Muscle Training Intervention in Heart Failure Article Review

Muscle Training Intervention in Heart Failure Article Review Principles of Research in Nursing Practice A Critical Appraisal of Padula, C. A., Yeaw, E. and Mistry, S. (2009) A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research, 22: 18-25. Guidelines by Burns and Grove (2011) form the basis of this appraisal. Statement of the problem purpose of the study Padula et al. (2009) begin by discussing the clinical problem that led to the research being conducted. Disabling dyspnoea in heart failure (HF) is affecting patients’ quality of life. Impaired inspiratory muscle function has been recognised as a potential source of dyspnoea in HF. The purpose of the research emerges logically from the clinical problem which is to determine the effectiveness of an inspiratory muscle training intervention (IMT) on dyspnoea and health-related quality of life (HRQOL). The purpose of the study is directly linked to the clinical problem because the experimental hypothesis; if upheld may facilitate improved therapies for HF patients. Literature Review This section is clearly defined and well organised. A review of the abstracts for the eight sources cited in the ‘IMT in HF’ section denotes that all are relevant primary data-based studies. There are only two sources cited within 5 years of the acceptance date for publication. Sources should be current (Burns Grove, 2011). The researchers fail to acknowledge whether a systematic search strategy was exercised (Moule Goodman, 2009). Furthermore, the investigators may have found additional sources if they had included theoretical literature. Padula et al. (2009) paraphrase the knowledge gleaned from each source and form a critique of the overall methodology used in these studies. Three of the studies did not employ a control group; this decision may have threatened their capacity to infer causal relationships. In the RCTs, sample sizes were small and effect sizes were not published. Consequently, the ability to detect differences in outcomes between groups was compromised (Seers Critelton, 2001). The literature review identifies gaps in the knowledge base which builds a case for the present study. Padula et al. (2009) report that further research is necessary to determine the precise intensity of IMT. Study Design Sample There is ambiguity regarding the study design as the researchers refer to the study as an RCT on two occasions. On closer inspection, the study does not meet the criteria for this classification as complete experimental control is not possible (CASP, 2014). The study is a two-group quasi-experiment with pre- and post-test design (Hek Moule, 2006). This design is appropriate to address the research question. Although participants are assigned to groups with equal probability, the method selected (i.e. coin toss) is not entirely appropriate for small sample sizes (i.e. n=31) because it may lead to imbalance between the size of the experimental group and control group. Schulz Grimes (2002) explain that when a succession of tails or heads is thrown, it is tempting for the researchers to modify the results. This may result in subtle differences between groups. A more sophisticated method would be to use computer generated random numbers (Crombie, 2005). RCTs are conducted in research units to ensure greater control over extraneous variability. The present study was conducted in patients’ homes. The research population was stable HF patients without coexisting pulmonary disease or cognitive impairment. The sampling method is nonprobability convenience because the researchers recruited participants by means of newspaper advertisements and physicians’ offices (Clark-Carter, 2001). This method may have excluded patients who did not visit their physician on a regular basis. The article fails to include a power analysis; a test to assess the study’s ability to detect significant differences. The researchers acknowledge that the sample was small (n=31). An effect size for IM strength was reported (d=0.48). Data Collection The data collection methods are appropriate for measuring the dependent variables (Padula et al. 2009). Test-retest reliability values are documented for the following measures: PI max, the Borg scale (1982), and self-efficacy. These values should be documented for all data collection methods (Burns Grove, 2011). This useful statistical test is a measure of the stability of the scores elicited over time (Sim Wright, 2000). A Chronbach’s alpha score was only documented for one of the measures. This statistical test measures internal consistency; i.e. how confident are we that the individual items in a scale are accurately measuring the same construct (Clark-Carter, 2001). The article reports that the research assistants followed a specified protocol, however this is not provided in the report. The article should document all the steps taken to reduce errors during the data collection process (Burns Grove, 2011). For example, it is unknown whether steps were taken to reduce user error in taking physiological measurements such as respiratory pattern. Measurements were taken at spaced intervals (i.e. weeks 1, 3, 6, 9 12); this design feature strengthens our confidence in the findings. Mention should be made here of the possibility of demand effects; the notion that participants may have modified their responses on the Borg scale to match the expectations of the study (McCambridge et al. 2012). Analysis The inferential analyses (ANOVA) conducted are appropriate for the type of data collected (Ratio/interval and ordinal; Dancey Reidy, 2011). Post hoc analyses were used to detect the location of the differences in two of the dependent variables; a best practice approach. A table showing all mean scores including significance levels for each dependent variable would be beneficial to the reader. A significant difference was detected for IMT strength in the experimental group (p Discussion The key findings are clearly stated and are consistent with previous literature. The researchers offer an alternative explanation to account for why a significant improvement in IM strength and dyspnoea in the IMT group was found. Participants may have become accustomed to the technique of generating high maximal inspiratory pressures; this is referred to as the training effect. This is a confounding variable that could compromise the internal validity of the study. The researchers account for why the secondary aim of the study was not met. The measurement for self-efficacy (the CSES) was inadequate for the purpose it was intended for. The researchers acknowledge the study’s limitations – the relatively small sample size (n=31). The strict inclusion criteria effects external validity as the findings cannot be generalised to patients with HF and coexisting COPD which is prominent in the population. This is acknowledged as a potential source of error. The study contributes to an evidence base for the use of IMT as an additional treatment for stable HF and provides recommendations for future research. Word count: 1100 References Borg, G. (1982). Psychophysical bases of perceived exertion. Science in Sports and Exercise, 14 (5): 377-381. Burns, N. and Grove, S. K. (2011) Understanding nursing research: building an evidence-based practice. 5th ed. Maryland Heights, MO: Elsevier Saunders. Critical Appraisal Skills Programme (CASP) (2014) CASP checklists [online]. Available from: http://www.casp-uk.net/#!casp-tools-chcklists/c18f8. [Accessed 1 June 2014]. Clark-Carter, D. (2001) Doing quantitative psychological research. East Sussex, UK: Psychology Press Ltd. Crombie, I. K. (2005) The pocket guide to critical appraisal. London: BMJ Publishing Group. Dancey, C. and Reidy, J. (2011) Statistics without maths for psychology. 5th ed. London: Prentice Hall. Hek, G. and Moule, P. (2006) Making sense of research: an introduction for health and social care practitioners. 3rd ed. London: Sage Publications Ltd. McCambridge, J., de Bruin, M. and Witton, J. (2012) The effects of demand characteristics on research participant behaviours in non-laboratory settings: a systematic review. PLoS One, 7 (6): e39116. Moule, P. and Goodman, M. (2009) Nursing research: an introduction. London: Sage Publications Ltd. Padula, C. A., Yeaw, E. and Mistry, S. (2009) A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research, 22: 18-25. Schulz, K. F. and Grimes, A. (2002) Blinding in randomised trials: hiding who got what. The Lancet, 359 (9307): 696-700. Seers, K. and Critelton, N. (2001) Quantitative research: designs relevant to nursing and healthcare. Nursing Times Research, 6 (1): 487-500. Sim, J. and Wright, C. (2000) Research in health care: concepts, designs and methods. Cheltenham, UK: Stanley Thornes. 1

Defending Privacy of Personal Information Essay -- Internet Web Comput

Defending Privacy of Personal Information Privacy does not have a single definition and it is a concept that is not easily defined. Information privacy is an individual's claim to control the terms under which personal information is acquired, disclosed, and used [9]. In the context of privacy, personal information includes any information relating to or traceable to an individual person [ 1]. Privacy can be defined as a fundamental human right; thus, privacy protection which involves the establishment of rules governing the collection and handling of personal data can be seen as a boundary line as how far society can intrude into a person's affairs. The Internet offers many benefits but it also creates many threats that undermines our personal privacy. Concerns about loss of privacy are not new. But the computer's ability to gather and sort vast amounts of data and the Internet's ability to distribute it globally magnify those concerns [1]. Privacy concerns on the Internet are centered on improper acquisition, improper use of personal information such as intrusions, manipulation, discrimination, identity theft, and stalking of personal information. Today the Internet stretches our geographic boundaries and force us to deal with global ethic based on moral principles held to be valid across the cultures. Due to the nature of the Internet, our personal information may be transmitted over the internet and that the transfer of personal information may be made to any country in the world, regardless of the extent of any data protection laws and regulations in any of those countries. Protecting privacy on the Internet It has long been believed that information is power. Thus, people collecting personal information in ... ... 2. Privacy and Human Rights 2003 3. Herman T. Tavani, "Privacy Online," Computers and Society, Vol. 29, No. 4, 1999, pp. 11-19. 4. A. Michael Froomkin, "The Death of Privacy ?", Stanford Law Review, May 2000. 5. CPSR: Electronic Privacy Principles 6. Daniel Lin, Michael C. Loui, "Taking the Byte Out of Cookies: Privacy, Consent, and the Web" Computers and Society, June 1998. 7. Herman T. Tavani, James H. Moor "Privacy Protection, Control of Information, and Privacy-Enhancing Technologies", Computers and Society, March 2001 8. FTC: Protecting Privacy and Security of Personal Information in the Global Electronic Marketplace 9. Jerry Kang "Cyberspace Privacy: A Primer and Proposal" Human Rights Magazine, Volume 26, Number 1, Winter 1999. 10. CPSR: Potential Threats to Privacy 11. An International Survey of Privacy Laws and Practice

Humanism The Renaissance And M Essays -- essays research papers

Humanism   Ã‚  Ã‚  Ã‚  Ã‚  The introduction of the concept of humanism greatly affected the Renaissance. The Humanistic influence shaped Renaissance art, writing, education and thinkers, its ideas were spread among all aspects of life. Machiavelli’s writings during the Renaissance were also affected by the ideas of humanism. His ideas reflect the thoughts of humanism in the way he thought governments and societies should be organized.   Ã‚  Ã‚  Ã‚  Ã‚  Humanism’s influence on art was very obvious, it could be seen slowly infiltrating all art throughout the Renaissance. At the begging of the Renaissance, most art was very dark and dismal. The works portrayed people doing very menial labor, the people did not seem happy and their clothing was very plain. As the Renaissance progressed and humanism’s influence was more felt the paintings used lighter colors, the people in them were smiling and their clothing many times included gold trim or accents. The late Renaissance art also has a larger focus on religion, as humanism inspired people in many forms by the use of religion.   Ã‚  Ã‚  Ã‚  Ã‚  Humanism came about with the idea that a person should have a very rounded education covering many aspects of society especially history, geometry, and art. During the renaissance as the ideas of humanism spread, especially in its educational sense, more schools and universities were erected and a much higher percentage of people were forma...

A Blend of Tradition and the Contemporary

Music has always been a part of the rich Lebanese culture and has played a very important role in many religious traditions. The beautiful rhythm of Arabic tunes mixed with peculiar characteristics of gypsy music in the country proved to be a great blend which resulted to a rich production of intensity that captivates listeners.The characteristic soothing rhythm and wild beats made Lebanese music known around the world. Traditional Lebanese music incorporates instruments such as the oud, the derbake and the ney. These instruments are still being incorporated to pop music that the new generation is enjoying today.The traditional music of Lebanon is usually sung in either Lebanese or Egyptian language. Aside from this, musicians, artists, singers etc, differ on the way they incorporate music to their individual sound.   The artists differ in so many ways. Some artists were known to differ in their music because of their Lebanese dialects. Most are distinct because of their style, the ir sound and instruments.Very few Lebanese musicians try to remain loyal to the traditional music which is called Jabali (of the mountains). One of which is Mohammed El Helani more popularly known as Assi Helani, who is a major music force in the Middle East since the 1990’s. He is a strong musician and follower of the traditional music like mawall and dabke.Dabke, which is usually presented during important and joyous occasions such as weddings, family parties and competitions. This is a very energetic music which usually leaves the audience ‘stomping their feet’-which is the literal meaning of Dabke.Pop music on the other hand is not a new fancy among the Lebanese audience. The growing influence of the western culture made it’s way not only on Lebanese every day living but also on it’s music. Although western pop music is very distinct from Lebanese pop music because it fuses pop melodies and it’s pop-Arabic roots at the same time. The pop music of Lebanon also focuses on the melodramatic melodies and sad states of mind.  Nancy Nabil Ajram is also a popular singer among the Lebanese people. A multi-platinum folk artist, Ajram is considered to be one of the most important superstars ranking 3rd among the best selling female singers of Lebanon. Her style is incorporating the traditional Lebanese music with and infusion of Western culture. Her formula proved to be very potent since most of her followers are the young and old alike of the generation.

Aeronautical Decision Making Essay

The airlines developed some of the first training programs that focused on improving aeronautical decision making (ADM). ADM is a systematic approach to the mental process used by airline pilots to consistently determine the best course of action in response to a given set of circumstances. Human-factors-related accidents motivated the airline industry to implement crew resource management (CRM) training for flight crews. The focus of CRM programs is the effective use of all available resources: human resources, hardware, and information. Human resources consist of all groups routinely working with the cockpit crew (or pilot) who are involved in decisions that are required to operate a flight safely. These groups include, but are not limited to: dispatchers, cabin crewmembers, maintenance personnel, and air traffic controllers. The importance of learning effective ADM skills cannot be overemphasized in the airline industry. While progress is continually being made in the advancement of pilot training methods, airline equipment and systems, accidents still occur. Despite all the changes in technology to improve flight safety, one factor still remains the same – the human factor. It is estimated that approximately 75 percent of all aviation accidents are human factors related. Historically, the term pilot error has been used to describe the causes of these accidents. Pilot error means that an action or decision made by the pilot was the cause, or a contributing factor that led to the accident. This definition also includes the pilot’s failure to make a decision or take action. From a broader perspective, the phrase â€Å"human factors related† more suitably describes these accidents since it is usually not a single decision that leads to an accident, but a chain of events triggered by a number of various factors. The poor judgment chain, sometimes referred to as the error chain, is a term used to describe this concept of contributing factors in human factors-related-accidents. Breaking one link in the chain normally is all that is necessary to change the outcome in a sequence of events. By discussing events that lead to an accident, it can be understood how a series of judgment errors can contribute to the final outcome of a flight. An understanding of the decision-making process provides a pilot with a foundation for developing ADM skills. Some situations, such as engine-failures, require a pilot to respond immediately using established procedures with little time for detailed analysis. Traditionally, pilots have been well trained to react to emergencies, but are not as well prepared to make decisions requiring a more reflective response. Typically during a flight, there is time to examine any changes that occur, gather information, and assess risk before reaching a decision. The steps leading to this conclusion constitute the decision making process are defining the problem, choosing a course of action, and implementing the decision and evaluating the outcome. The first step in the decision making process is problem definition. Defining the problem begins with recognizing that a change has occurred or that an expected change did not take place. The exact nature and severity of the problem are determined by the pilot’s senses and experience in flying. For example, a low oil pressure reading could indicate that the engine is about to fail and an emergency landing should be planned or it could mean that the oil pressure sensor is giving a faulty reading. According to the situation, each action by the pilot is taken differently. An important note is that once the pilot has identified the problem, other sources must be used to verify that the conclusion is correct. Once the problem has been identified, the pilot must evaluate the need to react to it and determine that actions that must be used to remedy the problem. The expected outcome of each possible action should be considered and the risks assessed before deciding on a response to the situation. Although a decision may be reached and a course of action implemented, the decision making is not complete. It is important to think ahead and determine how the decision could affect other phases of the flight. As the flight progresses, the pilot must continue to evaluate the outcome of the decision to ensure that it is producing the desired result. The decision-making process normally consists of several steps before choosing a course of action. To help remember the elements of the decision-making process, a six-step model has been previously developed using the acronym â€Å"decide. † Detect the fact that a change has occurred Estimate the need to counter or react to the change Choose a desirable outcome for the success of the flight Identify actions which could successfully control the change. Do the necessary action to adapt to the change Evaluate the effect of the action Another important aeronautical decision making is risk management. During each flight, decisions must be made regarding events involving interactions between the four risk elements: the pilot in command, the airplane, the environment, and the operation. The decision-making process involves an evaluation of these risk elements to achieve an accurate perception of the flight situation. A pilot must continually make decisions about competency, condition of health, mental and emotional state, level of fatigue, and many other factors. Airplane—a pilot will frequently base decisions on the evaluations of the airplane, such as performance, equipment, or worthiness in the air. Environment—this encompasses many elements not pilot or airplane related. It can include such factors as weather, air traffic control, navaids, terrain, takeoff and landing areas, and surrounding obstacles. Weather is one element that can change drastically over time. Operation—the interaction between the pilot, airplane, and the environment is greatly influenced by the purpose of each flight operation. Also, exercising good judgment begins prior to taking the control of an airplane. Often, pilots thoroughly check their airplane to determine airworthiness, but they do no evaluate their own fitness for flight. Just as a checklist is used when pilots check their pre-flight of an airplane, a personal checklist based on such factors as experience, currency, and comfort level can help determine if a pilot is prepared for the flight. In addition to a review of personal limitations, use the â€Å"i’m safe† Checklist in evaluation of the pilot.

International Student Organization

International student organization. East Carolina University is a university with enrollment around 30,000 students; 299 of them is international students from 67 countries. When students choose to attend the university; they begin a new part of life. Many students go to study in other cities, and some students go to other countries. America is a very popular and high-class education that is valued all over the world, and of course a lot of students from other countries want to get a degree here.People in different countries behave differently: religion, ethnicity, geographic location and quality of life plays an important role in the behavior of people. Therefore, students that come to America from other countries have more difficulty than those who were born and raced here. Foreign students need time to adjust to a different culture, a different language, and many other things.A possible way for international student to deal with the complexities of ECU joins the International Stud ent Organization (ISA). The ISA help international students understand American culture and feel more like at home by having festivals, shopping and field trips and a lot of different events. The ISA , one of over 200 student organizations at ECU, is mostly composed of foreign exchange students, or students who were not born in America although. The meetings and club are open to anyone who wants to join.The main reason it was setup was to give international students an opportunity to gain a greater understanding of the American culture in part through a campus experience, and also to offer non-international ECU students, with an interest in one cultures, knowledge and experience in working with individuals from other backgrounds. It also allows international and American students to share experience and learn about other cultures at personal point of view.The ISA cooperating with International House provides a special orientation for international students through the â€Å"First f riend program† (FFP) so that new students do not feel lonely. International Ports O’Call stage of PirateFest The International student organization was involved in many activities and events. One of the biggest events in which ISA was involved in was the Pirate festival. PirateFest gives international students a chance to share their culture to help others understand them etter. This â€Å"annual event celebrates eastern North Carolina's rich history steeped with famous pirates, including the infamous Blackbeard and Greenville's own Pirates of ECU† (Mike Davis), and encourages people to wear pirate regalia-hats, swords, and eye patches. The festival is held over two days and is composed of different stages, each of which represents a different event. The event feature food, art and crafts vendors and also musical and stage performers.Historical trolley tours stage is a very useful and interesting part of the festival because it's a great way to move around the fe stival especially for international students who do not know the location of streets in the city. One of the most interesting stages for international students was the â€Å"International Ports O'Call† because includes music, food, and attractions from nations around the world, and it will definitely help international students to feel more like at home and make it hard to forget about their culture.For international students who are coming to study in another country it is hard to find friends. It is not easy to get used to the different behavior of people and be open to new acquaintances. Therefore, and in cooperation with ISA the international house created the program called â€Å"First friend program†(FFP). To be involved in FFP both mentor and mentee must fill out an application, which has questions that help determine the background, interests, preferences and other information needed to help decide the best mentee-mentee match.The FFP is really easy because by filling out an application you know that you'll meet someone who has same interests as you. The FFP helps international students to adjust to life at ECU as quickly and smoothly as possible, and also enhance satisfaction with their academic and social experience. This program is very useful for students because they will not feel lonely and homesick, they are able to meet new friends and also international students can learn the nuances of culture from the inside, as well as be more successful in learning.Besides homework, tests and grades, a student social life is fun, but it is not always easy to find entertainment that are always enjoy. Many international students don't have a car and therefore their possibilities are limited, but the international house â€Å"every Friday makes shopping trips†(William Mallett). Drivers take students where they want to go and take them back to residence after shopping. Also every Thursday students can go to greenway excursions. Playing sp orts and socializing in the fresh air, very useful and at the same time you can see new parts of the city as well as make new friends.Most people believe that studying in a different country is a privilege because they are able to experience other cultures, and learn from them. However, in the United States it is not as good as they thought because International students have much more pressure being in this country, and sometimes they cannot handle it very well. Therefore, in the United States the life of an international student is very unfavorable if people compare it to the life of an American student.International students have to learn a new language to study, they cannot work while studying, and their tuition is much more expensive. When people moves to the United Stated to study they imagine that it will be very helpful, and they believe that learning a new language will not be a problem. However, when they really start studying their major, they find out that it is not easy since people have to really understand and appreciate the language. International students have to really learn English, and they have to know how to write it in order to have success.Also, for them to have success in university they have to participate in class, and analyze an amount of readings, and because they are international students, it is very difficult to achieve since they believe that Americans are going to laugh at them or make jokes of them if they say something incorrectly. For example, some Americans do not realize sometimes how hard is for international students being in a different country, with different people, learning a new language, and experiencing different cultures, so some of them do not really appreciate the effort that international students put on being in the United States.It’s way more pressure for international students. They have to have good grades and work as hard as possible, because if not people back home going to put a lot of shame on them and their parents. Studying in different country it is always competition for international students, but if students choose right University where people care about international students and trying to help it shouldn’t be that hard.International student organization definitely helps students from other countries feel more comfortable and less homesick, so they can you do best in classes to compete with other student on the same level. Work cited. Mike,Davis. â€Å"Arrrgh you ready for Pirate Fest? † East Carolinian, 12 April 2012 . Web. 1 November. Mallet,William â€Å"International Student Organization. † 30 october. 2012 [email  protected] edu Personal page Office of International Affairs www. ecu. edu/intlaffairs/

Memorial Health System Essay

In going through the case study of the Memorial Health System CPOE Implementation it is apparent that the direction of the implementation was developing trouble from the onset of the proposal and the evaluation (Wager, Glaser, 2009). The first problem that is apparent is the lack of belief in the project. When the board approved the CPOE initiative and appointed the champions of the project the CEO Fred Dryer and CIO Joe Roberts there was already opposition from some of the stakeholders about this project. The physician believed the CPOE system would create more workload for them as well as this system reducing the physician to secretaries. To minimize the effect of this indicator a physician would have been appointed as a champion of this project to serve as an advocate of the system (Wager, Glaser, 2009). To gain buy-in from other physicians and user of the new system to ensure they have adequate input into the decision- making process (Wager, Glaser, 2009). The lack of clarity of purpose is apparent in this implementation. The project does not determine the scope and expectations clearly the board approved a multimillion dollar initiative to install an enterprise-wide clinician provider order entry system to reduce medical errors. To minimize this indicator the implementation team must determine the scope of the project and what the organization hopes the project will achieve (Wager, Glaser, 2009). A senior health care executive should meet with the implementation team to set the tone and communicate how the project relates to the organization’s strategic goals (Wager, Glaser, 2009). The team will determine the scope, establish expectations, and institute a project plan to minimize this indicator (Wager, Glaser, 2009). Insufficient leadership support is another indicator that played a part in the failure of this implementation. When leadership wants to hear positive communication about a project and not the negatives the project will fail. To minimize this  indicator clear and concise communication on the progress of the project is necessary the leader involve in the project should make time for reports on the progress of the implementation to handle any issues that may occur that could hinder the progress of the project (Wager, Glaser, 2009). Appointing people who believe and committed to the project into leadership position to lead the team and make time for communication from team and other leadership (Wager, Glaser, 2009). Another issue that was an indicator of failure to this project was the requirements analysis was rushed several key workflow and system integration issues were missed. To minimize this indicator a thorough requirement analysis is done to ensure that all workflow analysis to support the change in workflow and the system requirements analysis to ensure the requirements needed for the system to work are aligned with the strategic goals of the organization (Wager, Glaser, 2009). Budget cut to the project was a big indicator the would lead to failure of this project because in the status review meeting it was presented that the project was on scope, on schedule, and on budget led to leadership taking resources from the CPOE project. It is important the present a true picture of how the project is going not just what someone wants to hear (Wager, Glaser, 2009). Present a clear picture of how the budget is spent and what the project will continue to spend as the implementation goes to completion, such as training, or a newer version of the software (Wager, Glaser, 2009). Showing an account of the budget can help to minimize this indicator (Wager, Glaser, 2009). This project was doom from the beginning there was not a clear scope or the expectation of the project. Analysis were not done there was not a detail project plan plus and unrealistic time line for the project to be implemented. Leadership did not communicate enough to persuade the stakeholders who were against the project to change their thoughts and so on. However, for the project to work the objectives of the initiatives are clear and communicating these objectives and initiative, and test the degree to which the organizational members have brought into them. Dividing the project into manageable pieces address the complexity and test the evidence that the project may be at risk from trying to do too much all at once. Reference Wager, K. A., Lee, F. W., & Glaser, J. P. (2009). Health Care Information System: A practical approach for health care management (2nd ed.). San Frncisco, CA: Jossey-Bas.