1.3: Population-Based Practice in Nursing
By the end of this section, you should be able to:
- Examine the paradigm shift in nursing practice from isolated care to the management of populations across health care systems.
- Discuss the scope of population health.
- Examine the competencies that define the knowledge, skills, and attitudes associated with the domain of population health.
Historically, elements within health care and nursing practice have been siloed, or separated and isolated, from one another. This isolation has resulted in specialists and providers of the same or different institutions failing to communicate with each other effectively or efficiently. For example, suppose Mx. Smith has a primary care provider, diabetes specialist, and heart specialist. The primary care provider and heart specialist may provide care in one hospital, while the diabetes specialist is at a separate clinic. Both the primary care provider and the diabetes specialist may prescribe medications or adjust dosages of the diabetes medications without telling each other of the care plan changes. Mx. Smith may not realize that some prescriptions overlap. Sometimes, providers may initiate a prescription for the same medication using two different brand names, which can lead to unintentional overdosing. Similarly, the primary care provider and the heart specialist could order laboratory testing for the same health problems and might not tell each other that the testing has been ordered and completed. This duplication of care is burdensome to Mx. Smith, who needs to go to a laboratory for bloodwork more than once and pay for testing twice. This lack of communication can be especially dangerous when critical information is not communicated between providers or care facilities (Kelly et al., 2019).
Siloing can also refer to treating one client disease or condition at a time without considering the client’s full picture of health, illness, and social situation. When care is siloed, Mx. Smith’s heart specialist may make recommendations about heart health that do not consider dietary or activity limitations relevant to the health of their kidneys that the diabetes specialist and primary care provider are working to address. Health systems that are not effectively integrated or properly collaborative make health and illness experiences complex for clients (Storfjell et al., 2017).
While modern health care has not solved the problem of barriers between providers and specialists entirely, a shift to focusing on population health and health promotion has prompted changes in all the health professions in order to reduce such siloing. This paradigm shift has led to more collaborative approaches across health care. Providers and specialists are encouraged to work together to improve client outcomes. Work to reduce silos and focus on population health continues, as some barriers still exist between providers, specialists, and clients. With a continued shift in focus to collaboration, integration, health promotion, preventive services, and population health, providers can work together to deliver comprehensive, holistic, and respectful care to health care consumers.
Delivering Population Health
Moving away from siloed systems is a positive change. In a health care system that has siloed practices, providers react to the presence of symptoms and concerns instead of proactively preventing diseases and promoting wellness. Population-based practices in nursing focus on improving the health of populations through proactive approaches, an emphasis on preventative care, and finding opportunities for early intervention. They focus on effectively managing chronic conditions across the health care continuum—the spectrum of health services that includes public health and preventive care, acute care, ambulatory care, and long-term/chronic care in different settings for members of a population (Figure 1.6).
- Public health focuses on preventive health measures, health promotion, and population-level health interventions. These measures can prevent disease, reduce the impact of disease, and improve outcomes across a population.
- Acute care involves medical care provided in hospitals and emergency departments for sudden or severe health conditions and emergencies. It can also involve disaster management in events such as multivehicle traffic accidents, train derailments, natural disasters, and mass shootings. Delivery of acute care in a timely and effective manner helps prevent mortality and complications among population members.
- Ambulatory care includes health services provided on an outpatient basis in clinics and health centers. Annual physical exams and health visits related to management of ongoing conditions are examples of ambulatory care encounters. Ambulatory care can respond to population health needs through offering targeted clinics or specialized health services in areas where select conditions are noted to be common or especially burdensome in a population.
- Long-term care services are delivered in skilled nursing facilities, residential facilities, and client homes. People with chronic illness, disability, or functional limitations as well as those receiving palliative care and hospice services obtain support in the long-term care setting. A spectrum of population health outcomes and related goals of care, from minimizing disability to supporting a dignified death, are relevant in this setting. Long-term care can help clients and their families alike. The provision of long-term care supports family members and other familiar caregivers, as some caregiving burdens and stress may be alleviated.
Thinking about health care as a continuum underscores the idea that health care does not just happen during annual physicals or when someone needs surgery or picks up a new prescription. The concept of the health care continuum affirms that health care services in the public health arena, outpatient settings, hospital units, rehabilitation centers, and family homes are all valid and necessary to population health. On the continuum, health care is comprehensive and coordinated across specialties, providers, facilities, and approaches.
What happens when clients need care in multiple areas along the continuum or move from receiving care in one area to receiving it in another? Transitional care involves coordination of clients as they move between care settings. Such coordination helps facilitate a smooth transition for the client or family and helps avoids harm or errors in the process. Transitional care activities may involve sharing of health care information between settings, client education, and support for needed follow-up encounters. These activities help maintain a critical link between settings, providers, and the client so that all may avoid barriers to good health and care delivery. Implementing transitional care across the population helps support healthy client outcomes, reduce health care costs and readmissions, and minimize the likelihood of adverse events during transitions. For example, a research group conducted a review of interventions to support the transition between pediatric health care and adult health care (Schmidt et al., 2020). For adolescents moving to an adult care provider, transitional care support helps achieve outcomes such as decreases in hemoglobin A1C levels (an important measure of diabetes control), increased participation in education and employment, improvements in disease self-management skills, and shorter lengths of hospital stays. The broad goals of population health align with those of transitional care, as professionals in both areas work to improve health outcomes for populations. Care Transition and Coordination Across the Community discusses this topic in more detail.
Read the scenario, and then respond to the questions that follow.
Alexandra, Sunshine, and Woody receive health insurance through a publicly funded state plan. As the plan only covers pregnant people and children, Christopher currently lacks health insurance. His hypertension is not being treated, and he has not seen a provider in a few years.
Although she has health insurance coverage, as a Black woman, Alexandra is at risk for experiencing adverse pregnancy outcomes due to systemic racism and bias in the health care system. She has had an uncomplicated pregnancy thus far, apart from experiencing frequent viral illnesses due to working in a day care center. She has taken time off to recover from these illnesses and has to take a day off every time she has a prenatal appointment due to the public transportation schedule, so she has missed a great deal of work recently.
- Which locations across the care continuum is the Lee family currently accessing?
- What locations across the care continuum would the Lee family benefit from that they are not currently accessing?
- How could transitional care support help the Lee family?
Nurses drive change in population health through development of innovative programs and initiatives across health care settings. The work of nurses encompasses the entire health care continuum, from prevention to treatment, as well as transitional care to support positive population health outcomes. To recognize the work, leadership, determination, and contributions of nurses who are at the forefront of innovations in population health for clients in hospitals, clinics, residential settings, and communities, the American Academy of Nursing (AAN, 2023) created the Edge Runners program. The AAN annually recognizes nurse-designed models of care that reduce cost, improve care quality, promote health equity, and increase client satisfaction. These projects support moving away from siloed systems in health care and promote population-based practices in nursing. Concepts such as preventive care, early intervention, chronic condition management, and addressing social needs are commonplace among nurse-led population health innovations. As nurses are uniquely positioned to recognize the challenges of navigating several layers of the health care continuum and to address transitional care needs, population health contributions from nurses support client health and optimal population health outcomes. See Appendix E to learn more about the Edge Runners program.
This video explores the important role of nurses in population health.
Watch the video, think about the noted “visible” and “invisible” contributions of nurses, and then respond to the questions that follow.
- How might nurses increase the visibility or public understanding of the “invisible” contributions of population health?
- What traditionally “invisible” work of nurses might align with your future professional interests?
Population Health Nursing Competencies
Nurses play a crucial role in advancing population health, but they are not alone in this endeavor. Given the importance of a focus on population health and population-based approaches, several leading organizations have developed competencies for trainees and professionals across health disciplines that direct population health education and skills. These initiatives, aim to strengthen the population health competencies of students entering health. For example, the Public Health Foundation has developed population health competencies to guide workforce development efforts, trainings, program curricula, job descriptions, and other resources to support population health professionals (Public Health Foundation, 2019). Similarly, Duke University developed a competency map that faculty of medical schools, medical residency programs, and physician assistant programs can use to support meaningful integration of population health in education (Kaprielian et al., 2013); these competencies continue to serve as an important framework (Johnson et al., 2020). In 2021, the American Association of Colleges of Nursing (AACN) approved new standards for nursing education, the Essentials , to define the curricular content and expected competencies of students completing pre-licensure and graduate nursing programs (AACN, 2021). The Essentials include a domain focused on population health, as the AACN recognizes the imperative role of nurses in advancing population health.
Some of the competencies related to population health that student nurses are expected to achieve by the time they finish their pre-licensure program include assessing population health data, identifying ethical principles to protect the health and safety of diverse populations, demonstrating effective collaboration and mutual accountability with relevant parties, proposing modifications to or development of policy based on population findings, and articulating a need for change (AACN, 2021). Table 1.1 lists the population health competencies. These competencies help nursing students prepare to address the health needs of populations once they become licensed as nurses. The content and concepts of this textbook, along with the course instructor’s expertise, activities, and assignments, will prepare each student to master the competencies.
| Competency | Sub-competency |
|---|---|
| Manage population health. | Define a target population, including its functional and problem-solving capabilities (anywhere in the continuum of care). |
| Assess population health data. | |
| Assess the priorities of the community and/or the affected clinical population. | |
| Compare and contrast local, regional, national, and global benchmarks to identify health patterns across populations. | |
| Apply an understanding of the public health system and its interfaces with clinical health care in addressing population health needs. | |
| Develop an action plan to meet an identified need(s), including evaluation methods. | |
| Participate in the implementation of sociocultural and linguistically responsive interventions. | |
| Describe general principles and practices for the clinical management of populations across the age continuum. | |
| Identify ethical principles to protect the health and safety of diverse populations. | |
| Engage in effective partnerships. | Engage with other health professionals to address population health issues. |
| Demonstrate effective collaboration and mutual accountability with relevant community partners. | |
| Use culturally and linguistically responsive communication strategies. | |
| Consider the socioeconomic impact of the delivery of health care. | Describe access and equity implications of proposed intervention(s). |
| Prioritize client-focused and/or community action plans that are safe, effective, and efficient in the context of available resources. | |
| Advance equitable population health policy. | Describe policy development processes. |
| Describe the impact of policies on population outcomes, including social justice and health equity. | |
| Identify best evidence to support policy development. | |
| Propose modifications to or development of policy based on population findings. | |
| Develop an awareness of the interconnectedness of population health across borders. | |
| Demonstrate advocacy strategies | Articulate a need for change. |
| Describe the intent of the proposed change. | |
| Define interested parties (stakeholders), including members of the community and/or clinical populations, and their level of influence. | |
| Implement messaging strategies appropriate to audience and other interested parties. | |
| Evaluate the effectiveness of advocacy actions. | |
| Advance preparedness to protect population health during disasters and public health emergencies. | Identify changes in conditions that might indicate a disaster or public health emergency. |
| Understand the impact of climate change on environmental and population health. | |
| Describe the health and safety hazards of disasters and public health emergencies. | |
| Describe the overarching principles and methods regarding personal safety measures, including personal protective equipment (PPE). | |
| Implement infection control measures and proper use of personal protective equipment. |
A focus on population health in a nursing program or a practicing nurse’s work does not mean ignoring or no longer managing acute needs. While a shift to a population health paradigm supports the work of nurses in multiple settings, these competencies apply to nurses working in acute or tertiary care settings as well. For example, nurses working in emergency care provide lifesaving interventions, but they can also recognize and address the upstream, population, and system-wide factors that lead clients to require emergency care (Fawcett & Ellenbecker, 2015). Population health competencies allow a nurse to be well-versed in and ready to address the complex needs of clients so they may provide more effective and comprehensive care. The focus on population health within nursing programs and nursing as a broad discipline does not mean that acute or emergent health needs are no longer important. Adopting a population health framework builds on the work of nurses and expands their impact in all settings. The Essentials and their competencies are relevant to the work of nurses across the care continuum, and ensuring that nurses of the future frame their practice through a population health lens helps them address the complex needs and conditions of clients today.
Read the scenario, and then respond to the questions that follow.
The Lee family’s city has been experiencing a drinking water crisis for several years. Alexandra or Christopher must go to a city building once per week to obtain drinking water for the family. The family is also supposed to bathe in this water, but the city does not provide enough water for drinking, cooking, and bathing.
- What are some population health concepts or components that are relevant to this problem?
- Which of the population health competencies or sub-competencies specific to this problem could a nurse demonstrate to support the Lee family?


25.1: Structure and Function
By the end of this section, you will be able to:
- Identify structures of the musculoskeletal system
- Recognize functions of the musculoskeletal system
- Recall effects of impaired function of the musculoskeletal system
The normal musculoskeletal configuration in individuals allows for normal posture and mobility. Abnormalities, such as genetic, congenital, or as a result from disease or injury, can have effects on musculoskeletal structure and function. Wherever the system is functionally impacted, alterations from normal abilities may be noticed by the affected patient and assessed by healthcare personnel, including postural or mobility variations, traumatic injuries, electrolyte imbalances, or hematologic abnormalities.
An assessment of the musculoskeletal system includes collecting data regarding the structure and movement of the body as well the patient’s mobility. This unit provides an overview of the structure and function of the musculoskeletal system and explores the effects of impaired function.
Structures of the Musculoskeletal System
The musculoskeletal system gives us the ability to move. It is composed of bones, muscles, joints, tendons, ligaments, and cartilage that support the body, allow movement, and protect vital organs (Figure 25.2). The next sections review the anatomy of the musculoskeletal system, including the skeleton, skeletal muscles, tendons, and joints.
Skeleton
The skeleton is composed of 206 bones that provide the internal supporting structure of the body (Figure 25.3). The bone , or osseous tissue , is a hard, dense connective tissue that forms most of the adult skeleton, the support structure of the body. In the areas of the skeleton where bones move (e.g., the rib cage and joints), cartilage , a semirigid form of connective tissue, provides flexibility and smooth surfaces for movement. The skeletal system is the body system composed of bones and cartilage and performs the following critical functions for the human body:
- supports the body
- facilitates movement
- protects internal organs
- produces blood cells
- stores and releases minerals and fat
The bones of the lower limbs are adapted for weight-bearing support, stability, and walking. The upper limbs are highly mobile with a large range of movements, along with the ability to easily manipulate objects with our hands and opposable thumbs.
It may appear that bones are static, but bone undergoes ossification and resorption throughout the life span. In the early stages of embryonic development, the embryo’s skeleton consists of fibrous membranes and hyaline cartilage. By the sixth or seventh week of embryonic life, the actual process of bone development, or ossification , begins. Bone development continues until about the age of 25 years (Breeland et al., 2023). The three types of cells involved are osteoblasts, osteocytes, and osteoclasts. Osteoblasts are immature bone cells and primarily produce collagen. Osteocytes are mature cells and facilitate new bone development. On the other hand, bones are remodeled by osteoclasts as they resorb or remove existing bone (Figure 25.4). In normal circumstances, this ossification-resorption process is in an appropriate balance; there are situations where this equilibrium is lost, and for example, bone loss becomes excessive—this is explored later in the chapter.
A ligament is a band of tissue that connect bones to one another, provide support and stability, and enhance joint movements. While bones are well supplied with blood, which supplies oxygen and other nutrients, ligaments are not well perfused which makes for a slower healing process for injured ligaments.
Skeletal Muscles
There are three types of muscle tissue: skeletal muscle, cardiac muscle, and smooth muscle. The skeletal muscle produces movement, assists in maintaining posture, protects internal organs, and generates body heat (Figure 25.5). Skeletal muscles are voluntary, meaning a person is able to consciously control them, but they also depend on signals from the nervous system to work properly. Other types of muscles are involuntary and are controlled by the autonomic nervous system, such as the smooth muscle within our bronchioles.
To move the skeleton, the tension created by the contraction of the skeletal muscles is transferred to the tendons, strong bands of dense, regular connective tissue that connect muscles to bones.
This short video illustrates how bones move muscles by the interaction of signals from the neurological system and the contraction of muscle fibers.
Tendons
A tendon is a band of fibrous collagenous tissue that provide a continuation of the muscle sheath to enable muscle attachment to the periosteum of bones (Figure 25.6). Tendons are both flexible and strong, and they enable movement by pulling the bone upon muscle contraction, using a lever action. Tendons also provide some shock absorption, as they take up some of the muscle impact associated with certain activities, such as jumping. The tensile strength of tendons provides resistance to injury, but certain events (e.g., traumatic injury, fluoroquinolone antibiotics) may cause tendon damage or rupture. Similar to ligaments, tendons are not perfused as efficiently as some tissues, so healing after a tendon is injured is a slow process.
Joints
A joint is a location where bones come together. Many joints allow for movement between the bones (Figure 25.7). Synovial joints are the most common type of joint in the body. A synovial joint has a fluid-filled joint cavity where the articulating surfaces of the bones contact and move smoothly against each other.
The articular cartilage is smooth, white tissue that covers the ends of bones where they come together and allows the bones to glide over each other with very little friction. Articular cartilage can be damaged by injury or normal wear and tear. Lining the inner surface of the articular capsule is a thin synovial membrane. The cells of this membrane secrete synovial fluid , a thick, slimy fluid that provides lubrication to further reduce friction between the bones of the joint.
Some joints are relatively immobile but stable. Other joints have more freedom of movement but are at greater risk of injury. For example, the hinge joint of the knee allows flexion and extension, whereas the ball-and-socket joint of the hip and shoulder allows flexion, extension, abduction, adduction, and rotation. The knee, hip, and shoulder joints are commonly injured and commonly seen in clinical settings.
Functions of the Musculoskeletal System
The musculoskeletal system has five main functions:
- support the body
- facilitate movement
- protect internal organs
- produce blood cells
- store and release minerals and fat
These functions adjust throughout the life span, according to the body’s needs.
Support, Movement, and Protection
Just as the steel beams of a building provide a scaffold to support its weight, the bones and cartilage of your skeletal system compose the scaffold that supports the rest of your body. Without the skeletal system, you would be a limp mass of organs, muscle, and skin. Bones also facilitate movement by serving as points of attachment for your muscles. While some bones only serve as a support for the muscles, others also transmit the forces produced when your muscles contract. From a mechanical point of view, bones act as levers, and joints serve as hinges.
Bones also protect internal organs from injury by covering or surrounding them.
Mineral Storage, Energy Storage, and Hematopoiesis
The most apparent functions of the skeletal system are the gross functions—those visible by observation. Simply by looking at a person, you can see how the bones support, facilitate movement, and protect the human body. On a metabolic level, bone tissue performs several critical functions. For one, the bone matrix acts as a reservoir for a number of minerals important to the functioning of the body, especially calcium and phosphorus. These minerals, incorporated into bone tissue, can be released back into the bloodstream to maintain levels needed to support physiological processes. Calcium ions, for example, are essential for muscle contractions and controlling the flow of other ions involved in the transmission of nerve impulses.
 The softer connective tissue that fills the interior of most bone is referred to as bone marrow . There are two types of bone marrow: yellow marrow and red marrow (Figure 25.9). The yellow marrow contains adipose tissue; the triglycerides stored in the adipocytes of the tissue can serve as a source of energy. The red marrow is where hematopoiesis —the production of blood cells—takes place. Red blood cells, white blood cells, and platelets are all produced in the red marrow. For example, a child who has a history of bleeding, bruising, and fatigue might be tested for a bone marrow disorder.
This video provides an overview of the structure and function of bones and muscles as well as a selection of some of the abnormalities affecting the musculoskeletal system.
Effects of Impaired Function of the Musculoskeletal System
There are approximately 150 different diseases and conditions that affect the musculoskeletal system, and about 1.71 billion people have musculoskeletal conditions worldwide (World Health Organization [WHO], 2022). These conditions are the leading cause of disability (WHO, 2022). Changes to the musculoskeletal system can have physical and psychological effects on a person.
Physical Effects
The musculoskeletal system is susceptible to an array of causes for variance from normal function. Based on the normal functions of the system, the impact on the body is somewhat predictable, considering which aspect of the system is not functioning properly. Physical effects commonly include the following:
- Inflammation: Illness and injury initiate the inflammatory processes. Five classic signs include pain, heat, redness, swelling, and loss of function.
- Pain (acute, chronic, or acute-on-chronic): Pain is the result of several possible musculoskeletal disorders.
- Limited dexterity and decreased mobility: Agility, strength, and movement can be limited by many factors.
- Electrolyte abnormalities: Calcium and phosphorous are stored in skeletal structures; imbalances can affect other electrolytes and overall health status.
- Impaired blood cell production: Altered bone marrow function potentially affects production of blood cells.
- Weakness and fatigue: Lack of energy and strength can result from different sources associated with musculoskeletal function and malfunction.
- Limitations in completing activities of daily living (ADLs): Malfunctions of normal function can impact ADLs in many ways.
Nurse:
Margaret, RN
Clinical setting:
Intensive care unit
Years in practice:
5
Facility location:
Aurora, Colorado
The patient was in his midtwenties; he was a rancher and had been on a tractor when it overturned, tossing him and then landing on top of him. Surprisingly, his musculoskeletal injuries were minor, considering a tractor had toppled onto him: a couple of rib fractures and some scrapes and abrasions. Why were his injuries not worse? When he fell off the tractor, and it ended up over him, he was lying in a pile of manure, which is soft and allowed him to be pushed further down, rather than on a hard surface where any resistance would have had to come from his own body.
However, lying in a pile of manure is not without risks. After all, it is full of bacteria, and he had several open wounds, so the risk for challenges to his immune system were huge. As his nurses, we had to be vigilant for signs of immune response to infection, which were likely to manifest through inflammatory reactions. We assessed him frequently, looking for new developments in the classic signs of inflammation. He was already experiencing loss of function—he had been intubated to address oxygenation issues brought on by the broken ribs, and we monitored for any changes indicating worsening in oxygenation and perfusion. And for the likely source of infection, we watched his wounds—marking regions of swelling and redness in order to identify any advancement of the processes, palpating for local warmth, and watching his face as we touched him, for responses likely to result from pain.
Such vigilance paid off: rising oxygen needs, diminished pedal pulses, falling blood pressure, and spikes in temperature and heart rate alerted us quickly to sepsis. The providers were promptly notified as changes occurred, and orders were thorough to address and support his body through the various physiological reactions involved in a systemic and potentially deadly cascade of events. He survived, and after a lengthy hospital course was transferred to a rehabilitation facility to regain lost muscle strength; after several months, he was discharged back to his ranch.
Any deviation from normal in the intricate functions of the musculoskeletal system can cause significant effects.  The subsequent consequences are not limited to physical but often also involve psychological effects.
Psychological Effects
As previously established, musculoskeletal disorders can impact patients through physical deformities or functional changes, and one of the most common issues is pain. Psychological effects of musculoskeletal problems frequently include the following:
- Pain (acute, chronic, or acute-on-chronic): Pain can be the result of many musculoskeletal disorders.
-
Reduced participation in activities: This may include the following:
- Society/group events: church attendance, social affairs, shopping, travel
- Employment: may miss work, or need to retire early for psychophysiological reasons
- Weakness: This can be a consequence of several musculoskeletal disorders.
- Anxiety and/or depression: This may be experienced relative to pain and worry about pending procedures, potential missed time at work, or job loss and family strain (Garnæs et al., 2022).
- Insomnia: Sleep can be impacted by many factors, including discomfort or pain, anxiety, or depression (Garnæs et al., 2022).
Scenario: Mr. Adams is scheduled for total knee arthroplasty in a week and is meeting with the orthopedic nurse for preoperative assessment and education. The nurse, Albert, is conscientious about describing key factors of the Enhanced Recovery After Surgery protocol followed by the hospital where Mr. Adams’s will have the surgery. Mr. Adams is wringing his hands and tapping one foot rapidly on the floor.
Nurse: Mr. Adams, I want to go over some things to expect after your knee operation next week. But first, do you have any questions?
Patient: It’s not really a question. I’m really nervous about this operation. I’m afraid I’ll get hooked on pain medicine. But I know it’s going to hurt, what with having my knee cut up.
Nurse: I can see you’re anxious. Let’s see if I can help you be more comfortable about this. Since you’re worrying about addiction, I’ll start with that. You’re right that right after the surgery, you can expect pain, and pain medicine usually includes what we call, “opioids, or narcotics.” While these are drugs that can cause addiction, when you need them, like for the first few days after an operation, and you take them correctly, the chances of becoming addicted are minimal.
Patient: But you see on TV, there are so many addicts in the world. They won’t give me fentanyl, will they?
Nurse: Your team of doctors usually uses a nerve block, which will keep pain under control for the first day or so. This helps you need less pain medicine through your IV, or as a pill. Your nurses will also ask you how your pain is at least every hour, but you can push your call button, and let them know if it gets worse before that, or you need something else. Again, if you take the pain medicine as your doctor prescribes, it is very unlikely to become addicted. It is common to only need a few days of opioids, and you can probably successfully switch to an anti-inflammatory drug like ibuprofen on day three. Maybe just taking the opioid at bedtime for another day or two.
Patient: What about the fentanyl? So much is on the news about there being so many overdoses.
Nurse: Many people worry about this, but that is not the same fentanyl used in the hospital. It is made in questionable ways and places. If you’re given fentanyl, it is made carefully in a laboratory and is as safe as other pain medicines like morphine or Dilaudid. The nurses will also be sure you have ice packs to help with the pain and swelling.
Patient: Oh good, I get so worried about things on the news.
Nurse: That’s one of the reasons for an appointment like this, Mr. Adams.
Scenario follow-up: Albert continues patient education, with more details about how to take pain medicine to keep pain under control. He also reviews recommendations for correct positioning of the operative leg after surgery, and how important it is to ambulate, starting on the same day of the surgery, barring any complications. Albert is careful to include opportunities for Mr. Adams to ask questions and vent his fears and worries. Before completing the appointment, the nurse has Mr. Adams demonstrate understanding the information by teaching the key points to Albert. He is given written information to review.
The psychological effects can become pervasive and invade other aspects of patients’ lives, causing recurrent emotional signs and symptoms. As conditions become more complicated, it can be more difficult to identify the root of the problem and appropriately treat the multiple factors involved. Even medication therapies bring complexity as each drug prescribed or recommended brings its own desired and potentially undesired results.


0.4: Class Expectations
What does your teacher expect of you this semester?
4 Ps to be a successful Spanish student:
- Presence : You can’t acquire Spanish if you’re not present in class! For in-person classes, show up to class on time! For online classes, participate in discussion boards, attend your LinguaMeeting sessions, and complete the practice activities!
- Don't try to cram the week's lesson into a few hours at the end of the week. Make a habit of spreading out your studying habits to get multiple repetitions with the language each week.
- Participation : Actively participate! You will get better at speaking Spanish the more you practice. Take every advantage in class to speak, listen, and use Spanish!
- Proficiency : Proficiency is the reward/consequence of Presence and Participation. If you’re fully present and participating, you will see your proficiency increase. Even if you already have a high level of proficiency, there’s always room for improvement!
- Perseverance : Learning a new language takes time, effort, and persistence. When you are confronted with a hard task or completely fail an exercise, don't give up! Ask for help! Try again! Keep at it!
Presence, Participation, and Perseverance will lead to Proficiency. ¡Sí se puede! You can do it!
Listen to the podcast ¨Adam Grant Helps Unlock Our Hidden Potential¨, where Maya Shankar, the host, and Adam Grant talk about unlocking potential. Start at 4 minutes, 28 seconds and end at 14 minute and 7 seconds for the language-specific content, but listen to the whole thing if you get the chance!
- Adam talks about learning how to dive. Where can you see Presence, Participation, Perseverance, and Proficiency in his example?
- Maya talks about learning Mandarin. Where can you see Presence, Participation, Perseverance, and Proficiency in her example?


7.3: Culture of Consumption
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“Change is in the very air Americans breathe, and consumer changes are the very bricks out of which we are building our new kind of civilization,” announced marketing expert and home economist Christine Frederick in her influential 1929 monograph, Selling Mrs. Consumer . The book, which was based on one of the earliest surveys of American buying habits, advised manufacturers and advertisers how to capture the purchasing power of women, who, according to Frederick, accounted for 90 percent of household expenditures. Aside from granting advertisers insight into the psychology of the “average” consumer, Frederick’s text captured the tremendous social and economic transformations that had been wrought over the course of her lifetime. 7
Indeed, the America of Frederick’s birth looked very different from the one she confronted in 1929. The consumer change she studied had resulted from the industrial expansion of the late nineteenth and early twentieth centuries. With the discovery of new energy sources and manufacturing technologies, industrial output flooded the market with a range of consumer products such as ready-to-wear clothing, convenience foods, and home appliances. By the end of the nineteenth century, output had risen so dramatically that many contemporaries feared supply had outpaced demand and that the nation would soon face the devastating financial consequences of overproduction. American businessmen attempted to avoid this catastrophe by developing new merchandising and marketing strategies that transformed distribution and stimulated a new culture of consumer desire. 8
The department store stood at the center of this early consumer revolution. By the 1880s, several large dry-goods houses blossomed into modern retail department stores. These emporiums concentrated a broad array of goods under a single roof, allowing customers to purchase shirtwaists and gloves alongside toy trains and washbasins. To attract customers, department stores relied on more than variety. They also employed innovations in service (such as access to restaurants, writing rooms, and babysitting) and spectacle (such as elaborately decorated store windows, fashion shows, and interior merchandise displays). Marshall Field & Co. was among the most successful of these ventures. Located on State Street in Chicago, the company pioneered many of these strategies, including establishing a tearoom that provided refreshment to the well-heeled female shoppers who composed the store’s clientele. Reflecting on the success of Field’s marketing techniques, Thomas W. Goodspeed, an early trustee of the University of Chicago, wrote, “Perhaps the most notable of Mr. Field’s innovations was that he made a store in which it was a joy to buy.” 9
The joy of buying infected a growing number of Americans in the early twentieth century as the rise of mail-order catalogs, mass-circulation magazines, and national branding further stoked consumer desire. The automobile industry also fostered the new culture of consumption by promoting the use of credit. By 1927, more than 60 percent of American automobiles were sold on credit, and installment purchasing was made available for nearly every other large consumer purchase. Spurred by access to easy credit, consumer expenditures for household appliances, for example, grew by more than 120 percent between 1919 and 1929. Henry Ford’s assembly line, which advanced production strategies practiced within countless industries, brought automobiles within the reach of middle-income Americans and further drove the spirit of consumerism. By 1925, Ford’s factories were turning out a Model-T every ten seconds. The number of registered cars ballooned from just over nine million in 1920 to nearly twenty-seven million by the decade’s end. Americans owned more cars than Great Britain, Germany, France, and Italy combined. In the late 1920s, 80 percent of the world’s cars drove on American roads.


2.2.2: Covalent Bonds and Other Bonds and Interaction
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Learning Objectives
- Compare the relative strength of different types of bonding interactions
Covalent Bonds and Other Bonds and Interactions
The octet rule can be satisfied by the sharing of electrons between atoms to form covalent bonds. These bonds are stronger and much more common than are ionic bonds in the molecules of living organisms. Covalent bonds are commonly found in carbon-based organic molecules, such as DNA and proteins. Covalent bonds are also found in inorganic molecules such as H 2 O, CO 2 , and O 2 . One, two, or three pairs of electrons may be shared between two atoms, making single, double, and triple bonds, respectively. The more covalent bonds between two atoms, the stronger their connection. Thus, triple bonds are the strongest.
The strength of different levels of covalent bonding is one of the main reasons living organisms have a difficult time in acquiring nitrogen for use in constructing nitrogenous molecules, even though molecular nitrogen, N 2 , is the most abundant gas in the atmosphere. Molecular nitrogen consists of two nitrogen atoms triple bonded to each other. The resulting strong triple bond makes it difficult for living systems to break apart this nitrogen in order to use it as constituents of biomolecules, such as proteins, DNA, and RNA.
The formation of water molecules is an example of covalent bonding. The hydrogen and oxygen atoms that combine to form water molecules are bound together by covalent bonds. The electron from the hydrogen splits its time between the incomplete outer shell of the hydrogen atom and the incomplete outer shell of the oxygen atom. In return, the oxygen atom shares one of its electrons with the hydrogen atom, creating a two-electron single covalent bond. To completely fill the outer shell of oxygen, which has six electrons in its outer shell, two electrons (one from each hydrogen atom) are needed. Each hydrogen atom needs only a single electron to fill its outer shell, hence the well-known formula H 2 O. The electrons that are shared between the two elements fill the outer shell of each, making both elements more stable.
Polar Covalent Bonds
There are two types of covalent bonds: polar and nonpolar. In a polar covalent bond, the electrons are unequally shared by the atoms because they are more attracted to one nucleus than the other. The relative attraction of an atom to an electron is known as its electronegativity: atoms that are more attracted to an electron are considered to be more electronegative. Because of the unequal distribution of electrons between the atoms of different elements, a slightly positive (δ+) or slightly negative (δ-) charge develops. This partial charge is known as a dipole; this is an important property of water and accounts for many of its characteristics. The dipole in water occurs because oxygen has a higher electronegativity than hydrogen, which means that the shared electrons spend more time in the vicinity of the oxygen nucleus than they do near the nucleus of the hydrogen atoms.
Nonpolar Covalent Bonds
Nonpolar covalent bonds form between two atoms of the same element or between different elements that share electrons equally. For example, molecular oxygen (O 2 ) is nonpolar because the electrons will be equally distributed between the two oxygen atoms. The four bonds of methane are also considered to be nonpolar because the electronegativies of carbon and hydrogen are nearly identical.
Hydrogen Bonds and Van Der Waals Interactions
Not all bonds are ionic or covalent; weaker bonds can also form between molecules. Two types of weak bonds that frequently occur are hydrogen bonds and van der Waals interactions. Without these two types of bonds, life as we know it would not exist.
Hydrogen bonds provide many of the critical, life-sustaining properties of water and also stabilize the structures of proteins and DNA, the building block of cells. When polar covalent bonds containing hydrogen are formed, the hydrogen atom in that bond has a slightly positive charge (δ+) because the shared electrons are pulled more strongly toward the other element and away from the hydrogen atom. Because the hydrogen has a slightly positive charge, it’s attracted to neighboring negative charges. The weak interaction between the δ+ charge of a hydrogen atom from one molecule and the δ- charge of a more electronegative atom is called a hydrogen bond. Individual hydrogen bonds are weak and easily broken; however, they occur in very large numbers in water and in organic polymers, and the additive force can be very strong. For example, hydrogen bonds are responsible for zipping together the DNA double helix.
Like hydrogen bonds, van der Waals interactions are weak interactions between molecules. Van der Waals attractions can occur between any two or more molecules and are dependent on slight fluctuations of the electron densities, which can lead to slight temporary dipoles around a molecule. For these attractions to happen, the molecules need to be very close to one another. These bonds, along with hydrogen bonds, help form the three-dimensional structures of the proteins in our cells that are required for their proper function.
Interactions between different types of molecules
: In this interactive, you can explore how different types of molecules interact with each other based on their bonds.
Key Points
- A polar covalent bond arises when two atoms of different electronegativity share two electrons unequally.
- A non-polar covalent bond is one in which the electrons are shared equally between two atoms.
- Hydrogen bonds and Van Der Waals are responsible for the folding of proteins, the binding of ligands to proteins, and many other processes between molecules.
Key Terms
- hydrogen bond : A weak bond in which a hydrogen atom in one molecule is attracted to an electronegative atom (usually nitrogen or oxygen) in the same or different molecule.
- covalent bond : A type of chemical bond where two atoms are connected to each other by the sharing of two or more electrons.
- dipole : Any object (such as a magnet, polar molecule or antenna), that is oppositely charged at two points (or poles).


15: Tectonics and Landforms
By the end of this chapter you should be able to:
- Describe the theory of plate tectonics and the evidence used to support it.
- Compare and contrast the environmental setting of the four types of plate boundaries.
- Explain the relationship between earthquakes, volcanoes, and plate boundaries.
- Draw simple diagrams showing the effect of stress on rock materials.
- Describe the movement associated with faulting.
- Describe landform features resulting from folding.
In this chapter you'll travel back to a distant time when the geography of the Earth's crust was much different than it is today. The search for answers to Earth's dynamic nature will set the context for explaining modern day tectonic activity. Tectonics is study of the processes that control the structure and properties of Earth's lithosphere. Plate tectonics is the process of plate formation, movement, and destruction. It explains the evolution of Earth's surface through time, the building of mountains, formation of deep valleys, and the movements of lithospheric plates that have impacted climate, human evolution and the distribution of plant and animal species. By the conclusion of the chapter you should be able to explain how plate movement has created many of the surface features of our present day Earth.
Thumbnail: San Andreas Fault in the Carrizo Plain, aerial view from an altitude of 8500 feet. (Courtesy Wikimedia Commons )


15.12: Emerging Adulthood - The Bridge Between Adolescence and Adulthood
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The next stage of development is emerging adulthood and is characterized as an in-between time where identity exploration is focused on work and love, which occurs from approximately 18 years of age to the mid to late 20s.
When does a person become an adult? There are many ways to answer this question. In the United States, you are legally considered an adult at 18 years old, but other definitions of adulthood vary widely; in sociology, for example, a person may be considered an adult when they become self-supporting, choose a career, get married, or start a family. The ages at which we achieve these milestones vary from person to person as well as from culture to culture. For example, 50 years ago, a young adult with a high school diploma could immediately enter the workforce and climb the corporate ladder. That is no longer the case, a Bachelor’s and even graduate degrees are required more and more often—even for entry-level jobs (Arnett, 2000). In addition, many students are taking longer (five or six years) to complete a college degree as a result of working and going to school at the same time. After graduation, many young adults return to the family home because they have difficulty finding a job.
This is a relatively newly defined period of lifespan development, Jeffrey Arnett (2000) explains that emerging adulthood is neither adolescence nor is it young adulthood. Individuals in this age period have left behind the relative dependency of childhood and adolescence, but have not yet taken on the responsibilities of adulthood. “Emerging adulthood is a time of life when many different directions remain possible when little about the future is decided for certain when the scope of independent exploration of life’s possibilities is greater for most people than it will be at any other period of the life course” (Arnett, 2000, p. 469). 77
77. Psychology – 9.3: Stages of Development by OpenStax is licensed under CC BY 4.0 ; Lifespan Development: A Psychological Perspective by Martha Lally and Suzanne Valentine-French is licensed under CC BY-NC-SA 3.0


1.3.5: The Trait Approach to Leadership
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Learning Objectives
- What are the trait perspectives on leadership?
Ancient Greek, Roman, Egyptian, and Chinese scholars were keenly interested in leaders and leadership. Their writings portray leaders as heroes. Homer, in his poem The Odyssey , portrays Odysseus during and after the Trojan War as a great leader who had vision and self-confidence. His son Telemachus, under the tutelage of Mentor, developed his father’s courage and leadership skills. 41 Out of such stories there emerged the “great man” theory of leadership, and a starting point for the contemporary study of leadership.
The great man theory of leadership states that some people are born with the necessary attributes to be great leaders. Alexander the Great, Julius Caesar, Joan of Arc, Catherine the Great, Napoleon, and Mahatma Gandhi are cited as naturally great leaders, born with a set of personal qualities that made them effective leaders. Even today, the belief that truly great leaders are born is common. For example, Kenneth Labich, writer forFortunemagazine, commented that “the best leaders seem to possess a God-given spark.” 42
During the early 1900s, scholars endeavored to understand leaders and leadership. They wanted to know, from an organizational perspective, what characteristics leaders hold in common in the hope that people with these characteristics could be identified, recruited, and placed in key organizational positions. This gave rise to early research efforts and to what is referred to as the trait approach to leadership . Prompted by the great man theory of leadership and the emerging interest in understanding what leadership is, researchers focused on the leader—Who is a leader? What are the distinguishing characteristics of the great and effective leaders? The great man theory of leadership holds that some people are born with a set of personal qualities that make truly great leaders. Mahatma Gandhi is often cited as a naturally great leader.
Leader Trait Research
Ralph Stogdill, while on the faculty at The Ohio State University, pioneered our modern (late 20th century) study of leadership. 43 Scholars taking the trait approach attempted to identify physiological (appearance, height, and weight), demographic (age, education, and socioeconomic background), personality (dominance, self-confidence, and aggressiveness), intellective (intelligence, decisiveness, judgment, and knowledge), taskrelated (achievement drive, initiative, and persistence), and social characteristics (sociability and cooperativeness) with leader emergence and leader effectiveness. After reviewing several hundred studies of leader traits, Stogdill in 1974 described the successful leader this way:
The [successful] leader is characterized by a strong drive for responsibility and task completion, vigor and persistence in pursuit of goals, venturesomeness and originality in problem solving, drive to exercise initiative in social situations, self-confidence and sense of personal identity, willingness to accept consequences of decision and action, readiness to absorb interpersonal stress, willingness to tolerate frustration and delay, ability to influence other person’s behavior, and capacity to structure social interaction systems to the purpose at hand. 44
The last three decades of the 20th century witnessed continued exploration of the relationship between traits and both leader emergence and leader effectiveness. Edwin Locke from the University of Maryland and a number of his research associates, in their recent review of the trait research, observed that successful leaders possess a set of core characteristics that are different from those of other people. 45 Although these core traits do not solely determine whether a person will be a leader—or a successful leader—they are seen as preconditions that endow people with leadership potential. Among the core traits identified are:
- Drive —a high level of effort, including a strong desire for achievement as well as high levels of ambition, energy, tenacity, and initiative
- Leadership motivation —an intense desire to lead others
- Honesty and integrity —a commitment to the truth (nondeceit), where word and deed correspond
- Self-confidence —an assurance in one’s self, one’s ideas, and one’s ability
- Cognitive ability —conceptually skilled, capable of exercising good judgment, having strong analytical abilities, possessing the capacity to think strategically and multidimensionally
- Knowledge of the business —a high degree of understanding of the company, industry, and technical matters
- Other traits —charisma, creativity/originality, and flexibility/adaptiveness 46
While leaders may be “people with the right stuff,” effective leadership requires more than simply possessing the correct set of motives and traits. Knowledge, skills, ability, vision, strategy, and effective vision implementation are all necessary for the person who has the “right stuff” to realize their leadership potential. 47 According to Locke, people endowed with these traits engage in behaviors that are associated with leadership. As followers, people are attracted to and inclined to follow individuals who display, for example, honesty and integrity, self-confidence, and the motivation to lead.
Personality psychologists remind us that behavior is a result of an interaction between the person and the situation—that is, Behavior =f[(Person) (Situation)]. To this, psychologist Walter Mischel adds the important observation that personality tends to get expressed through an individual’s behavior in “weak” situations and to be suppressed in “strong” situations. 48 A strong situation is one with strong behavioral norms and rules, strong incentives, clear expectations, and rewards for a particular behavior. Our characterization of the mechanistic organization with its well-defined hierarchy of authority, jobs, and standard operating procedures exemplifies a strong situation. The organic social system exemplifies a weak situation. From a leadership perspective, a person’s traits play a stronger role in their leader behavior and ultimately leader effectiveness when the situation permits the expression of their disposition. Thus, personality traits prominently shape leader behavior in weak situations.
Finally, about the validity of the “great person approach to leadership”: Evidence accumulated to date does not provide a strong base of support for the notion that leaders are born. Yet, the study of twins at the University of Minnesota leaves open the possibility that part of the answer might be found in our genes. Many personality traits and vocational interests (which might be related to one’s interest in assuming responsibility for others and the motivation to lead) have been found to be related to our “genetic dispositions” as well as to our life experiences. 49 Each core trait recently identified by Locke and his associates traces a significant part of its existence to life experiences. Thus, a person is not born with self-confidence. Self-confidence is developed, honesty and integrity are a matter of personal choice, motivation to lead comes from within the individual and is within his control, and knowledge of the business can be acquired. While cognitive ability does in part find its origin in the genes, it still needs to be developed. Finally, drive, as a dispositional trait, may also have a genetic component, but it too can be self- and other-encouraged. It goes without saying that none of these ingredients are acquired overnight.
Other Leader Traits
Sex and gender, disposition, and self-monitoring also play an important role in leader emergence and leader style.
Sex and Gender Role
Much research has gone into understanding the role of sex and gender in leadership. 50 Two major avenues have been explored: sex and gender roles in relation to leader emergence, and whether style differences exist across the sexes.
Evidence supports the observation that men emerge as leaders more frequently than women. 51 Throughout history, few women have been in positions where they could develop or exercise leadership behaviors. In contemporary society, being perceived as experts appears to play an important role in the emergence of women as leaders. Yet, gender role is more predictive than sex. Individuals with “masculine” (for example, assertive, aggressive, competitive, willing to take a stand) as opposed to “feminine” (cheerful, affectionate, sympathetic, gentle) characteristics are more likely to emerge in leadership roles. 52 In our society males are frequently socialized to possess the masculine characteristics, while females are more frequently socialized to possess the feminine characteristics.
Recent evidence, however, suggests that individuals who are androgynous (that is, who simultaneously possess both masculine and feminine characteristics) are as likely to emerge in leadership roles as individuals with only masculine characteristics. This suggests that possessing feminine qualities does not distract from the attractiveness of the individual as a leader. 53
With regard to leadership style, researchers have looked to see if male-female differences exist in task and interpersonal styles, and whether or not differences exist in how autocratic or democratic men and women are. The answer is, when it comes to interpersonal versus task orientation, differences between men and women appear to be marginal. Women are somewhat more concerned with meeting the group’s interpersonal needs, while men are somewhat more concerned with meeting the group’s task needs. Big differences emerge in terms of democratic versus autocratic leadership styles. Men tend to be more autocratic or directive, while women are more likely to adopt a more democratic/participative leadership style. 54 In fact, it may be because men are more directive that they are seen as key to goal attainment and they are turned to more often as leaders. 55
Dispositional Trait
Psychologists often use the termsdispositionandmoodto describe and differentiate people. Individuals characterized by a positive affective state exhibit a mood that is active, strong, excited, enthusiastic, peppy, and elated. A leader with this mood state exudes an air of confidence and optimism and is seen as enjoying work-related activities.
Recent work conducted at the University of California-Berkeley demonstrates that leaders (managers) with positive affectivity (a positive mood state) tend to be more competent interpersonally, to contribute more to group activities, and to be able to function more effectively in their leadership role. 56 Their enthusiasm and high energy levels appear to be infectious, transferring from leader to followers. Thus, such leaders promote group cohesiveness and productivity. This mood state is also associated with low levels of group turnover and is positively associated with followers who engage in acts of good group citizenship. 57
Self-Monitoring
Self-monitoring as a personality trait refers to the strength of an individual’s ability and willingness to read verbal and nonverbal cues and to alter one’s behavior so as to manage the presentation of the self and the images that others form of the individual. “High self-monitors” are particularly astute at reading social cues and regulating their self-presentation to fit a particular situation. “Low self-monitors” are less sensitive to social cues; they may either lack motivation or lack the ability to manage how they come across to others.
Some evidence supports the position that high self-monitors emerge more often as leaders. In addition, they appear to exert more influence on group decisions and initiate more structure than low self-monitors. Perhaps high self-monitors emerge as leaders because in group interaction they are the individuals who attempt to organize the group and provide it with the structure needed to move the group toward goal attainment. 58
Concept Check
- What are the trait perspectives on leadership?
References
41. F. A. Kramer. 1992 (Summer). Perspectives on leadership from Homer’s Odyssey. Business and the Contemporary World 168–173.
42. K. Labich. 1988 (Oct. 24). The seven keys to business leadership.Fortune,58.
43. Stogdill, 1948; R. M. Stogdill. 1974. Handbook of leadership: A survey of theory and research . New York: Free Press.
44. Ibid., 81. See also Stogdill, 1948.
45. S.A. Kirkpatrick & E.A. Locke. 1991. Leadership: Do traits matter? The Executive 5(2):48–60. E.A. Locke, S. Kirkpatrick, J.K. Wheeler, J. Schneider, K. Niles, H. Goldstein, K. Welsh, & D.-O. Chad. 1991. The essence of leadership: The four keys to leading successfully . New York: Lexington.
46. Kirkpatrick & Locke. 1991. The best managers: What it takes. 2000 (Jan. 10). Business Week ,158.
47. Locke et al., 1991; T.A. Stewart. 1999 (Oct. 11). Have you got what it takes? Fortune 140 (7):318–322.
48. W. Mischel. 1973. Toward a cognitive social learning reconceptualization of personality. Psychological Review 80:252– 283.
49. R.J. House & R.N. Aditya. 1997. The social scientific study of leadership: Quo vadis? Journal of Management 23:409– 473; T.J. Bouchard, Jr., D.T. Lykken, M. McGue, N.L. Segal, & A. Tellegen. 1990. Sources of human psychological differences: The Minnesota study of twins reared apart. Science 250:223–228.
50. S. Helgesen. 1990. The female advantage . New York: Doubleday/Currency; J. Fierman. 1990 (Dec. 17). Do women manage differently? Fortune 122:115–120; J.B. Rosener. 1990 (Nov.–Dec.). Ways women lead.Harvard Business Review68(6): 119–125.
51. J.B. Chapman. 1975. Comparison of male and female leadership styles. Academy of Management Journal 18:645–650; E.A. Fagenson 1990. Perceived masculine and feminine attributes examined as a function of individual’s sex and level in the organizational power hierarchy: A test of four theoretical perspectives. Journal of Applied Psychology 75:204–211.
52. R.L. Kent & S.E. Moss. 1994. Effects of sex and gender role on leader emergence. Academy of Management Journal 37: 1335–1346.
53. Ibid.
54. A.H. Early & B.T. Johnson. 1990. Gender and leadership style: A meta-analysis. Psychological Bulletin 108:233–256.
55. G.H. Dobbins, W.S. Long, E. Dedrick, & T.C. Clemons. 1990. The role of self-monitoring and gender on leader emergence: A laboratory and field study. Journal of Management 16:609–618.
56. B.M. Staw & S.G. Barsade. 1993. Affect and managerial performance: A test of the sadder-but-wiser vs happier-and-smarter hypothesis. Administrative Science Quarterly 38:304–331.
57. J.M. George & K. Bellenhausen. 1990. Understanding prosocial behavior, sales performance, and turnover: A group-level analysis in a service context. Journal of Applied Psychology 75:698–709.
58. Dobbins et al., 1990.


Questions to consider:
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Why are you in college?
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What are the rewards and value of a college degree?
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Why this course?
This chapter started with the profiles of two students, Reginald and Madison, but now we turn to who you are and why you are in college. Starting this chapter with
you
, the student, seems to make perfect sense. Like Reginald and Madison, you are probably full of emotions as you begin this journey toward a degree and the fulfillment of a dream. Are you excited about meeting new people and
finally
getting to take classes that interest you?  Are you thrilled to be making important decisions about your future? Are you worried about making the right choice when deciding on a major or a career? All these thoughts, even if contradictory at times, are normal. And you may be experiencing several of them at the same time.
Figure 1.3: Decision-making about college and our future can be challenging, but with self-analysis and support, you can feel more confident and make the best choices.
Why Are You in College?
We know that college is not mandatory—like kindergarten through 12th grade is—and it is not free. You have made a
choice
to commit several years of hard work to earn a degree or credential. In some cases, you may have had to work really hard to get here by getting good grades and test scores in high school and earning money to pay for tuition and fees and other expenses. Now you have more at stake and a clearer path to achieving your goals, but you still need to be able to answer the question.
To help answer this question, consider the following questioning technique called “The Five Whys” that was originally created by Sakichi Toyoda, a Japanese inventor, whose strategy was used by the Toyota Motor Company to find the underlying cause of a problem. While your decision to go to college is not a problem, the exercise is helpful to uncover your underlying purpose for enrolling in college.
The process starts with a “Why” question that you want to know the answer to. Then, the next four “Why” questions use a portion of the previous answer to help you dig further into the answer to the original question. Here is an example of “The Five Whys,” with the first question as “Why are you in college?” The answers and their connection to the next “Why” question have been underlined so you can see how the process works.
While the example is one from a student who knows what she wants to major in, this process does not require that you have a specific degree or career in mind. In fact, if you are undecided, then you can explore the “why” of your indecision. Is it because you have lots of choices, or is it because you are not sure what you really want out of college?
Five Whys in Action
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The Five Whys in Action
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|
Why are you in college?
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I am in college to
earn a degree in speech pathology
.
|
|
Why do you want to
earn a degree in speech pathology
?
|
I want to be able to
help people who have trouble speaking
.
|
|
Why do you want to
help people who have trouble speaking
?
|
I believe that
people who have trouble speaking deserve a life they want
.
|
|
Why do you feel it is important that
people who have trouble speaking deserve a life they want
?
|
I feel they often
have needs that are overlooked and do not get treated equally
.
|
|
Why do you want to use your
voice to help these people live a life they deserve
?
|
I feel it is my purpose to help others achieve their full potential despite having physical challenges.
|
Do you see how this student went beyond a standard answer about the degree that she wants to earn to connecting her degree to an overall purpose that she has to help others in a specific way? Had she not been instructed to delve a little deeper with each answer, it is likely that she would not have so quickly articulated that deeper purpose. And that understanding of “why” you are in college—beyond the degree you want or the job you envision after graduation—is key to staying motivated through what will most likely be some challenging times
How else does knowing your “why,” or your deeper reason for being in college, help you? According to Angela Duckworth (2016), a researcher on
grit—
what it takes for us to dig in deep when faced with adversity and continue to work toward our goal—knowing your purpose can be the booster to grit that can help you succeed.
1
Other research has found that people who have a strong sense of purpose are less likely to experience stress and anxiety (Burrown, 2013)
2
and more likely to be satisfied in their jobs (Weir, 2013).
3
Therefore, being able to answer the question “Why are you in college?” not only satisfies the person asking, but it also has direct benefits to your overall well-being.
ACTIVITY
Try “The Five Whys” yourself in the table below to help you get a better sense of your purpose and to give you a worthy answer for anyone who asks you “Why are you in college?”

Once you have explored your “why” for enrolling in college, it may be worth reviewing what we know about the value of a college degree. There is no doubt you know people who have succeeded in a career without going to college. Famous examples of college dropouts include Bill Gates (the cofounder and CEO of Microsoft) and Ellen DeGeneres (comedian, actor, and television producer, among her many other roles). These are two well-known, smart, talented people who have had tremendous success on a global scale. They are also not the typical profile of a student who doesn’t finish a degree. For many students, especially those who are first-generation college students, a college degree helps them follow a career pathway and create a life that would not have been possible without the credential. Even in this time of rapid change in all kinds of fields, including technology and education, a college degree is still worth it for many people.
Consider the following chart that shows an average of lifetime earnings per level of education. As you can see, the more education you receive, the greater the increase in your average lifetime earnings. Even though a degree costs a considerable amount of money on the front end, if you think about it as an investment in your future, you can see that college graduates receive a substantial return on their investment. To put it into more concrete terms, let’s say you spend $100,000 for a four-year degree (
Don’t faint! That is the average sticker cost of a four-year degree at a public university if you include tuition, fees, room, and board
). The return on investment (ROI) over a lifetime, according to the information in the figure below, is 1,500%! You don’t have to be a financial wizard to recognize that 1,500% return is fantastic.
Figure 1.4: Every education level brings with it potential for greater lifetime earnings. These are simply averages and may not apply to all career types and individuals. For clarity, the “professional degree,” attaining the highest earnings, refers to degrees such as those given to doctors or lawyers. Credit:Source: Georgetown University Center on Education and the Workforce analysis of the US Census Bureau, American Community Survey (ACS), 2009–2019.Note: The figure is based on data for 25- to 64-year-olds working full-time, full-year.
Making more money over time is not the only benefit you can earn from completing a college degree. College graduates are also more likely to experience the following:
-
Greater job satisfaction.
That’s right! College graduates are more likely to get a job that they like or to find that their job is more enjoyable than not.
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Better job stability.
Employees with college degrees are more likely to find and keep a job, which is comforting news in times of economic uncertainty.
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Improved health and wellness.
College graduates are less likely to smoke and more likely to exercise and maintain a healthy weight.
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Better outcomes for the next generation.
One of the best benefits of a college degree is that it can have positive influences for the graduate’s immediate family and the next generations.
One last thing: There is some debate as to whether a college degree is needed to land a job, and there are certainly jobs that you can get without a college degree. However, there are many reasons that a college degree can give you an edge in the job market. Here are just a few reasons that graduating with a degree is still valuable:
-
More and more entry-level jobs will require a college degree. According to Georgetown University’s Center on Education and the Workforce, in 2020, 35% of jobs will require a college degree.
4
-
A credential from a college or university still provides assurance that a student has mastered the material. Would you trust a doctor who never went to medical school to do open-heart surgery on a close relative? No, we didn’t think so.
-
College provides an opportunity to develop much-needed soft skills. The National Association of Colleges and Employers has identified eight career-readiness competencies that college students should develop: critical thinking/problem solving, oral/written communication, teamwork/collaboration, digital technology, leadership, professionalism/work ethic, career management, and global/intercultural fluency.
5
There are few occasions that will provide you the opportunity to develop all of these skills in a low-stakes environment (i.e., without the fear of being fired!). You will learn all of this
and
more in your classes. Seems like a great opportunity, doesn’t it? If you find yourself asking the question “What does
this
course have to do with my major?” or “Why do I have to take
that
?” challenge yourself to learn more about the course and look for connections between the content and your larger educational, career, and life goals.
ANALYSIS QUESTION
In what ways will earning a certification or college degree be valuable to you now and in the future? Be sure to describe the financial, career, and personal benefits to earning a certification or college degree.
Why This Course?
Now that you have considered why you are in college and why a college degree may be valuable to you, it’s time to focus on why you are reading this book. Most likely, you are enrolled in a course that is helping you learn about college and how to make the most of it. You may be asking yourself “Why am I taking this course?” or even “Why do I have to read this book?” Answers to the first question may vary, depending on your college’s requirements for first-year students. Nevertheless, you are probably taking this course because your college believes that it will
help you succeed in college and beyond
. Likewise, the reason your professor has assigned this book is because it has been designed to give you the best information about how to make your transition to college a little smoother and attain your degree or certificate with more clarity. If you are not convinced just yet of the value of this course and its content, consider the following questions that you will be encouraged to answer as you learn about how to succeed in college:
-
What will college expect of me in terms of skills, habits, and behaviors, and how can I develop them to ensure that I am successful?
-
What do I need to know about how to navigate the process of completing a college degree?
-
How can I ensure that I develop worthy long-term goals, and how best can I meet those goals?
These questions are designed to assist you in the transition from high school, or the workforce, to the new world of college. And this won’t be the last monumental transition that you will experience. For example, you will experience a new job more than once in your life, and you may experience the excitement and challenge of moving to a new house or a new city. You can be assured that transitions will require that you identify what you need to get through them and that you will experience some discomfort along the way. It wouldn’t be such a great accomplishment without a little uncertainty, doubt, and self-questioning. To help you, the next section speaks specifically to transitions for the purpose of making your next steps a little smoother.
Footnotes
-
1
Duckworth, A. (2016).
Grit: The Power and Passion of Perseverance.
NY: Simon & Schuster.
-
2
Burrow, A.L. & Hill, P.L. (2013). Derailed by diversity? Purpose buffers the relationship between ethnic composition on trains and passenger negative mood.
Personality and Psychology Bulletin
, 39 (12), 1610-1619.
DOI
[doi 10.1177]
[doi]
[doi.org]
[doi.org]
[doi.org]
.
-
3
Weir, K. (2013). More than job satisfaction: Psychologists are discovering what makes work meaningful--and how to create value in any job.
American Psychological Association
, 44 (11), 39.
-
4
Carnevale, A.P., Smith, N., & Strohl, J. (2013). Recover: Job growth and education requirements through 2020. Georgetown University's Center on Education and the Workforce. Retrieved from
cew.georgetown.edu
[cew.georgetown.edu]
.
-
5
National Association of Colleges and Employers. (2019). Career readiness defined. Retrieved from
www.naceweb.org
[www.naceweb.org]
.


20.1B: Phagocytes
Phagocytes are the white blood cells that protect the body by ingesting harmful foreign particles and help initiate an immune response.
- Describe the types of phagocytes and their roles in initiating an immune response
Key Points
- Many white blood cells and other cells in the body use phagocytosis to engulf and kill cells.
- Phagocytosis occurs over several steps, which include binding to an opsonized pathogen with a receptor and killing it using an oxidative burst.
- Monocytes are phagocytes that can differentiate into macrophages and dendritic cells based on conditions within the body.
- Macrophages are the cleanup crew for the innate immune system. They remove debris, pathogens, and dead neutrophils after an inflammatory response.
-
Neutrophils are
polymorphonuclear (PMN) granulocytes that are the first responders to an inflammatory response.  - Mast cells are circulation PMN granulocytes that trigger an immune response by releasing an inflammatory mediator when they detect an antigen with their toll-like receptors.
Key Terms
- oxidative burst : A chemical reaction that occurs in phagocytes in which an engulfed pathogen is destroyed by exposure to oxidative stress from reactive oxygen species.
- PMN granulocyte : A type of phagocyte that contains PMN granules, most notably neutrophils and mast cells, but also basophiles and eosinophils.
Any cell that undergoes phagocytosis, a process in which pathogens and other foreign particles and debris are engulfed by a cell to be destroyed, is considered a phagocyte. Most phagocytes are types of white blood cells that use phagocytosis to perform basic innate immune system function within the body.
The Mechanism of Phagocytosis
Phagocytosis is the process by which a phagocyte engulfs a pathogen or debris. It can occur in almost any tissue, most often in the bloodstream and interstitial space but also the alveoli of the lungs and the parenchyma of most other major organs in the body. Typical phagocytosis occurs over the course of a few steps:
- A receptor on the phagocyte’s cell membrane binds to a foreign particle, such as a pathogenic microbe or a toxin. The Fc receptor is typically the receptor of use, which binds to antibodies that have opsonized (marked) a pathogen or toxin.
- The cytoplasm surrounds and engulfs the bound pathogen through endocytosis.
- The engulfed pathogen is kept in a vacuole called a phagosome, which then binds to the lysosomes inside the cell.
- A series of chemical reactions called an oxidative burst occurs, which uses reactive oxygen species and NADPH oxidase to damage and kill the pathogen through oxidative stress. Oxidative stress can kill a cell through DNA, cell membrane, or mitochondrial damage.
- The remains of the pathogen are expelled by exocytosis.
These are the general mechanisms used by phagocytosis to engulf and kill pathogens, but some variations can occur. For instance, other receptors may be used to engulf pathogens, and other non-oxidative methods (such as lysozyme) exist to kill the phagocytized pathogen.
Types of Phagocytes
There are many classes of phagocytes within the body, each with different specialized functions involving phagocytosis. Most phagocytes are derived from stem cells in the bone marrow. The main types of phagocytes are monocytes, macrophages, neutrophils, tissue dendritic cells, and mast cells. Other cells, such as epithelial cells and fibroblasts, may also engage in phagocytosis, but lack receptors to detect opsonized pathogens and are not primarily immune system cells.
Monocytes
Monocytes develop in the bone marrow and reach maturity in the blood. Mature monocytes have large, smooth, lobed nuclei and an abundant cytoplasm that contains granules, but are not technically considered granulocytes. Monocytes ingest foreign or dangerous substances and present antigens to other cells of the immune system. Monocytes form two groups: a circulating group and a marginal group that remains in other tissues (approximately 70% are in the marginal group). Most monocytes leave the blood stream after 20–40 hours to travel to tissues and organs; during this process, they differentiate into macrophages or dendritic cells depending on the signals they receive.
Macrophages
Mature macrophages are derived from monocytes, granulocyte stem cells, or the cell division of pre-existing macrophages. Macrophages do not have granules, but contain many lysosomes. They are found throughout the body in almost all tissues and organs, but are rarely found in the bloodstream. Macrophages cause inflammation through the production of interleukin-1, interleukin-6, and TNF-alpha. Macrophages are activated in a number of ways, including by T cells, cytokines such as IFN-gamma, or pathogen-derived compounds such as LPS toxins from bacteria. During inflammation, they enter about 72 hours after the initial response to clean up debris and dead neutrophils.
Dendritic Cells
Dendritic cell : Dendritic cell characterized by membranous projections that resemble spines.
Dendritic cells are specialized antigen-presenting cells that have long outgrowths called dendrites, which help to engulf microbes and other invaders. They express MHC class II molecules, which makes them the ideal antigen-presenting cell. Dendritic cells are present in the tissues that are in contact with the external environment, mainly the skin, the inner lining of the nose, the lungs, the stomach, and the intestines.
Once activated, they mature and migrate to the lymphoid tissues, where they present antigens to T and B cells to initiate the adaptive immune response. This involves deriving T and B cells that are specific towards a single antigen from naive lymphocytes.
Neutrophils
Neutrophils are a type of PMN granulocyte normally found in the bloodstream. They are the most abundant type of phagocyte and the first responder during inflammation. Once they have received the appropriate chemokine signals, neutrophils leave the bloodstream and reach the site of an infection through adhering to the vascular endothelium to squeeze into the tissues. There, they rapidly engulf invaders coated with antibodies, damaged cells, or cellular debris. They also degranulate to release perforin, granzyme, proteases, and other chemicals to cause cytotoxic damage to pathogens (and occasionally normal bodily tissues as well). Neutrophils die after phagocytosis, becoming pus that is later cleaned up by macrophages.
Extravasion of Neutrophils : Neutrophils move through the blood to the site of infection by rolling onto the vascular endothelium and adhering to it to slip through small gaps into the tissues during an inflammatory response.
Mast Cells
Mast cells are PMN granulocytes with toll-like receptors that tend to trigger inflammatory responses. Mast cells express MHC class II molecules and can participate in antigen presentation; however, the mast cell’s role in antigen presentation is not well-understood. Mast cells can consume, kill, and process their antigens. In addition to these functions, mast cells produce cytokines kept in their granules, such as histamine, that induce an inflammatory response when a pathogen is detected. Because of this function, allergic inflammatory responses occur when a mast cell is sensitized to an antigen that it normally wouldn’t react to.
Leukocyte Differentiation : Phagocytes derive from stem cells in the bone marrow. Monocytes differentiate into dendritic cells and macrophages, while mast cells and neutrophils are in a separate group of PMN granuolcytes as well.


4.1: JUKI DDL-8700 Sewing Machine
A. UPPER PART OF MACHINE
- Machine Table – The table holds the machine head and allows for garment space while sewing.
-
Machine Head -The machine head controls the upper thread, thread tension, stitch length control, backstitch lever and needle housing.
- Thread Stand – The thread stand holds the cones of thread for the upper threading of the machine head.
4. Hand Wheel – The hand wheel allows you to control the movement of the needle manually.
5. Backstitch Lever – The backstitch lever controls the directions of the stitching by allowing the machine to stitch backwards to secure the stitching line.
6. Stitch Length Dial – The stitch length dial controls the length of stitches. Average stitch length for seams is 2.5-3.
7. Tension Dial – The tension dial controls the amount of tension placed on the upper thread. There should be no need to change the tension dial once set for standard fabrics.
8. Throat Plate – The throat plate covers the lower bobbin housing and allows the feed dog (serrated feet) to move the fabric forward while stitching. It also has seam allowance markings.
9. Bobbin Plate Cover – The bobbin plate cover hides the bobbin case mechanism that holds the lower thread. It slides to the left to open and see into the bobbin case housing.
10. Bobbin Winding Mechanism – The bobbin winding mechanism is located on the right side of the machine. It is used to wind the bobbin with the lower thread for stitching.
11. Presser Foot and Needle Shank – The presser foot holds the fabric is place while stitching. It lifts and lowers with a lever on the back of the machine head or by the knee lifter under the machine table. The needle shank holds the needle in place while stitching.
12. Table Light – The table light is located toward the back of the table and is adjustable on a flexible arm. The power switch is located on the top of the light and if left on will turn on and off with the machine power button.
B. LOWER PART OF MACHINE
1. Power Switch – The power switch is located just under the table on the right side of the machine table.
2. Knee Lifter – The knee lifter controls the lifting and lowering of the presser foot.
3. Foot Peddle – The foot peddle controls the operating of the machine.
4. Motor Speed Dial – The motor speed dial is located on the motor housing and is adjustable from 0—3450. Average speed for class is 350.
C. ACCESSORIES
1. Bobbin Case – The bobbin case holds the bobbin full of thread. Show here are both sides of the bobbin case.
2. Bobbin – The bobbin holds the lower thread and is inserted into the bobbin case to be placed in the lower part of the machine.
3. General Straight Stitch Presser Foot – This presser foot holds the fabric in place while stitching. The general presser foot is shown here.
4. Invisible Zipper Foot – The invisible zipper foot is grooved on the bottom for zipper teeth to glide through and provide a concealed zipper for polyester or nylon zippers.
5. Slim Zipper Foot – The slim zipper foot with a notch on the side is used to insert lapped, center and fly front zippers. This foot can also be used to get into tight corners and attaching piping.
6. Machine Needle – The machine needle for the lockstitch sewing machine has a shank, shaft and eye. Sizes vary upon fabric choice.
7. Drawer Contents – Each machine has an accessories drawer located under the edge on the left side of the machine table. Located in the drawer is a box with a bobbin case, invisible zipper foot and slim zipper foot. This box and its contents stay with the machine at all times. In addition, the drawer will have a screwdriver for changing out the presser feet and for changing the needle.


6.5: Normal Random Variables (5 of 6)
Learning Objectives
- Use a normal probability distribution to estimate probabilities and identify unusual events.
We now know that the empirical rule gives probabilities for values that lie exactly 1, 2, and 3 standard deviations away from the mean. But how do we determine the probability that a value lies some fraction of a standard deviation away from the mean? In this situation, we will use technology to find the probability.
For now, we use a simulation to find the probability based on a z -score. Statistical packages can also be used to find probabilities associated with a normal curve.
Example
The Distribution of z-Scores
Recall that we use the area under a normal density curve to find a probability. If we convert the x -values into z -scores, the distribution of z -scores is also a normal density curve. This curve is called the standard normal distribution .
Here we compare the normal density curve for the foot lengths to the standard normal curve:
The normal curve pictured on top is the model for the distribution of foot lengths. Note that the values on the axis are foot lengths. The distribution has a mean of 11 inches and a standard deviation of 1.5 inches. A foot length of 13 inches is marked. The shaded area is 0.0918. This is the probability that a randomly selected male will have a foot length greater than 13 inches: P ( X > 13) = 0.0918.
The normal curve pictured on bottom is the standard normal distribution. This represents the distribution of z -scores. Note that the values on the axis are z -scores. The mean is 0 and the standard deviation is 1. The z -score corresponding to X = 13 inches is marked.
The shaded area here is the same, 0.0918. This is the probability that a z -score is greater than 1.33: P ( Z > 1.33) = 0.0918.
Here is the main idea: Since the areas are the same, we use the standard normal curve to find the probabilities associated with any normal density curve .
Note: The standard normal distribution always has a mean = 0 and a standard deviation = 1. To understand this, recall that a z -score is the number of standard deviations X is above (or below) the mean.
- When the x -value is the mean, the z -score is 0.
-
We can illustrate this for the foot lengths: If
X
is the mean, then
- When X is 1 standard deviation above the mean, the z -score is 1.
-
We can illustrate this for the foot lengths: If
x
-value is 1 standard deviation above the mean,
X
= 11 + 1.5 = 12.5.
- Similarly, the z -score for the x -value that is 1 standard deviation below the mean is −1.
Example
Using the Standard Normal Curve to Find Probabilities
We use a simulation based on the standard normal distribution to find probabilities. In this simulation, the numbers on the horizontal axis are z -scores. The areas are rounded to four decimal places, so these areas are not exact values.
Use this image from the simulation to find the probabilities:
- Find P (−1.21 < Z < 1.21). In words, we want to find the probability that the z -score is between −1.21 and 1.21. This probability is the light blue area. So the answer is 0.7737.
- Find P ( Z > 1.21). In words, we want to find the probability that the z -score is greater than 1.21. This probability is the blue area to the right of Z = 1.21. So the answer is 0.1131.
- Find P ( Z < −1.21). In words, we want to find the probability that the z -score is less than −1.21. This probability is the dark blue area to the left of Z = −1.21. So the answer is 0.1131. Note that this is the same as P( Z > 1.21) because of the symmetry in the normal distribution. Both tails have the same area.
- Find P ( Z > −1.21). In words, we want to find the probability that the z -score is greater than −1.21. This probability is the area to the right of −1.21. This is the sum of the green area and the dark blue area. So the answer is 0.7737 + 0.1131 = 0.8868.
Note: Here is another way to use the simulation to find P ( Z > −1.21). Here we moved one slider as far to the left as possible, then located the other slider at Z = −1.21.
Notice that the area is 0.8869, not 0.8868. This discrepancy is due to rounding. The simulation uses a mathematical model to find the areas. These areas are rounded to four decimal places. Don’t worry about this small difference. Either answer is acceptable.
We now practice using the simulation based on the standard normal curve to find probabilities. Later we use this same simulation to find probabilities for any normal distribution.
Click here to open this simulation in its own window.
Click here to open the above simulation in its own window.
Contributors and Attributions
- Concepts in Statistics. Provided by : Open Learning Initiative. Located at : http://oli.cmu.edu . License : CC BY: Attribution


<IP_ADDRESS>: Parable of the Old Men and the Young
Parable of the Old Men and the Young
Parable of the Old Men and the Young License: Public DomainSo Abram rose, and clave the wood, and went,
And took the fire with him, and a knife.
And as they sojourned both of them together,
Isaac the first-born spake and said, My Father,
Behold the preparations, fire and iron,
But where the lamb for this burnt-offering?
Then Abram bound the youth with belts and straps,
And builded parapets and trenches there,
And stretched forth the knife to slay his son.
When lo! an angel called him out of heaven,
Saying, Lay not thy hand upon the lad,
Neither do anything to him. Behold,
A ram caught in a thicket by its horns;
Offer the Ram of Pride instead of him.
But the old man would not so, but slew his son. . . .