Obesity is Not a disease- Michel Tanner AMA Declares Obesity a Disease- Liz Neporent

John Pollina

One of the most controversial issues related to the health field is obesity. Obesity affects one-third or thirty-five percent of Americans today. The biggest controversy around this topic is whether obesity should be considered a disease. The American Medical Association or AMA has recently declared obesity as a disease after years of debates. However even with this declaration there are still major controversial debates circulating about this topic and how the AMA was right to do so and how it was the wrong thing to do. Furthermore, two articles were written about both the different sides of this debate to demonstrate the difference of opinions.

Writer “A” is Liz Neporent of ABC News who wrote an article about the AMA’s recent declaration of obesity as a disease and those that support the affirmation. Obesity researcher James O’Hill welcomes the decision from the AMA because high BMI numbers really put people at risk. Moreover, a member of the AMA Board of Trustees, Dr. Patrice Harris stated that by declaring obesity as a disease, they expected that it would open up a variety of medical interventions that would in turn help the one-third of Americans with obesity. Moreover, the overall opinion of this writer shows is that many doctors agree with the AMA and that it is a step in right direction in order to move forward with an increasingly growing concern. By increasing the level of importance by making obesity a disease, third-party payers are encouraged to raise the level of coverage for obesity treatments as well as more studies in this area. Thus, allowing this decision, the high rate of people with obesity will get the help they need with the ability to have their treatments covered to potentially lower the rates of people staying and becoming obese. (Neporent, 2013)

Writer “B” or Michael Tanner, wrote an article about how obesity should not be considered a disease. He does not deny that this country has a growing obesity problem however; his opinion is that by declaring obesity as a disease the AMA is not really helping these people. He states that the AMA decision transfers responsibility to lose weight from the individual to society as a whole. He also states that bringing the government into this situation will not be affective in fighting the problem against obesity. In fact, having the government involved could make losing weight even more problematic than it already is. By medicalizing obesity you could potentially be escalating patient and doctor dependence on costly surgical or pharmacological treatments rather than social resolutions like exercising in a community gym to achieve healthy behaviors. Thus, his overall opinion is that the AMA is seeking a way to tackle obesity with money and the lack of individual responsibility instead of allowing these individuals to take accountability for their lives and improve on their own. (Tanner, 2013)

The problem when reading about Writer A’s opinion is that they seem to be too fixated on the increase of money to fix a public health problem. They recognize that there is a problem but the way to fix it is by receiving money from a third party. They don’t feel like a person should have any responsibility for the way they eat or for the lack of exercise in their life. The AMA sees a growing problem and seeks to relieve it through government means. Too much of their opinion is based on money that they do not even factor in that doctors and physicians should already be talking to their clients about their weight and encourage them to pursue a healthy lifestyle. They don’t cast any blame or guilt on behalf of the individuals and just state that the government will include more resources to tackle weight lose problems since it is a disease. (Neporent, 2013)

On the other hand, writer “B” brings up good points that contradict what writer A talks about. This writer has more of a fix-yourself attitude where people should be able to fix their weight problems themselves rather than resorting to expensive medical treatment like surgery and expensive pills. However, this writer speaks in a way that every case of obesity is exactly the same. There are cases where people are too lazy to do things to lose weight. However, there are cases with people who have tried many things but it is too difficult due to other factors in their life. Writer “B” is relays his opinion that everyone with an obesity problem doesn’t try to live a better life and is not acknowledging that there are circumstances where drastic measures do need to happen. (Tanner, 2013)

Writer “A” has effective qualities in support of their position in the debate over obesity which is clear because the policy has passed. They successfully reached out to the one-third of Americans with obesity problems by showing that they want to help them by recognizing that obesity is a disease and change needs to occur. What makes their position more effective is having other doctors in the field talking about how great it this change is and how it’s a step in the right direction. People want to feel like they are getting assistance and by the AMA and the other doctors agreeing, they won the support of thirty-five percent or one-third of the population. Moreover, their argument shows heart and support in wanting to assist people in living longer and providing the necessary tools to do so.

On the other hand, writer “B” has ineffective qualities. The writer definitely has a clear message that people who are obese should not find an easy way out of their situation. People should be living a healthy lifestyle and taking responsibility for eating habits. However, the reason the writer is not that effective is because there is not a lot of people that would back up his prospects. The only people that would back them up are people who are health conscious which not most people are.

All in all, both writers bring strong points to the argument as to whether obesity should be considered a disease. They both acknowledge that obesity is a problem but they disagree on how it should be handled. Writer A wants more money from third parties to cover costs of intervention strategies in order for people to receive treatments. On the other hand, writer B feels that personal responsibility trumps over everything and the individual should take a more proactive approach in their daily lives. Being labeled as a disease, for writer “A”, gives more opportunities medically to seek help. However, being labeled as a disease for writer “B” gives the people no responsibility for their unhealthy lifestyles and gives more leeway to sue food industries for their own choices. Furthermore, each writer makes persuasive arguments for their side and provides great contribution to the topic which will continue to be debated.

As for my opinion I undeniably side with writer “B” that obesity should not be considered a disease. For me, I feel like people want someone to blame when they are sick or overweight. Now the AMA and doctors that agree have given into the people by giving them someone to blame (food industries, ect) and saying that your obesity is not your fault. Moreover, I recognize that obesity is a problem in this country and it should definitely be addressed but not by making one-third of Americans being categorized by having a disease. Obesity can cause people to live shorter lives, develop obesity and

hypertension

. However, smoking can cause lung cancer and emphysema and that is not considered a disease. Dietary choices and exercise is what plays a vital role in obesity. More attention should be on prevention and personal responsibility. People should not blame food industries for their lack of self-control. Everyone has the choice to eat or not to eat something. There are so many things one can do to lose weight which is why I would not consider obesity to be a disease. Someone with cancer or a mental illness is a few examples of what a disease is because cancer attacks the body and sometimes you can’t fight or protect yourself from it. Lastly, as someone who used to be overweight when I was younger, being athletic now influences by ability to be anything but objective. I continue to work hard to eat right and exercise to remain healthy which is what many of these people should be doing rather than surgical treatments and pills.

References

Tanner, M. (2013, July 3). Obesity Is Not a Disease.

National Review Online.

Retrieved from:

http://www.nationalreview.com/article/352626/obesity-not-disease-michael-tanner

Neporent, L. (2013, June 19). AMA Declares Obesity a Disease.

ABC News.

Retrieved from:

http://abcnews.go.com/Health/american-medical-association-classifies-obesity-disease/story?id=19439304

Overview of Vagus nerve anatomy:

Cranial nerve ten (CN X), the vagus nerve, is a functionally diverse yet critical mediator of assorted modalities of innervation. The vagus nerve has the longest course of all cranial nerves and extends from the head to the abdomen (Fig 1). It elicits sensory, special sensory, motor and parasympathetic innervation along its route and therefore is composed of both sensory and motor fibres. Primarily, the vagus nerve will supply organs of the thorax and abdomen (Baccaro et al., 2013).

Figure 1. Course of vagus nerve (CN X) from the head to the abdomen with all corresponding branches evidenced. (Taken from Kim [Kenhub], 2018)

Originating from the medulla of the brainstem, the vagus nerve travels via the jugular foramen with the glossopharyngeal and accessory nerve. The auricular branches arise within the cranium to supply sensation to the posterior external auditory canal and external ear. Within the neck, the vagus nerve will pass through the carotid sheath, travelling inferiorly to the jugular vein and common carotid artery (Rohen et al., 1998). At the base of the neck, the right and left vagus nerves will follow different pathways. Within the neck various branches of the vagus nerve arise including the pharyngeal branches, superior laryngeal nerve and the recurrent laryngeal nerve (on the right side only). The right vagus nerve will pass anteriorly to the subclavian artery and posteriorly to the sternoclavicular joint to enter the thorax. It then travels posteriorly to both the aortic arch and right primary bronchus. The left vagus nerve will pass inferiorly between the left common carotid and left subclavian artery and posterior to the sternoclavicular joint to enter the thorax (Rohen et al., 1998; Baccaro et al., 2013). It then travels anteriorly to the aortic arch and posteriorly to the left primary bronchus before reaching the oesophagus. The vagi will then reform in the lower thorax as anterior and posterior trunks. At approximately the level of the 10

^th

thoracic vertebra, the vagus will pierce through the diaphragm, travelling with the oesophagus. At this point, the vagus will supply the abdomen via three branches (Baccaro et al., 2013).

1. Gastric Branch

The right vagus nerve branches will form the posterior gastric plexus on the postero-inferior surface of the stomach. The left vagus nerve will form the anterior gastric plexus on the antero-superior surface of the stomach (Fig 2). Both these divisions and plexi are located between the layers of the lesser omentum. Anterior gastric fibres will extend to the upper duodenum and pylorus, while the posterior vagal trunk and posterior gastric branches will supply fibres to the abdominal autonomic plexus. From here, vagal fibres will be dispersed to regions surrounding coeliac, renal and superior mesenteric arteries (Rohen et al., 1998; Baccaro et al., 2013).

Figure 2. The branching of the vagus nerve in the abdomen. Anterior gastric branches of the anterior vagal trunk are observed to supply the antero-superior surface of the stomach (Taken from Kim, 2018)

2. Coeliac branches

The right vagus nerve derives the coeliac branch of the vagus nerve. These will join the coeliac plexus innervating the pancreas, kidneys, spleen, suprarenals and intestine (Fig 3) (Rohen et al., 1998; Baccaro et al., 2013).

3. Hepatic branches

The left vagus nerve will give rise to the hepatic branch and will join with the hepatic plexus to travel along the lesser omentum towards the liver (Fig 3) (Rohen et al., 1998; Baccaro et al., 2013).

Figure 3. Depicted course of coeliac branch and hepatic branch of anterior vagal trunk (Taken from Kim, 2018)

Introduction to Vagotomy

Gastric peptic ulcers are a form of gastrointestinal disease, evolving from disorders such as gastrointestinal reflux and heartburn. Complicated cases of gastric peptic ulcers can be managed through vagotomy. Vagotomy is a surgical procedure involving disconnection of the branches of the vagus nerve to reduce or disable the production and secretion of stomach acid (Seeras & Prakash, 2019). Generally, this is a final resort when medications, diet alterations and alternative management strategies elicit no effect on patients suffering from peptic ulcer disease (PUD). Vagotomy will be performed on patients suffering from severe complications of peptic ulcers including perforation, bleeding, recurrent ulcer formation and obstruction of digestive flow (Clement et al., 2017; Seeras & Prakash, 2019). The principle underlying vagotomy is owed to the anatomical and functional understanding of the vagus nerve. Since, the vagus nerve plays a central role in acid section, the disruption of vagal innervation is founded to be an antisecretory measure. Therefore, the primary aim of vagotomy is to reduce gastric acid secretion in patients developing complications from PUD (Lipof et al., 2006). Surgical vagotomy has historically played a crucial role in the treatment of PUD and was considered as the frontline gold standard method for PUD treatment in the late 1940s. The introduction of acid-reducing medications led to a drastic decrease in the vagotomy procedures performed in the late 1970s. The number of vagotomies performed in emergency cases however still persists (Seeras & Prakash, 2019; Lipof et al., 2006).

There are 4 main types of surgical vagotomies that may be performed.

1. 
   Highly selective vagotomy.
   
   This involves disconnecting nerve branches supplying the acid-secreting glands of the stomach. Divisions supplying antrum, hepatic and coeliac branches are preserved.
2. 
   Parietal cell vagotomy.
   
   This utilises a selective severing of nerve fibres which supply the proximal two-thirds of the stomach. This is predominantly performed on patients with duodenal ulcers.
3. 
   Selective vagotomy.
   
   This encompasses disconnection of the vagal nerves entering the stomach with the hepatic and coeliac branches preserved from disconnection. This procedure is rarely performed.
4. 
   Truncal or total abdominal vagotomy.
   
   This involves disconnection of the two main vagus nerve trunks entering the abdomen. Drainage procedures such as pyloroplasty are conjunctively performed along with truncal vagotomy (Seeras & Prakash, 2019).

Advances in medication and the understanding of gut microbiota and bacteria have rendered vagotomy procedures as less common modern-day approaches to treating PUD. Moreover, only 5% of bleeding ulcers eventuate in operative measures (Lipof et al., 2006). Surgical procedures are only adopted following a failure to achieve haemostasis endoscopically, recurrent bleeding despite attempts at achieving haemostasis and severe perforations (Clement et al., 2017).

Surgical Procedure

Prior to surgery, either a laparotomy or a laparoscopy is performed. A laparotomy is an open surgery, whereby an abdominal incision is created bypassing the abdominal muscle to gain entry into the abdominal cavity. Here, the vagus nerve is identified and located, and the branches of interest are clamped and cut out. A laparoscopy encompasses 4-5 incisions which are created in the abdomen (Lipof et al., 2006; Seeras & Prakash, 2019). A port is passed through one incision and carbon dioxide is then administered through the abdominal cavity for inflation. A laparoscope will then be passed into the abdomen along with other surgical equipment and instruments through the remaining incisions (Baccaro et al., 2013). The vagus nerve is then identified with the laparoscope and instruments. The vagus nerve and the corresponding branches are again clamped and cut out (Seeras & Prakah, 2019).

Vagotomy is generally performed with stomach drainage, pyloroplasty, resection, or diversion procedures to treat PUD complications. Most commonly, pyloroplasty is performed. Vagotomy results in decreased peristalsis and alteration to the emptying patterns of the stomach. Therefore, pyloroplasty encompasses widening the stomach outlet (the pylorus) to the intestine, to accommodate for altered emptying patterns that will proceed post-operatively (Seeras & Prakash, 2019). This conjunctive procedure alleviates the chance of obstruction or delayed emptying (gastroparesis) in the gastrointestinal tract.

Complications

Generally, there are potential risks attributed to vagotomy surgical procedures. The following are primary complications that can be exhibited as a result of the procedure (Seeras & Prakah, 2019).

• Internal bleeding following incorrect incision of identification of the vagus nerve. This may result in ruptured arteries or leaking veins
• Post-operative infections
• Shock from blood loss
• Deep vein thrombosis
• Trouble urinating
• Allergic reactions to anaesthesia
• Dumping syndrome which is generally presented with the onset of stomach cramps, nausea and vomiting, diarrheas and tachycardia after eating. This is attributed to the changes in anatomy and physiology following vagotomy surgery.
• Muscle fibre injury (when mistaken for vagal branch)

Clinical Significance

While vagotomy has lost significance as a primary, frontline technique in treating PUD, its significance arises in alternate areas of medicine. More recently, studies assessing the significance of vagotomy in treating diseases such as Parkinson’s, dementia, ischemic heart disease and obesity has arisen to determine vagotomy as clinically significant in modern day clinical medicine. It also opts for a greater understanding of the multifaceted role of the vagus nerve in treating diseases causing increased levels of morbidity globally. These are particularly attributed in determining a protective ability of deficient vagal signals in attempting to overcome cardiovascular disease, obesity and neurodegenerative illnesses.

Preliminary evidence highlights that truncal vagotomy displays a potential protective effect against Parkinson’s disease. Interestingly, evidence is consistent in suggesting that truncal, but not selective vagotomy is related to a lower risk and incidence of Parkinson’s disease (Liu et al., 2017; Lin et al., 2018) (Fig 4).

Figure 4. Cumulative incidence of Parkinson’s disease following truncal and selective vagotomy. Truncal vagotomy suggests a related lower incidence of Parkinson’s disease (Taken from Liu et al., 2017)

Moreover, subdiaphragmatic vagotomy is also also implicated to prevent weight gain and induce weight loss in severely obese mice (Mc4r -/-). This suggests that weight loss in obesity is a direct result of a loss of signalling in vagal motor neurons (Dezfuli et al., 2018). Hence, publications have deduced that hyperactive vagal efferent signalling underlies hypothalamic obesity syndromes which are ameliorated by sub-diaphragmatic vagotomy (Dezfuli et al., 2018). This poses as a considerable area for further investigation, specifically in human trials to assist with weight management and obesity rates which can be implicated in secondary diseases such as heart disease.

Additionally, acid-reducing vagotomy is also suggested to be associated with a reduced risk of ischemic heart disease. Particularly, patients with PUD are implicated to have increased risks of ischemic heart disease (Koniaris et al., 2016). Thus, vagotomy is attributed to play a central role in decreasing the onset of ischemic heart disease (Koniaris et al., 2016). While, the mechanism of the relationship is unknown, what is clear is that the vagus nerve is implicated in an increased incidence of heart failure. Hence, more findings are needed to support physiological mechanisms in being able to apply specific vagotomy procedures to patient groups with increased genetic and environmental risks of developing ischemic heart disease (Koniaris et al., 2016).

 

Conclusion

Although now uncommon, surgical vagotomy may still have clinical significance for the treatment of various complications other than PUD. However, in light of this it is still important for physicians to have knowledge of the procedure and its complications to form effective treatment strategies for patients presenting with complicated PUD. Truncal vagotomy has become a generally obsolete procedure following the introduction of proton pump inhibitors (PPIs) such as omeprazole. Nevertheless, emergency vagotomy may be performed in cases where PPIs and other alterations do not elicit any improvements in the disease.

Conclusively, vagotomy procedures require further examination in the treatment of other clinically significant diseases. Several studies in recent years attribute vagotomy to induced neural protection, cardiac protection and weight loss. The scope of these studies are significant in grounding the need for further directional studies incorporating vagotomy as a possible treatment therapy in Parkinson’s disease, dementia, ischemic heart disease and obesity. Therefore, vagotomy resides as a clinically significant procedure in inducing multifaceted therapies encompassing a broad spectrum of affected patients.

Along with understanding the central role of the vagus nerve and its innervating capacity, vagotomy can be manipulated to achieve standardised mechanisms in the treatment of Parkinson’s, dementia, ischemic heart disease and obesity. Hence, the revival and incorporation of this procedure into modern clinical settings is likely to form therapeutic treatments against common health issues. With an increasing obese population, cardiovascular disease resides at the heart of morbidity rates in the general populous. In addition, an aging population also suggests the need for treatment strategies in maintaining neural cognition to overcome neurodegenerative diseases such as Parkinson’s and dementia. Hence, it is critical for vagotomy studies to be emphasised clinically in developing a century old surgical procedure as a modern tool for overcoming modern day health issues.

References

 

• Baccaro, LM., Lucas, CN., Zandomeni, MR., Selvino, MV., Albanese, EF 2013, ‘Anatomy of the Anterior Vagus Nerve: An anatomic description and its application in surgery’,
  
  Anatomy & Physiology: Current Research
  
  , vol.3, no. 2, pp. 1-5
• Clement, S., Prasad, R., Rao, R 2017, ‘A clinical study of gastric outlet obstruction’,
  
  Internation Surgery Journal
  
  , vol. 4, no. 1, pp. 2349-2351
• Dezfuli, G., Gillis, RA., Tatge, JE., Duncan, KR., Dretchen, KL., Jackson, PG., Verbalis, JG., Sahibzada, N 2018, ‘Subdiaphragmatic vagotomy with pyloroplasty amerliorates the obesity caused by genetic deletion of the melanocortin 4 receptor in the mouse’,
  
  Frontiers in Neurosceince,
  
  vol. 12, pp.104
• Koniaris, LG., Wu, S., Fang, C., William T., Muo, C 2016, /Acid-reducing vagotomy is associated with reduced risk of subsequent ischemic heart disease in complicated peptic ulcer: An Asian population study’,
  
  Medicine
  
  , vol. 95, no. 50, pp. 5651
• Lin, S., Lin, C., Wang, I., Lin, C., Lin, C., Hsu, W., Kao, C 2018, ‘Dementia and vagotomy in Taiwan: a population-based cohort study’,
  
  Epidemiology Research
  
  , vol. 8, no.3
• Lipof, T., Shapiro, D., Kozol, RA 2006, ‘Surgical perspectives in peptic ulcer disease and gastritis’,
  
  World Journal of Gastroenterology
  
  , vol. 12, no. 20, pp. 3248-3252
• Liu, B., Fang, F., Pedersen, N., Tillander, A., Ludvigsson, JF., Ekbom, A., Svenningsson, P., Chen, H., Wirdefeldt, K 2017, ‘Vagotomy and Parkinson Disease’,
  
  Neurology
  
  , vol. 88, no.21
• Rohen, JW., Yokochi, C., Lutjen-Drecoll, E., Romrell, LJ 1998, Color atlas of anatomy: a photgraphic atlas, Schattauer, Stuttgart
• Seeras, K., Prakah, S 2019, ‘Truncal Vagotomy’,
  
  StatPearls
  
  , pp. 1

 

 

 

Nurse staffing ratios and shorthanded staff in both day and night shifts effect not only nurse satisfaction but also has a big impact in patient experience, safety, and outcomes. Despite the amount of research supporting appropriate and safe nurse staffing it is still a big problem for hospitals to manage. This paper will explore the influence of understaffing nurses and the negative effects on patient safety measured through the patient’s health, wellbeing and outcomes. Depending on the department (ICU/CCU, cardiac unit, medsurg, etc) understaffing has an affect in various ways compared to that of a less acute patient versus that of a higher acuity. Regardless, these patients are vulnerable to a lack of surveillance, medication errors and lack of basic care. These are direct examples of the effects of shorthanded staffing. Indirect consequences may include erroneous documentation, lack of managing important nursing tasks such as obtaining vital signs and overall lack of nurse wellbeing due to not having a break nurse or charge nurse or both. With the appropriate number of nursing staff and ratio will result in better patient experiences, outcomes, and decreased hospital acquired infections and mortality.

In the past few decades there has been many changes in the nursing community, specifically, in what dictates an appropriate level of nurse staffing and ratio. Although on paper it may seem easy to accommodate each patient with the appropriate number of nurses but as

Driscoll

, Grant, Carroll, et al (2018) stated managers try to “understand the influence of the multiple factors that make up each individual care”. These factors include managers understanding the patient acuity and dependency nature, patient throughput and the current nurse skills and scheduled staff for the day and night shift. Halm (2019) iterates “in order to fully incorporate assessment of patient risk, a multitude of factors should be considered when planning the number of staff and skill mix needed on a given shift”. These factors were previously stated, in addition, to teamwork with supportive services and interprofessional collaboration. In conjugation of determining these factors three staffing models are utilized by hospitals. The first is a budget-based model. In the budget-based model nursing staff is allocated according to nursing hours per patient day. Nursing hours refers to the total number of hours worked by all nurses on the unit for a given time period, which is usually a twenty-four-hour period. Total patient days reflects the average number of patients in a day. The second model is the nurse-patient ratio. This model is calculated through the number of nurses per number of patients or patient days. A pure nurse-patient ratio will not consider individual patient needs or nursing judgement. This model will usually be used in combination with the budget-based staffing. Lastly, the patient acuity is utilized when the patient characteristics are used to determine a shift staffing need. This model considers the complexity of care needed by certain patient diagnosis, comorbidities and severity of illness. Managers who are responsible for staffing using this model should consider more than just how long it takes to do certain nursing tasks such as performing initial assessments, taking vitals and administering medications. Those responsible need to consider the full scope of nursing practice. The scope of nursing practice according to the American Nurses Association (ANA) include: assessment, nursing diagnosis, identifying outcomes, planning, implementation, coordination of care, health promotion and teaching, consultation, evaluation and prescriptive authority and treatment for those of advanced practice registered nurses. Some patient characteristics considered for their acuity include: age, diagnosis, severity of illness, comorbidities, socioeconomic status, ability to provide self-care, anticipated length of stay, family and/or other caregivers that are included in patient education and plan of care. Most organizations will use a combination of models and tailor them to the nursing culture and specific needs.

Another factor for scheduling and staffing is reimbursement. Since the 1980s the hospitals nurse staffing was based on the number of beds, even if the beds were not being used. Since the reimbursement change, hospitals have been trying to control costs by matching nursing resources to the average census. Two types of variability is utilized and are as follows: artificial and natural. Artificial variability is controlled by surgical schedules. Natural variability results from factors we cannot control, such as, the flow of Emergency Department (ED) patients, natural disasters or mass-casualty events. Artificial variability is easily managed by involving surgeons to work on elective and nonemergency surgeries over a course of a week or two. This will better manage the needs of the unit(s) and appropriate hospital staffing in accordance to type of surgeries, account of average emergent surgeries from previous year statistics, and hospital throughput. Natural variability includes clinical variability and professional variability. Clinical variability is characterized by the differences among the patient’s diseases, signs and symptoms, and socioeconomic factors. Direct-care nurses are affected the most and can be managed in several ways. Depending on the hospital processing organization and available resources a Registered Nurse (RN) patient assignment may have patients who are either all diabetic, all having heart failure, or all with pneumonia. The other option would to mix the type of patient characteristics where one is diabetic, one pneumonia and one with heart failure assigned to one RN and the other RNs to have similar assignments. Professional variability related to how physicians, nurses and others practice along with their schedule. This type of variability affects the patient’s progress, census and length of unnecessary delays. Staff skills, motivation, mentoring nursing students and variations in beliefs are main factors that influence staffing and scheduling with professional variability. Regardless, a unit needs to properly staffed and with doing so “studies do report the higher the level of nurse staffing, the greater the reduction in inhospital mortality” (Driscoll, Grant, Carroll, et al. 2018).

To decrease the healthcare costs direct-care nurse, or bedside nurse, have been pressured to show an impact on patient outcomes using nursing-sensitive indicators. A lot of this data is collected and analyzed to accommodate and properly staff specific units based on these indicators. Some indicators may include: catheter-associated urinary tract infections, thirty-day mortality, patient falls, longer lengths of stay, pressure injuries, failure to rescue, intravenous infiltrations, upper gastrointestinal bleeding, nosocomial infections, shock, patient restraint use, pneumonia, and pain management, etc. With these considered managers, staffers and direct-care nurses can provide their input and improve the patient care, quality and processing with proper staff levels. Although managers and staffers try to consider staff calling off sick or floating to another unit there are other factors that go unforeseen, such as direct admissions, number of expected discharges and delays of discharging. Bedside nurses are then looked upon for their input because they are at the point of providing care and can make suggestions to improve the process. With this we will dive into nursing delivery models and care delivery models.

Every unit and each hospital have a specific model or combination of models for nursing care. There are five different nursing delivery models which include: primary nursing, float nursing, team-based nursing, functional nursing and modular nursing. Some care delivery models are as followed. Primary care team models have a nurse care manager partnered with another nurse in which they are responsible for a specific group of patients. A twelve-bed hospital model has a registered nurse who acts as a patient-care facilitator for a small group of patients, about twelve, and coordinates all care and serves as a liaison for the other healthcare team members involved in each patient care. A transitional care model has a registered nurse assigned to a patient at admission, who coordinates the patient’s care throughout the hospital stay and follows the patient through discharge for up to three months after. In a planetree patient centered model all staff members are considered as caregivers and patients are partners in their care. In a hospital at home an acute hospital-level are is given at home with registered nurses visiting once to twice daily to assess the patient, assess and administer infusions and provide education/evaluations. Whichever, the hospital or unit a registered nurse is working a consistent model should be followed and implemented with clear roles and responsibilities. Without this proper staffing will be insufficient and confusion will disorientate the health care team resulting in inconsistent patient outcomes and “adverse events” (Glette, Aase and Wiig, 2017).

Appropriate nurse staffing and ratios are difficult to achieve. Although there are some guidelines and models a hospital and unit specific variabilities the staffing and ratios will not be perfect. Managers strive to achieve and better staff each unit based on calculated and collected data from previous years and research-based practices from within itself or by observing other hospitals current practices. Many factors come into play when deciding the right amount of staff to assign to a floor and ratios to follow depending on the state. With the help of direct care nurses or previously known as bedside nurses, staffers and managers can improve predictions, patient throughput, experience and outcomes. There will always be room for improvement for a policy and/or practice especially when it involves nurse staffing.

References

• Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., … Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6–22.
  
  https://doi.org/10.1177/1474515117721561
  
• Glette, M. , Aase, K. and Wiig, S. (2017) The Relationship between Understaffing of Nurses and Patient Safety in Hospitals—A Literature Review with Thematic Analysis.
  
  Open Journal of Nursing
  
  ,
  
  7
  
  , 1387-1429. doi:
  
  10.4236/ojn.2017.712100
  
  .
• Halm, M. (2019). The influence of Appropriate Staffing and Healthy Work Environments on Patient and Nurse Outcomes.
  
  American Journal of Critical Care, 28
  
  (20), 152-156. https://doi-org.summit.csuci.edu/10.4037/ajcc2019938.

Student’s name: Nguyen Viet Dung

ABSTRACT

Passive smoking is a serious problem in Vietnam nowadays. Particularly, public smoking in Vietnam is a common habit, which comes from people’s unawareness. Many effective measures have been taken to put an end to passive smoking. This paper, based on secondary research, discusses the locations where smoking usually happens, the effects of passive smoking and some solutions and recommendations. Based on the findings of the research, the paper draws the conclusion that although passive smoking is still common at the present, there is actually hope that passive smoking will be no longer exist in the future.

1. 
   Introduction
   
   

Passive smoking, or second-hand smoking, is known as the inhalation of second-hand smoke (SHS) or environmental tobacco smoke (ETS) by people other than the active smoker.

Exhiled smoke is call exhaled mainstream smoke. The smoke drifting from a lit cigarette is call sidestream smoke. The combination of mainstream and sidestream smoke is called second-hand smoke (SHS) or environmental tobacco smoke (ETS).

(Better Health Channel 2012, p.01)

According to Ho Chi Minh City Health Education and Communication Center , smoking-related diseases kill over 40,000 people in Vietnam each year and if no measure is taken, nearly 10 percent of the Vietnamese population will have died from smoking-related diseases by 2030. According to the 2010 global adult tobacco survey, out of two Vietnamese people over 15 years old, one is addicted to tobacco (WHO 2010). About 8 million workers suffer from passive smoking at working places, and as many as 47 million people are regularly exposed to smoking at home (WHO 2010).

The effects of smoking is very dangerous and if no measures are given to prevent this problem, it can spread more over and over. So many laws which prevent and protect for non-smokers should be taken to protect the people individually and the atmosphere generally, but it is a time-consuming process and it demand the consideration of many groups in society. Therefore, this paper, with the purpose of helping stop the passive smoking, discusses the objects, the effects of passive smoking and what measures to solve this problem.

2. Discussion of findings

2.1. Where is second hand smoke make a problem

The workplace is a major source of SHS (Second Hand Smoke) exposure for many adults (American Cancer Society 2014). SHS in the workplace has lead to an increase risk for heart disease and lung cancer among adult non-smokers (American Cancer Society). The only way to prevent SHS at work is smoke-free workplace policies. It separates smokers from non-smokers, cleans the air. Workplace smoking restrictions may also encourage smokers to smoke less or even quit.

Everyone can be exposed to SHS in public places, such as restaurants, shopping centers, public transportation, schools, and daycare centers. (American Cancer Society 2014)

Public places where children go are a special area of concern. Make sure that our children’s day care center or school is smoke-free. According to WHO, Vietnam is among the countries having the highest rates of male tobacco smokers in the world, and is also one of the countries where smoking in public places are popular, affecting the health of non-smokers who are exposed to second-hand smokes.

Smoking at home is a very common action in people’s life. We spend more time at home than everywhere else, a full-of-smoke house can harms our families, guests or even pets.

Children’s growing bodies are especially sensitive to the poisons in SHS. Others may seem like small problems, but they add up quickly – the time for doctor visits, medicines, lost school time, and often lost work time for the parent who must stay home with a sick child are all costs that can impact a family.

(American Cancer Society 2014)

Making our home smoke-free may be one of the most important things we can do for the health of our family.

If someone smokes in the car, the poison can build up quickly and this is especially harmful to children.

In VietNam, our gorvenrment has created the laws that ban smoking in the car, public transportations or even private cars to protect the health of children. Many facilities such as city buildings, malls, schools, colleges, and hospitals ban smoking on their grounds, including their parking lots and on the glass of windows.

2.2 The effects of passive smoking

A person who smoke indoors causes a permanent low-lying smoke cloud that other people inside have no choice but to breathe (Better Health Channel 2012).Those ammonia, sulphur and formaldehyde insided in tobacco irritate the eyes, nose, throat and lungs (Better Health Channel 2012).

Exposure to second-hand smoke can either trigger or worsen symtomps and might be the cause of cancer. Below is health risks of passive smoking affecting various objects:

Firstly, health risks affecting prefnant women and unborn babies. Astralian data indicates that about 20 percents of women smoke during pregnancy. Both active smoke or passive smoke seriously affect the fetus. Mothers who smoke during this time usually face up with many risk such as :

+ Increase risk of miscarriage and stillbirth

+ Increase risk of premature birth and low birth weight

+ Increase risk of sudden unexpected death in infants, which includes sudden infant death syndrome and fatal sleep accidents

+ Increase risk of complications during birth.

Secondly. Health risks affecting children. Children are especially vulnerable to the damage effects of second-hand smoke, according to Better Health Channel. Australian data provides that more than 40 percents children who live in a full-smoke home. Breathing smoke discharged by smokers can cause many health risks, include :

+ Increase risk of developing a range of respiratory illnesses including bronchitis, bronchiolitis and pneumonia. They are also more prone to getting colds, coughs and glue ear (middle ear infections). Their lungs show a reduced ability to function and slower growth.

+ More likely to develop asthma symptoms

+ More likely to have symptoms such as cough, phlegm, wheeze and breathlessness.

+ Increased risk of meningococcal disease, which can sometimes cause death or disability.

Finally, health risks affecting partners who have never smoked. When a person who have never smoked lives and shares the atmosphere with a smokers, he or she can be effected by tobacco-related diseases and other health risks, including :

+ Improving the risks of heart disease. People who do not smoke live in a smoky house have higher rate of heart disease than those who do not

+ Leading to increased risk of various health conditions such as heart attack and stroke.

+ The level of antioxidant vitamins in the blood is reduced

+ Leading to the development of atherosclerosis.

+ 20 to 30 percent higher risk of developing lung cancer

+ Increase the risk of stroke, nasal sinus cancer, throat cancer, breast cancer, long- and short-term respiratory symptoms, loss of lung function, and chronic obstructive pulmonary disease

2.3. Solutions and recommendations for passive smoking

In Vietnam , in term of country, governments have interceded and provided some laws, some organizations about this problem.

Firstly, it is essential to create some smoking laws. For example, the smoking ban was firstly passed in Vietnam at May 2013, was stated that “sale of tobacco products near educational premises and selling of tobacco products to under-18 children will be an offence” (cited in

Vietnam To Impose Smoking Ban By 2013

).

Secondly, governments have established a lots of organizations about the harms of public smoking and tobacco smoke. Typically, the “World No Tobacco Day” was organized in Vietnam on 25 May 2013 . According to the statement of Nguyen Quoc (2013), The Ministry of Health and the World Health Organization on May 25 jointly organized a meeting in response to ‘World No Tobacco Day’ and launched a tobacco free week, highlighting the health risks associated with tobacco consumption and advocating effective policies. The theme of this year’s campaign is ‘Ban Tobacco Advertising, Promotion and Sponsorship’. At the meeting, Nguyen Thi Xuyen, deputy health minister, said tobacco is one of the leading causes of diseases and deaths in the world. Moreover, a ‘No Smoking Week’ has been launched from May 25 to 31. At the meeting The Ministry called for organizations, companies and individuals to obey a no smoking ban in offices, educational facilities, hospitals and public places.

Finally, restaurants and hotels in capitals must be banned from smoking. For more details, In

HCMC wants restaurants, hotels to be no-smoking zones,

T.Dat (2012) noted that The Department of Health and the People’s Committee of Ho Chi Minh City held a seminar on August 24, to discuss the negative and harmful effects of smoking in public places and have asked restaurants and hotels in the City to commit to creating a non-smoking environment in their premises. In addition, a promotion of smoke-free restaurants and hotel in 4 February 2014 was promoted by The city’s Department of Culture, Sports and Tourism. Department vice director, Mai Tien Dung, said the agency would encourage restaurants and hotels not to allow smoking in public areas and to eventually ban smoking throughout premises including guest rooms. World Hospital Organisation’s Office in Hanoi representative, Le Duc Truong, added that many countries banned smoking in restaurants and hotels to ensure a healthy environment.

Here is some recommendations in order to solve this problem.

Free from tobacco smoke must be safeguarded through actions by national and local governments, community leaders, health workers, educators and parents.

Successfully eliminating exposure to tobacco smoke requires comprehensive efforts at all level: international level, national level, regional and local level.

Media campaigns, education to inform the public and especially parents can be part of a comprehensive stragety to advice people and improve their awareness and understanding about the adverse health effects of SHS and effective ways of controlling exposure.

In the future, more study on the effects of SHS on people’s health is essential. Suggestion for a future follow-up study is also very important.

3. Conclusion

From all the finding above, it is clear that passive smoking in Vietnam is still a really serious problem. It has developed greatly and causes a lot of harms over the years. Another sad fact is that there are yet many reasons for people to continue smoking, which cannot be solved soon. However, there are also reasons to believe smoking will be stopped in the future thanks to authorities’ determination and the supporting of many groups on society. Then, hopefully, we can see the future that no longer has tobacco smoke in the atmosphere .

REFERENCES

Better Health Channel 2012,

Passive smoking,

viewed February 2012, page 1.

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Passive_smoking

WHO December 2009,

10 facts on second-hand smoke,

fact 3, fact 6.

http://www.who.int/features/factfiles/tobacco/tobacco_facts/en/index2.html

http://www.who.int/features/factfiles/tobacco/tobacco_facts/en/index5.html

WHO 2010,

Global Adult Tobacco Survey(GATS), page 1 & page 2.

http://www.who.int/tobacco/surveillance/en_tfi_vietnam_gats_fact_sheet.pdf

American Cancer Society, Secondhand Smoke, viewed 11 February 2014

http://www.cancer.org/cancer/cancercauses/tobaccocancer/secondhand-smoke

Kamilah Qasimi , Vietnam To Impose Smoking Ban By 2013,viewed 19 June 2012

http://topnews.ae/content/212099-vietnam-impose-smoking-ban-2013

T. Dat – Translated by Uyen Phuong, HCMC wants restaurants, hotels to be no-smoking zones, viewed 25 August 2012

http://www.saigon-gpdaily.com.vn/Hochiminhcity/2012/8/102520/

Nguyen Quoc – Translated by Anh Quan, ‘World No Tobacco Day’ organized in Vietnam, viewed 27 May 2013

http://www.saigon-gpdaily.com.vn/Health/2013/5/105124/

Wanwisa Ngamsangchaikit, Hanoi to go smoke free, viewed 4 February 2014

http://www.ttrweekly.com/site/2014/02/hanoi-to-go-smoke-free/