Before embarking on a research, the teacher must consider the following three categories to realize success. Before starting, it is important to begin by specifying the relevant research questions which can as well assist in carrying out this undertaking in a more organized way. Secondly, the educator must have a series of troublesome questions that can at times be difficult deciding on which query to put a lot of efforts on while carrying out the research study. Lastly, the teacher may lack any guiding question or concept that he or she would like to explore during the action research study. The case study precisely fits the second option such that one may have more than two starting points that have a great probability for awesome action research projects but can be at the cross roads on which question best fits my research project. The question are;
Can misbehavior in school pay off for the white students and not for the Black African American students?
Strategies for Student Success, Composition, and Rhetoric II English, Physical Conditioning
In the paper, we are going to discuss the semester undertaken in the school, and having completed my work for this for this course there are some experiences both positive and negative that I gained in the during the courses undertaking. In this assignment am going to write a reflection on the semester and what I have learned and the result I obtained.
During the semester I intended to get into the course that I wanted to pursue, at first I was very excited because it was my dream targeting to learn what I have eager to. At first, things seemed very complicated but it came to a time when I had to adapt and get fixed in the curriculum. The experience in interacting with my colleagues was very interesting that it helped in the conducive environment in learning. Despite joining the coursework I had had some major issue that was very difficult to understand how the systems work and operate and adjusting to them effectively. The lecture rooms were so intense due to the feeling of getting the new idea of what am going to take.
The general coping helped in creating companionships and social engagements. This fact depended on the time I had on the environment other than concentrating on the class works. Due to my family emotional and physical support had me acquire the best in my performance knowing that I have homesickness, family support, this factor was the most important for my well-being in the school course. I also had confidence and had made a firm decision on the carrier course that I had chosen. This has a great impact in my self-esteemed and helped me in better performance in the academics. The financial support was very satisfying and reliable as it gave me a clear momentum in focusing on my studies.
The college offered a receptive to support services. This helped in the academic assistance measures in the academic skills. The receptivity to the personal counseling helped in the receiving of personal matters that my studies are very interesting and going accordingly. The curriculum receptivity to support services helped in identifying and receiving assistance getting involved in social activities which helped in my physical health being while in school. All these were the benefits that I experienced during the course term in school.
The school provided an academic motivation that helped in the academic progressions and better knowledge. This helped me to work on and pursue the dream I had up to the end of the semester. The study measured the amount of time and the effort that I was putting into the studies. The lecturers were helping in the development of clear study routines during the class time and the assignment plans.
Although the learning was good all through the semester there were problems that affected me and the strength that I possessed through the course of my coursework. These effects were majorly based on the practical lifestyle that I had in the school. I was having a hard time concentrating on the studies due to homesickness. This was potentially the major weakness that I possessed during the entire semester. My strength was doing the homework’s and assigned assignments to my best. These helped in the performance and better assignment in the schools. All this were very encouraging to the focus of finishing the semester and completion of the semester, the hardworking lecturers, supportive family and innovating school is the most amazing part that helped me in the completion and so I know this factors will help me pass.
Decision Making Management
The group has made various decisions in relation to all the areas within the simulation hotel which include marketing issues in week 3, operational issues, capital expenditures and ownership issues in week 4 and human resource management issues in week 5. The simulation hotel has a long history since its opening in the 1950s, offering traditional facilities to upper middle-class people who wanted a coastal vacation or off-season breaks. This essay will discuss the decision making management that the group made, including the reasons behind the decisions and the decision making theories and models used in making the decision before finally concluding.
What are the decisions?
The first decision made was the implementation of the pricing mechanism for the hotel’s F & B and room sales. The decision was made to address the hotel’s marketing issues and to position the hotel between the existing industry competitors such as Palace Hotel (4-star) and The Park Hotel (3-star).
The second decision made was the move to improve the facilities such as constructing Business Service, Hotel Shop and Leisure Club and refurbishing the hotel to make it in 4stras condition. This was done in week 4. However, this particular decision manifested to be a wrong decision as this was made without considering the capitalization and operational issues, and therefore, hurt the financial status of the hotel.
Lastly, in week 5, the group decided on the human resources issue where the hotel was suffering from high staff turnover and low staff satisfaction rates. The first move was to reduce the training systems to Level 1 so as to decrease the training cost. But this move failed so the group decided to return the training systems of staffs to Level 2 and Level 3 for the Department heads.
The reasons behind the decisions
The decision to implement the pricing mechanism for the hotel was due to the group’s intention to position the hotel in between its 4-star and 3-star hotel competitors’ price range. So for its Weekday room, the hotel’s rate is $100.00 while its 4-star competitor (The Palace) was priced at $135 and The Park (3-star) at $95.75, respectively. This pricing scheme was implemented to all the other products of the hotel such as Weekend single room and price for lunch. Moreover, since the Monthly indicator report showed that the hotel was experiencing difficulties in terms of sales (occupancy, beverage and meal) so the group also decided to allocate money for advertising as part of the hotel’s marketing strategy. Also, the group chose to retain the prices despite the additional expenses on advertising to attract more customers. These marketing strategies transformed into positive results as manifested in the increase in sales in all of the hotel’s products from April to June.
On the other hand, the second decision which involved the move to improve the hotel facilities through construction and refurbishing was caused by the group’s desire to attract more clientele and to upgrade the hotel’s condition into 4stras. However, this decision failed as the group was not able to foresee the decrease in sales in the hotel’s occupancy, meals and beverages. While its capital expenditures increased due to the ongoing construction and refurbishing, its net income decreased due to the decline in sales, hence, the hotel suffered from shortage of funds. Although spending on a capital expenditure could be a future investment, it is normally costly and should always be studied very well to determine whether the company has enough funds to support the investment or there are other means to finance the capital expenditure (Ritzer 2013).
The third decision made by the group regarding human resources management was triggered by the high staff turnover and low staff satisfaction rates of the hotel. This problem was caused by the reduction in budget for marketing and human resources due to the capital expenditure made on the extension and improvement of the hotel facilities. So much money was put in the construction and renovation of the hotel so the group had to squeeze the budget for staff training, bringing it to the less expensive Level 1 from Level 2. Thus, the hotel suffered from unskilled and not loyal staffs that were inefficient in producing better product and service. However, this problem was resolved when the group decided to bring back the staff training system to Level 2 and Level 3 for the department heads, respectively. The decision resulted positively in Year 2 May.
Decision making theories and models used in making the decisions
Pricing and marketing strategies
Cultural Competence in Health Care Practice
Over the years, Australia continues to absorb new people from varied groups, each contributing to complex adjustments in language, culture, health services and changes in social and political stability of the country. The continuous flow of migration from family immigrants, skilled workers and indigenous peoples became a factor in reshaping the Australian society and has also affected the definition of health for Aboriginal people, which was once alleged as not being given more culturally appropriate health services. Based on the definition given by the National Aboriginal and Islander Health Organisation (NAIHO) in 1982, health for the Aboriginal people must be multidimensional and cover all facets of their lifestyle, giving importance on how they value harmony with the environment as much as they value survival. In addition, Eckermann et al (2010, p. 64) states that “Health is not just the physical well-being of the individual but the social, emotional and cultural well-being of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life.” In essence, every indigenous person should have access to health care services of the state to realize his maximum potentials, which in the end will bring a positive impact to the well-being of his own community.
This essay will discuss the above statement and identify the principles of cultural competency. Further, it will also ascertain how a health care practitioner applies the principles of cultural competency in meeting the needs of Aboriginal and Torres Strait Islander people before finally concluding.
Cultural competency is defined as the notion that professionals, agencies and systems apply similar behaviors, policies and attitudes to cross-cultural situations (Grote 2008, p. 14). Many immigrants with CALD (culturally and linguistically diverse) backgrounds claim that they find difficulty in accessing culturally appropriate justice, educational and health services because of the manner that Australia was inhabited. Prior to the colonisation, every indigenous community had its own history, cultural identity and the belief that they needed to have a clear adaptation to their environs, especially to the land which they considered as a sacred entity, for their unique ways of life (Eckermann et al., 2010). However, things have changed when Australia was colonised and the indigenous peoples were devastated and their well-being ignored. The authors add that the health of the Aboriginals were not really given attention since the colonisation and some of the indigenous groups were not even entitled to receive meat in their food rations and could only eat meat if they hunt (Eckermann et al., 2010, p. 62). Even to this date, statistics show that the mortality of the indigenous people is earlier than non-indigenous Australians and their life expectancy is less than ten years (73.7) as compared to non-Indigenous Australians (83.1) (Australian Bureau of Statistics 2013). The recent call for better culturally appropriate health services for the indigenous peoples necessitates that the principles of cultural competence be applied. National Health and Medical Research Council (NHMRC) (2005, p. 23) states that the principles of cultural competence are: engaging consumers and communities and sustaining reciprocal relationships; using leadership and accountability for sustained change; building on strengths – know the community, know what works; and a shared responsibility – creating partnership – sustainability.
To achieve a more culturally appropriate health services, it is vital that health consumers (whether indigenous or non-indigenous) know the best way to gain the best of health and healthy living environments. Engaging the consumers and their communities in disseminating health information and education is a good way in sustaining healthy relationships. Having a reciprocal relationship will establish the exchange of learning and cultural information which eventually could lead to the formation of partnerships between the health care practitioner and the indigenous communities. The advantage of engaging consumers with CALD background is the assurance that the health measures to be taken are in line with the indigenous peoples’ cultures, practices and beliefs. Collaborating with the indigenous and promoting peer health education will help in strengthening the indigenous people’s communities in supporting its fellow members in cases where the health practitioner is not around (Pulver et al., 2010, p. 6). Moreover, the indigenous people or the member of the community in particular could act as liaison and interpreter at the same time and be in-charge in the proper conveyance of accurate information to both parties. Since the NAIHO definition of health includes covering all aspects of the Aboriginal’s lifestyle, engaging the indigenous in caring for their fellows ensures that proper observance of their cultures and beliefs are uphold, especially in treating women, older people and those with sensitive health conditions.
Since not all leaders are born, a health practitioner can train the indigenous to lead and be accountable in sustaining change. The health practitioner can apply the principle of cultural competence in the Aboriginal community by encouraging the indigenous to get involved and participate in bettering their overall well-being by helping them visualise and develop goals that are doable within a specific period of time. Since health involves the recurring concept of life-death-life, the health practitioner should encourage the community members to think of strategies that will sustain their good health. This is also another form of empowering them to stand for their right and be concerned for their future and the future of their community. Letting the indigenous think of ways to improve their lives is already a move to raise their awareness to lead. However, the health practitioner should not forget to educate the indigenous that power begets responsibility. It should be explained that they should always be ready for the consequences of their actions in whatever measure or activities they perform or initiate. The health practitioner can encourage possible leaders in the community to help in planning, making strategies, implementing rules and regulations and developing both short-term and long-term goals, in a way that will not disrespect or diminish their cultural practices (Walker & Sonn 2010, p. 165; PIL 2009; NMHRC 2005, p. 28).
In using leadership and accountability for sustained change, health practitioners should seek the guidance of the indigenous community’s elders to make sure that the internal protocols are not ignored. Relationships based on trust between health practitioners and the community members must be built to guarantee honesty and transparency on funding as the partnership is expected to be long term (Hunt 2013, p. 3).
Further, a health practitioner can apply cultural competence in addressing the needs of the Aboriginal and Torres Strait Islander people by fully knowing their culture, their strengths and weaknesses, their health needs and their openness to change. It is important that health practitioners take into consideration the belief of the indigenous people on the sacredness of the land and how the person belonged to the land and not the other way around (Cook 2010). Hence, in providing a more culturally appropriate health care, health practitioners should have exchanges of information and sharing of interventions with the locals to determine what is the right intervention to their physical health needs. Health practitioners should always bear in mind not to generalise the interventions to everyone in every situation but to always communicate if the medical intervention is in line with the community’s cultural practice of treatment (Morris 2003, p. 14). However, in more serious clinical conditions that require more complex intervention, the health practitioner should work in partnership with the community and educate them on how the approach that is being proposed is more likely to work on achieving the desired health outcomes. Knowing the community and knowing what approach works with them in getting the message across is helpful in encouraging the indigenous to participate. Health practitioners can use channels like dance, music and sport in encouraging the indigenous youth to listen and learn the importance of healthy lifestyle in achieving good health. In line with this, health practitioners should have a thorough research on the behaviors, culture and practices of the indigenous people to encourage them to participate and their health needs properly addressed.
Since health does not only pertain to the physical well-being of the person but is extended to the person’s cultural, emotional, social well-being of the whole community, it is imperative that health practitioners work with the consumers, in this case the indigenous, and engage them in a shared responsibility of caring themselves and their fellows. However, sometimes it is better said than done but to secure partnership and sharing of responsibilities between the indigenous peoples and health practitioners, there should be a clear agreement between parties as there may be issues that needed to be resolved first. Further, during the process, the issues that may be brought up can be identified and determined if it will need a long-term action or can be resolved just through episodic programs (NMHRC 2005, p. 29). Having a clear understanding of the situation and roles to play could lead to easier acceptance of a partnership and sharing of responsibilities. Sharing of responsibilities does not only lighten the task but also increases the monitoring of health strategies, minimises commission of mistakes and increases the chances of expanding the delivery of services to other communities.
However, to make sure that the community health programs are sustained and the Aboriginal and Torres Strait Islander people participate in shared responsibilities and health care partnership, it is important that health practitioners seek out sufficient government funding for sustained outcomes. Health practitioners should ensure that the created partnership becomes a legal obligation of the health government sector so the indigenous peoples will not be discriminated and be given the equal opportunity to more culturally appropriate health care services (Hunt 2013, p. 2). When health practitioners demand that the indigenous community be engaged in the partnership of providing more culturally appropriate health care services, the engagement must be based on a clear agreement of shared power, decision-making process and transparent conflict resolution schemes (Hunt 2013, p. 2).
Cultural competency dictates that culturally appropriate health care should be for all – indigenous or non-indigenous. However, the continuous inflow of migration from family immigrants, skilled workers and indigenous peoples has re-shaped the Australian society and affected the definition of health for Aboriginal people who claim that they are not being given more culturally appropriate health services. This was further intensified with the recent call for better culturally appropriate health services for the indigenous peoples and statistics show that most of them have poorer health and their life expectancy is ten years lesser than the non-indigenous Australians. Based on the definition given by the National Aboriginal and Islander Health Organisation (NAIHO) in 1982, health for the Aboriginal people must be multidimensional and cover all facets of their lifestyle, giving importance on how they value harmony with the environment as much as they value survival. In addition, Eckermann et al (2010, p. 64) adds that health is not limited to the wellness of the physical body of the person but also includes the emotional, cultural and social safety and happiness of the entire community. Furthermore, the concept of wellness does not cover only the lifetime of the individual but goes through the life cycle concept, taking into account the after-death life as human beings believe in the concept of eternity. Thus, to apply the principles of cultural competency to the health care of the Aboriginal and Torres Strait Islander people, health practitioners should have a thorough research on the indigenous peoples’ culture, practices and beliefs. They should build reciprocal relationship and engage the indigenous and their communities in health education and dissemination of health information to ensure that interventions are in line with their cultural observance. It is also helpful to employ staff with CALD background who would act as liaison and interpreter between the two parties. Further, knowing the community and knowing what approach works with them help in encouraging the indigenous to participate and share responsibility. Using channels like dance, music and sport in getting them listen and get involved in keeping a healthy lifestyle are also valuable in addressing the health needs of every indigenous because healthy people mean a healthy community.
Australian Bureau of Statistics 2013, Life tables for Aboriginal and Torres Strait Islander Australians, 2010 – 2012, Australian Bureau of Statistics, Canberra.
Cook, M 2010, ‘Sacred land: a question of value’. Available at : <www.resource.mccnsh.edu>, Accessed: 17 Oct 2015.
Critiquing an article
The research article entitled “Association between cardiovascular events and sodium-containing effervescent, disperable, and soluble drugs: nested case-control study” was authored by Jacob George, Waseem Majeed, Isla S. Mackenzie, Thomas M. MacDonald and Li Wei and deals about the relationship between the incidence of cardiovascular events and intake of drugs containing sodium as compared to the incidence of cardiovascular events in patients taking the same drugs but are non-sodium formulations. A report by the Institute of Medicine in 2010 suggests that a reduction of sodium intake to the recommended levels could prevent cases of hypertension, save healthcare funds and improves quality life years. The central hypothesis was: patients taking drugs containing sodium formulations could increase the risk of cardiovascular events as compared to patients taking the same drugs but with no-sodium contents. The study was performed to determine the association of sodium formulation to the incidence of cardiovascular events.
The title of the article accurately described the content of the study, the particular aim that the authors would like to pursue and the type of study that would be used. It can also draw attraction for readers to continue reading because their interests can be stimulated by the mere title alone.
The abstract was informative and clearly provided a good synopsis of the purpose, methods of study, results and the conclusion of the study. It also described what to look for if the reader decided to continue reading the article. It provided vital information of the study, including the statistical findings and the formed conclusion.
The authors have provided good background information about the topic and evidences on why the topic was worth studying. It also stated evidences for the need of the study and the aims and rationale that the authors wanted to pursue.
The research was a nested case-control study using the United Kingdom’s CPRD (Clinical Practice Research Datalink) database which contains data of primary care practices from January 1987 to December 2010. The study population was comprised of residents in the United Kingdom who were registered with their physician for more than one contact during the above-specified period. The study patients consisted of patients aged 18 years and above who had received at least two prescriptions of drugs with sodium-formulation or the matched non-sodium formulation of the same drugs. Included in the selection of drugs were drugs that had over 1000 prescriptions in the entire database. Patients included in the study were those who were prescribed with sodium-formulation or the standard formulation of the drug within the study period. Their cases were followed-up until December 2010 and those who died, had an outcome event, switched drugs or left the practice within the study period were censored. Excluded in the study were patients who were diagnosed with malignancy, salt wasting conditions, malabsorption syndromes or had history of drug and alcohol abuse prior to the entry date.
The sample was big enough as it included patients from 1987 to 2010. The selection of the study sample was less biased as it concentrated on a subset of controls from the study cohorts (Sedgwick 2014) in comparing the effects of sodium-formulated against the standard formulation of the same drugs. Furthermore, the study addressed a clearly focused issue, which is the association of sodium-containing drugs to the incidence of cardiovascular events. In analysing the collected statistics, the study used conditional logistic regression which is effective in investigating the associations between an event (cardiovascular event) or a nonevent and a set of prognostic factors (sodium-containing formulation and non-sodium containing formulations of the same drugs); and in cases with small analysis strata (Pearce 2016). There were some confounding variables in the study, such as smoking and patient’s diet, which could have affected the results of the study.
The characteristics of the study samples were significant as more have peripheral vascular disease, diabetes, were smokers, had history of angina, have chronic kidney diseases and were taking drugs for cardiovascular diseases. The results supported the hypothesis and other studies related to the effects of sodium to increasing risk of cardiovascular diseases (Burnier, Wuerzner & Bochud 2015). Although there were controversies on the association of dietary sodium and incidence of cardiovascular diseases, the study found a significant trend (P<0.01) in the dose-response relation in terms of cumulative drug dose. This finding has validated the UK’s claim that daily doses of sodium-containing drugs exceeded the recommended daily sodium allowance for an adult. The result of the study was beneficial to public health as consumption of high sodium through ingestion of drugs was not clearly labelled, and therefore, not regulated. However, the findings would have been clearer if the statistical data and comparisons were illustrated through graphs for easier viewing and stronger emphasis on the importance of the association of sodium-containing drugs to the increasing risk of cardiovascular diseases.
The issue studied was relevant as it investigated a potential threat to health which was not obvious as the drugs were normally from a doctor’s prescription. The aims and objectives of the study were met as it was able to establish the association between the effects of the ingested drug with sodium formulation and cardiovascular events. There were some repetitions in the study but seemed important in validating results and comparing them to the findings of previous studies on the effects of salt intake to the incidence of cardiovascular diseases.
The results can be generalised to a bigger and wider population as the practice of prescribing sodium-containing drugs is observed by most doctors worldwide. The study implies that greater caution should be taken by doctors in prescribing sodium-containing drugs. In addition, it also implies that government agencies should deal more with the issue and conduct further studies to confirm the results, perhaps, improve their regulations in the admissible daily sodium allowance for adults.
Strengths and limitations
Karen Hussar, Ed.D.
PY101: Introduction to Psychology
29 April 2016
The research “Practicing compassion increases happiness and self-esteem” was authored by Myriam Mongrain, Jacqueline Chin and Leah Shapira” and deals with the effect of practicing compassion towards others in relation to increasing a person’s pleasure and self-regard. The central hypothesis was: Practicing empathy offers lasting improvements in happiness and self-regard of a person as compared to writing about an early memory; and would benefit anxious people in a short period of time.
The study was made online with 719 persons with age ranging from 17 to 72 years old participated: 82.2% of the total participants were females, 16.4% were males and 1.4% did not indicate their sex. All of the participants were Canadian; the majority was with Caucasian heritage, mostly Christian (48.5%) and mostly had high level of education. Majority was earning less than $50,000 per year; mostly single and no children.
The selection of the study sample was biased as it used voluntary response samples. Samples are considered voluntary response samples when their participation is voluntary and was a response to the researcher’s appeal for voluntary participants (Moore 2003). In this case, the researchers had appealed for voluntary participants through the Canadian Facebook. This type of sampling tends to oversample persons who are highly opinionated about the topic and undersample those people who do not care about the topic of the study, resulting to not representing the entire population being considered (Moore 2003).
The study both used experimental and correlational type of research. It was experimental because participants were randomly assigned to a control group or compassionate action condition group where their actions were manipulated and controlled (Nebeker 2016). It was also correlational because it explored relationships between variables, in this case, the current state of happiness of the participants, response choices, compassionate actions and the payment status of each participant. The statements describing the participant’s current state ranged from 1 – 5 using Steen Happiness Index (SHI), whether ‘life is wonderful’ to ‘life is bad’. The response choices assess the sample’s incidence of experiencing symptoms of depression, ranging from none or rarely (0) to most of the time (4). The compassion actions included showing of help or support to others, such as talking to a homeless or just simply showing love to those in the environment. The payment that the participants received depended on the time they participated in the study and their payment status also served as motivation for the participants to come back and complete the survey. Those in the control group were asked to write a description of an early memory while the samples assigned in compassionate action condition were given 5 to 15 minutes each day for 7 days to do some compassion activities to others around them. Data were collected daily through the designated forms that they were required to fill in which also served as the result measurement.
Results and Discussion
The results of the study support the hypothesis that practicing empathy towards others increases lasting pleasure and self-regard of a person as compared to writing about an early memory and may benefit anxious people in a short period of time. The results showed correlations of happiness in being employed and doing compassion to others. Some of the participants were given $30 remuneration and all of them were included in the $1000 raffle draw. Also, being active and at the same time knowing that you are helping others initiate the body to release happy hormones (Bloom 2011). The correlations between the payment, the possible winning in the raffle, the feeling of being valuable to others and being physically active could contribute to the increase of self-esteem and joy of a person. The authors implied that the payment status of the participants played an important role in elevating the motivation of those in the compassion action condition compared to those in the control group.
I think the study was not well executed as there were remunerations involved. A person will feel delighted if he knows he will be paid for his actions, which somehow could raise some doubts if his increased happiness was really due to the compassion action or because of the payment involved and his chances of winning the $1,000 prize raffle. I think the study could have been more reliable if it did not use voluntary response samples and did not use monetary payments to join and finish the survey. Another limitation that prevents generalizations is the selection of the samples which was biased and mostly represented Canadian, females and with high level of education only. Also, the study automatically excluded those with no access to internet as it was conducted online. But since the hypothesis made was in parallel with other previous studies made about the topic, future research representing a wider population and using a different type of research is suggested.
Studies show that people with intellectual disability have worse health condition than the general population and are more likely to have health problems such as heart conditions, epilepsy, morbid epilepsy and diabetes. Intellectual disability is not considered a psychiatric or mental health problem but it affects the learning capability and the daily living skills of the person because his cognitive (thought-related) processing is damaged (Ministry of Health, 2013; State Govt. of Victoria, 2014). In particular, some people with intellectual disability and are suffering from Down syndrome also have diabetes, conditions that are chronic and affect the patient’s entire life span.
This essay will use a case study to discuss the health effects on a person of having an intellectual disability and type 2- diabetes and the impact of the nurses’ ability to promote the health and wellbeing of the patient. It will be using the ICF model to discuss how the patient’s activity and participation across his lifespan is affected by having intellectual disability and type 2- diabetes. Further, it will identify an evidenced-based intervention/strategy for managing diabetes 2 and how a community nurse adapt this strategy to ensure the patient’s optimal health and wellbeing across his lifespan before finally concluding.
The case study involves an adult man of 45 years, with Down syndrome, moderate intellectual disability and type 2- diabetes. This man lives in a community group that is staffed by support workers and he attends a disability-specific day program Mondays thru Fridays. The community nurse is expected to manage the holistic care of this man.
A person is considered having moderate intellectual disability if he has an IQ between 35 and 50 and has difficulty in learning and processing information, grasping abstract concepts like time and money and struggles in understanding the intricacies of interpersonal interactions (State Gov. of Victoria, 2014). He may be able to learn to travel using regular public transport but will find it hard to handle money and plan trips. On the other hand, diabetes is a chronic disease that occurs when the pancreas is unable to produce the right amount of insulin or when the body cannot use effectively the insulin that it produces, resulting to the inability of the body to break down glucose into energy. Type 2- diabetes is often associated with lifestyle factors such as poor diet, lack of physical activity, overweight or blood pressure. According to Cardol, Rijken, & Van Schrojenstein Lantman-de Valk (2012), type 2 diabetes is common in people with intellectual disability due to their poor diet and lack of physical activity.
People with intellectual disability, Down syndrome and type 2 diabetes (just like the man in the case study) face health challenges such as becoming overweight due to physical inactivity, feel lethargic most of the time, experience mood swings, skin infections, always feeling hungry, experience leg cramps, may sometimes behave awkwardly in social gatherings, have difficulty in planning and organising their daily life and experience difficulty with academic learning (Diabetes Australia, 2013; Tracy, 2012). They are also at risk of getting gum disease and dental problems, infections and emotional problems due to the co-existing Down syndrome (NIH, 2014). The potential impact of these health challenges on the health of the patient may include frequent hospitalisation and body impairments, thus limiting his physical activities and restricting his participation in life situations (Goddard et al., 2008).
The man’s (case study) activity and participation across his lifespan is affected because of his intellectual disability and diabetes. The ICF model will be used to illustrate the effect of his health condition to his activity and participation across his lifespan:
The man has Down syndrome, intellectual disability and type 2- diabetes. Because of this health condition, his body functions and structures are impaired. Impairments refer to the problems in body functions (physiological and psychological) and body structures (parts of the body such as limbs, organs and their components) that cause a loss or significant abnormality (Wilson, n.d.). Hence, for the man in the case study, the body functions that are most likely to be impaired are his mental functions, functions of the cardiovascular, haemotological, immunological and respiratory, functions of the digestive, metabolic and endocrine system, neuromusculosketal and movement-related functions and functions of the skin and related structures. For the body structures, the most likely to get impaired due to his current health status are the structures of the cardiovascular, immunological and respiratory system, structures related to the digestive, metabolic and endocrine system, structures related to movement and skin and related structures. The impairment of these body functions and body structures will lead to the decreased in the person’s activities and participation in his life’s situations.
Although the man may not be totally disabled, the potential impairment of his body functions and body structures could result to the limiting of his execution of activities/tasks or his involvement in a life situation. He may have difficulties in learning and applying knowledge, restricted participation in general tasks and demands, difficulties in mobility and self-care, difficulties in interpersonal interactions and relationships, controlled participation in major life areas and restricted participation in community, social and civic life.
The environmental factors are the social, physical and attitudinal environment in which the man lives and conduct his life. However, these environmental factors can either serve as a barrier or a facilitator to the man’s functioning. For example, if his social environment such as his friends and family are not supportive and would not provide him training to manage self-care or lifestyle changes then the environmental factor serves as barrier. However, if his social environment provides him training to self-care, supports him to achieve lifestyle changes or provides him broader social relationships to include neighbors and more friends in the community, then the environmental factor becomes a facilitator of man’s functioning.
Managing type 2 – diabetes requires lifestyle changes and ongoing coordination by the patient to his healthcare provider. This is quite tasking if the patient has co-existing chronic illnesses such as presented in the case study and is not given proper support by his environmental factors. Although management of diabetes can be done even at home, it takes a good bunch of support for a patient to fully adopt lifestyle changes and deal with the psychosocial and medical consequences of the health condition (Cardol et al., 2012). Health literacy is one skill that should be taught to patients with type 2- diabetes because it is vital in managing self-care such as interpreting blood sugar values, reading labels on medicine bottles, reading educational brochures, injecting insulin or doing a blood test (Tripp-Reimer, Choi, Kelley & Enslein, 2001). Since type 2- diabetes can be controlled, the community nurse can do a holistic approach by encouraging patient to take a more active role through self-management practice and taking some personal control on choices over daily activities. Proper disease education should be given to patients so they will know what daily activities are essential to the management of their illness and achieving quality life. It is also through the disease education that patients can enhance their self-management skills and encourage less dependence on healthcare providers (Cardol et al., 2012).
As a community nurse, I can adapt this strategy/intervention by emphasising in the health literacy the importance of lifestyle changes in terms of taking medication, food intake and physical activities. According to Cardol et al. (2012), diabetes patients with Intellectual Disability and diabetes patients without Intellectual Disability are both aware that diabetes is a serious disease specifically if one is already required to take insulin. They also both know what food to eat and what food they could not but still they are put in a situation where knowing versus doing becomes difficult to act on. Hence, as a community nurse, I will emphasise on building the patient’s self-efficacy through small steps till he becomes accustomed to the change and improve his intake of the right foods such as whole grains (Rizvi, 2009). Further, I would encourage the consumption of adequate amounts of dietary fiber from plant foods such as vegetables, low intake of fruits, adequate amounts of whole and high-fiber grain products and legumes. These plant foods have fewer calories, refined sugar, fat and rich in micronutrients and nonnutritive ingredients that provide extra health benefits. A meal that is fiber rich is processed more slowly in the gastrointestinal tract and therefore promotes fullness. The beneficial features of the high-fiber diet promote the prevention and treatment of cardiovascular disease, obesity and type 2- diabetes (Rizvi, 2009). Further, I will encourage the patient to engage in a moderate intensity physical activity such as brisk walking regularly to prevent inactivity.
Moderate intellectual disability with co-existing type-2 diabetes is a chronic condition that affects the patient’s entire life span. However, these two illnesses are manageable and a community nurse can ensure optimal health and wellbeing of the patient through the holistic approach of providing disease education to the patient and his family. The ICF model is a valuable tool that a community nurse can use in illustrating the effects of the health condition of the patient in relation to his activity and participation in life situation. People with moderate intellectual disability may have difficulties in learning and processing information but given proper support, the patient can be trained over time.
Critical Response Paper
Question: As Malala Yousafzai recently attested before the UN, the pursuit of education is
far too often a life-threatening endeavor for girls throughout the “developing”
world. Why is education often perceived as dangerous or irrelevant for girls? What seems to be the result when girls are “tracked” into designated “female” fields of study, as in Iran? Taking into account Sen’s perspective on development as a practice of freedom, how might education be re-imagined in the “developing” world to maximize women’s freedom?
The pursuit for education in some countries could be life-threatening but the courage that Malala Yousafzai showed manifests the characteristics of a new woman of the world because she was able to overcome her weaknesses and hopelessness and embraced a new courage and determination to pursue education against all odds.Malala Yousafzai’s speech before the UN describes the awakening of women in distressed countries who are capable of voicing-out their opinions and fighting for their rights to education and fair treatment. Malala’s concerns are not about revenge or fighting back but for girls to be given the chance to enjoy their right to equality of opportunity which is achievable through education. Though the right for education is available in Pakistan, Malala and the other girls out there still had to risk their lives before they can enjoy that right. The perception that education is dangerous and irrelevant for girls stem from the terrorists belief that the “the pen is mightier than sword” and education will empower women to seek for change and equality in treatment and opportunities (BBC, 2013). And this scenario frightens the extremists because they do not want change and they do not want women to have equal rights as men in the society.
Moreover, the fear of the Taliban against education maybe because they are too conservative to accept the changes in the developing world and they are scared to face the fact that women could outperform them in every field of endeavors. This may sound egoistic but that seems to be the case and they are pursuing it by twisting the doctrines of Islam to serve their personal interests. The Taliban rule insists that Islam women are prohibited from pursuing education because their place is in their homes as the “manager and master of the house” (Mehran, 2003). They refuse to acknowledge that according to the Islamic Republic, women have dual roles – primarily as mothers and wives and as responsible members of the society who can contribute to national progress (Mehran, 2003). In addition, they also ignore the Islamic tradition that parents have the responsibility to educate their daughters to achieve her maximum potentials (Esfandiari, 2012).
What is happening in Iran is the government’s concealed move to curtail women’s education. Although the government is not vocal in its discouragement, they leave it to the universities to implement the new policy. The barring of 36 Iranian universities for women to enroll in 77 academic fields such as Accounting, Chemistry, Commerce, Engineering and Education is the universities’ move to follow the quota system which favors men (Esfandiari, 2012). However, the Iranian government’s reason that the move was to Islamize the educational system maybe reasonable because although they have implemented the gender segregation and streamlined the courses that women could take, they still continue to allow the women to pursue education.
The choice of courses for women maybe limited but such courses in Nutrition, Health, Sewing, Cooking, Knitting and Handicrafts are all valuable fields of study in preparation for their future roles as good mothers and wives. People in the West or other non-Islam countries may not like this “study limitation” but the post-revolution Iran has its own perception of what a good Islam woman is and how to mold their girls into becoming one in the future. Since most of their people are Islam who follows their own doctrines and traditions, it would be better to let them do their own thing as long as they are not depriving their girls the right to education and the equality to opportunities. It may sound futile to study courses that will only prepare a woman to become future wives and mothers but it is worth considering that courses such as Sewing, Cooking, Knitting, Nutrition, Health and Handicrafts do not end-up only in homes but could provide women with opportunities for employment. Courses in Nutrition and Health could make girls as future doctors or nutritionists. Moreover, courses in Cooking, Sewing, Knitting and Handicrafts could provide girls opportunities to become entrepreneurs, cooking guru or educators on that field.
Taking into consideration Amartya Sen’s (1990) view on development as a practice of freedom, education can maximize women’s freedom in the “developing” world because she can have access to her rights because of her financial independence. It is a fact that a woman increases her status if she is financially stable, able to acquire properties and capable of deciding on her own because she does not need the approval of others. However, being financially independent is most likely to achieve if a woman was educated. But considering the plight of girls in distressed countries such as Afghanistan and Pakistan, depriving them of education will only lead to their continued struggle for respect, equal opportunities, and freedom of choice when it comes to marriage.
There was a time when being uneducated was not a hindrance to getting employment; however, that time has long gone and the global world shuns a person who does not even know how to read and write. Most likely, these uneducated will end-up in odd jobs that require strength but pay low, or for the girls, sex work is the easiest job. And being trapped in these types of work, especially sex work will only make their lives worse, except when luck strikes and someone saves her from that predicament. Illiteracy most of the time leads girls to limited employment opportunities and low bargaining position for her rights and basic necessities (Nussbaum, 2004).
A girl who is not educated will not even have the courage to file legal cases because of her ignorance of her rights and lacks the basic skill to file the complaint. She will not even have the courage to voice-out her refusal to marry at ten years old for the fear of being disowned and alone. Even if she works hard all day in the house, her efforts will not be noticed because of the common belief that she needs to work for her food. However, if she has a “gainful employment”, if she works outside of her home and earns money, all her efforts will be properly compensated. But gaining “decent” employment will not be that easy if she lacks the education required to qualify for the job.
Hence, due to her inability to qualify for work, she may not be entitled to her freedom of choice, freedom to voice-out opinions, freedom to refuse and freedom to be treated equal. Even in the country’s political struggle, a woman can only exercise her freedom to vote if she knows how to read and write. Although fingerprints are acceptable now in some countries in lieu of the person’s signature, it is still imperative that a woman at least knows how to read.
Critical reflection of an ethical situation
What was your initial reaction to the situation?
My initial reaction to the situation was to feel sorry for both the patient and his family. Both parties have the right to know the real health condition of the patient, but since the patient’s choice is to keep it secret from his family, the nurse has no choice but to respect the patient’s decision.
Identify what you feel is the ethical dilemma/situation from the scenario
The ethical dilemma in the scenario is the decision of the patient, Mr. M to keep from his family his devastating health condition. The nurse is caught in the situation where she is at a loss on how to convince the patient to inform his family regarding his health. The nurse is in an ethical dilemma of trying to maintain her honesty and fairness to everybody whilst upholding the rights of the patient to his own choice and confidentiality (College of Nurses of Ontario 2009).
What are the client’s values, wishes or beliefs in this situation? Consider cultural beliefs.
The patient’s wish is to keep his real health condition from the knowledge of his family. He wishes this because of his beliefs that keeping his family uninformed of his real health condition will also keep them from worries and pains that go with the thought of losing a family member due to a terminal cancer. This belief comes from the cultural belief that “what you don’t know won’t hurt you”. The client patient holds a strong value of being not a burden to anyone, be it in a form of physical burden or emotional burden.
What personal values or beliefs were in question during this situation?
The personal values or beliefs that were in question are the values of respect for life, maintaining commitments, patient well-being, truthfulness, patient choice, fairness and privacy and confidentiality (College of Nurses of Ontario 2009).
Identify and discuss 2 nursing ethical values that were in question in this situation. Refer to the CNO Ethics Standard to identify these values.
The two nursing ethical values that were in question in the situation are client choice and respect for life. Client choice refers to the right of a person to make choices, including giving consent or refusal of care. Every person has his own values, wishes and beliefs and when faced in a dilemma, he has the right to exercise his own choice of what is best for him. However, in the field of nursing, nurses are informed that there are certain limitations in following a client’s choice. One, it is beyond the limit if a client patient chooses to risk the safety of others. Also, a client choice is restricted if his choice involves the promotion of restricted policies such as smoking, drugs and the likes. Moreover, practices that are illegal in Canada or Ontario are also restricted to be followed. In cases like these, nurses are not obliged to heed the client-patient’s choice. In the case study, the choice of the patient to keep his real health condition secret from his family does not fall in any of the limitations (College of Nurses of Ontorio 2009).
Another is respect for life. Life is so precious and needs to be protected, treated fairly and respected (Keyserlingk 1979). It includes the considerations of having a good quality of life; however, there are some instances when a person has different expectations of what a quality life is for him. Although nurses have their own perception of what a quality life is, sometimes their personal beliefs do not coincide with the patient’s. In cases like this, when the nurse feels that her personal beliefs conflict with that of the patient’s, then she is advised to request for a replacement and withdraw from providing care for the particular patient(College of Nurses of Ontorio 2009).
What are some possible options to resolve this ethical situation? Identify at least 2 options.
One of the options in resolving this ethical situation is to compassionately tell the patient that it will be for everybody’s good if the family will be informed of his true health condition. If the patient still does not comply and the nurse feels that the client’s view conflicts with her own personal values and the situation hinders her from caring further to the client, then the nurse should request for a replacement who can be more effective in handling the situation. In cases where there is no replacement, the nurse should continue to administer care for the patient whilst she is informing her employers of the situation. It is now up to the employers to act on the matter and decide on what should be the best and fitting management strategy in handling the dilemma/situation (College of Nurses of Ontario 2009; Ham 2004).
Another option would be to completely respect the patient’s choice. Part of the rights of the patient is his right for privacy and confidentiality and the right of choice. If the patient’s beliefs and values dictate that it is the best option not to inform his family about his real condition to avoid extending to them the misery and pain that he is suffering, then it should be respected. Anyway, eventually his true condition will be revealed to his family because his health will continuously deteriorate as time pass by. In that event, probably the patient will realize that he needs to say goodbye to his family and his family to him, as well. When that time comes, the initiative to inform his family of his real condition will be coming from the patient himself.
What are the ethical and/or legal responsibilities in this situation as the RPN? Please refer to the CNO ethics standards or guidelines that may relate to this situation to guide your understanding of it and your role.
The article of Towle & Godolphin (2011) regarding the neglect in the chronic disease self-management in medical education is awakening because it reveals the need to align medical education to the changes in the medical needs of people. It is true that as the population ages and the people live longer, the occurrence and complexity of chronic illnesses increase. The authors’ arguments are supported with statistics; however, they forgot to identify in particular the chronic illnesses that the people are suffering from. Identifying some of the commonly-known examples of chronic diseases will provide more clarity in the presentation of facts and will help the readers relate to what is being discussed.
The authors aim to both inform and persuade the people and the authorities about the neglect that is happening in the medical education. In their intention to inform, they have quite presented their arguments accurately, openly and with consistency using statistics and evidence-based literatures. Meanwhile, in their intention to persuade, they tried to appeal to the emotions of the readers by enumerating the reasons for the need to involve patients as educators. Further, the authors are both credible as they are both doctors and professors at the University of British Columbia, an indication that they are experts of the topic being discussed.
The authors’ argument that to address the increasing health problem of chronic disease management is by embracing the concept of making the patients and their families as partners in education because they are “experts by experience” is logical. People who have been dealing with the same health problem such as HIV and Chronic Kidney Disease for long term know that they can only control the disease but not totally cure it so they have gained expertise in managing the disease and learned to “live with it”.
Further, the authors were truthful in claiming that patients with chronic illnesses have important experiences that can help in enriching medical education at all levels but these are only sporadic and would require enthusiasts and external funding to materialise. The neglect to be properly addressed will need more than “experts by experience”. It will need a systematic approach and institutional commitment that acknowledge the values of patients as educators.
Though the authors have presented their arguments and supporting facts, the article still needs more evidence to show that there is more studies about acute diseases than chronic diseases, causing them to conclude that there is an ‘ongoing neglect’ on the latter. Further, the article would have been more convincing had the authors presented more evidences about the context of a partnership relationship between patients and professionals. Also, the article failed to present an actual study about a medical education involving patients as educators; what they have presented are examples of initiatives done in the United Kingdom and North America.
However, the article’s strength is the realisation that there is a wide gap in the understanding of CDSM between the health professionals and patients. This is a major realisation because it entails that the two parties involved have differing perceptions about a single concept. This realisation is fundamental in detailing the roles of the professionals and the patients and in determining the aims and missions of the medical education if pushed through.
Overall, the authors were successful in informing the public and the authorities about the ongoing neglect whilst at the same time, were able to persuade the readers that patients with chronic diseases could help in medical education by becoming ‘experts by experience’.
Critical Analysis of Teaching Materials
The ability to critically analyse teaching materials intended for English for Academic Purposes (EAP) is significant in training students using English language for study. Since instructions are usually written in English, having a good understanding of the teaching materials will give teachers a better advantage in teaching.
This report will analyse three teaching materials, namely, English for Academic Purposes by Cathy Cox and David Hill, Cambridge Academic English by Craig Thaine and Gateways to Academic Writing by Alan Meyers. These materials will be analysed to identify their specific audiences (language level, level of study and general disciplinary focus), and the academic skills selected for attention. Further, the suitability of the features selected for subjects, genres and language to their target audiences will be evaluated before finally concluding.
Cox, C. & Hill, D. (2004). English for Academic Purposes. Pearson Education Australia
This particular teaching material is intended for students who are currently in higher education or aspiring to go to higher education after their EAP course. Students are taking EAP not just for the sake of learning the English language but also to address the need to learn and use the English language to succeed in their academic careers (Gillett, 2000). The audience for this teaching material is adults aged 18 and above. It uses simple English and the instructions are easy to follow so this could be used by students who have English as secondary language (ESL). The teaching material is composed of different sections, where every section provides a different learning. It has sections for testing academic reading and listening; and sections that encourage the use of speaking, writing and critical thinking skills. Though the teaching material uses simple English and easy to follow instructions, the level of study is generally for the undergraduates. However, its section involving the need to write a research report and to critically analyse an article report of a research, could also be aimed at postgraduate students. Its general disciplinary focus is on Arts and Sciences where the learner uses the English language in understanding instructions and findings, critically analysing research outcomes and enhancing creativity to perform a mini-research.
The language used is concise and the information is densely packed. It encourages the expounding of the word in its exercises involving giving of definition or description to a word, i.e. family. Instead of just asking for the definition of family, the exercise in the teaching material requires the student to include other details that define the word family such as the relationships, are they living together, are they communicating and if they share the same culture. Moreover, it goes down to include information of what a normal family is and other researches of known authors about family. This is achieved through the use of increased nominalisation, increased lexical density and increased abstraction, thus, resulting to increased length of sentence (Veel, 1997).
Veel (1997) defines nomalisation as the “process by which events, qualities and relationships come to be represented not as verbs, adverbs or conjunctions, but as things, nouns”. On the other hand, lexical density refers to the compactness of the information in the grammatical structure (Schleppegrell, 2004). Abstraction involves the use of technical words (such as in research reports) and gives emphasis on non-concrete entities such as notions, concepts, ideas and facts. It sequences arguments, exposition and nomalisation (Schleppegrell, 2004). The research article which was included in the teaching material and to be critically analysed by the students, contain argument, explanation of the methods used, findings, conclusion and recommendations. This article also serves as the guide in the student’s next task of creating his own mini-research.
The subject treated in the teaching material is English for Academic Purposes (EAP) and this subject is suited to academic analysis. Moreover, the academic writers, Cox & Hill, construct the voice textually by providing their views on how research can be constructed (Ivanic & Camps, 2001). The genres are staged as meanings are made in steps. Texts are connected to contexts through genre because the writers make choices regarding purpose and structure. It uses procedure by providing instructions on how the goals are done. Since the teaching material is a textbook, the information presented is most likely to be widely accepted because it is assumed that all information is revealed as categorical fact.
In this age of technology, change is inevitable and modifications in healthcare systems are significant in ensuring optimum health outcomes. In providing healthcare services, the use of paper-based documentation has been the practice but the recent introduction of digital health initiatives paved the way to the use of computer-based records. Though some literatures suggest that the use of combined paper-based documentation and digital interventions could result to more benefits, further studies are still needed for its reliability (Shaw, Hines & Carroll, 2018). This paper will critically analyse the case of shifting from paper-based documentation to computer-based records which I had experienced whilst working at an aged care facility. I will critique on the impact of the change to the nurse’s performance as well as on his/her learning absorptions. Moreover, I will find the gaps in the transition between the paper-based documentation and digitalised healthcare record when health professionals are educated. I will also apply the knowledge of the Kolb’s learning theory into my case study and suggest recommendations that will help learners to smoothly transit from the traditional to the modern method of documenting health records.
Whilst working at an aged care facility, I experienced dealing with a number of policy changes. One of those was the new neuro observation policy where the original paper-based documentation was changed into a computer-based care system. During the handover, I was given a leaflet explaining how to update the information into the new system. However, I experienced difficulties in typing-in the data into the system, resulting to my perception that there was a mismatch in the presentation of the new policy. I also realised that updating the health policy would require a number of requirements for the registered staff to perfect the implementation. I also reflected that trainings and monitoring are key to the successful transition.
The Electronic Health Record (EHR) refers to the patient’s stored medical information, including the computerised entry of the physician’s order and the decision support assistance for the patient’s good quality care (Joukes et al., 2016). Though it seems to provide easier access to patient’s health information, earlier studies show that implementing a new EHR could lead to both enhanced (Buntin et al., 2011) and reduced quality of care (Mohan, 2013). This is due to the fact that the new EHR is not a simple technical project but more of a socio-technical task because it requires the active involvement of the end-users (nurses) as well as the organisation. Hence, it is very vital that the end-users are educated on the process to maximise the chances of positive change (Joukes et al., 2016).
Furthermore, the use of electronic systems in aged care facilities is aimed towards improving the quality of documentation, information handling, and saving time; but the study made by Wang, Yu & Hailey (2015) showed that it was no better as compared to the paper-based system. This was because their study showed that the nurses had the tendency to change the terms used in the paper-based documentation such as ‘diagnosis’ or ‘nursing problem’ into ‘observation’ when using the computer-based system. The omission of the diagnosis or nursing problem in the computer-based system documentation could affect the qualitative aspect of the care plan and other factors that need to be understood. Meanwhile, in the study made by Meibner & Schnepp (2014), the results showed that in implementing the shift from paper-based to electronic system required the nurse’s know-how in IT since the process needed a different type of processing of information. Hence, the success of this implementation is dependent on the end-users’ IT experience. If the nurses find it difficult to encode health information, then the implementation would result to poor clinical documentation. However, improving the quality of data encoding could result to better documentation and improved quality of care. The more IT experience the nurses have, the better their chances of gaining benefits and overall improvement. However, Munyisia, Hailey & Yu (2012) state that the health care workers in a nursing home find it more comfortable using the computer-based documentation over the paper-based after six months of continuous use. This suggests that the success of implementing computer-based documentation depends on the familiarity of the health caregivers. The study found that six months of continued practice is relatively mature. However, perceived improvements were not consistently maintained after 18 or 31 months and they theorised that to realise the most of the benefits of the new system required more training and education for the end-users.
The different studies I have mentioned reflect that the success or failure of the transition is dependent on the skills of the end-users (nurses) to implement the computer-based care documentation. In this regard, education and IT training are highly important in realising the perceived benefits of using the electronic system. And in doing so, applying the knowledge of the Kolb’s learning theory is beneficial in the education of the end-users. Kolb’s theory recognises that there are four phases in the cyclical learning process, namely, concrete experience, reflective observation, abstract conceptualisation and active experimentation (Kolb, 2014). Having the actual experience to perform the encoding of health care information to the computer-based documentation system will provide the nurse to have a feel of the situation and the understanding of how it is done. It will also provide the nurse the impression of the degree of difficulty of the new system, even in following the computerised treatment orders of the doctors. In the second stage, the nurse gets to reflect back about the new experience and develops an understanding about the differences and advantages of paper-based documentation and computer-based care system. The third stage of the cycle is abstract conceptualisation where the nurse develops a new idea based on the reflection he/she made about the new experience. This is also the stage where the nurse conceptualises new idea or modifications that she thinks will help in ensuring that he/she can perform the new computer-based care system and take advantage of its promised benefits. In the fourth stage, which is active experimentation, the nurse or the learner can think of a plan on how to use the computer-based care system for an upcoming experience. The learner uses the new system to all their patients and sees how it would turn out – whether it will simplify their operations or would just complicate things and not realise the promised benefits; or would just result in another new experiences. Based on Kolb’s theory, effective learning happens when the learner progresses through the cycle of having an actual experience, then followed by reflection and understanding of the experience, leading to the learner’s formation of theories and conclusions, which eventually are then used to try the system in future circumstances, resulting in the creation of new experiences (Kolb, 2014). Hence, it is really vital that the learners are tasked to perform the new system so they can assess its useability as well as its importance in helping them become more efficient and effective as healthcare workers. Through time, their continuous use of the system will give them the ideas on how to further improve the process to reach the organisation’s goals.
With the growing needs in the medical industry to document health care information, the computer-based care system is such a relief for better delivery of health services. However, Lippincott Nursing Education (2017) reveals that the success of the transition depends on the ability of the nurses to use the computer-based care system efficiently and effectively. And with so many nursing graduates with minimum experience of using the new system entering the healthcare workforce, the potential of errors, additional costs and longer period of transition time are higher. Based on a quantitative descriptive study conducted by Miller et al. (2014), there are 13 gaps on why novice nurses experience difficulty in using EHR when integrated into the workplace and these do not include email use, presentation development, search engine usage or word processing, where most new nurses were seen as strong. The 13 gaps in the skills needed for the electronic health record system were data entry, spreadsheet development, medication administration, graphics documentation and tracking, lab results retrieval, documentation, diagnostics results retrieval, treatment documentation, patient education documentation, accessing electronic charts contents, patient education material retrieval, accessing prior admission data, discharge planning documentation and updates and care plan development and updates (Miller et al., 2014). Just the mere titles of the area of skills suggest complexity that really needs trainings and additional education. This explains why the transition from the paper-based documentation system into computer-based documentation care system would take a while because aside from being technical, these also need connection with other departments. The novice nurses may have the fundamental IT know-how but that would not be enough as the new system requires practical experience (Lippincott Nursing Education, 2017). However, these gaps in the transition can be narrowed if the health professionals are trained and educated on these areas.
To provide the new nurses smooth transit from the paper-based documentation system into computer-based documentation care system, the organisation should always consider on-site trainings so they can perform the skill of using the new system correctly on a regular basis. There should be enough resources for continuous education in place that can be consulted from time to time until the learners reach their mastery. The knowledgeable RNs in the organisation who are well versed of informatics as well as the new system should be made available for support for the new learners. It is also wise if the organisation would adjust the workload of the learners so they can have time to fully comprehend the new system. It is also significant to include IT courses in the nursing curriculum to make the transition time, as well as training time, shorter. Providing health organisations IT expert educators will also hasten the transition because the trainings and continuous education of the learners will be done on a more regular basis. Moreover, the management should promote the spirit of personal commitment on the part of the nurse (learner) and deepen their professional interest (Rassin, Kurzweil & Maoz, 2015). Applying the Kolb’s learning theory, the learners can learn and understand deeper if they are provided with practical connection, then allowing them to reflect and actually do what they have learned in a real-life setting. In this way, their learning will remain because they exactly know how to do it and how to do it right. In cases where the nurses had no informatics knowledge prior to his/her entry, the employers should have the infrastructure program to help the nurse be EHR-ready. The program should be in a form of a classroom where the new employees can have time to study and learn about the new system. It is also wise to provide valuable supervisor support for the learners on their respective nursing units.
The Kolb’s learning theory signifies that a learner can better absorb learning if he/she progresses through the holistic cycle of having an actual experience, then reflection and understanding of the experience, resulting to his/her formation of theories and conclusions which he/she can try in future circumstances to create new experiences. Majority of the studies I have mentioned earlier pointed to the fact that the success or failure of the transition of paper-based documentation into computer-based documentation care depends on the skill of the learners (nurses) to implement the new system correctly. And Meibner & Schnepp (2014) state that the learner’s knowledge in IT and Informatics will influence and expedite learning of the new system as they already have the basic skills needed and will just have to train for the 13 gaps mentioned by Miller et.al. (2014). Overall, the learner’s smooth transit from the paper-based to digitalised system still boils down to continuous education and training support from the organisation. Without the organisation’s management support and personal commitment of the learner, achieving the promised benefits of the new system will always fail because it needs commitment, time and lesser workload to perfect the learning.
Cost effectiveness and educational policy
(1) What are the alternatives that the authors consider for comparison? Why are these considered to be appropriate alternatives? Which ones are most widely used? Are there others that you would consider? Why?
The alternatives that the author considered for comparison are lectures, discussion modes, personalized instruction and other modes. These alternatives are appropriate for comparison because these are the current methods used in teaching in schools. It is important that the cost effectiveness of the four types of teaching mode alternatives be compared to determine the costs against the effects or the outcomes of each method and which alternative provides the same level of outcomes but with least cost. Lectures and discussion modes are the ones that are most widely used, although they may have different costs and effects on education. However, each of the mode alternatives has its own advantages and disadvantages over others and not all students have the same pace of absorbing learning. Lectures may be valuable in presenting huge amount of information but the learnings could be easily forgotten by the students because they do not have direct participation as they are often in passive mode during lectures. On the other hand, discussions mode puts the students in an active mode as they directly interact and engage in the discussion of topics. It can also promote a democratic way of thinking and encourages self-expression. However, some students may be too shy to interact or some may be too engrossed that they could end up in heated debates and quarrelling. However, a study made by Hafezimoghadan et al. (2013) showed that the combination of lecture and discussions as against to the traditional discussions or lectures alone was preferred and significantly enjoyed by medical students although this preference did not improve their test scores. Personalized instructions, on the other hand, promotes higher student engagement as technology can be used in the instructions, but may not be generalizable to all students’ learning. I would still prefer the combination of lectures and discussions because this mode of teaching encourages reflective thinking, more student engagement and organized presentation of information.
2) How do Brown & Belfield estimate costs of the alternatives? Are their estimates complete? If not, why not? Do you see any biases?
Brown and Belfield estimated costs of the alternatives by using cost imputation and constructing a costing template for estimating costs. The cost items were broken down into ingredients or components, namely, cost for the time of the provider staff – including instructional time and material preparation – in making assessment and for induction. Other costs include software physical inputs, such as the learning materials, and the hardware physical inputs, such as overheads and premises. The cost for student effort (such as assembly of learning materials) was also considered as a cost ingredient.
All the resources needed in every alternative were estimated, such as the teacher’s reading/studying of the lecture for each study, or the use of ingredients, such as materials. The use of ingredients that could lead to the change of ingredients from lectures to independent study is expressed in units and each unit has corresponding prices. Even the additional time spent by the staff is priced appropriately using the assumed salary scale. There were also estimated prices for software and hardware physical inputs and the measurement of costs were rated as per participant and adjusted depending on the duration of each course. The estimated pricing was priced at current prices to produce a standard cost metric. It was also presumed that personalized instruction needs more resources for planning, staffing and instruction; independent study needs lesser instruction and more student efforts, and discussions mode needs more study efforts than lectures. They have also provided that the imputing cost for teaching staff should be 2/3 of costs, 1/10 for any curriculum materials and other support materials, and the remaining portions are for physical premises. These schematic facts guided the authors in attributing changes in costs to each mode alternative.
The estimates provided by the authors are complete as they have taken into consideration everything that needs to be measured in terms of costs. There seem to be no biases as every alternative was given consideration and every ingredient needed in undertaking the alternative was given the appropriate imputed costs. The methods used by the author are in parallel with Holland and Levin’s (2017) where all the ingredients or resources needed for the successful implementation of a strategy, in this case, alternative mode, must be determined and be given a dollar value. The costs identified by Brown and Belfield were based on real-life expenditures (ingredients) rather than generic descriptions. Knowing the cost metrics of a mode alternative could lead to a better guidance in decision making. These can also contribute in providing significant information in planning because it can identify and provide a better understanding on which costs are flexible and which are fixed (Holland and Levin, 2017).
3) How do Brown & Belfield estimate effectiveness of the alternatives? Is this measure of effectiveness appropriate? What would you add if the data were available? What method of analysis is used for determining effectiveness?
Brown and Belfield estimated the effectiveness of the alternatives by assessing the relative effectiveness of lectures using the 298 trials as documented by Bligh (2000). The measures were standardized using Cohen effect size, and in most cases, were calculated independently, often based on p-values. The review showed that 52% of the trials displayed no significant difference in terms of effectiveness between the other modes and lectures. It also revealed that only 27.2% of the trials indicated that lectures are more effective as compared to other modes; one-fifth or 20.8% of the trials showed that lectures are less-effective. Lectures also appeared as clearly more effective as compared to personalized instructions in 45 trials. Lectures also appeared as similarly effective to enquiry and discussion modes in 109 trials. In 40 trials, lectures and independent study showed equivalence in effectiveness. Lectures also appeared as more effective as compared to ‘other’ modes in 104 trials. Using the mean effect size and the fixed effects weighting for the adjustment of quality of each trial, three modes (personalized systems, discussion and independent study) appeared to be less effective as compared to lectures. Tests of statistical significance were also used to determine the effectivity of lectures to the other modes and the results showed that none among the other modes appeared to be an improvement on lectures.
However, I find the measure of effectiveness used by Brown and Belfield lacking and needs more method of evaluation to really measure the effectiveness of lectures as against the other modes, namely, discussion, personalized instruction and ‘other’ modes. It would be more helpful if studies reflecting students’ evaluation on the different mode alternatives were also reviewed, as well as studies that show students’ grades on exams on topics studied using lectures, discussions, personalized instructions and ‘other’ modes. Lake (2001) states that cognitive theory suggests that learning cannot be achieved by passive reception of information but only through the active involvement of students. This suggests that lectures are not enough to achieve better learning as the students could be in the passive mode when receiving information. Based on his study on medical students, their attentions during lectures appear high only in the first ten (10) to fifteen (15) minutes of the lecture and goes down abruptly thereafter. Furthermore, reviewing trials that depict the students’ exam grades on topics studied using the different modes can also indicate the measure of learning that the student gained using the different modes and the effectiveness of each mode alternative in learning retention.
If there were available data, qualitative data management and analysis could be a good way of analyzing the effectiveness of the mode alternatives. The collected information from qualitative research is converted to text and reviewed to check for patterns, either similarities or differences in the answers of the participants. Thus, repeated dislike or fondness of using the mode alternative can be grouped and coded as favoring one of the mode alternatives for effectiveness (Robson, 2001).
(4) What is the Brown & Belfield conclusion on cost-effectiveness? Do you agree with their conclusion? Where would you be cautious?
Brown and Belfield’s conclusion on cost-effectiveness suggests that lectures remain as the cost-effective mode of education in sharing information because of its being less costly than any other mode alternatives. Though ‘other’ mode seemed to be more effective than lectures in imparting information, it was still more costly. Personalized instruction appeared to be less effective and more costly. Independent study and discussion modes may be less costly than lectures but were also less effective. Overall, the studies showed that none of the other mode alternatives proved to be more cost-effective than lectures in sharing information and knowledge.
I do not totally agree with their conclusion because their costs were only imputed and therefore, not totally reflect the true costs as experienced in real-life scenarios. Furthermore, the experiment was small-scale; hence, its results may differ when tested in bigger environments. It is also debatable if the same cost-effective analysis can be generalizable to all courses as there may be other issues that might be raised especially if the course requires development of skills. Though Brown and Belfield’s conclusion was in parallel with Soper (2016), stating that the instructional methods such as lectures, self-study and teacher guided e-learning were equally effective in providing knowledge, yet they were not equal in terms of time and cost effectiveness. In Soper (2016) study, lecture was considered effective in providing knowledge but costly because of the fees of the teacher and the time spent by the student nurse just to hear the lecture. And to be present during the lecture would mean her absence to performing her multi-task duties in the hospital. Also, the cost-effectiveness of lectures may be limited to the students’ role as passive learners only. Their chances of developing their critical thinking skills could also be limited as they tend to just accept what their teachers lecture. In this mode of teaching, critical thinking is not promoted, as well as the students’ cognitive engagement. According to Schmidt et al. (2015), lectures mode of teaching is based on the idea that students acquire knowledge just by being told the information. Storytelling may good to others but not to everybody, especially to those who have poor attention span.
Higher education learning should not be limited to lectures as lecturing promotes the thinking that knowledge can be transmitted to other just by communicating and transmitting it. However, Schmidt et al. (2015) states that the human mind does not function as receiver and students need to do something with the data or information he gets so he can remember it and use it at some other time. To be totally cost-effective, the focus on the mode should not be limited to the imputed cost but also to the cost of not developing the students’ critical thinking skills in their acquisition of knowledge.
Constipation is one of the most common acute health problems experienced by people and one of the patients who presented at the outpatient department was Mrs. Fields, a 74-year old woman complaining about her difficulty to pass stools, mostly dry and hard, usually accompanied by abdominal cramps, feeling of unemptied bowel afterwards and bloated abdomen. When interviewed, she related that she seldom drinks water and rarely eats fruits and vegetables. She was diagnosed with constipation. This paper will critically explore the suppositions that dietary modifications are better first-line approaches in addressing constipation rather than the traditional pharmacologic approach, such as the use of fibre supplements and laxatives. Peer-reviewed articles written by credible authors will be used in undertaking the critical approach.
Description of Constipation
Selby & Corte (2010, p. 1) describe constipation as the consistent difficulty to move bowel, often eliminating dry and hard stools and with a feeling of unfinished emptying. The aetiology of constipation is varied although its main cause could be due to lack of physical activity and diet (Blekken et al.2016, p.2; Pieszak 2011, p. 1). Other causes are pregnancy, travel, overusing of laxatives, resisting the urge to defecate, irritable bowel syndrome with constipation, use of medications for pain, high blood pressure, depression, allergies and low calcium or iron; medical conditions such as stroke, intestinal blockage, diabetes, low thyroid hormones, health issues on pelvic floor muscles and colonic inertia (Sugerman 2013, p. 1416; Blekken et al. 2016, p. 2). The pathophysiology of constipation starts when colonic secretion is interceded through chloride channels resulting to a net reabsorption of fluid and electrolytes, causing the stools to stay in the colon longer than usual. When this happens, the stool becomes drier, developing into pebble-like stools as they will be pressed firmly together and become too large and hard to pass through the anal canal. For persons with cystic fibrosis, the cystic fibrosis transmembrane conductance regulator (CFTR) channel becomes non-functional, causing too dry stools and constipation (Andrews & Storr 2011, p. 16B). Colonic motility is induced by repetitive nonpropulsive contractions, causing the stool to move. Coordinated, larger contractions push the stool forward from the ascending colon towards the left colon. This high-amplitude propagated contractions (HAPCs) usually happens in the morning when the person wakes up and could be heightened or triggered by eating or drinking, causing the person to feel the urge to move his bowel at this time. However, if colonic motility happens at inappropriate time such as during sleep, where nocturnal bowel movement is not normal, the stool moves to the rectum, causing distention and the strong urge to eliminate waste. When the time is inappropriate (such as during sleep), the stool is stored in the rectum temporarily, causing the disappearance of the urge and propagating contractions. Adult’s colonic transit normally ranges from 20 h to 72 h. When the frequency of HAPCs is decreased, constipation occurs (Andrews & Storr 2011, p. 17B; Basilisco & Coletta 2013, p. 887).
The patient, Mrs. Fields, experienced difficult passing of stools that were hard and dry, had abdominal cramps, bloated abdomen and felt the sense of not-fully emptied bowel. It could be that the patient lacked water, thus, her colon did not receive sufficient amount of liquid to transport her waste materials to rectum, the part of body in-charge of expelling the stool (Andrews & Storr 2011, 16B).
Critical discussion of management strategies
Diet and lifestyle modification
Constipation can be managed in three ways: diet or lifestyle modification, behavioural modification and pharmacological interventions (Impact 2010, p. 25; Chang et al 2015, p. 1). One of the risk factors of constipation is diet-related; specifically, daily low intake of water (Mohamed & Hanafy 2013, p. 60). According to Markland et al. (2013, p. 796) increased liquid intake is a better intervention than physical exercise and dietary fibre in managing constipation. Based on their study, women are at more risk of constipation than men and those who consumed less total liquid in their diets were slightly associated with constipation as compared to those who have low intake of dietary fibre and have more physical activity. Those who have low intake of dietary fibre and have more physical activity were found to be not significantly associated with constipation. This finding was supported by Andrews & Storr (2011, p. 16B) stating that for the estimated 1.5L of liquid received by colon from the small intestine, around 200ml to 400ml are expelled in the stool, hence, defecation becomes inconvenient or difficult if the person is in dehydration state. Although Markland et al. (2013, p. 802) still believe that fibre, diet and exercise help in regular elimination of bowel, the results of their study where they used a validated scale in determining stool consistency convinced them that increased intake of liquids influenced stool consistency whilst fibre and exercise could have an effect on the frequency of elimination. However, Markland et al. (2013, p. 802) were not discounting the fact that their study had several limitations and future studies related to their findings are needed.
On the other hand, Yang, Wang, Zhou & Xu (2012, p. 7378) found that the intake of dietary fibre definitely increases stool frequency of persons having constipation; however, their findings also showed that dietary fibre has no effect on stool consistency, painful defecation and treatment success. Dietary fibres are that roughage in plant foods that the body cannot absorb or digest and pass unbroken through the stomach, small intestine and out of the body through the colon. Based on the meta-analysis that Yang et al. (2012, p. 7380) performed, intake of dietary fibre has significantly increased the number of stools of patient with constipation but not the stool consistency as 75% of the samples who were given dietary fibre or placebo still reported to experience hard stools. This study correlates with the observation of Markland et al. (2013, p. 802) that dietary fibre influences stool frequency but does not improve stool consistency.
However, Mena et al. (2013, p. 63) insist that the standard modification of diet alone is not enough in relieving constipation. Based on their study, there was a weak yet positive correlation amongst dietary fibre and frequency of defecation, as well as intake of fluids. The stool quantity was also positively associated with the intake of fluids and dietary fibre. However, constipation severity improved when linked to higher physical activity (Mena et al. 2013, p. 58). Although lack of physical activity contributes to constipation (Mena et al. 2013, p. 62), higher level of physical activity increases severity of constipation because of the increased need of the body to hydrate due to sweating brought by laborious exercises. Too much physical activity could lead to inadequate fluids in the body, thus, severing constipation. Furthermore, the results also showed no association between dietary factors in relation to constipation severity and stool consistency. This indicates that a person can still be constipated even with normal output volume and stool frequency. Therefore, the authors concluded that the standard dietary modification alone is not enough to provide sufficient relief of constipation. Though their study correlates with other studies mentioned above, further studies to confirm their findings on the roles of conventional physical activity and dietary in the relief of constipation, specifically, functional constipation (Mena et al. 2013, p. 63) should be made in the future. Furthermore, additional study should be made to confirm their finding that constipation severity increases with physical activity.
According to Khalil (2015, p. 1041), recurrence of constipation is high, hence, the need for education on behaviour and physical activity to reduce incidence of recurrence. Some of the identified risk factors associated with constipation were low intake of dietary fibre, positive family history, low birth weight, sedentary lifestyle and too much consumption of junk foods. The undigested fibres in the colon increase the stool output as well as the colonic transit. The aim of the study was to determine the effects of physical activity and life style in inhibiting the recurrence of functional constipation. The maintenance therapy included the use of laxatives and dietary interventions to ensure that bowel movements happen at normal intervals and through good evacuation (Freeman et al. 2014, p. 888; Orozeo 2012, p. 21). The dietary interventions include increased intake of fluids, fibres and carbohydrates. The sorbitol found in the juices of apples, pear and prune can increase water content of stools and frequency of stools. Parents were also provided dietary education, specifically the supplementation of fibre. Since relapse is common, hence, maintenance therapy was recommended, including the behavioural modification where the parents were provided person-to-person session on health education to improve their knowledge about constipation and change their practices and attitude in caring for their child. Some of the knowledge taught were the toilet training, which is sitting on the toilet for about 5 to 10 minutes 20 minutes after meals (Freeman, et al. 2014, p. 900); using proper toilet base, increasing physical activities for at least five (5) hours each week and monitoring the ‘successes’ and setting rewards for ‘successes’ (Khalil 2015, p. 1042).
The results of the study showed that the inclusion of health education, toilet training, physical activity and behaviour training report was effective in reducing the time element in treating constipation, less number of constipation recurrence and in increasing normal bowel habits. However, it was not significantly effective in reducing the use of stimulant medications nor statistically significantly effective in reducing the recurrence of constipation. But despite of its being not statistically significant, the study proved that the inclusion of medical and dietary protocols in the management of constipation has lessened the need for extra medication (Khalil 2015, p. 1045). Furthermore, the study correlates with other studies previously mentioned (Markland 2013, p. 802; Yang, Wang, Zhou & Xu (2012, p. 7378) on the association of dietary fibre, fluids and physical activity in the management of constipation (Bae 2014, p. 203). However, this study needs additional research to confirm its findings. Additional study on the use of health education on dietary fibres, fluids and physical activity should be done but must exclude the use of laxatives to determine the effectiveness of the non-pharmacological approach in managing recurrence of constipation.
The significance of providing education and counselling to families on the effects of withholding behaviours in achieving regular defecation and the importance of behaviour interventions (regular toileting and reward systems) (Freeman et al.2014, p. 889; Kopper et al. 2015, p. 349) was further explored by Nurko & Zimmerman (2014, p. 82). According to the authors, treatment of constipation starts with education. It is vital that parents know that faecal incontinence happens not because of voluntary defiance but due to the involuntary overflow of stool, which usually happens when there is too much stool retention in the rectum. This also happens when there is a presence of nerve malfunction due to over-straining when defecating. In modifying behaviour, parents were taught about regular toileting training where the child or any other person sits on the toilet bowl for five to 10 minutes after meals to train or encourage the rectum to expel waste at this time. However, the result of their study showed that in spite of the importance of behaviour modification in the management of constipation, it does not seem to contribute to the treatment success, except in cases where the patient has causal behaviour problems. In the end, the authors still suggested the use of increased dietary fibre intake to manage constipation and increase the likelihood of discontinuing the use of laxatives. However, additional and more improved study should be made on the relevance of toilet training to the management of constipation, specifically if not combined with dietary fibres and physical activity. Does toilet training contribute to stool frequency alone or does it also affect stool consistency?
Meanwhile, Portalatin & Winstead (2012, p. 12) agrees that lifestyle modifications and increased fibre and fluids should be the first-line management of constipation but in the event that these non-pharmacologic interventions do not treat the constipation, then laxatives should be included in the interventions (Franklin, Spain & Edlund 2012, p. 9; Tack & Lissmer 2009, p. 502; Rungsiprakarn et al. 2015, p. 1). However, the choice on the kind of laxative to use depends on whether the constipation is considered normal transit or slow transit (Dinning et al. 2011, p. 121). Portalatin & Winstead’s (2012, p. 12) journal article was comprehensive and was able to meet its aim of providing its readers a comprehensive summary of the different options available for the management of constipation – starting from the conservative approach (dietary fibres, fluids and lifestyle manoeuvres) to the different pharmacological interventions available such as the bulk laxatives, stimulant laxatives, stool softeners, enemas and suppositories, prokinetic agents, chloride channel activator, peripheral u-opioid antagonists, other newer agents available in the market and other alternative treatments such as anorectal biofeedback and defecation training. However, its limitations include minimal studies to refer to that used the medications. Furthermore, it did not enumerate the limitations of each of the medical interventions and the possible negative effects if used for long term. Though the article is quite informative, additional study should be made to further discuss each interventions, its limitations and effectiveness.
Identify and briefly explain the structural and functional changes that occur in the kidneys as Chronic Renal Failure develops.
Chronic renal failure is described as an irreversible, slow but progressive process that develops over a period of time and caused by many diseases that destroy the nephron mass of the kidneys. It starts from gradual to lifetime loss of kidney function, most of the time, over months to years. When the kidney function is lost, buildup of waste, water and toxic substances in the body that are usually expelled by the kidney occurs. Moreover, the inability of the kidney to function results to other health problems such as bone diseases, anemia, acidosis, disorders of fatty acids and cholesterol and blood pressure (DeRossi & Cohen, 2008; Kathuria, 2013). The process may be too slow that symptoms are not felt until the function of the kidney is less than one-tenth of the normal utility (Carroll, 2006).
Due to the build-up of waste products and fluid in the body, chronic kidney disease affects body functions and systems such as the production of red blood cell, vitamin D, control of blood pressure and bone health. These lead to the development of complications such as anemia, bone disease, high blood, fluid retention and metabolic acidosis (Upadhyay et al, 2011; Cibulka & Racele, 2011). Chronic kidney disease is sometimes difficult to detect because some of its early symptoms are also experienced in other diseases. The symptoms include fatigue, headaches, loss of appetite, dry skin, itching, unexplained weight loss and nausea. When kidney function gets worse, other symptoms may present such as abnormal light or dark skin, drowsiness, bone pain, confusion, concentration problems, cramps, bad breath, numbness, blood in the stool, easy bruising, unusual thirsting, swelling of hands and feet, shortness of breath, sleep problems, hiccups, decreased level of sexual interest, cessation of menstruation, and metallic taste in the mouth (Wexner Medical Center, 2013; Abboud & Henrich, 2010).
There are 5 stages of chronic kidney disease, each stage showing increasing severity starting from slight kidney damage with normal filtration, mild decrease in kidney function, moderate decrease, severe decrease and the last stage is kidney failure (Carroll, 2006). The fifth stage is considered as the end stage where the kidneys reach almost total loss of function and there is dangerous buildup of water, toxic substances and waste and the patient needs transplantation or dialysis to survive (Kathuria, 2013). Moreover, it was observed that patients with chronic kidney disease have altered salivary composition; urea and bicarbonate are linked with taste changes and found to effect food consumption especially protein-rich foods. Studies show that CKD patients have lesser ability in perceiving umami, sour and bitter tastes (Tomas et al, 2008).
Although there is no certain cure for CKD, the Renal Replacement therapies that patients undergo aim to slowdown the progress of the disease, manage the basic causes and contributing factors, treat complications and replace lost kidney function (Kenny, 2012). To slow the progress of the disease, it is necessary to control the patient’s blood glucose, high blood pressure and diet. However, diet control must be done under consultation with a dietitian and medical practitioner.
Explain why Rolcaltrol and Epoetin are used in the management of chronic renal failure and how they moderate this renal dysfunction
Rolcaltrol and Epoetin are used in treating chronic renal failure. Rolcaltrol is an artificial Vitamin D equivalent which is found to be effective in the absorption of calcium from the gastrointestinal tract and its consumption in the body. Due to the build-up of waste products and fluid in the body, chronic kidney disease affects body functions and systems such as the production of vitamin D which is essential in the absorption of calcium in the body. Vitamin D is responsible for the building and maintenance of sturdy bones, keeping the proper level of calcium in the blood, preventing bones from becoming malformed or weak, keeping the right level of phosphorous in the blood and preventing osteomalacia in grown-ups and rickets in children (Dorough & Colman, 2013). Due to the inability of people with CKD to activate vitamin D in the kidney, vitamin D supplements are helpful.
A nursing implication when caring for a person with an acute exacerbation of heart failure is the need to manage fluid volume excess.
Explain the pathogenesis that leads to fluid volume excess when a person has developed an acute exacerbation of chronic heart failure
The pathogenesis that leads to fluid volume excess starts with sodium retention. A person may develop an acute exacerbation of chronic heart failure if he has increased total body sodium resulting to a progressive ventricular dysfunction due to volume overload. Too much sodium prevents the Na+ pump/Na+-ATPase of arterial and arteriolar vascular smooth muscle cells stimulating the sodium-calcium exchanger (Bart, 2009). This results to increasing intracellular calcium levels and vasoconstriction and decreasing the synthesis of nitric oxide. Further, sodium retention increases levels of asymmetrical dimenthl L-arginine, an endogenous inhibitor of nitric oxide production (Bart, 2009).
Due to the retention of sodium in the body that obligatory water accumulates, leading to increased extracellular fluid volume and increased pressures on both left and right sides of the heart. When the heart decreases its ability to pump blood to the body efficiently, it backs-up into the veins that carry blood through the lungs to the left side of the heart. When the pressure in these blood vessels increase, the fluid is pushed into the alveoli (air spaces) in the lungs, which eventually decreases the movement of oxygen through the lungs, causing shortness of breath (Mathay & Martin, 2010). Pulmonary congestion causes elevated left-sided pressures, which can be recognised with symptoms such as rales, dyspnea on exertion, cough and through radiographic findings (Bart, 2009).
b) Discuss two nursing strategies used to manage pulmonary oedema, a consequence of fluid volume excess and provide evidence-based rationales for these strategies.
Two nursing strategies in managing pulmonary oedema, a consequence of fluid volume excess, are (1) improving oxygenation and (2) educating patient on how to do fluid management themselves including monitoring and controlling their symptoms. The patient may be given oxygen therapy where high concentrations of oxygen are used to combat hypoxemia. Intubation and ventilator support may be needed to improve hypoxemia and prevent hypercarbia (Tilney, 2010). Further, symptom monitoring is vital in fluid management. An indication of excessive fluid retention is weight gain so patients should be encouraged to weigh regularly, usually after eating breakfast. A weight change of 2 lb in a day is significant. Weight should be evaluated in relation to nutritional status. Poor nutrition and decreased appetite may be accompanied by fluid retention though the net weight may remain the same. Monitor for bloated neck veins and ascites. Assess for changes in respiratory pattern, crackles in lungs and shortness of breath. Examine by touch any presence of edema in ankles, tibia, sacrum and feet. Monitor chest x-ray reports because when interstitial edema accrues, the x-rays show hazy white lung fields. Moreover, input and output of fluid should be monitored closely because the shifting of fluid out of the intravascular to the extravascular spaces may cause dehydration (Galanes & Gulanick, 2012).
If therapy is to be given, check signs of hypovolemia. It is important that patients are educated on proper monitoring of their signs and symptoms by keeping diaries at home when discharged. An appropriate therapy (such as oxygen therapy) can be effective in improving acute pulmonary oedema within a few hours; however, if left untreated, can be life-threatening. The ability of the nurse to identify problems and decide for the right management is very vital (Baird, 2010).
Intravenous furusemide (Lasix) is used in the management of an acute exacerbation of chronic heart failure.
c) Explain the mechanism of action of frusemide
The intention of providing unique, stylish and trendy garments that exude luxury but reasonably priced led to the concept of making ready-to-wear garments inspired from the idea of ‘see-through look’. However, the sexy image of the ‘see-through’ garments was modified to look chic, sophisticated and simple. As a startup, the focus will be towards articulating the difference of my collection over its competitors (Stella McCartney and Celine), stressing on its distinctive choice of color, high quality materials, trendy style, functionality and affordability. Though it is hard to make claims as the company is still in its infancy, third-party reviews could be presented to the public to make the market positioning credible.
Moreover, to be competitive against established brands like Stella McCartney and Celine, the collection will be priced slightly lower to get the attention of the consuming public and penetrate the market. And to achieve a lower cost, the fabrics will be sourced from Dong-Dae Moon Fabric Market in Korea which cost less than £10 per yard. My primary brand will be Angela Kim, my name, an indication that my designs are a reflection of my personality, lifestyle and visions. My secondary branding will be Reverie Clouds, meaning, my dream and my inspirations.
As a newbie with limited budget, selling online would be more feasible and practical. Though there are still some expenses in creating a website and maintaining it, it is still very minimal as compared to opening a freestanding store to sell the collection. Moreover, the convenience and wide coverage of buyers that online selling offer are big opportunities to build the brand and introduce it to the rest of the world at the most possible lowest cost.