The tourism sector is a major and substantial contributor to any nation’s source of income. Tourist attraction sites are unique and different in different parts of the world. The great and unique features of such locations tend to attract tourists from different places. The fees citizens and foreigners pay to enter such sites contribute to the income of the government and other private bodies. With this broad knowledge, this paper attempts to narrow down and examine specific tourism sites, Lake Geneva, in Switzerland. It entails examining the factors that have led to the place of being a major tourism site by most tourists. It will also cover the improvements that need to be made to enhance the lake and its surroundings as a major tourism site (Region Du Leman, 2011).
Lake Geneva is among the largest lakes in the world. Approximately 60% of the lake is found in Switzerland, while the remaining 40% is found in France. On the map, the lake is located 46.43o north and 6.55o south. The lake has several outflows and inflows. Among the inflows are rivers Rhone, La Vonage, Dranse, and Aubonne, with the main outflow being river Rhone. Lake Geneva has an approximate length of 73 kilometers and a width of 14 kilometers.
On average, the lake has a surface area of 580 kilometers squared. An average depth of 155 meters enables the lake to hold a water volume of 89 kilometers cubed. As is with many lakes, this lake is also covered by a number of islands such as Ile de Peilz, Chateau de Chillon, Ile de Salagon, Ile de la Harpe, Ile Rousseau, and Ile de Choisi. Among the settlements that surround the lake include Geneva, Lausanne, Montreux, and Vevey, which are all found in Switzerland. On the France side, the settlements include Evian and Thonon (OECD, 2008).
Reasons why most tourists chose Lake Geneva region as their touring site
Switzerland, which is covered by about 60% of the lake, is the most toured country. A number of factors have contributed to the high number of foreigners touring this area across the world. The chief contributor to the massive flow of tourists into the site is the high level of peace experienced by the country. Switzerland is among the very few countries that rarely face the violence of any kind. This even makes the country a strategic position for the World Bank. Generally, peace in a country always ensures the safety of its tourists. In addition, the country is alleged to have very friendly and welcoming citizens.
Majorly, the hospitality of the residents would attract tourists into such an area. The winter and summer seasons experienced in the region attracts tourists. During winter, ice always covers the Alps Mountains. As the summer season replaces the winter season, the ice formed on the mountain always melts, creating beautiful scenery for the tourists. In fact, the lake is said to have formed through retreating of the glaciers. The crescent shape of the lake portrays the lake with a unique feature that appeals to a large number of tourists. On top of the above features, the region also enjoys several other attractive features similar to other tourist sites.
These include the exceptional setting that attracts different types of sports such as hiking and walking, cycling and mountain biking, skating, going out and entertainment, ball sports, swimming, horseback riding, shopping, and probably enjoying the great weather at the beach. Festivals and events such as the long-held traditions of bullfighting, to have favored tourism in the country. Museums, castles, religious monuments, historical sites, available architecture and design of the region and celebrities such as Phil Collins who reside in the area cannot be overlooked upon in their contribution towards making Lake Geneva a major attracting site in the world (Mirbabayev & Shagazatova, n.d.).
The infrastructure facilities around Lake Geneva
Lake Geneva is located adjacent to the capital city of Switzerland. This location has favored the lake region in a number of ways. With the World Bank having its headquarters in Geneva, Switzerland, the country has a substantial improvement in the infrastructure sector. The roads and railways are sophistically constructed to handle the massive movement going on in the region. The international airport located in Geneva enables sufficient and convenient transportation of tourists. The electricity majorly produced by the running rivers such as river Rhone has ensured a constant supply of electricity in the region (Region Du Leman, 2011).
This has helped other supportive areas of tourism, such as restaurants, run efficiently. A strong communication network for the Lake Geneva region has strongly boosted communication in the area. In particular, the region is endowed with internet services that majorly provide information relating to the region. Although the region enjoys the above-mentioned infrastructure, the region still suffers from a shortage of restaurants or generally accommodation facilities, given the high number of tourists touring the site. The supply of these facilities is less as compared to their demand. The small number of hotels and restaurants may, therefore, affect the tourism sector (OECD, 2008) negatively.
Importance of developing new hotels and restaurants at Lake Geneva region
The essential subsections of the tourism sector that boost the economy are hotels and restaurants. These are the eating and resting places for the tourists. The number of these facilities in a region will determine the number of tourists it can accommodate. A Region that is frequently toured should have adequate facilities to avoid shortages arising from the high demand of tourists. Lake Geneva region does not have adequate hotels and restaurants for its tourists who frequently visit the area. The small number of accommodation facilities calls for more hotels and restaurant development in the region to serve the projected high tourism growth levels in the future in the country.
Indeed, bearing in mind that Switzerland enjoys high levels of peace as compared to other countries, Switzerland will undoubtedly continue to experience a high number of tourists touring the area. Therefore, more tourists, who would choose to tour other countries due to the restaurants and other accommodation facilities by tourists, would still visit the tourist site given that the region has adequate accommodation facilities. This will eventually raise the level of the country’s income. Specifically, Switzerland earns most of its foreign income through the tourism sector (Mirbabayev & Shagazatova, n.d.).
Features for Future Growth
Lake Geneva and its surroundings can still benefit from the creation and development of new attractive features as well as other amenities. First, the government of Switzerland should think of coming up with hospitals that meet international standards. This will ensure adequate treatment services for tourists. Again, due to language barriers, the government should think of nationalizing the English language to enable smooth communication between the residents and tourists.
Due to a high number of tourists, the government or other interested private bodies should develop new attractive sites such as animal orphanages in other places other than Geneva. This will lead to employment in other parts of the country and decentralize the economy of the country. Finally, the government should expand highways in the country to reduce the frequent traffic jam around the city of Geneva. This will enable the effective and efficient movement of vehicles.
Tourism plays a crucial role in Switzerland’s economy. Lake Geneva has greatly contributed to the tourism sector because many tourists touring the country also tour the lake based on the distinct and exceptional scenery of the lake. Most tourists are also attracted by the stability of this country in terms of peace. Therefore, tourism will generate more cash if setbacks, such as a shortage of restaurants and hotels, are solved.
Mirbabayev, B. & Shagazatova, M. (n.d.). The Economic and Social Impact of Tourism. Web.
OECD, (2008). Tourism in OECD Countries 2008: Trends and Policies. OECD Publishing.
Region Du Leman, (2011). Culture and Heritage. Web.
Patients Post Cardiac Arrest Syndrome: Theory Of Comfort
This paper is focused on Kolcaba’s theory of comfort and practice. Its purpose is to consider how it can be applied in practice when working with patients who have the post-cardiac arrest syndrome. The paper is based on five articles that discuss related topics. It gathers trustworthy and reliable evidence to prove the advantage of Kolcaba’s theory. Moreover, two recommendations regarding the implementation of the theory in practice are provided.
This paper is focused on Kolcaba’s theory of comfort and practice. Its purpose is to consider how it can be applied in practice and examine the way it can enhance the health condition of the adult through the geriatric population following a diagnosis of post-cardiac arrest syndrome (PCAS). There were several reasons why this theory was selected among the others. First of all, this happened because of the fact that patients with myocardial infarction tend to require something more than just strict medication compliance.
They do need cardiac conditions relaxation as well because it can improve health outcomes greatly with minimal interventions. Except for that, it is generally known that multiple cardiac conditions and complications are often triggered not by physical issues related to the diseases that people have but by stresses stimulated by the environment such as too bright lights. The middle range theory of comfort and practice when applied to this particular set of patients would have a positive effect as it is designed to improve their overall quality of life.
This work is based on the qualitative research that was conducted when dealing with structured texts. The information was obtained through literature analysis. There were 5 data sources in total: 3 primary research articles, 1 scholarly article, and 1 article that actually applies the theory of comfort. In order to reach these articles, several databases were searched, including the university website, ProQuest, EBSCO, PubMed, and Questia.
The information was found when using the key phrases “post-cardiac arrest syndrome” and “comfort theory”. Inclusion criteria dealt with the language in which the article was written (English), the topic discussed (PCAS or/and comfort theory (CT)), and authoritativeness (trust-worthy peer-reviewed journals). The year of publication (2011 – present) played a critical role when selecting primary research articles and the article that actually applies the theory. Still, it was not so vital when choosing the scholarly article partially prepared by the theorist. Exclusion criteria were the absence of primary research (but for the article that discusses the issue from the theoretical point of view), no specific health intervention, and lack of clearly identified outcomes/conclusions.
Theory of Comfort and Practice
As it was already mentioned, this paper discusses Kolcaba’s theory of comfort and practice. It was chosen to prove that patients who have problems with the heart (PCAS, in particular) require not only standard treatment that deals with the prescription of medication. Even being unconscious patients are likely to be affected by changes in the environment and react to them. Multiple cardiac issues can be observed if the patient is constantly affected by stressful situations.
Thus, it is extremely vital for one to relax and spend time in calm. Cardiac conditions are rather serious, so the fact that influences of stress cannot be observed as clear as the symptoms of the disease does not mean that they can be ignored. Unfortunately, even being in the healthcare facilities patients can still face stresses because of too loud alarms, people talking, etc. With the help of the theory of comfort and practice, healthcare professionals will have a possibility to assist many patients and enhance their overall quality of life, which is likely to have positive effects on the health status of the whole country.
The implementation of the CT is likely to bring the most benefit to such population because it is not only effective but also rather easy to maintain. Being used in practice, it combines nursing approaches that are universal, which was considered as one more reason to refer to this theory. Moreover, it is claimed to represent those values that are highly respected by the nursing professionals. While many professionals who developed nursing theories paid little or no attention to the comfort of the personnel, Kolcaba underlined its importance for efficient outcomes while at first she also discussed it from the patient/family perspective (Kolcaba, Tilton, & Drouin, 2006).
Considering her theory, Kolcaba defines three main types of comfort that are to be taken into consideration:
- Relief. It occurs when the related needs of a particular person or family are decently met;
- Ease. It can be experienced when a person is calm.
- Transcendence. It is connected with the person’s ability to rise above the things that disturb one. In the majority of cases, it deals with problems and pain (Kolcaba, Tilton, & Drouin, 2006).
Professionals also discussed a concept that is opposed to comfort – discomfort. It was found out that discomfort is not just an unpleasant feeling. It deals with both physical and emotional aspects that influence holistic beings adversely. Therefore, CT is considered along with “nursing values and domains such as care, symptom management, interaction, holism, healing environment, identification of needs, and homeostasis” (Kolcaba, Tilton, & Drouin, 2006, p. 539).
Comfort can be observed in four contexts regardless of the role of the individual who experiences it. Physical comfort deals with human physiology. Psychospiritual one is connected with the realization of one’s internal self. Sociocultural comfort covers people’s relationships with both family and other individuals. It includes various traditions and rituals that are practiced by the representatives of the general public. Finally, environmental comfort is concentrated on the things that surround a person and their characteristics. It is the external background, which includes smells, colors, temperature, and other features.
According to the CT, the fact that patients and their relatives are satisfied with services and feel comfortable can be extremely beneficial for the healthcare facility. First of all, in such a situation they are willing to take part in health-seeking behaviors. As a result, the cost of care and length of stay can be affected greatly. They are likely to reduce because individuals start taking care of their health more, and the process of healing and recovery streamlines.
In the same framework, people become more satisfied, which the received cervices (patient) and way of working (nurses). Families’ financial condition becomes more stable while the healthcare system receives more positive publicity.
The article prepared by Bascom, Riker, and Seder (2016) is focused on caring for patients with the PCAS and the ability to specify specific injuries sustained by an individual so that one can benefit and be effectively treated. The researchers paid attention to the study that was previously conducted by Thomsen and his colleagues. Its purpose was to prove that bradycardia is tightly connected to the enhanced survival rates. Professionals referred to Target Temperature Management when gathering data.
The sample of this research included 950 comatose patients. They all survived cardiac arrest. A part of them (447 individuals) started at 33°C. Even though no considerations regarding the patient’s age, gender, ischemic time, etc. were initially discussed, the authors tried to predict health outcomes for patient groups. The sample was selected due to its convenience. The research was maintained in a quasi-experimental form and revealed a set of quantitative data.
Unfortunately, it is not mentioned if the institutional review board (IRB) approval was obtained. Still, as the study was conducted in the healthcare facility, all required steps were likely to be considered. The data provided was valid and reliable, as it was assessed and discussed along with the results of other professionals. The findings of the research revealed that bradycardia is a normal reaction that is expected to be seen after the PCAS outcomes. Thus, its presence proves that the patient is recovering and getting back to the normal condition (Bascom, Riker, & Seder, 2016). As quantitative research with convenient sampling, this research utilizes level III evidence according to the hierarchy developed by Facchiano and Snyder (2012).
Another article related to the topic was prepared by Cour, Bresson, Hernu, and Argaud (2016). Professionals successfully utilized the Sequential Organ Failure Assessment to evaluate the severity of the PCAS. The purpose of this research was to make use of this assessment to discuss the prognostic effects of organ failures. The authors applied their study to the patients who were in the intensive-care unit because they suffer the PCAS.
The sample for this research was convenient and included 304 patients with an average age of 66. About 55% of all participants were males, which proves that gender biases can be almost totally eliminated. The study was quasi-experimental and provided a wide range of quantitative data. The local ethics committee approved it, which proved that the necessity of this research existed and that professionals followed all standards when conducting it. After admission to the hospital, patients experienced various health outcomes. The research was valid and reliable, as the data was assessed by several professionals and was tightly focused on the topic.
All in all, the findings showed that the Sequential Organ Failure Assessment can assist healthcare personnel when they need to define the severity of the PCAS so that they receive an opportunity to predict if the patient will have problems and complications connected with the early organ failure. Except for that, the authors of the article emphasized that multiple organ failure in the patients who have the PCAS is connected with a bad prognosis. As quantitative research with convenient sampling, this research utilizes level III evidence according to the hierarchy developed by Facchiano and Snyder (2012).
In their work León-Pérez, Wallston, Goggins, Poppendeck, and Kripalani (2015) discussed the well-being of the patients who have cardiac issues. Professionals did not approach their considerations to those who are unconscious but stated that stress may affect one’s health outcomes adversely. The authors stated that individuals may suffer because of the depressive symptoms when they are discharged.
The purpose of their research was to prove that healthcare professionals can benefit greatly if they are aware of the features that can be used to identify potentially vulnerable to stress patients, as they can trigger various interventions to assist these people when they are still at the hospital and improve their health condition. All in all, professionals tried to find out whether stress experienced during the first days after the discharge is associated with the symptoms of the same nature faced a month after the discharge. Except for that, they considered how post-discharge stress influences health outcomes in relation to prior symptoms.
The researchers wanted to get to know if health competence and social support can reduce such negative impacts. The convenient sample included individuals of both genders who were over 17 and were admitted to Vanderbilt University Hospital because of their heart diseases. It was a cohort study that revealed quantitative data. It received approval from the Institutional Review Board, which made the research more authoritative and ensured its appropriateness.
Valid and reliability of this research were ensured with appropriate assessment and appropriate measurements. When the research was conducted, professionals found out that the psychological well-being of the patients with cardiac issues is adversely affected by post-discharge stress. As a rule, those who had prior symptoms suffer more. Still, coping resources, including health competence and social support can improve the situation significantly. Being a cohort study, this research utilizes level IV evidence according to the hierarchy developed by Facchiano and Snyder (2012).
The article prepared by Krinsky, Murillo, & Johnson (2014) is extremely vital for this paper. It is focused on the practical application of CT to patients who have cardiac issues. Professionals tried to prove that the implementation of the CT can enhance the patient’s condition and be advantageous for the nursing practice. They paid enormous attention to a quiet time intervention. Thus, the main aim of this research was to reveal the sense of CT and show that it can benefit cardiac patients with the help of quiet time, to enhancing their experiences at the healthcare establishments.
The study was based on two case studies, which limited the sample to two male patients who had suspected acute coronary syndrome and were selected randomly. This was a systematic review, which measured the way patients felt on the basis of qualitative data. The information mentioned in the study was trustworthy, as it was obtained by the professionals from the authoritative literature sources and case studies.
The findings of this research showed that nurses are able to provide comfort-focused interventions. It was proved that when clients felt comfort, their satisfaction rates increased. At the same time, nurses and healthcare facilities received an opportunity to reduce their expenditures and discharge patients faster. The CT, which was developed by Kolcaba, can be used as a source of efficient and effective ways of enhancement patient comfort, which streamlines the process of recovering in its turn. Being a systematic review, this research utilizes level I evidence according to the hierarchy developed by Facchiano and Snyder (2012).
All in all, the evidence received from the articles is of decent quality. It is related to the selected topic, which allows us to use this information in the current paper. Unfortunately, the articles do not discuss the CT applied to the patients with PCAS. Still, they consider each topic separately, which provides an opportunity to analyze the information and develop conclusions and recommendations on their basis.
The evidence presented in the articles mainly referred to the III level of evidence, which is rather trustworthy and reliable. The sample usually was extended, which allowed professionals to provide generalized conclusions that are rather advantageous in the sphere of healthcare. Still, the findings mostly dealt with individuals who suffer because of some cordial issues, which is also appropriate for the discussed population of patients with PCAS.
Implementing Theory of Comfort and Practice to Patients Post Cardiac Arrest Syndrome
The PCAS is “the sequela of a whole-body ischemia-reperfusion event and often leads to multisystem organ failure – most dramatically of the brain and heart” (Bascom, Riker, & Seder, 2016, p. 448). As a rule, it lasts for 3-5 days, and patients are very vulnerable during this time. They require not only usual treatment with medications such as antiepileptic drugs or antibiotics but also efficient care provided by nurses. Mainly, these patients do not receive enough oxygen, and their metabolism reduces.
From the very beginning, they are also often unconscious, which means that they are not able to tell the nurse what is required. Thus, it is critical to ensure that education and environmental interventions are undertaken.
The nurses should be educated regarding the CT not in the patient’s perspective but also in their own one. In this way, they should get to know what is included in the concept of comfort and how it can be provided. Fortunately, the CT follows the values of nurses and is not likely to face resistance (León-Pérez et al., 2015). Professionals should be taught in groups and have an opportunity to practice while working. Their success will be measured by gathering feedback from other healthcare professionals, patients, and their families. This educational intervention does not require extreme changes that are why all nurses can be involved in training for three weeks. During this time nurses will receive information, practice, and be assessed.
Another intervention deals with environmental changes. The healthcare facility is to be adapted to maintain quiet time. Professionals will need to measure the hospital noise levels to make sure that they are appropriate and do not disturb the patients. “Prolonged effects of excessive noise exposure on patients and staff alike can have deleterious effects on their health and well-being” (Krinsky, Murillo, & Johnson, 2014, p. 149).
Moreover, the patient’s heart rate and blood pressure can increase because of the alterations in the environment (Cour et al., 2016). Quiet time intervention can prevent such changes and provide patients with comfort if professionals adjust the lights in the patient’s room, the volume of “monitoring alarms, pulse oximetry, blood pressure cuffs” (Krinsky, Murillo, & Johnson, 2014, p. 149). Access to some areas can be limited; professionals can be ordered to speak in low tones. All healthcare services can be scheduled not to disturb patients (Kolcaba, Tilton, & Drouin, 2006). If needed, the administration should remodel a part of the facility.
Thus, the articles discussed in this paper showed that patients with PCAS are very vulnerable and unstable. They require a calm environment that is free from stresses, which is not likely to be present in the healthcare facilities.
Thus, professionals should utilize the CT and implement quite a timely intervention to make it easier for nurses to maintain their tasks and enhance patients’ health outcomes. In this way, it is critical to adapt to the healthcare environment (reduce noises, lights, schedule services, etc.) and educate nurses regarding the scope of care and the way it should be provided. The reviewed evidence is applicable to practice. It is trustworthy and reliable. Even though the research that would focus on PCAS patients and the CT does not exist, obtained information was enough to discuss this topic.
Bascom, K., Riker, R. R., & Seder, D. B. (2016). Heart Rate and the Post Cardiac Arrest Syndrome: Another Clue to Individualizing Care? Critical Care Medicine, 44(2), 448-449. Web.
Cour, M., Bresson, D., Hernu, R., & Argaud, L. (2016). SOFA score to assess the severity of the post-cardiac arrest syndrome. Resuscitation, 102(1), 110-115. Web.
Facchiano, L., & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. Journal of the American Academy of Nurse Practitioners, 2(1), 279-286. Web.
León-Pérez, G., Wallston, K. A., Goggins, K. M., Poppendeck, H. M., & Kripalani, S. (2015). Effects of stress, health competence, and social support on depressive symptoms after cardiac hospitalization. Journal of Behavioral Medicine, 39(3), 441-452. Web.
Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. Journal of Nursing Administration, 36(11), 538-544. Web.
Krinsky, R., Murillo, I., & Johnson, J. (2014). A practical application of Katharine Kolcaba’s comfort theory to cardiac patients. Applied Nursing Research, 27(2), 147-150. Web.
The Affordable Care Act And Its Implications
Status of One of the IOM Recommendations
The Affordable Care Act (ACA) has introduced multiple changes to the healthcare system of the United States, supposedly improving access to health-related services. The regulation allowed implementing improvements at a range of levels, including legal and financial ones (“The Affordable Care Act turns six,” 2016). The specified changes have affected the focus and scope of modern nursing, as the Delaware Board of Nursing (2010) reports.
Specifically, the need for “reconceptualizing the role of nurses within the context of the entire workforce, the shortage, societal issues, and current and future technology” (p. xiii) appeared. When viewing the identified IOM through the lens of the current situation in nursing and healthcare, one has to admit that understaffing remains problematic in the nursing setting. The observed issue persists due to the lack of opportunities for providing nurses with educational options and chances for receiving appropriate benefits for nurses.
Indeed, a closer look at some of the modern realities of nursing will indicate the need to address an increasing shortage of nurses in most healthcare organizations. The lack of nurses in hospitals and nursing organizations affects the quality of care, leading to a rise in medical errors, patient dissatisfaction, and negative outcomes (Nantsupawat et al., 2017). Therefore, the current status of the specified IOM recommendation leaves much to be desired.
From the perspective of consumers, the specified situation reduces the willingness to adopt the proposed healthy behaviors. Other health professionals, in turn, start viewing interdisciplinary cooperation with nurses as barely possible due to the low level of professional and conflict management skills. Finally, organizations suffer significantly from the specified problem since their performance rates drop drastically, causing a drop in patient satisfaction rates and the subsequent devastating reduction in their revenues.
ACA: Pros and Cons
The Affordable Care Act (ACA) has introduced a range of opportunities for improving care, yet it has also created a range of challenges for maintaining its quality high. Therefore, an overview of the positive and negative aspects of ACA is overdue. Although the current health politics seems to align with most of the aspects of ACA, certain changes might need to be made for the regulation to have the expected effect on the well-being of Amerian citizens.
For instance, the 2016 report indicates that the opportunities for protecting customers’ rights have been missed, leading to the infringement upon the rights of healthcare service buyers, instead (Jost, 2018). Thus, it is critical to align alterations in the healthcare system with the improvement of the existing economic principles so that patients could feel secure and acquire the products that they need to maintain good health (Centers for Medicare and Medicaid services, n.d.).
Therefore, when determining what is fundamentally wrong with ACA and what prevents from integrating it into every domain of the current healthcare and political environments, one must mention a shift in the current framework for legal and economic relationships (Ho, 2018). Specifically, the state has to ensure that buyers are provided with irrefutable rights. The specified step will allow avoiding the situations in which the ACA principles are abused by organizations.
For this purpose, the U.S. government will have to introduce multiple changes on the state and federal levels. Integrating different areas of economy and finances will also be required. The specified alterations are likely to take at least five years for the key changes to settle. In the specified process, a nurse will play the role of an educator and mediator between the healthcare institutions and the representatives of the economic, legal, and financial fields.
Furthermore, opportunities for providing nurses with the required educational and financial options have to be created. As a result, the rates of turnover in healthcare facilities will drop, and the understaffing issue will be eventually addressed. Furthermore, the proposed step will help improve the quality of nursing services. Thus, the existing system for providing care to U.S. citizens will be upgraded.
The Affordable Care Act turns six. (2016). Web.
Centers for Medicare and Medicaid services. (n.d.). Affordable Care Act: Working with states to protect consumers. Web.
Delaware Board of Nursing. (2010). The future of nursing: Leading change, advancing health. Washington DC: The National Academies Press.
Ho, V. (2018). Refinement of the Affordable Care Act. Annual Review of Medicine, 69, 19-28. Web.
Jost, T. (2018). The Affordable Care Act under the Trump administration. Web.
Nantsupawat, A., Kunaviktikul, W., Nantsupawat, R., Wichaikhum, O. A., Thienthong, H., & Poghosyan, L. (2017). Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International Nursing Review, 64(1), 91-98. Web.