community hospitals in the U.S, most of the healthcare facilities are owned by private companies and 60% of the community hospitals are non-for-profit organizations, 20% are for-profit and 20% are owned by government. In U.S, the most value of healthcare system in America is the health professional, also considered as health providers (AHA, 2018). THE NURSING WORKFORCE According to U.S Bureau of Labor (2018), the total labor force was around 160 million. Nurses are playing an important role in the healthcare system. Nursing demographic consists of: 1.5 million certified nursing assistant (CNA), which represents about 1% of the U.S labor force who are responsible supporting patients’ daily activities such as taking vital signs, dispensing prescribed medications, bathing and transporting patients. Certified nursing assistant is concerned as nursing assistant as general or patient care assistant. CNA is like medical assistants that both assist physicians, nurses and such healthcare providers. Usually, CNAs are assigned in an inpatient hospital and residential facilities such as nursing home and day care centers. Till 2016, the average salary for CNA was $26,590 while VA hospitals might offer better salary, around $37,450. Alaska pays the highest average salary which was $17.81/hour while it was $11.6/ hour in West Virginia. In fact, the market expected the demand for CNAs would increase about 11% during 2014 to 2024. 738,000 licensed practical nurse (LPN), which represents about 0.5% of U.S labor force, who are responsible for administering injections, surgical preparation and communication between patients and physicians. LPNs also do assistant works such as recording and maintaining communication with patients, registered nurses and physicians. LPNs are directly assigned to take care of patients that keep patients comfortable. Sometime, LPNs are assigned to take blood pressure, insert catheters and such activities. LPNs usually work in hospitals, nursing homes, doctor’s offices and any healthcare facilities. In fact, LPNs are the direct contact between patients and physician that they are responsible for keep patients’ knowledge about treatment and procedures. The average salary for an LPN was $44,000 and the number is expected to increase. Connecticut state pays the highest average salary which was 24.30/ hour, comparing to the lowest paying state West Virginia with $14.25/ hour or $29,640 per year. 3 million registered nurse (RN), which represents the largest group of all types of nu rse and 1.9% of U.S labor force, who are qualified with license to make nursing diagnoses and work as a supervisor of CNAs and LPNs. RNs work with physician and healthcare teams to improve healthcare quality and treatment quality. RNs also educate patients for their health conditions and support patients and their family members on further living. Since it is the largest group, the competition is fierce. Depending on the specialty, education and experience, the average salary was around $70,000 in 2015. Some hospitals might offer better payment to $100,000. California owns the largest number of RNs, which was around 300,000 and it pays the highest salary in America, which was $98,400 on average. The market expected a 16% increase of RNs from 2014 to 2024.151,000 advanced registered nurse practitioner (ARNP), who received additional education with master’s degree or post graduate degree and additional medical experience. ARNPs work as clinical nurse specialist and nurse anesth etists that they are certified to diagnose, prescribe medication and therapy, provide treatment and counsel to patients. ARNPs are specify into multiple types such as acute care, nursing information, nurse administrator, travel nursing, family nursing, psychiatric nurse, neonatal nurse and pediatric nurse. The average wages for ARNPs was $95,000 or $46.40/ hour. During the first decade of 21st century, the job opportunities in the healthcare segment of United States grew with a pace of 20% while, in all other segments of the industries nationwide, the same growth was merely 3%. The growth rate has boomed in the US healthcare market, demanding for more and more registered nurses and nursing professionals in the current decade as well. These opportunities have created various job profiles so far in the evolving hospital settings. New hospitals and home care-based jobs are also emerging rapidly. â€Å"It is anticipated that the rate of employment in the health care sector will grow faster than the rate of employment in all other sectors between 2014 and 2024, with projected increases of nearly 22% and 5%, respectively. Other service sectors are projected to grow by about 8% during the same time period .†Ã‚  (Martiniano, Chorost, & Moore, 2017). Currently there are more than six million of the staff available across states in the healthcare settings for RNs and NPs working in various administrative positions in United States. The growth rate is also having positive rays of hopes in terms of having future job employments because of the fact that between 2014 to 2024, it is estimated that the home care based jobs are expected to increase by 60% while jobs in the offices of the healthcare practitioners are also said to have the increase of 25% because as of now, there are more than 4 million of jobs that are available in the same position—the job positions are subjected to be vacant and filled at the same time, depending on the conditions of the nurses who are employed and leave their jobs due to unforeseen conditions (Martiniano et al., 2017). Researches showed that there would be a 1 million shortage of RN in 2020 because of the dropping economic situation in America. In fact, the shortage has been ongoing since 1998 that it has been always a lack of supply. The supply was higher than the increase of demand. There were several reasons behind the shortage. Ageing of nurses might be the most concerned issue in recent that many nursing practitioners are getting older. Since 2012, the 50-60 year-age group represented the largest group on RNs and these group is expected to retire before 2025 but they are the ones who are the most experienced for taking care of patients (Levit & Patlak, 2009).   The U.S government also supports foreign-born nurses in order to fill the gap between supply and demand. In 2008, international nurses represented 15% of the nursing workforce. One concern was the communication that international nurses might have problems on communicating with patients and doctors even thought they had passed the English language test such as TOEFL and IELTS. In fact, foreign-born nurses on average cost less than American born nurses and they contribute extra value on international patients (Levit & Patlak, 2009). NURSING PROFESSION’S QUALIFICATION With the expansion of the ACA, allowing more people access to health care and insurance coverage, and the aging of the population, which increases the nationwide rate of terminal illnesses such as heart failure and cancer, the demand for care is higher than ever and there prompts the big question of whether the current health care workforce can adequately meet that demand. To fill the obvious gap that will occur, non-physician providers will be needed. Potential candidates for the positions are no other than advanced trained nurse. In the1990s, funding for nursing education drew the attention of policymakers as people realized there would be substantial shortfalls of nurses in the next decades. Efforts to increase funding for nursing education have been intermingled with advocacy for increased emphasis on baccalaureate entry-level education. In the past, many RNS were educated in hospital-based diploma programs, but most of these programs has been converted to associate or bachelor’s degree programs. The shift in nursing education from hospitals to universities marked the importance of the body of knowledge that the nursing profession should possesses. More essentially, it defined nursing as something much more than assistant to the physician. As an effort to alleviate a looming cycle of nursing shortage, community colleges and technical schools started offering nursing program in the 1970s. Since then, the nursing education has greatly evolved to better prepare their students for the ever-changing and challenging world of health care system. The two most common paths for people pursuing a nursing degree is either obtaining a 2-year associate degree (AND) or a 4-year baccalaureate program (BSN). Many community and technical colleges offer ADN programs and they are more attractive to prospective nurses because of their affordability and a shorter time period to finish. Graduates from the programs are qualified to sit for the National Council Licensure Examination for Registered Nurse (NCLEX-RN). This type of program provides a solid foundation for entry-level nursing positions at a wide array of health-related establishments, including hospitals, primary care clinics, and nursing homes. In addition, nurses can later register for the RN-to-BSN bridge programs to obtain their BSN. The 4-year BSN, while more time consuming, opens up more opportunities for nursing students upon their graduation. BSN candidates receive intensive training not only in the clinical field, but also in leadership and communication skill. The goal is to provide more professional development to their students through a comprehensive curriculum that covers some of the most pressing issues within the profession, such as public health, social sciences, nursing research, and management and leadership. Most of nursing programs are not recommended to be taken online as they are hands-on profession. Averagely, nursing program costs $15,000 per academic year (Registered Nursing Degrees, 2018). In the 1990s, nurses once passed their board licensing received the same licenses and often hired to perform the same jobs. Their background education, whether they had an associate degree (ADN) or a baccalaureate degree in nursing (BSN), did not differentiate the task they performed in any health care facility. While the practices and educational differences between ADN and BSN were proven to exist, there was a general but often weak correlation in patient outcomes based on the initial education preparation of the RN providing the care (Kovner & Schore, 1998). A meta-analysis done in 1988 by Joyce Johnson pointed out that BSN RNs attained higher scores in the field of communication, problem solving, and professional role when compared with AND RNs. Contrariwise, these associations decreased when experience was taken into account, and no distinguishing result existed in measuring level of leadership and autonomy between BSN and ADN RNs.  Time has changed and so as the complexity of the health care system. The role expectations and educational outcome differences for ADN and BSN has been more clarified. Although the health care system required nurses prepared at both levels of education, the graduates of these programs hold different competencies and should be valued for those differences (N/A, 1995). A study done in 2003 further proved this notion by showing the connection between higher levels of nursing human capital and improvement in patient outcomes – a 10 percent increase in nurses with baccalaureate degree yielded a 5 percent decrease in patient mortality and complications (Kutney-Lee, Sloane, & Aiken, 2013). This clarification in the roles of ADN and BSN nurses are vital to the delivery of high quality care and require the restructure of their education curriculum as well as validation in the systems in which these graduates are employed.      ISSUES IN THE NURSING LABOR FORCE Like many other health care professional, the nursing workforce has many problematic areas that need to be resolved. One of the most pressing one is the shortage in labor force. The Patient Protection and Affordable Care Act (ACA) since its enactment in March, 2010, has successfully provided insurance coverage for around 19.2 million people and dropped the number of uninsured population from 20.5 percent to 12.2 percent in 2016 (Garrett & Gangopadhyaya, 2016). This influx of new patients has driven up the demand for nurses with the U.S. Department of health and Human Services projected a shortfall of over one million nurses by 2020 (DHHR, Resources, Workforce, & Analysis, 2017). However, the current state of the workforce is gradually depreciated due to several factors. The aging baby boomer nurses reaching their retirement ages contributes as the first factor in this shortage crisis. This aging workforce has been dealing with increasing pressure due to higher work demand resulted fr om nursing shortages, and their health suffers tremendously with a significant higher number of senior nurses experiencing chronic pain, tiredness, and exhaustion among the group (Gabrielle, Mannix, & Jackson, 2008). An obvious fix to this problem is to increase the number of qualified nurses in the labor market through nursing school recruitment campaign. Unfortunately, the majority of nursing schools nationwide do not have the capacity to accept new candidates due to a lack of faculty, budget constraints and limited clinical sites for students to practice. While all schools reported reaching their full capacity and even going over their students limit each year, many applicants got rejected, with 78 percent of ADN applicants and 62 percent of BSN candidates, all of them had qualified credentials, were turned away from nursing school in 2016 (Nursing, 2016). This would directly reduce the chance to generate enough nursing graduates to meet the upcoming demands facing the health car e industry. Beside the restricted nursing enrollment rate, health care providers only preferred nurses who already had several years of experience and turned down many potential applicants only because they newly graduated. Another realistic alternative to fill the gap in nursing staff is by hiring foreign-educated nurses. However this solution is poorly received since it stirs up concerns regarding the level of competency of nurses trained outside the U.S. and immigration issues (Williams, 2014). A shortage of nurse will ultimately lead to a change of nurse staffing pattern in care centers, with one nurse tending for more patients. A study by Cummings and Estabrooks (2003) pointed out the negative effects the change in nurse staffing patterns had brought upon the remaining nursing staffs’ health and their competency to provide quality care. Other research literature also reported imbalance nurse staffing pattern can drive up the rate of preventable medical errors and adverse events (e.g. hospital-acquired pressure ulcers, wrong blood transfusion) (Cho, Ketefian, Barkauskas, & Smith, 2003). The predominant effects of hospital restructuring on nurses are mostly negative with a decrease in efficacy and ability to provide quality care, reduction in job satisfaction, and disparity in teamwork among care providers, which resulted in an increase in turnover rate. Cost containment initiatives in many health care establishment can also further deplete the nursing workforce. The U.S. health care expenditure has skyrocketed over the past decade and accounted for 17.9 percent in the overall share of gross domestic product (GDP) and more than $10,000 per capita in 2016 (Llanos & Rothstein, 2007) (CMS, 2016). Regardless, the U.S. index for health care outcomes such as life expectancy, maternal mortality, child and infant mortality are far behind other OECD nations (Institute of Medicine, 2007). As a result, several health reform programs were introduced in an attempt to increase access-to-care for the population, reduce the health care cost, and improve the quality of health care. The implementation of these pilot programs put tremendous pressure on health care providers and organizations to contain their cost while maintaining optimum treatment to their patients. Many care facilities decided to restructure their workforce by decreasing the overall labor pool. As one of the largest personnel group in the health care workforce and oftentimes claimed for the largest piece of the hospital budget pie, approximately 33 percent of hospital operation cost (Walston, Burns, & Kimberly, 2000), nursing positions were the primary target for cost-containment strategies in many organization. The result was an increase in substitution for lower credential nursing position, such as Licensed Practical Nurse which only required two years of associate degrees, or even unlicensed personnel like patient-care technicians. This shift in work force in the 1990s, however, had driven up the rate of medication errors, patient injuries and infection (Kunen, 2001). To better adapt to the ever changing environment of health care bureaucracy and population health priorities with finite capital and human resources, all health-related establishments should develop strategies with emphasis in organization and culture restructure that has positive impact on the outcomes of patients and nurses. Beside financial incentives, political advocacy from both the federal and state government, as well as professional opinion and standard setting can further make changes to the recruitment and retention of qualified nurse workforce. THE GOVERNMENT’S EFFORT IN SOLVING THE ISSUE OF NURSE SUPPLY One of the problems the healthcare system in the U.S. is facing is that of shortage of nurses. Some factors which contribute to this shortage is the fact that women have more options in choosing their career path in society today when compared to the past. From an economic point of view, this problem of shortage is cause more by the supply side rather than the demand side thus, making it a more complex shortage (B. & J.I., 2001). This shortage of nurses might worsen in the long run if the government do not develop and implement solutions to solve this problem. Some economic solutions where developed in the past to help solve this problem such as relocation coverage, new premium packages and sign on bonuses; however, they were all short-term solutions which helped in redistributing the supply of nurses instead of increasing it (B. & J.I., 2001). Due to the shortage of nurses in the healthcare system, the government has developed and implemented solutions which will be examined below. The government is trying to recruit more students and educators in the nursing field to combat with the increasing demand in the workforce. For some years now, recruitment of students in the school of nursing has been declining. According to the American Association of College of Nursing, the number of nursing students who enrolled in the bachelor’s degree program had been declining in the past five years (Larson, 2016). In 1999, the number of nursing students felt by 4.6% nationwide. Nursing master program also suffered the same fate with a decline of 1.9% in some states (Larson, 2016). To better utilize the current aging workforce, healthcare circles decided to recruit the old and retired practicing nurses who can no longer administer treatment to the growing population and appointed teaching positions to them in nursing schools. They came to a conclusion that this ageing nurse’s will better teach the students as they are teaching out of experienced and it is said exp erienced is the best teacher (Johnson et al., 2006). Practice and experience are two important factors that teachers most acquired in order to teach students effectively. Also, in San Diego, six hospitals donated $ 1.3 million to support a program known as â€Å"Nurses Now†, which will be an opportunity to add faculty members and additional nursing students in the San Diego University (Costantini, 2016). Moreover, in order to support students to do nursing, the Texas hospital donated $ 425,000 in scholarships to local students to do their bachelor’s degree program in nursing. Moreover, in New Jersey the Board of Free holders donated scholarships to local students who accepted to work in the long term care facility in the USA (Costantini, 2016). These are examples of some successful collaborative efforts between healthcare organizations, nursing schools and the USA government to help solved the problem of nursing shortage in the USA. Moreover, in order to solve to problem of shortage, hospitals are re-implementing intensive training programs for nurses in various specialities. This has gone a long way to retain nurses who are seeking for a transfer and has also help build a vocation development path for nursing staff. A research that has been done on Magnet hospitals indicate that some of the organizational characteristics that create a centre of attention and retain nurses are professional practice models for delivery of healthcare with independence and responsibility to make decisions (B. & J.I., 2001). Moreover, effective managerial structure, quality patient services and investment in nurses’ professional development in the healthcare system are very necessary and important. Nurses must be involved in developing and implementing the practice of care in hospitals since they are very close to patients. Some of this practise includes; participating in the financial management of the hospital and developin g new strategies in hospitals. If healthcare leaders developed intensive programs for nurses in each specialities, it will motivate them to realize that they are very important in the healthcare system thus, encouraging them to remain in their various specialities in nursing. Furthermore, healthcare leaders need to developed models of care in order to solve the problem of nurses shortage in the USA, the government need to implement regulatory and policy issues (Johnson et al., 2006). Some regulatory and policy problems could also cause the nursing shortage such as federal and state laws, licensure and nursing practice act, and requirements from reimbursement organizations, private organization and the government (Johnson et al., 2006). Inside an organization, insistent process developments initiatives can assist standardize and simplify documentation. Healthcare leaders should drive this problem with some consultation from some internal experts in reimbursement, patient documentation and risk management. Furthermore, nursing trainers should use technology as one of the training tool.  Although most of the section in nursing learning is clinical experience, most of the classroom teaching can be done through the new technology we have today such as internet teaching, distance education, and accelerated educational programs.  As the healthcare of patients become more associated to technological improvement, routine nursing performance can drilled by utilizing the same technology. Technology improvement could also be use to test and certified nursing educators (Larson, 2016). All these new methods of teaching nurses through technology advancement will motivate younger adults who like using the internet and other forms of technology to learn to join the nursing field thus, helping to solve the problem of nursing shortage. In addition, to help solve the problem of nurse shortage in the USA, healthcare leaders should concentrate on training our own nursing and retaining them from traveling to other countries such as Canada. One good approach to solve this problem is to employ bachelors and masters students who are already in the faculty programs and provide them with qualified training and prepared them as well-trained nurses to be employ in the nursing field (Buchan & Aiken, 2008). Guidance into the clinical faculty is one of the best in this context, and this will improve nursing student’s capacity to do their work in the nursing field efficiently. The main idea is to guide them to grow into the nursing profession and eventually make nursing their profession of choice. This strategy will work well to the nursing field advantage because, it will encourage students to choose nursing as a career thus, increasing the number of nurses for the future. To continue, to solve the problem of nursing shortage in the USA, the government should augment the supply of nurses by using tax credit. For example, three bills where pass to permit the creation of refundable tax credit for all register nurses (Johnson, Posner, Biermann & Cordero, 2006). This is a positive impact that would have help retain nurses in the profession and it will also help to increase their salaries. Moreover, it will motivate them to maintain their various positions in hospitals thus, working positively in reducing the problem of nurse shortage in the USA. More so, in order to solve the problem of nursing shortage in the USA, hospital managers should offer bonuses to nurses who accept and sign up to work in that hospital for a long period of time. For example, in St. Paul hospital in Minnesota, the hospital leaders are giving out bonuses of about $8,000-$10,000 to nurses with essential care experience who have sign up to work in the hospital for a long period (Larson, 2016). This strategy has help St. Paul hospital to keep most of it nurses. If more hospitals could adopt this method, it will help solve the problem of nurse’s shortage in the USA. Moreover, in order to solve the problem of nurse shortage in the USA, the government need to increase the salaries of nurses. The work load of nurse’s especially register nurses is much as they are the ones who spend most of the time taking care of patients (B. & J.I., 2001). Most of them leave the nursing field because they are not well pay for the work they do and most of the time, some are not pay for the extra work they do. In order to solve this problem, the USA government has increased the salary of nurses for example in California; the salary of register nurses went up to $94, 120 per year (B. & J.I., 2001). This has motivated many people to join the nursing field. According to experts’ projections from the Bureau of Labour Statistics, by 2022, the nursing field will experience an increase in the number of register nurses of about 526,800 (B. & J.I., 2001). This is a good sign for the healthcare field for the future – absolutely a field with good prospects . ALTERNATIVES FOR THE SHORTAGE IN NURSING SUPPY Nurses form an essential part of the working force in the healthcare system in the USA and the great role they play cannot be ignored. This explain why the USA government, over the years have been trying to solve the problems nurses are facing in the healthcare system in order to motivate more people to join the nursing field. Due to all this, some recommendations are made to help improve the nursing working force. One of the recommendations is that, healthcare leaders should change consumers’ knowledge of healthcare services. Most patients like meeting register nurse for them to take care of them whereas; they are other nurses in the hospital who can take care of them better. Healthcare leaders’ need to change this perception some patients have concerning the choice of nurses. More so, some patients believe that nurses who are well paid do the work better than nurses who are less pay. That is why patients keep traveling from one state to another in order to seek for hospitals where nurses are been well pay. For example, most Americans travel to big states such as California in order to receive treatment from physicians and nurses. This believes is not good because it creates nurses shortage in big states compare to small states (Costantini, 2016). The USA government should develop and implement public health programs that will help educate the population on how to prevent certain illnesses. This will help reduced the number of people who get sick, thus reducing the number of patients, nurses have to take care of. People should do more of physical activities and eat healthy in order to avoid unnecessary illnesses which could be avoided by doing this. Also, the population should be sensitize about the problem of nursing shortage in the country. This will motivate them to take good care of themselves in order to avoid falling sick. Based on the execution of these recommendations, it will assist to achieve healthy people 2020 objectives. These recommendations are strategic plans that can be utilize by the government, people, private and public health providers and communities to improve the health of the population thus making the USA government to achieve its goal of healthy people 2020. CONCLUSION Nurses play a very significant role in providing medical treatment to patients and they also help to re-enforce the physician’s shortage labour force in the USA. Many health care organizations can not do with out nurses as they play a significant role. If the shortage of nurses worsens, many patients will no longer have access to care thus, creating a huge problem in the country. The USA government need to take the problem of nursing shortage in the country very serious as the baby boomer nurses retirement will cause a serious shortage. With the fast growing population of America, as many immigrants are coming in, it is necessary for the USA government to attract more nurses into the health care system. It there is surplus of nurses in the country, it will help the government, Medicare & Medicaid and other health organizations contain healthcare cost which is very expensive. It will also increase quality and access to medical care. REFERENCES B., N., & J.I., E. (2001). The nursing shortage: solutions for the short and long term. Online Journal of Issues in Nursing, 6(1), 4. Cho, S.-H., Ketefian, S., Barkauskas, V. H., & Smith, D. G. (2003). The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research, 52(2). CMS. (2016). National Health Expenditure Data. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html Costantini, S. D. (2016). Challenged by a Nursing Shortage? Consider These Short-Term Solutions and Long-Term Strategies. Avant Healthcare. Retrieved from https://avanthealthcare.com/nursing-shortage-solutions-strategies/ Cummings, G., & Estabrooks, C. A. (2003). The effects of hospital restructuring that included layoffs on individual nurses who remained employed: a systematic review of impact. Journal of Sociology and Social Policy, 8(9). DHHR, Resources, H., Workforce, B. o. H., & Analysis, N. C. f. H. W. (2017). Supply and Demand Projections of the Nursing Workforce: 2014-2030. HRSA Health Workforce. Gabrielle, S., Mannix, J., & Jackson, D. (2008). Older women nurses: Health, ageing concerns and self-care strategies. Journal of Advanced Nursing, 61(3). Garrett, B., & Gangopadhyaya, A. (2016). ACA Implementation Monitoring and Tracking. The Urban Institure, 19. Institute of Medicine, B. o. H. S. (2007). Rewarding Provider performance: Alligning incentives in Medicare. National Academies Press. Johnson, K., Posner, S. F., Biermann, J., Cordero, J. F., Atrash, H. K., Parker, C. S., . . . Curtis, M. G. (2006). Recommendations to Improve Preconception Health and Health Care United States Retrieved from Kovner, C. T., & Schore, J. (1998). Differentitated levels of nursing work force demand. Journal of Professional Nursing, 14(4), 11. Kunen, J. (2001). The New Hands-off Nursing. Kutney-Lee, A., Sloane, D. M., & Aiken, L. (2013). An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality. National Institutes of Health, 32(3). Larson, J. (2016). Creating Solutions to the Nursing Shortage. Retrieved from https://www.americanmobile.com/nursezone/nursing-news/creating-solutions-to-the-nursing-shortage/ Levit, L., & Patlak, M. (2009). Ensuring quality cancer care through the oncology workforce: sustaining care in the 21st century: workshop summary: National Academies Press. Martiniano, R., Chorost, S., & Moore, J. (2017). Health Care Employment Projections, 2014-2024: An Analysis of Bureau of Labor Statistics Projections by Setting and by Occupation. March 2012. In. Medicare, C. f., & Services, M. (2015). National health expenditures 2012 highlights. Published August. N/A. (1995). A Model for Differentiated Nursing Practice. National Organization for Associate Degree Nursing American Association of Colleges of Nursing Nursing, N. L. f. (2016). Percent of Programs that Turned Away Qualified Applicants by Program Type, 2012 † 2016. In. Nln.org: National League for Nursing. Registered Nursing Degrees. (n.d.). Retrieved April 03, 2018, from https://www.allnursingschools.com/registered-nursing/degrees/ Walston, S. L., Burns, L. R., & Kimberly, J. R. (2000). Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research, 34(6). Williams, J. (2014). Implication of Foreign-Educated Nurses on United States Nursing Collegiality. Newyork: Springer Publishing Company.

Promote and implement health and safety in health and social care

The Health and Safety Executive (HSE) is responsible for regulating health and safety at work. This is done by a code of practice for employers, employees and visitors in order to prevent illness and accidents. The legislation that best relates to health or social care work setting is The Health and Safety Act Work Act 1974. This legislation best describes the work that employer and employees have to follow and provide. The health and safety and security of employers and its visitors must be protected. In order to follow up this legislation, the employer has to draw up health and safety policy and procedures and must be followed according to the legislation. The employer has to provide a safe work place, safe access to and from place of work, a risk assessment of potential a hazard and health and safety training as well as information on health and safety. The points of health and safety policies and procedures agreed with the employer are as follows: To secure the health, safety and welfare of people at work To protect others from risks arising from the activities of people at work †¢ To control the use and storage of dangerous substances †¢ To control the emission into the atmosphere of noxious or offensive substances At a work place it is your duty to take care of yourself and anyone else who may be affected by your actions. No task should be done by you which you have not been trained or instructed to do so. No equipments should be misused in the interest of health an d safety. The responsibilities of a manager should be that they make you aware of everything that is regarding to health and safety at work. Such as, make you aware of health and safety policies and procedure and get you signed to confirm that you have been made aware. Others such as family members or carers have also responsibilities to consider such as health and safety in maintaining security, hand washing and no smoking rule. No task should be carried out without having had a special training. No need to be playing a hero if you are not trained to help at what ever the situation is. Medication should only be given by a trained staff and who also can demonstrate competence. There is so many things that could possible go wrong regarding giving a patient medication. Sudden accidents that may occur in work setting could be falling down the stairs or slipping on a wet floor. Illness that could occur are poisoning, allergy and burns. The procedure that should be followed if the floor is wet, a sign should be put up to make people aware that it is dangerous and slipper and cleaned straight away. The procedure that should be followed if someone gets poisoned or has a severe burns they should be taken to the A&E. Stress is an organism's response to a stressor such as an environmental condition or a stimulus. Stress is a body's way to react to a challenge. There are many signs that indicates stress, those are as follows: poor concentration tearfullness anxiety and depression high blood pressure weight gain or loss insomnia Signs that indicate own stress are physical stressors, emotional stressors and social stressors. Physical stressors are pain in your body, illness, disability, lack of sleep, poor diet and too much exercise or none. Emotional stressors, dealing with family problems, meeting deadlines, looking for a job, responsibilities at work and home and helplessness. Social stressors, relationships, financial problem, coping with children, moving house, getting married and having a baby. In order to overcome stress, is to build emotional strength within you, controlling your situation, having a good social network and always have a positive outlook on certain things. Challenging yourself by setting goals, builds confidence and helps you take charge of your life. Been active has a lot of benefits, not just by calming your emotions and help you think more clearly but also by cleaning up unwanted toxin in your body.

Kap Report Endline September 2012

KNOWLEDGE ATTITUDES AND PRACTICES (KAP) END-LINE ASSESSMENT On Water, Sanitation and Hygiene LOLKUACH Village, IDPs of Akobo September-2012 DRC-Gambella WASH Team Conducted in the frame of an ECHO funded project â€Å"Improving access to short-term food security, safe drinking water, hygiene and basic household items in Ethiopia† Wanthowa Worda, Gambella, Ethiopia September 30, 2012 i TABLE OF CONTENTS 1 2 3 3. 1 INTRODUCTION SUMMARY OF FINDINGS METHODOLOGY Objectives of the Survey 1 2 3 3 4 4. 1 FINDINGS General Background Information 4 4 5 5. 1 5. 2 5. 3 WATER RELATED INFORMATIONWater Sources Water collection and storage Household Water Treatment 5 5 9 11 6 6. 1 6. 2 HEALTH AND HYGIENE Diseases Washing Hands and Good Hygienic Practices 12 12 15 7 7. 1 7. 2 SANITATION Defecation Waste and Waste Management 18 18 20 8 9 CONCLUSION RECOMMENDATIONS 23 24 25 10 REFERENCES i 1 Introduction The 2012 report states that as of end of 2010: Over 780 million people are still without acce ss to improved sources of drinking water and 2. 5 billion lack improved sanitation. If current trends continue, these numbers will remain unacceptably high in 2015: 605 million people will be without an improved drinking water source and 2. billion people will lack access to improved sanitation facilities. An estimated 801,000 children younger than 5 years of age perish from diarrhea each year, mostly in developing countries. This amounts to 11% of the 7. 6 million deaths of children under the age of five and means that about 2,200 children are dying every day as a result of diarrheal diseases. Unsafe drinking water, inadequate availability of water for hygiene, and lack of access to sanitation together contribute to about 88% of deaths from diarrheal diseases (UNICEF, WHO, 2012: 2; Center of Disease Control and Prevention, 2012).As to Andrea Naylor: although worldwide there have been thousands of projects to address water and sanitation issues as they relate to public health with c ontinued improvements since the 1980’s, research has shown that due to lack of evaluation surveys on the effectiveness and success of these interventions, many are not sustainable . To this end, the essence of conducting end-line survey is very critical to gauge the effectiveness and success of the interventions of DRC-Gambella. The Gambella Region has an approximately population of 332,600 people, with 49,457 living in Akobo and Wantawo Woredas.These populations are subjected to water shortage and floods. Moreover the population is prevalently pastoralist and follows seasonal migration patterns for cattle grazing and protection of livestock from drought and floods. The perennial attacks by the Murle tribe, coupled with intra-clan conflicts among the Nuer tribes of Ethiopia and South Sudan, aggravates a situation of chronic displacement, making populations of bordering areas, especially Akobo, susceptible of massive and prolonged internal displacements.Conflicts, drought and floods are the key challenges to the populations in Akobo and in Wantawo. The consequent perennial movement makes the community vulnerable to food insecurity, disease and water shortage. It is in view of this that Danish Refugee Council seeks to address in the short term the basic needs of these populations by providing access to clean drinking water, and tools to improve hygiene and to build the capacity of the community to respond to these challenges. From the period of July 2011 to June 2012, DRC implemented a Water, Sanitation and Hygiene project, funded by ECHO, with the goal of rehabilitating 7 hand pumps (and subsequently chlorinating the water), distributing NFI kits, hygiene kits, and implementing hygiene promotions. DRC decided to conduct two in-depth KAP surveys (as a baseline and endline) to evaluate the impact brought by the implementation of the project in the targeted area.The baseline survey was conducted in the month of May 2012 and the end line survey was conducted in the second week of September 2012. In the period between the two surveys, a number of activities covering water, sanitation and hygiene were implemented in the frame of the project. 2 Summary of Findings Project outputs and behaviour and knowledge change (as indicated by the pre and post implementation KAP surveys) indicate the following key findings: o o o o o o Seven hand pumps were rehabilitated/ disinfected Hygiene promotion targets were surpassed. planned: 5,490 beneficiaries; 10,950 reached) Hygiene kit distributions were surpassed (planned: 2,250 beneficiaries; 8,870 reached) NFI kit distributions were surpassed (planned 6,300 beneficiaries; 7,470 reached) The number of respondents who use hand pumps as source of water increased from 4% to 75% Knowledge and practice of feasible water purification practices such as boiling, filtration or adding tablet/sachet has been greatly improved Instance of diarrhoea has decreased from 60% to 24% of respondents stating that they had h ad diarrhea in during the 3 weeks prior to the survey Knowledge that rain water is a safe drinking water source has improved from 24% to 62% of respondents, however, the use of rain water remains limited.Knowledge of the causes of unsafe drinking water (including germs, visible particles and bad taste) increased from 40% to 81%. The practice of open defecation has reduced from 100% to 15% of respondents. Hand washing at critical times has increased from 34% to 85% of respondents. 2 o o o o o o o Appropriate waste disposal mechanisms improved from 39. 2% in baseline to 75% of respondents.. Although there has been an improvement in the knowledge of respiratory and eye infection transmission/protection, there is still room for improvement 3 Methodology A cross sectional, qualitative study was conducted through house to house interviews, taking 150 respondents randomly as study subjects. The sample represents nearly 10% of the total targeted household 1 n Lolkuach village (1,500 househo ld). The questionnaire (See Annex I) was employed to collect data on general background information, knowledge, attitude and practices of the IDPs of Lolkuach village. However the results can also be considered pertinent for the host communities if considering the cultural and environmental homogeneity. Verbal consent from the respondents was obtained after explaining the purpose of the study. Data was collected from 13 to 14 September 2012. The data from the questionnaires was entered into SPSS software (version 13) by the principal investigators for further analysis. Data reliability was assured using different techniques such as: ?Properly designed questionnaires were prepared and pretested. ? Data collectors were hired locally and tested during the training on the contents of the questionnaire. Constant supervision was done by DRC WASH Team Leader, and problems encountered at the time of data collection were reported immediately and appropriate actions taken. 3. 1 Objectives of the Survey ? To identify gaps in knowledge regarding health and hygiene practices and existing practices leading to negative impact on health. ? ? To describe the socio demographic, cultural information of respondents and villages. To find out the information on incidence of communicable disease due to unhygienic practice. 1It is estimated, on the base of IOM Akobo IDPs database, that the number of households currently living in Lolkuach is 1500 and average family size is 5. 3 ? To assess the effectiveness and impact of the DRC water, sanitation and hygiene promotion activities. 4 Findings 4. 1 General Background Information The beneficiaries of the programme, and KAP survey respondents are all part of the displaced NuerGajok population from Akobo Woreda now living in Wantawo. Among the KAP survey respondents, the majority (about 65 %) were female, whereas 35% were male. Females were particularly targeted for the KAP survey, as they were the primary recipients/participants in the DR C project, and are traditionally responsible for child care and household WASH issues.This survey was conducted near the end of the rainy season, in Lolkuach IDP settlement. Respondents reported moving between the river banks temporary camps and dry land permanent villages according to seasonal variations. During the dry season, the majority of the respondents live in Dimbierow village (79%), and Nyawich village (17%), while only 4 % of the respondents indicated that they live in Lolkuach village throughout all the year. However there are frequent movements among the settlements throughout all the year. Most of the respondents (86. 2%) indicated that they arrived at Lolkuach between February and June 2009 following a recurrence of conflict with Lou Nuer in Akobo woreda.Minority of the respondents arrived during the same period of 2008 (12. 8%) or 2010 (1 %). Most of the respondents therefore have been displaced since 2009. When respondents were asked if they plan to return to their villages of origin, a pronounced number (55%) indicated that they don’t have any plans to return due to security problems (expressed as ‘war’, ‘conflict’, ‘insecurity’). The remaining 45% of the respondents indicated that they plan to return back in the future if the security situation is restored and the construction of the road from Mathar to Akobo is finalized. In this regard, as it can be observed from the baseline survey, no significant difference noted in the end line survey.However looking in detail at the positive answers (from the 45% of respondents), 21% expressed a plan to go back within six months and the remaining 34% indicated a time longer than six months. Moreover even the respondents who indicated that they have a plan to return back to 4 Kebele of origin also mentioned their fear about the security situation (expressed as ‘if peace come back’, ‘if cattle raiding ends’, if the construction of th e road to Akobo is completed and similar). 5 Water Related Information 5. 1 Water Sources Before the project interventions, the baseline data indicated that almost 100% of the respondents were accessing unsafe drinking water from the river, which is contaminated from the presence of livestock and open defecation. At the end of the project implementation, the hand pump aintenance/rehabilitation/water chlorination, coupled with pure sachet distributions, bucket distributions, and hygiene promotions resulted in a significant positive change. As you can observe from the Figure 1, the majority of the respondents are now using water from newly maintained/rehabilitated hand pumps. Due to seasonal movement however, the proportion of respondents using hand pumps during the dry season reduces, as many of the beneficiaries move to areas without hand pumps. The following graph outlines both the shift in hand pump use (pre and post intervention), and also the relation of this use in terms of sea sons. There are still not sufficient hand pumps in Lolkuach area to support the population however, which explains why 100% of the respondents are not using these protected sources.Considering that the 7500 inhabitants of Lolkuach, Thore and Lolmokoney have only 7 hand-pumps (hand dug wells), this is insufficient as per SPHERE standards)2 , highlighting the need to construct new hand pumps. 2 Considering the maximum number of users for 1 hand pump should be 500, at least 15 hand pumps would be needed in Lolkuach 5 Seasonal Use of Protected Water Sources – Pre and Post Intervention 100 90 80 70 60 50 40 30 20 10 0 Dry Season Rainy Season % of Respondents Seasons Baseline Endline Figure 1: Shift in Use of Protected Water Sources (KAP baseline an d end-line) Seven hand pumps in Lolkuach and surrounding villages were disinfected and beneficiaries received pure sachet as well bucket and filter.From the findings, the graph below states that it is only 27% of the respondents indicat ed that the main problems with their water source are water is dirty and it tastes bad. Whereas 40. 7% of the respondents also signified that the water source is far. Problems Related to Water Supply 100 90 80 70 60 50 40 30 20 10 0 Dirty Water Bad Taste Irregular FlowSource is Dried Distance to No problems Up Source % Respondents Baseline Endline Water Source Issues Figure 2: Main problems related to water supply. 6 Consequently 63% of the respondents consider the water they are using is safe for drinking, and 33% consider it is unsafe instead (Figure 3).This represents a reduction in the proportion of respondents who stated that they were using unsafe water from 77% in the baseline to 33% in the end-line survey. Of these 33% of respondents who noted that they were drinking unsafe water, 8% of the respondents were using hand dug wells (Which were rehabilitated by DRC) as source of water for drinking. Figure 3: consideration of water safety Figure 4: reasons why 33% declared water i s unsafe In relation to the safety of water, the reason why 33% of respondents declared that they are using unsafe water is mainly because the water contains germs, is not filtered and not cleaned. This shows that their understanding about the causes of unsafe water has improved since the baseline (Figure 4).When it comes to use of rainwater as source, though improvement is registered, much needs to be done to bring about significant change. Considering the shortage of safe water sources in the area observed by DRC, and the abundant rain-fall in Gambella region3, reasons for not using the rainwater (which is almost distilled4) were assessed more closely. Although the number of respondents who believe that 3 The annual rain falls in Gambella region ranges between 800 and 1200mm, but about 85% of rains are concentrated between May-October (Woube, 1999). 4 In this regards, Dev Sehgal, indicated that rainwater harvesting is an easy method to collect drinking water, and the quality of th e water is almost distilled.First when the water touches the catchment surface it usually gets contaminated (Dev Sehgal, 2005). 7 rainwater is unsafe has reduced from 76% to 38% of respondents, more can be done to raise awareness on this water collection method. Of the 38% of respondents who would not collect rain water given the choice, the principal reasons were given as follows: Figure 5: Investigation about unused rain water When questioned on their knowledge of safe drinking water and water pollution causes, respondents were given the option of providing more than one answer. The number of respondents who indicated that drinking water shouldn’t have germs, visible particles and/or bad taste, increased from 40% at the baseline to 81. 3% at the end-line.The respondents who indicated that the proximity of a latrine to water sources can cause water contamination increased from 7. 2% in the baseline to 15% in the end-line survey. In this regards, water quality and health coun cil indicated that especially the proximity of latrine to water sources can cause Removing the first harvested water, so-called first flush, can prevent this. When the rain starts to fall the first water cleans the catchment surface and fills up the first flush diverter, by the time it is full a ball closes the opening and leads the water to the main tank. The downside of rainwater harvesting is that it requires double storage, as it is hard to purify water at the same speed as it rains (Gould, J. & Nissen-Petersen, E. , 2005). 8 contamination .The majority of the respondents (85%) also indicated that garbage disposal or animals feces containers near a water source, or unprotected source can cause water contamination (Figure7). 5 Knowledge of Causes of Water Source Pollution 100 90 80 % Respondents 70 60 50 40 30 20 10 0 Defecation Nearby Garbage Nearby Dirty Container Causes of Pollution Figure 7: Knowledge of Water Source Pollutants Baseline Endline Although only a small proportio n of respondents acknowledge that water can be contaminated through the ground from a latrine constructed too close to a water source, 95% of respondents are now aware that defecation near a water source is a pollutant, resulting in a change of behavior in which open defecation has reduced from 100% in the baseline to 15% in the end-line survey. 5. 2 Water collection and storageFrom the Figure 8, it can be observed that nearly 50% of respondents less than 50 minutes to fetch water during dry seasons6, meaning that SPHERE standards for these respondents are met for watersource distance because of the rehabilitations of the hand pump in the vicinity of the village. Concerning rainy season, it can be observed that respondents spend more time getting water. As it is observed, respondents need to travel some distance to fetch water and during the dry season respondents also move to river banks. Hence, this can make the access to hand pump difficult. So besides constructing 5 The causes o f water pollution vary and may be both natural and anthropogenic.However, the most common causes of domestic water pollutions includes : garbage disposal and defecation near water sources, animals feces, sharing the same sources with animals, use of dirty or open water container can affect the safety of our water . Use (Water Quality and Health Councils, 2010; CAWST, 2009; Laurent, P. , 2005). 6 According to SPHERE key indicators, the maximum distance from any household to the nearest water point is 500 metres 9 new hand pumps, encouraging the community for rain water catchment strategy is very essential at household at household level. 70 60 50 40 30 20 10 0 0-50 50-100 Min 100-250 Min More than 250 Dry Season Rainy SeasonFigure 8: Average time spent to collect water Given that water collection requires women and girls to walk distances to find water sources, there may be heightened protection issues for these family members, although protection was not assessed in the KAP. Questio n posed to respondents on what devices that they are using to store and collect water indicated that 55% of the respondents are using plastic jerry cans to collect water and 34% of the respondents use plastic bucket for water collection. For storing water, nearly 33% of the respondents use traditional clay pot and plastic jerry cans; the rest 36% of the respondents indicated plastic jerry cans or buckets with lid.DRC distributed NFI (Contains 2 Jerry cans each 20 litters among others) and Hygiene kits (Contains 2 Buckets each 10 litters among other) to 302 and 283 households respectively living in Lolkuach areas. To this end, most of the respondents own more than one container. But still those who didn’t receive water storage and collection device also were among the respondents who took part in the survey, we can 10 observe that 70% of respondents meet the minimum SPHERE7 requirement for water collection container, and 74% meet the requirement8 for water storage. Whereas in the baseline, it was noted that only 50% of the respondents met the requirement for water storage and collection devices. 5. 3 Household Water TreatmentThe knowledge of practical purification methods like boiling, filtration or adding tablet/sachet was assessed. As it can be observed from Figure 12, there is great leap in knowledge of the basic methods of household water treatment. For instance, use of purifying sachet/tablet increased from 8% at baseline to 85% at the end-line survey. The findings also suggested that the majority of the respondents (more than 75%) know the use of feasible practices like boiling, filtration or adding tablets/sachet for water treatments9. This figure was only 25% in the baseline survey. After the baseline survey, it is worth to note that DRC-Gambella has been distributing purifying sachet and providing demonstrations for those villages with no access to hand pumps. 7According to SPHERE key indicator: Each household has at least two clean water collec ting containers of 10-20 litres, plus enough clean water storage containers to ensure there is always water in the household. The amount of storage capacity required depends on the size of the household and the consistency of water availability e. g. approximately 4 litres per person would be appropriate for situations where there is a constant daily supply 8 Requirement for storage is calculated according to certain specificities, but considering the minimum of 4lt/person/day, for an average household of 5, should be at least 20 lt. 9 Different researchers suggested some feasible practices like boiling, filtration or adding Figuret/sachet and chlorination for water treatment (CAWST, 2009; Davis & Lambert, 2002). 11Knowledge of Household Water Treatment 140 120 % Respondents 100 80 60 40 20 0 special container Boiling Use of sachet Cleaning Filtering container with cloth Covering sunlight Baseline Endline Figure 12: Knowledge of household water treatment methods 6 Health and Hygiene 6. 1 Diseases Respondents were asked about the diseases their family experienced during the three weeks before the interview. The number of respondents who caught diarrhea in the three weeks prior to the interview reduced from 60% in the baseline to 27. 3% in the end-line survey. Hence, you can see from the end-line survey that hygiene conditions and practices are improving.When it comes to the causes of diarrhoea, more than 85% of the respondents referenced unsafe drinking water, children feces, germs/bacteria, open defecation, poor hygienic practices and flies as causes of diarrhea (Figure 16), indicating that the hygiene promotion has resulted in an increase in knowledge. 12 Figure 16: Knowledge about diarrhea transmission Interviewees were asked to indicate in a multiple choice question, which action to be taken to protect their families from the different diseases that they suffered from. The respondents who indicated that they can be protected from malaria by sleeping under m osquito net increased from 40% to 75%. Keeping the environment clean and good hygienic practices also attributed as a method of prevention of malaria by many respondents (Figure 14). 13 Knowldge of Malaria prevetion measure 120 100 Respondents 80 60 40 20 0 Keeping environment Clean Safe water Good hygienic practice Use mosquitonet Wash cloth Wash hand Baseline Endline Figure 14: knowledge of malaria prevention measures When it comes to skin diseases, most of the respondents indicated that good hygienic practice as way of prevention of skin diseases (Figure 15). 14 Figure 15: Knowledge of skin diseases prevention measur es Nearly 51. 2% of the respondents indicated that good personal hygiene, keeping the environment clean, use of safe water for drinking, washing hands, washing clothes and hanging them in the sun can protect their families from respiratory and eye problems.The above results indicate that the knowledge of the people has improved with regards to respiratory illness and eye infection transmission and protection, however there is still room for improvement. 6. 2 Washing Hands and Good Hygienic Practices General question about hygiene and more specific ones about hand washing were posed. Keeping food away from flies, bathing regularly, keeping compounds clean, protecting food and washing hands are considered as good hygienic practices by the majority of the respondents in the end-line survey. This means that the figure increased from nearly 51% at the baseline to nearly 85% in the endline. 15 Figure 18: Knowledge about keeping good hygieneLikewise, when respondents specifically asked if they wash their hands, 89% of the interviewees gave affirmative answer in the end-line Survey. People who wash hands reported to be doing it in order to eliminate bad smell and prevent diseases. Similarly more details of the hand washing practice can be seen from Figure 20, and it can be concluded that more than three fourth of the population who wash their hands, ar e doing it at the appropriate times. 16 Figure 20: Frequency of hand washing practice While the vast majority of the respondents (95%) stated they would like to bathe once a day, when it comes to practice, 29% of respondents expressed they have problems in taking bath regularly mainly because of lack of container and soap (Figure 21).Hygiene practices were also considered to be a major issue by nearly 40. 6% of the respondents, these respondents indicated that poor practices are due to both a lack of access to hygiene items, and a poor attitude brought on by a lack of knowledge. So the majority of the respondents signified that the distributed hygiene kits solved some of their problems and they were adhering to good hygienic practices. 17 7 Sanitation 7. 1 Defecation Before the DRC intervention, the majority of the adults practiced open defecation. Because changing habits is not easy, the baseline assessment was designed to understand the risk practices that were most widespread and identify those that could be changed.From the point of view of controlling diarrhoea, the priorities for hygiene behavioral change included hand washing at critical times and safe stool disposal. To this end, the efforts of the organization brought significant behavioral change. From the end-line survey it is noted that 85% of the respondents use traditional latrines, which is up from 0%. Similarly, when asked to indicate the best option for defecation, 85% indicated the latrine. On the other hand, privacy, water pollution, presence of bad smell and flies, as well as spread of disease was reported as the main problem related to open defecation practices (Figure 23). Respondents were also asked about post defecation cleansing habits and mostly indicated pieces of paper. Figure 23: Problems related to defecation practice 18Considering the majority of respondents indicated that a latrine is the best option for defecation, and that the main issue with defecation is privacy, disease, wa ter pollution, smell and environmental pollution, it was observed that the traditional latrine which is constructed by the participation of the communities has been welcomed and used by the community. In the baseline survey it was found out that inadequate sanitary conditions and poor hygiene practices played major roles in the increased burden of communicable disease within the village. Similarly, the baseline information stated that beneficiaries had problems with access to safe water and sanitation facilities. To this end, DCR Gambella set a strategy to solve the problems through community participation. DRC- Gambella inculcates the basic principles and approaches Sanitation) of into CLTS the (Community newly Lead Total PHAST designed Participatory hygiene and Sanitation Transformation) training. As both approaches opt for communities’ participations and empowerment and focus on igniting a change in sanitation and hygiene behaviour, a PHAST training manual that encompasses both PHAST methodology and catalysts for change in sanitation behaviour was prepared and distributed. After community based health promotions work, and community conversation establishments at each village, the accessibility to sanitation facilities and sanitation practices improved. 1446 households who completed hand washing points and traditional pit latrine (See the figure on the right side) were awarded NFI to recognize their efforts of behavioral changes.Hand washing after stool contact and safe disposal of stool have been priorities in hygiene and sanitation promotion interventions in Wanthowa Woreda. By understanding that for the quickest and widest adoption of good hygienic practices it is often more cost-effective to rely on social ambitions rather than health arguments to encourage change, DRC linked hygiene promotion works with social and cultural values, norms as well as NFI distributions, such that all hygiene promotions were linked with cultural problems of Nuer socie ty and social values. As a result good improvements in both hand 19 washing and safe stool disposal were registered. This can be confirmed by looking at the end line KAP survey results. 7. Waste and Waste Management The majority of disease measures are related to environmental conditions: appropriate shelter, clean water, good sanitation, and vector control, personal protection such as (insecticide-treated nets, personal hygiene and health promotion). Appropriate waste disposal mechanism is vital to avoid environmental pollution and breading place for vectors and pathogens. In this regards, the majority of the respondents (75%) indicated that they are now burning the household solid wastes on timely bases (Figure 24). The number of respondents who had been disposing solid wastes in open space and river significantly decreased after the interventions.Figure 24: waste disposal practice 20 The problems concerning waste were indicated in flies, bad smell, breeding place for mosquitoes. Majority of the respondents understood that appropriate solid waste disposal plays a vital role in minimizing the breading of vectors and other pathogens (Figure 25). Figure 25: Problems related to waste disposal The majority of respondents indicated that the practice used to dispose household waste is burning. Improvement in waste disposal and keep the villages clean is observed by DRC field staffs. Similarly the views of the majority of the respondents on the attributes of clean and health village is improved.It is noted that availability of safe water, cleanness of the village and availability of latrine considered by more than three fourth of the respondents as the attributes of clean and health village in the end-line survey. But those we stated the same were nearly 50% in the baseline survey. 21 Similarly, the benefits of keeping a village were mainly identified as decrease of diseases occurrence, improved beauty of village, minimized presence of mosquitoes and flies by more t han three fourth of the respondents in the end-line where as this nearly 53% in the baseline. From end-line survey, it can be inferred that majority of respondents indicated that important public health factors such as availability of safe water and atrines, absence of stagnant water and mosquitoes among the attributes of an healthy village. They also noted that this has great impact in reduction of infection disease prevalence. Hence, it can be concluded that the understanding of the majority of the respondents on disease transmission, transmission routes and its preventions tremendously improved after the interventions. 22 8 Conclusion Diarrhoea causes dehydration and kills approximately 2. 2 million people, mostly children, every year. Children are more likely than adults to die from diarrhea because they become dehydrated more quickly. In the past 10 years, diarrhea has killed more children than all of the people lost to armed conflict since World War II.Its occurrence is closel y related to the opportunities that poor people (especially poor mothers) have to improve domestic hygiene10. Diarrhoea does not only cause disease and early death in children, but also affects children’s nutritional status, stunting children’s physical and intellectual growth over time. Skin and eye infections are especially common in arid areas. Both diarrhoea and other infectious diseases have health as well as socio-economic consequences. Washing more often can greatly reduce their spread11 . Similarly, the training manual of Amhara region indicated that improved hygiene, particularly hand washing at critical times can reduce diarrhea by one third and reduce malnutrition12. Soiled hands are an important source of transmitting diarrhoeas.Recent research also suggests that hand washing is an important preventive measure in the incidence of acute respiratory infections, one of the top killer of children under five. 13 This KAP survey was conducted in order to compare its results with the results of the baseline survey, to identify whether the hygiene promotion activities conducted in the frame of the ECHO funded project had been effective. The baseline and end-line survey results revealed that positive results have been achieved in the overall hygiene situation. In the baseline survey the situation was poor i. e. lack of safe water, poor sanitation facilities, poor hygiene practice etc. At the end of the project, an improvement was noted in the overall hygiene and sanitation behaviour.Though improvements were noticed after the implementation of project, it should not be forgotten that it takes time to consolidate behaviour changes, so more follow up is necessary for further improvement. 10 11 12 (Curtis et al. , 2000). Brian Appleton and Christine van Wijk (IRC), 2003. Amhara Regional State Health Bureau, 2011; Isabel Carter, 2005 13 See for instance the study of Ryan et al. published in 2001 23 9 RECOMMENDATIONS Although the WASH project can be en seen as a success, the team noted some recommendations for future interventions. ? ? Construct 15 shell wells in Lolkuach village so that inhabitants meet SPHERE standards Assess whether it is possible to dig wells in the locations where people move to during the dry season ?Introduce rain water harvesting techniques, which are easy sources of potable water and would reduce the distance travelled to access water, thus improving the protection status of the women and girls that are responsible for this task. ? ? Follow up on well water quality in rehabilitated wells Although respondents recognized that animal feces can contaminate water, only 15% in the end-line noted that the proximity of a latrine to a water source can contaminate drinking water. This could be stressed and improved in future hygiene promotion activities. 24 10 References 1. Amhara Regional State Health Bureau (2011). Training Manual on Hygiene and Sanitation Promotion and Community Mobilization for Volunteer Com munity Health Promoters (VCHP)/ Draft for Review. Online Available at: http://pdf. usaid. gov/pdf_docs/PNADP828. pdf 2. Andrea Naylor.Development and Implementation of Sanitation Survey Using a Knowledge Attitudes Practices (KAP) Model. University of South Florida (Tampa): CGN6933 â€Å"Sustainable Development Engineering: Water, Sanitation, Indoor Air, Health† and PHC6301 â€Å"Water Pollution and Treatment†. 3. Brian Appleton and Christine van Wijk (IRC) (2003). Hygiene Promotion Thematic Overview Paper. IRC International Water and Sanitation Centre 4. Boot, Marieke T. and Cairncross, Sandy (1993). Actions speak: The study of hygiene behaviour in water and sanitation project. The Hague: IRC International Water and Sanitation Centre. 5. CAWST (Centre for Affordable Water and Sanitation Technology) (2009) Household water treatment and safe storage factsheet: natural coagulants.Online Available at: http://cawst. org/en/resources/pubs/file/38-hwts-fact-sheets-academic-en glish 6. Davis, J. and Lambert, R (2002) Engineering in emergencies – A practical guide for relief, workers 2nd edition, Rugby: Practical actions publishing 7. Dev Sehgal, J. (2005) A guide to rainwater harvesting in Malaysia. Online Available at: http://www. wasrag. org/downloads/technology/A%20Guide%20to%20Rainwater%20Ha rvesting%20in%20Malaysia. pdf 8. Esrey, S. A. (1994). Complementary strategies for decreasing diarrhea morbidity and mortality: water and sanitation. Paper presented at the Pan American Health Organization, March 2-3. 9. Gould, J. & Nissen-Petersen, E. 2005) Rainwater catchment systems for domestic supply. Rugby: ITDG publishing. 25 10. Green, C. E. (2001). Can qualitative research produce reliable quantitative findings? Field Methods 13(3), 3-19. 11. Isabel Carter (2005). Encouraging good hygiene and sanitation. A PILLARS Guide. Tearfund. A company limited by guarantee. Regd in England No 994339. Registered Charity No 265464. 12. Laurent, P. 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The Inflence of Rivers and Climate on Baghdad, Iraq Essay

The Inflence of Rivers and Climate on Baghdad, Iraq The Tigris and Euphrates Rivers, along with their reaction to the climate, have both helped and hurt Baghdad, Iraq. The rivers provided pathways to other civilizations, allowing Baghdad to grow into the transportation and cultural center of Iraq. Its fertile soil, deposited by flooding, provided the area with the ability to become the birthplace of civilization through tremendous agricultural production. Although the flooding of the rivers greatly enhanced the area, it has also had disastrous effects, severely damaging food production and the culture of its people. Baghdad’s geographical location has allowed the city to flourish due to the availability of transportation. The†¦show more content†¦The success of agricultural production allowed the area around Baghdad to become one of the first civilized societies in human history. Agricultural production was so tremendous that it provided people from ancient Mesopotamia to the relatively recent society of Baghdad a surplus to trade that other cultures desperately needed. The culture flourished as a result of its use of agricultural opportunity. The unpredictability of flooding has lead to highs and lows of agricultural production. The high points of agricultural production led to a prosperous, well fed, and culturally rich society. A few decades ago, Iraq had an extremely high level of food per capita in comparison with the surrounding areas. An increase in availability of food from 1,958 calories in 1961 to 3,200 calories per person between 1984 and 1990 surpassed the people’s requirement of 2,250 calories each day.3 This provided the people with a rich life, incorporating food as a large part of their culture. The cuisine was rich and diverse, consisting of large quantities of meat, grains, fresh fruits and vegetables, dairy products, with saffron and mint as widely used spices. Because it was available, extra food was usually