Nurses are at the forefront of an evolutionary wave in health care. Whether we take leadership or not will determine nursing’s future.These ten trends can revitalize nursing if nurses break free from the confines of the medical model and use their education and skills to become wave riders.1. Aging Boomers
Boomers are living longer. Quantity of life is driving a desire for better quality of life. This generation wants to learn how to stay vital, mobile, healthy and productive. They are looking for guidance in health promotion and wellness, not only disease prevention and treatment.2. A 2nd Boom
Boomers Grandchildren are driving a huge demand for family health information and support for new and working moms. From birthing to family health education and sick child care, family systems need and want professional advice and innovative strategies to raise a brighter, stronger next generation.3. Information explosion
Internet access provides health consumers with tons of information, but not the knowledge or wisdom to know how to use it without getting confused. They need knowledgeable health professionals as gatekeepers, trusted advisors, or health system navigators.4. Holism
People are increasingly spending out of pocket dollars for alternative and complementary health care. Nursing education focuses on systems, whole person, life cycle perspectives that can guide in selecting appropriate options along a continuum of care.5. Consumer driven health care
As consumers rely less on employer health coverage and more on personal health spending, they are seeking innovative and home based solutions for care including advanced home monitoring, telephone consultation, personalized care, and individualized treatment.6. High Tech – High Touch
The need for personal connection, listening, and caring has never been higher. Nurses consistently rank first in every consumer poll for most trusted professional.7. Shortages and Cost Containment
Professional shortages and a drive to contain costs, creates a push to use mid-level and low-level providers for technical care. Nurses will continue to be driven away from the institutional bed side. With decreasing numbers of people in institutional care, face to face professional health care will be delivered in the home and community.8. Accessibility
Health information and care will be delivered on a global, mobile, remote, phone and internet basis. Nursing phone advice lines are increasingly popular with consumers.9. Back to Basics
With increased interest in information and coaching on proper food and nutrition, supplements, stretching, meditation, simplicity, life balance, joy in work, and relationships wellness and health coaching is a growing field.10. Self-Care/Self-Responsibility
People are realizing that doctors, medication and illness care are not going to keep them well. Employers, third party payers and common sense are driving consumers to take health care into their own hands. This trend will continue to drive an increase in self care information and reduction in in-patient and long term care.Tomorrow’s nurses are not working under a doctor’s direction, or in an institution. To remain viable, nursing will have to think beyond the institutional medical care box.Consumers are desperate for professional nurses to fill the need for proactive community
and home based health care.Tomorrow’s nurses will be innovative community health leaders, who develop and deliver services directly meeting the changing needs of health consumers.Progressive, professional nurses will form cooperatives, and creative health delivery systems that support families throughout the life span. They will provide continuity of health information and care while supporting people to navigate an ever more specialized and complex techno-medical system.Grab A Board – Surfs Up!© Aila Accad, RN
The Health Care Evolution – Ten Trends That Can Revitalize Nursing
Software Maintenance Implications on Cost and Schedule
Abstract The dictionary defines maintenance as, “The work of keeping something in proper order.” However, this definition does not necessarily fit for software. Software maintenance is different from hardware maintenance because software doesn’t physically wear out, but often gets less useful with age. Software is typically delivered with undiscovered flaws. Therefore, software maintenance is: “The process of modifying existing operational software while leaving its primary functions intact.” Maintenance typically exceeds fifty percent of the systems’ life cycle cost . While software maintenance can be treated as a level of effort activity, there are consequences on quality, functionality, reliability, cost and schedule that can be mitigated through the use of parametric estimation techniques.1. INTRODUCTION One of the greatest challenges facing software engineers is the management of change control. It has been estimated that the cost of change control can be between 40% and 70% of the life cycle costs . Software engineers have hoped that new languages and new process would greatly reduce these numbers; however this has not been the case. Fundamentally this is because software is still delivered with a significant number of defects. Capers Jones estimates that there are about 5 bugs per Function Point created during Development . Watts Humphrey found “… even experienced software engineers normally inject 100 or more defects per KSLOC . Capers Jones says, “A series of studies the defect density of software ranges from 49.5 to 94.5 errors per thousand lines of code .” The purpose of this article is to first review the fundamentals of software maintenance and to present alternative approaches to estimating software maintenance. A key element to note is that development and management decisions made during the development process can significantly affect the developmental cost and the resulting maintenance costs.2. SOFTWARE MAINTENANCE Maintenance activities include all work carried out post-delivery and should be distinguished from block modifications which represent significant design and development effort and supersede a previously released software package. These maintenance activities can be quite diverse, and it helps to identify exactly what post-delivery activities are to be included in an estimate of maintenance effort. Maintenance activities, once defined, may be evaluated in a quite different light than when called simply “maintenance”. Software maintenance is different from hardware maintenance because software doesn’t physically wear out, but software often gets less useful with age and it may be delivered with undiscovered flaws. In addition to the undiscovered flaws, it is common that some number of known defects pass from the development organization to the maintenance group. Accurate estimation of the effort required to maintain delivered software is aided by the decomposition of the overall effort into the various activities that make up the whole process.3. APPROACHING THE MAINTENANCE ISSUE Maintenance is a complicated and structured process. In his textbook, Estimating Software Intensive Systems, Richard Stuzke outlines the typical software maintenance process. It is apparent that the process is more than just writing new code.The following checklist can be used to explore the realism and accuracy of maintenance requirements.o Which pieces of software will be maintained?o How long will the system need to be maintained?o Are you estimating the entire maintenance problem, or just incremental maintenance?o What level of maintenance is required?o Is that which is being called maintenance in fact a new development project?o Who will do the maintenance? Will it be done organically by the original developer? Will there be a separate team? Will there be a separate organization?o Will maintainers be using the same tools used during development? Are any proprietary tools required for maintenance?o How much Commercial-Off-The-Shelf (COTS) is there? How tightly coupled are the interfaces?o Some follow-on development may be disguised as maintenance. This will either inflate maintenance figures, or else cause shortfalls if basic maintenance gets pushed aside. These questions will help you ask whether maintenance is being honestly represented.o Is the activity really an incremental improvement?o Are healthy chunks of the original code being rewritten or changed?o Will additional staff be brought in to perform the upgrade?o Is the maintenance effort schedule regular and fairly flat, or does it contain staffing humps that look like new development?4. SANITY CHECKS Although sanity checks should be sought on a year-by-year basis, they should not be attempted for overall development. The reason for this is that maintenance activities can be carried on indefinitely, rendering any life-cycle rules useless. As an example, consider Grady (p. 17):We spend about 2 to 3 times as much effort maintaining and enhancing software as we spend creating new software.This and similar observations apply at an organizational level and higher, but not for a specific project. Any development group with a history will be embroiled in the long tail ends of their many delivered projects, still needing indefinite attention. Here are a few quick sanity checks:o One maintainer can handle about 10,000 lines per year.o Overall life-cycle effort is typically 40% development and 60% maintenance.o Maintenance costs on average are one-sixth of yearly development costs.o Successful systems are usually maintained for 10 to 20 years.Finally, as in development, the amount of code that is new versus modified makes a difference. The effective size, that is, the equivalent effort if all the work were new code, is still the key input for both development and maintenance cost estimation.5. FIVE ALTERNATIVE APPROACHES All software estimation techniques must be able to model the theory and the likely real world result. The real world scenario is that over time, the overlay of changes upon changes makes software increasingly difficult to maintain and thus less useful. Maintenance effort estimation techniques range from the simplistic level of effort method, through more thoughtful analysis and development practice modifications, to the use of parametric models in order to use historical data to project future needs.5.1 Level of Effort As is sometimes the case in the development environment, software maintenance can be modeled as a level of effort activity. Given the repair category activities and the great variance that they show, this approach clearly has deficiencies. In this approach, a level of effort to maintain software is based on size and type.5.2 Level of Effort Plus Stuzke proposed that software maintenance starts with basic level of effort (minimum people needed to have a core competency and then that that basic core staff must be modified by assessing three additional factors; configuration management, quality assurance, and project management. His process addressed some of the additional factors affecting software maintenance.5.3 Maintenance Change Factor Software Cost Estimation with COCOMO II (Boehm 2000) proposes a deceivingly simple, but also quite useful methodology for determining annual maintenance. Maintenance is one of the menu selections in the menu bar. In COCOMO II Maintenance encompasses the process of modifying existing operational software while leaving its primary functions intact. This process excludes:o Major re-design and re-development (more than 50% new code) of a new software product performing substantially the same functions.o Design and development of a sizeable (more than 20% of the source instructions comprising the existing product) interfacing software package which requires relatively little redesigning of the existing product.o Data processing system operations, data entry, and modification of values in the database.The maintenance calculations are heavily based upon the Maintenance Change Factor (MCF) and the Maintenance Adjustment Factor (MAF). The MCF is similar to the Annual change Traffic in COCOMO81, except that maintenance periods other than a year can be used. The resulting maintenance effort estimation formula is the same as the COCOMO II Post Architecture development model.As stated previously, three cost drivers for maintenance differ from development. Those cost drivers are software reliability, modern programming practices, and schedule. COCOMO II assumes that increased investment in software reliability and use of modern programming practices during software development has a strong positive effect upon the maintenance stage.Annual Maintenance Effort = (Annual Change Traffic) * (Original Software Development Effort)The quantity Original Software Development Effort refers to the total effort (person-months or other unit of measure) expended throughout development, even if a multi-year project.The multiplier Annual Change Traffic is the proportion of the overall software to be modified during the year. This is relatively easy to obtain from engineering estimates. Developers often maintain change lists, or have a sense of proportional change to be required even before development is complete.5.4 Managing Software Maintenance Costs by Developmental Techniques and Management Decisions During DevelopmentWhen it comes to maintenance, “a penny spent is a pound saved.” Better development practices (even if more expensive) can significantly reduce maintenance effort, and reduce overall life cycle cost. The more effort put into development, the less required in maintenance. As an example, the software development cost and schedule can be significantly impacted (reduced) by letting the number of defects delivered grow. This cost and schedule reduction is more than offset by the increase in maintenance cost. The following discussion is an example of how management decision can significantly affect/reduce software maintenance costs.Lloyd Huff and George Novak of Lockheed Martin Aeronautics in their paper “Lockheed Martin Aeronautics Performance Based Software Sustainment for the F-35 Lightning II” propose a series of development and management decision designed to impact and reduce software maintenance costs. They propose an eight step process to estimate and control software maintenance . Their proposed steps are:1. Strive for Commonality2. Apply Industrial Engineering Practices to Software3. Engage4. Adopt a Holistic Approach to Sustainment5. Develop Highly Maintainable Systems and Software6. Manage the Off-the-Shelf Software7. Plan for the Unexpected8. Analyze and Refine the Software Sustainment Business Case (use Parametric software sustainment cost estimates)5.5 A Parametric Assessment of Software MaintenanceParametric models like SEER for Software allow maintenance to be modeled in either of two ways:Estimating maintenance as a part of the total lifecycle cost. Choosing the appropriate Maintenance category parameters will include an estimate of maintenance effort with the development estimate for the individual software program. Several reports and charts show breakdowns of development vs. maintenance effort. This method is best used to evaluate life cycle costs for each individual software program.Estimating maintenance as a separate activity. Using the appropriate maintenance parameters for the software to be maintained you can model the maintenance effort as a separate activity. This method will allow you to fine tune your maintenance estimate by adjusting parameters. Maintenance size should be the same as development size, but should be entered as all pre-existing code. This method can also be useful in breaking out total project maintenance costs from project development costs.A good parametric estimate for maintenance includes a wide range of information. Critical information for completing a software maintenance estimate is the size or amount of software that will be maintained, the quality of that software, the quality and availability of the documentation, and the type or amount of maintenance that will be done. Many organizations don’t actually estimate maintenance costs; they simply have a budget for software maintenance. In this case, a parametric model should be used to compute how much maintenance can actually be performed with the given budget.Estimating and planning for maintenance are critical activities if the software is required to function properly throughout its expected life. Even with a limited budget, a plan can be made to use the resources available in the most efficient, productive manner. Looking at the diagram above, you can see that not only are the multiple inputs that impact the maintenance, but there are several key outputs that provide the information necessary to plan a successful maintenance effort.6. Conclusion The conclusions of this article are:o Software maintenance can be modeled using a simplistic method like Level of Effort Staffing, but this technique has significant drawbacks.o Software maintenance costs can be significantly affected by management decisions during the developmental process.o Software maintenance can be accurately estimated using parametric processes.o Software maintenance is best modeled when development and management decisions are coupled with parametric cost estimation techniques.REFERENCES [1] Software Maintenance Concepts and Practices (second Edition) by Penny Grubb and Armstrong Takang, World Scientific, 2005.[2] Estimating Software Intensive Systems; Richard Stuzke, 2005, Addison-Wesley.[3] Lloyd Huff, George Novak; Lockheed Martin Aeronautics; Lockheed Martin Aeronautics Performance Based Software Sustainment for the F-35 Lightning II.[4] G. Edward Bryan, “CP-6: Quality and Productivity Measures in the 15-Year Life Cycle of an Operating System,” Software Quality Journal 2, 129-144, June 1993.[5] Software Sizing, Estimation, and Risk Management; Daniel D. Galorath, Michael W. Evans, 2006, Auerbach Publications.
The Best Art Schools In America
Of the thousands of art schools in America, a few stand out in the art world as the best schools based on academic value. Some are dedicated art schools and some are colleges of general education with outstanding departments.Rhode Island School of Design enjoys the highest profile in art and design, and superlative respect among experts in the art world. A student with a degree from RISD will have their resume’ moved to the top of the pile. It is, however, not without substantial investment. At an average cost of over 100,000.00 per year, only the very serious artist major need apply. That may, in fact, be a large part of the respect given to graduates of this school.Yale University, already one of the most respected centers of education in America, also enjoys the status of having one of the best art schools in America for undergraduate work. Yale offers courses for several areas of visual art and techniques, as well as art history – a firm foundation for more intense graduate work.The Art Institute of Chicago offers one of the most unique opportunities for interpolation of art education and history to be found. AIC is actually located INSIDE one of America’s finest museums offering an outstanding experience for those who relish saturation in their passion and discipline.Cranbrook Academy of Art, located in southeast Michigan north of Detroit, has developed its reputation for modernism in architecture as well as many other genres in the field.At Maryland Institute College of Art the primary focus (no pun intended), is on visual arts such as graphic design, illustration, animation, and video film. A graduate from MICA applying at Pixar or Disney would be well positioned for serious consideration.Virginia Commonwealth University, a public college, offers some eighteen undergraduate majors from fine arts to many of the modern forms of digital and design. This is a quality education at a more affordable price. But, it’s not a shoe-in. Entrance is moderately difficult, so this is not for the student tenuous about a career in this field.California Institute of the Arts is well-known as the first academy to offer programs in both visual and performing arts. This only makes sense since Hollywood is the entertainment industry’s capital. Majors are offered in fine arts, theater, dance and music.Carnegie Melon University College of Art offers a well-rounded choice in schools of Art, Architecture, Design, Drama, and Music commensurate with CMU’s overall reputation.University of California Los Angeles (UCLA) offers possibly the most interesting variety in majors at their School of Arts and Architecture. Majors in World Arts and Cultures, Ethnomusicology, and Urban Design are definitely for out-of-the-box thinkers looking for highly specialized careers.Art Center College of Design, a private college located in Pasadena, CA, originally built its reputation as a vocational school. It still maintains a real-world focus on craftsmanship, technique and professionalism. If practical skills and abilities are your goals, Art Center’s roads to real-life clients such as Nike and Disney have earned it a position as one of the 11 best design schools in America.