Acute Stress Disorder Rehabilitation

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“Up to 65 per cent of Australians are likely to experience or witness an event which threatens their life or safety” (19). Quite often trauma victims can recover by their own. However, with others it may have a negative reaction to a traumatic event which can then lead to an illness called Acute Stress Disorder (ASD) (16). This disorder is associated with mental and physical conditions combined thus causing reductions in a person’s quality of life and as a consequence includes economic burdens (12). (3) Due to the result of all the accumulating evidence, Diagnostic and Statistical Manual – fifth edition (DSM-5) has marked and modified goals and criteria for ASD. Under new criteria, ASD diagnosis will no longer predict chronic Post-traumatic Stress Disorder (PTSD). It will help to identify more severely affected survivors of trauma prior a diagnosis of PTSD can be made. Furthermore, the acuity people will perhaps get benefit from earlier interventions and short-term rehabilitation programs that are the great help in the recovery process. Early rehabilitation interventions, including self-care strategy, thought control strategy, and cognitive behavior therapy (CBT) would speed up recovery and prevent chronic longer term problems. Besides that, family members, clinicians, and social support networks play an important role in support mechanism for recovery process. Inaddition, some potential barriers are also discussed in predicting of new problems and relapse which may occur in order to manage them.


Potential recovery

According to (2) DSM-5 in 2013, ASD was relocated in Trauma- and Stressor-Related Disorders. ASD is a psychological and physical shock which usually appears in response to a traumatic event in a person’s life. The acutely traumatized person can be directly exposed to or be the witness of a traumatic events such as serious accident (21%), physical assault (19%), rape or witnessing a mass shooting (50%) or natural disaster (10%)(19). (9) Symptoms of ASD occur immediately right after the trauma, and it lasts for more than 2 days and less than 1 month (4). The victim usually suffers from anxiety, distress, intense fear, helplessness, avoidance behaviours or re-experience the event (16). (15) It has been recorded that 15% to 45% of children and adolescents directly experience to at least one traumatic event. There is no statistics of how many distressed people can fully recover due to these traumas; however in many studies it has been confirmed that ASD patients can have a full recovery under appropriate treatments. This study strongly emphasis on ASD rehabilitation rather than attempting to predict subsequent PTSD. Due to ASD timeframe is short, many victims are usually been ignored. Particularly, children and adolescent are in high risk of developing PTSD which leads to long-term psychological sequel in their life and causes a burden on health care systems. Therefore, (15) highlighted that recognizing ASD symptoms is an important step in toward enhancing intervention in the right time and speed up the recovery process. Additionally, with a formal diagnosis, it will allow highly distressed people to claim compensations from the health care service and payment for recovery treatment (4). In order to get appropriate diagnosis and early intervention, physicians play a critical role for assessments and monitoring all physical and psychological symptoms.


Recovery process

Whenever a referral from a physician has been made, the traumatized patients will go through a rehabilitation process. This process needs self-care strategy, thought control strategy, and CBT to support patients’ recovery and to decrease the future incidence of PTSD. (7) With self-care strategies, it focuses on personal strengths and their own judgment. Whether any kind of psychotherapies are provided to traumatic people, they should rely on their own recovery ability first. Without their own effort, all the supports will become ineffective. Traumatic patients, then, will receive reassurance and support, such as simple information and advices on self-care to overcome the normal recovery process. However, if the person cannot scope with these extremely severe events, and express a prolonged distress, or interfere with daily activities, they will need to be referral to another level of psychotherapy.

Currently, it has been found that thought control strategy is an acceptable strategy for managing trauma related distress in the short term rehabilitation. Use of thought control strategy will aim to reduce the

emotional distress

by sharing the traumatic stories in the unforgettable period of time (14). There are four components (worry, distraction, social element and re-appraisal) which are the most commonly used to focus on helping the patient to normalize reactions to trauma (22). The first being Worry/Stress, it is best trying to get the patient to not concentrate on the stressful thought itself. Encouraging the patient to try and replace worry or stress with other day to day concerns that may hold a more minor bearing. The second is distraction. Finding a healthy distraction could be simple as think about things that provide a positive feeling or immerse the patient in an activity that is pleasurable. This will stop the patient concentrating on the traumatic event and allow them to go about a daily routine. The third would be social elements that could help. This could be asking or speaking with friends about their thoughts and how they have dealt with such events in their lives. Asking about what worked for them or what may have helped them avoid concentrating on the stressful event. This would be discussed fully so that the patient could reflect and understand how this could apply to their situation. The fourth is re-appraisal, trying and interpreting their feelings and understanding why these things are affecting them emotionally and rationalize their reactions to these feelings. From here they should challenge the validity of their emotions and feelings in order to control positive or negative feelings.

If these self-care strategy and thought control strategy still have not worked well for recovery, CBT would be the next step of treatment in rehabilitation. (12) CBT will be given in five therapy sessions this comprising prolonged exposure (PE) and cognitive restructuring (CR). (12) found that these sessions provide brief forms of treatment in reducing acute symptoms of ASD in the initial month after trauma exposure. (8) PE focuses in emotional processing of thoughts. It helps interrupt and reserve recovery process by blocking cognitive and behavioral avoidance. This is accomplished through in vivo and imaginal expose. Vivo exposure involves repeatedly activities and situations that are avoided because of trauma. Overtime, the patient can reduce distressing emotion and fear. Then, they can cope effectively through these distresses. Imaginal exposure is related to repeatedly describe the event aloud in details, then recording. After that, they listen to their record in order to help them to realize their coping skill.


Following initial assessment, patients were informed that they would



be reassessed after 6 weeks


Support mechanism

Besides psychotherapy in rehabilitation process and early supportive care structure being delivered is an important step which supports the recovery process. Its result last long in reductions of ASD symptoms. Supportive care deliverers are family members, physician or social support network will help the traumatic patient go though the acute phase. (17on) In most cases, family members usually ask for advices on how to help their love in stressful situation. This will let the family to be able to utilize a communal experience in order to enhance the therapeutic growths. The use of positive family members has also been shown effectively assisted their traumatic member to manage their stressful conditions. They provide support, love and reinforce coping strategy with the trauma. The individual does not feel isolated, but also they feel warm and being caring. The individual, therefore, can describe what happened and how they response though this hard time.

However in some cases family sometimes is not enough to support traumatic patients. If the trauma patients and their family feel unable to cope with this traumatic event, they can seek professional help from a physician such as an Australian Psychological Society (APS) psychologist. An APS psychologist will help the severe distress people to understand and manage the symptoms associated with the trauma. An APS psychologist would develop effective coping strategies for affected individual as well as their family to support the recovery process (18). If not, traumatic people also seek help from social support network such as Beyondblue, Sane or Mental Health organizations. Beyondblue is a support service designed to support, give advice and create actions. Whatever the situation is, Beyondblue always listens to their distress stories and share their misfortune. Beyondblue members can really help patients come to terms with their illness and help them to move forward (23). Similarly, The Australian Centre for Posttraumatic Mental Health is a not-for-profit organization which its aim to reduce the impact of trauma causing to the victims. They connect the capability of individual’s family with their organizations within the community. Therefore, they can understand about the traumatic victims, then, help them to prevent and recover from the adverse mental health effects of trauma.


Barrier : wrong diagnosis, overwhelm with treatment, comorbid psychiatric disorders

Due to a shorten timeframe of ASD, there appear some barriers which prevent the recovery process such as late diagnosis, overwhelmed treatments. Besides that some will subsequently develop comorbid psychiatric disorders. In case of traumatic events happen, the victims are late identified. Then, they will receive some simple advices how to overcome that situations. They are supposed to recover on their own. However, there are still significant people who cannot go through this recovery process by themselves. They need help from physicians to be assessed in order to receive a formal diagnosis. This process somehow is taken time which lead to a late diagnosis. If this is too late for appropriate treatment of stress disorder, it will develop further into PTSD. Furthermore, without this proper diagnosis, traumatic patients will not get the benefit from standard rehabilitation treatments (4). This problem can be predicted by the role of physicians who can manage clinical judgments in order to give their patient an early diagnosis.

For those patients who have received treatments within hours or days after an acute trauma incident, they sometime do not response well to treatment plan due to overwhelm of different interventions. They will present a psychosocial and environment difficulties related to problems such as agitation, emotional pain, and dissociation. Quickly treatment but also slowly explanation and monitoring the response from patients will enhance effective support to recovery process. With patients that respond positively and appear to be recovered from ASD, they sometimes sudden relapse when new event happen to their life. They suffer from fear about safety for themselves as well as their family. The relapse can be recognized by close family members who help the patients to report it to physician in order to get continual treatment (17).

Treatment of ASD is usually focused on its specific symptoms. However, some subsequently develop with ASD might be appear such as depression, withdrawal, shame or drug and alcohol abuse, and even suicidal behavior (17). The comorbid psychiatric disorders occur due to the inability scoping with that such traumatic events. These occurssing will significantly affect the recovery process; therefore, it is a requirement for careful attention in both pharmacologically and psychotherapeutically. The patient at high risk of suicide or drug and alcohol abuse should be highlighted during initial assessment. It is necessary to evaluate this potential harm which gets into the treatment pathway and the recovery process.


Conclusions

In conclusion, (4) the criteria set for ASD in DSM-V will allow identifying the people who had negative reaction to a traumatic event. Because of the short duration, it is necessary to assess severe traumatic people as quickly as possible. Then, they can receive an appropriate diagnosis in order to get benefit from rehabilitation treatments. Having an early treatment will move towards healing and recovery process. Moreover, as a result of suffering both physical and psychological conditions, these fragile people require a high level of support from family member, physicians as well as social support network to be back to normal life.

Analyze and resolve problems related to healthcare services, delivery, and finance.

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Analyze and resolve problems related to healthcare services, delivery, and finance.

Course Objectives Execute leadership in all levels of private and public healthcare policies, resource allocation, and priority setting. Compose and manage systems and processes to assess organizational performance for continuous improvement of quality, safety, and effectiveness. Execute and employ appropriate quantitative and qualitative techniques to manage and allocate human, fiscal, technological, informational, and other important resources. Classify and apply economic, financial, legal, organizational, political, and ethical theories and practices. Analyze and resolve problems related to healthcare services, delivery, and finance. ASSIGNMENT- Reviewing the course objectives, type, and deliverables. Explain your proposed approach for conducting research necessary to develop quality deliverables and explain how the information gleaned will support your career development in healthcare management.

How has your view of the role of the APN changed from what your view was prior to beginning the program?

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How has your view of the role of the APN changed from what your view was prior to beginning the program?

 

TYPE Reflection
If you have completed courses in the MSN-FNP, or have experienced working with or receiving care from an APN, describe your experience. How has your view of the role of the APN changed from what your view was prior to beginning the program? What has been your biggest revelation about the roles of the NP? If you were asked to talk to a group of undergrad nursing students about opportunities in the field, what would you tell them about pursuing their education to become an APN? Include scholarly reference material to support your ideas and opinions.
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Virginia Hendersons Need Based Theory and Implications

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Virginia Henderson’s Need Based Theory and Practice Implications

According to Nicely and DeLario (2010) Virginia Henderson’s theory, Need Based, which is derived from the Principles and Practice of Nursing is a grand theory that focuses on nursing care and

activities of daily living

. This theory is appropriate to my future practice setting as a Family Nurse Practitioner within the Emergency Department or Fast Track/Urgent Care setting. This theory is applicable within this setting since “meeting patient needs in the areas of respiration, nutrition, elimination, body mechanics, rest and sleep, keeping clean and well groomed, controlling the environment, communication, human relations, work, play, and worship (Masters, 2015, p. 384), as these will be advanced nursing care areas that I will need to promote for my patients basic needs.

Henderson’s Background and Theory Development

Virginia Henderson, born in 1897, was a world renowned Nurse educator, researcher and author of many nursing textbooks whose career spanned 60 years; considered by many as the modern day Florence Nightingale (Masters, 2015). A profound change occurred in her life which was around the time of WW one, during this time her nursing experience evolved while in school which resulted in obtaining a bachelors and a masters in nurse education (Masters, 2015). This experience was able to help her see a vision for basic nursing care with patient focus on patient independence with activities of daily living (ADLs), being the basis of her framework and practice. Henderson became a professor at Yale University where she wrote many nursing textbooks that emphasized nursing care, studies, principles and practice (Masters, 2015). She was able to define her personal nursing theory and create the theory that focused on basic nursing care and patients ADL’s. Encouraged by her nursing research she was able to speak around the world and focused on an international approach for better patient care (Masters, 2015). According to Masters (2015) Virginia Henderson received several honorary degrees during her respectable nursing career which included the Christiane Reimann Prize from the International Council of Nursing.

Possible Reference for Theory

Due to Virginia Henderson being an author she received a position collecting, reviewing and chronicling every nursing research that has been published allowing her to write volumes on nursing research and studies (Vera, 2014a). This may have allowed her to come up with analytical applications on what nursing was and could have drawn her strengths and assumptions from her review of researched material. Some may say that Maslow’s Hierarchy of Needs was the reference to her theory as the needs are somewhat similar of what actions or roles one may be or need assistance with in order for independence and wellbeing.

Phenomenon of Nursing and Common Problems

The common problems of Virginia Henderson’s need based theory, this theory outlines the 14 components of fundamental nursing care and interventions that patients have or use as part of their independence and ADLs (Masters, 2015). As a future APRN the common problems that are resolved are 14 components that maintain the patient’s physical functions, safety and maintaining a sense of wellbeing and finding oneself in relation to where they see themselves in life (Masters, 2015).

Deductive Reasoning for Theory

Virginia Henderson utilized scientific method which is considered deductive reasoning to come up with the needs based theory. Deductive reasoning allows for an inquiry decision to arrive at a solution to an issue, an action – reaction system where there is a cause to a component there will be an effect on the component, with independence on its own essence with or without external circumstances (Masters, 2015). According to Masters (2015), Virginia Henderson’s utilized the physical, emotional and mental (psychological components) to deductively arrive to this theory even though she did not intend to imply a new nursing theory; the theory is in relation to Maslow’s theory though Henderson was not aware but the 14 sub-concepts relate and coincide with Maslow’s.

Explanation, Definition and Interpretation of Concepts and the Four Metaparadigms

Henderson made an assumption of her work that it was not a nursing theory so she did not fully identify her concepts but researchers were able to come up with concepts from her work that actually follow the common metaparadigm’s of nursing which she included within her definition of nursing. According to Masters (2015), Virginia “did not intend to develop a theory of nursing, she did not develop the interrelated theoretical statements or operational definitions necessary to provide theory testability (p. 390)”. Concepts include person, environment, health and nursing. Person is defined “as the patient who is composed of biological, psychological, sociological, and spiritual components (Masters, 2015, p. 387)”. These compositional segments are not separate entities but help to assist the nurses towards interventions for the 14 components of care, the person and family are not separate either but are considered a whole item (Masters, 2015). Virginia Henderson was able to keep all concepts of theory and definition consistent throughout since they overlapped and interrelated with each other to include a whole person aspect.

Environment is important to a person’s perception of health and wellbeing but can also affect a person’s physical as well as mental wellbeing. Henderson identified a person’s environment as external elements that help to mold and shape an organisms life and physical change; three areas of environment that are important are biological, physical and behavioral (Masters, 2015). Biological includes anything that is living and breathing organism, such as flora and vertebrate, physical components like basic elements for life such as the sun, elemental chemicals and compounds. Both physical and biological elements work harmoniously together in symbiosis, when something changes it affects the whole ecological system and puts a strain on the symbiotic relationship of the physical and biological environment (Masters, 2015). Behavioral health influences the person and is the last component of environment; influencers include socioeconomic elements, political, cultural, and spiritual aspects.

Health was not a component of Henderson concept that was clearly defined but Henderson did imply that health was in relation to one’s independence (Masters, 2015). Basically, the 14 components of basic needs relate to the persons health as health relates to independence with activities of daily living.

Nursing is very clearly defined by Virginia Henderson and she has one of the best known definitions of nursing. According to Virginia Burggraf (2012) Virginia Henderson defined nursing as:

the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

As for advanced practice nursing fields Virginia Henderson was a proponent for nurses to be independent practitioners she may have not wanted full practice independence as she was not for nurses taking on what she perceived as physician duties such as diagnosis, treatment, and making judgment calls (Masters, 2015).

Proposition of Concepts

Masters (2015) suggest that nurses are viewed as a helper, assistant and companion to a patient’s health role and wellbeing. The relationship aspect is that when a patient is sick the nurse helps the patient to get better and recover, while the patient is in rehabilitation role the nurse assists the patients in achieving independence. Lastly the nurse is a companion during planning of care, goal setting, and preventive maintenance initiatives.

Assumptions of Needs Theory

According to Masters (2015) there are seventeen assumptions of the Needs theory that were implicated from Henderson’s theory they include: Nurses must assist people with illnesses; nurses must collaborate within an interdisciplinary team and become independent professionally from the physician; 14 concepts of nursing describe patient needs and complete nursing functions; goals are achieved with a symbiotic relationship between patient and nurse with health promotion as the nurses main goal; patient and family are one with mind and body being one within the person; assist patient with independence while the patient controls their physiological and psychological harmony; people function in health at all times and must maintain independence and relationships; people maintain health status with knowledge and awareness; illness effects environment conditions and nurses should maintain a safe environment; nurses must be culturally competent and must maintain best practice methods while relying on evidence-based research methods.

As explained above the four major concepts were defined by Virginia Henderson that also describes the four metaparadigm’s as Henderson theory is the foundation of nursing practice. Henderson theory does include sub-concepts which will be explained. These 14 sub-concepts are: normal respiration, proper nutrition and hydration, waste elimination and management, mobility for posture maintenance, sleep and relaxation, proper appearance and grooming, thermoregulation through external factors, safe environment and preventive injury, communicate emotional concerns and distress, spiritual worship, career leading to achievement, recreational activities, and utilization of health resources and using healthcare facilities (Vera, 2014b). These are all relevant elements to an APRN as these can be used within assessment towards finding the patient’s independence level and to assess patient’s assistance in obtaining or maintaining activities of daily living for basic needs (Masters, 2015).

Theoretical Clarity and Applicability

Virginia Henderson theory is very easily understandable and covers a broad range of nursing especially the APRN as independence was a goal for Henderson’s nursing goal besides patient’s health promotion. The definition of nursing is clear and very lucid and applicable to her assumptions and components of theory. Since it was not her motive to come up with a nursing theory consistency within the theory is adequate though death is not clarified as she maintains that nurses should be there for patient death and comfort but no suggestion as what one must do or grief assistance with the family and patient.

Theory Sub-concepts in Practice and Guidance of Nursing Actions

Utilizing Virginia Henderson’s basic needs theory and its 14 concepts will be beneficial in my practice as a new Family Nurse Practitioner. As I would like to work within the emergency department, putting into action clinical provider interventions would lead to examples such as: concept of breathing normally would lead me to administer my patient oxygen with an Albuterol treatment and treat with intravenous Solu-Medrol.

Eating and drinking appropriately, proper nutrition is vital for diabetes management, weight management, heart health, wound healing, autoimmune disease, and patients overall health.

Body waste removal, imbalanced removal of body waste can indicate if there is an organism illness such as C. difficile, being aware of normal elimination methods and treating with antifungals and antibiotics with probiotic treatment for maintenance for good gut health.

Movement and mobility, it is important to maintain my patients independence so splinting fractures from sports injuries, or advising low impact exercise and flexibility exercises to arthritic and osteoporosis patients are crucial to my practice development.

Sleep and relaxation is important sub-concept of Henderson theory, maintaining my patients sleep rhythm and patterns by decreasing external stimuli while my patient is in the ED at night, and providing privacy and comfort during the day and more importantly at night will allow a calmer and more enhanced patient experience.

Dressing appropriately is important to the patient’s perception of physical self and wellbeing. Being able to dress independently is an important ADL, within the ER this can be seen when patient is able to wear a gown and apply it on themselves without assistance, providing them time to dress themselves without being an inconvenience to acuity.

Body temperature regulation is important to the patient’s physical health, if a patient can not regulate their temperature heat blankets or mechanical regulated blankets like a Bair hugger can be applied to maintain proper thermoregulation.

Clean body and protection of the skin, importance of promoting proper body hygiene and infection prevention practices and isolation procedures for my fellow employees and nurses and educate them to teach patients as well as family upon entering the ED and seeing the patient.

Avoiding a dangerous environment, it is important to teach staff to transport patients within the ED and to other areas of the hospital is important for their physical health. Properly utilizing body mechanics, identifying fall risk patients intervening by locking bed and wheelchair wheels when necessary and maintaining a clean uncluttered patient room and hallway environment for patient safety.

Communication with others about feelings, it is important to use interpersonal and therapeutic communication and as a future APRN it is vital for me to actively listen to my patients and fellow team. Being able to empathize with a patient can open up to psychiatric, emotional and social traumas one may have occurred during an assessment history intake and being able to empathetically listen while making a proper medical judgement call is important for patients wellbeing.

Spiritual worship is important to the person’s mental and emotional wellbeing. As an APRN allowing others cultural and spiritual options influence their medical decision needs to be respected and nurtured as vital for the patients and families. Assimilation into the healthcare system that may or may not nurture their spiritual/cultural decision. This will increase my spiritual/cultural competence.

Work that increases oneself worth, important for patients mental health, leads to feelings of independence. Allowing one to continue their work and hobby benefits them to feel independent and able to fulfill their ADL’s. So maintaining ones finger after a work related accident by suturing and referral or assistance with a plastic surgeon is important knowledge to maintain in allowing ones independence.

Recreation activities benefits the patients physical health, some patients come to the ED after a sports injury so maintaining a sprain ankle by wrapping it and teaching the patient to utilize crutches and slowly introduce low impact, low weight bearing exercise while teaching proper NSAID administration is important in preserving my patients future recreational activities.

Normal health development and its resources, when I become a new APRN learning the different patients and diagnosis I see and utilizing a cohesive interdisciplinary team who is more knowledgeable as a resource is important for best practices towards the patient for their optimum health.

Conclusion

Virginia Henderson’s needs theory is applicable to many disciplines of nursing with various practice scopes. Utilizing this theory and putting it into action within practice is very adaptable and allows one to reflect on their nursing competency when it involves maintaining a person’s health promotion and independence level. As stated by Masters (2015) with Henderson’s philosophy of applying best practice methods which involve evidence-based research, advanced practice application of theory can be a foundation for their nursing process.


References

Burggraf, V. (2012). Overview and summary: The new millennium: Evolving and emerging nursing roles.

OJIN: The Online Journal of Issues in Nursing

,

17

(2). doi:10.3912/OJIN.Vol17No02ManOS

Masters, K. (2015). Models and theories focused on nursing goals and functions. In J. B. Butts, & K. L. Rich (Eds.),

Philosophies and theories for advanced nursing practice

(2nd ed., pp. 377-407). Burlington, MA: Jones & Bartlett Learning.

Nicely, B., & DeLario, G. T. (2011). Virginia henderson’s principles and practice of nursing applied to organ donation after brain death.

Progress in transplantation, 21

(1), 72-77.

Vera, M. (2014).

Virginia henderson – The first lady of nursing

. Retrieved from

http://nurseslabs.com/virginia-henderson/

Vera, M. (2014).

Virginia henderson’s nursing need theory

. Retrieved from

http://nurseslabs.com/virginia-hendersons-need-theory/

Contemporary literature has identified the increasing incidence and prevalence of depression in Australia. Discuss this phenomenon in relation to the reasons for this increase.

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Contemporary literature has identified the increasing incidence and prevalence of depression in Australia. Discuss this phenomenon in relation to the reasons for this increase.

 

Topic 1

• Contemporary literature has identified the increasing incidence and prevalence of depression in Australia. Discuss this phenomenon in relation to the reasons for this increase. In your answer consider gender specific differences and the nurse’s role in the treatment and management of the illness.
OR
Topic 2

• Individuals who experience borderline personality disorder often have difficulties in emotional regulation leading to unstable and intense interpersonal relationships. Discuss this statement and the use of pharmacological and non- pharmacological treatments and nursing interventions for these individuals.
The discussion is to be supported with relevant and credible references. There are to be a minimum of ten references at least two (2) being researched based journal articles. No Wikipedia and only two (2) web based sites.

 

Study of Care for Early onset Dementia Sufferer

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In this case study I will be outlining the nursing care I would provide for 69 year old Simone who has been diagnosed with early onset dementia and wishes to remain living at home with her 40 year old paraplegic daughter whom she cares for. As I have only a few brief details about Simone’s current condition, I will be hypothesising and considering various outcomes based on possibilities in her life. I will discuss the diagnosis of different types of dementia and their/its possible effect on Simone then a possible care package based on evidence from literature.

Dementia is the name given to a condition which is a gradual, progressive decline in a person’s memory and other cognitive abilities which eventually affects their function and ability to care for themselves (Alzheimer’s Scotland 2010.) Despite huge advances over the last century, the diagnoses of dementia and its sub-types remains a challenge (Gold 2002.) The most common form of dementia is Alzheimer’s Disease (AD) which affects 55% of people with dementia in Scotland. This disease slowly destroys the brain cells and connections affecting a person’s cognition and function (Alzheimer’s Scotland 2010.)

The functional assessment staging (FAST) tool provides a detailed framework for the expected evolution of AD. It works by outlining the stages of AD that the person should go through and by assessing them regularly against these stages, the assessor can decide if they have AD or not. For example, Simone seems to be at stage “4: Mild Dementia: IALDs become affected, such as bill paying, cooking, cleaning ansd travelling.” If she has AD the next stage would be “5: Moderate Dementia: Needs help selecting proper attire” but if she was assessed instead to be at “6a: Moderately Sever Dementia: Needs help putting on clothes” then she would have missed a stage in the progression of AD. She would either not have AD or have another type of dementia as well (Medical Care Corporation 2010.) Thus any deviations from this tool can give the assessor a clue to another process (Gold 2002.)

If this was the case then there is a strong possibility that vascular dementia (VD) would be diagnosed. This type of dementia accounts for around 20% of sufferers in Scotland and a further 20% have VD and AD known as mixed dementia (MD.) The most common sub-type of VD is multi-infarct dementia (MID) when the brain has been damaged by small strokes but it can also be causes can be attributed such as irregular heart rhythms and high blood pressure. The effect on the person is very similar to AD but the progression is different. While the decline in AD is gradual as per the stages in the FAST tool, the condition of the person with VD will be generally be step-wise and sudden caused by a series of strokes. This could cause the condition of the person to deteriorate quickly missing out one or more of the FAST stages (Alzheimer’s Scotland 2010b.)

There is evidence that the FAST tool is superior to the Mini Mental State Examination (MMSE) in measuring the evolution of AD (Gold 2002.) The MMSE is the standard tool used to screen for cognitive impairment and is recommended by the National Institute for Health and Clinical Excellence (NICE 2007) for deciding whether drug treatment should be used for the person with dementia. It rates the person’s cognition from 0 to 30 based on functions such as memory, arithmetic and orientation. NICE (2007) advises that dementia medication, such as donepezil, galantamine or rivastigmine, should only be used in moderate to moderately severe cases of AD, i.e. a score of between 10 and 20 and that memantine can be prescribed for moderately severe to severe AD. 64 carers of people with dementia responded in a questionnaire saying that they believed that early prescription of medication was necessary to see any benefit in the person with dementia. Also that these benefits should be discernible for at least six months or it was not worth taking the medication (NICE 2007.)

And so Simone would most likely be prescribed a medication. However, dementia is not the only cause of the signs that Simone presents with. Diagnosing dementia is extremely difficult and is partly carried out by eliminating other more treatable causes such as confusion and depression (Nazarko 2009.) Although Nazarko uses the word “eliminate” and Simone has been diagnosed with dementia, it is possible that she is also suffering from depression. The prevalence of depression is increased to 10-20% in people with dementia (Ouldred & Bryant 2008) and considering that Simone’s daughter has suffered from two bouts of depression in recent years, this is a consideration.

After diagnosis, the CMHN must decide on how to ensure that a care package is put in place. The traditional biomedical approach to disease with its focus on the pathology and emphasis on cure has often created an attitude of hopelessness for chronic conditions such as dementia. This has led to carers making people physically comfortable as their condition deteriorates instead of an attempt to improve the person’s quality of life holistically. However, this has been changing over recent years, with more interventions to enable sufferers to live as full a life as possible (Woodrow 1998.)

Primary prevention, to avoid early pathological changes and secondary prevention, to delay pathological processes that lead to a worsening in the client’s condition, are strategies that NICE (2007) states are worthwhile pursuing. The earlier the diagnosis is made, the more effective secondary interventions can be. In Simone’s case, her earlier diagnosis will mean that supports and resources can be put in place and will have a better chance of working effectively.

The first thing that the nurse must achieve is the building of a therapeutic relationship with Simone, something that Egan (2009) calls the empathic relationship. The nurse must listen to the client, understand them and their concerns, and respond to them in a constructive way (Egan 2009.) Once the assessment is complete and a diagnosis has been made, dialogue between nurse and client may start to diminish and be contained within the context of the initial appraisal of the client’s condition. This can lead to discussions only around symptoms, their severity and frequency and their management. This leaves the client, who is struggling to make sense of their condition in the context of their whole life, without the necessary support from the nurse to do so (Eckhart 2007.) And so the nurse must maintain a holistic and person-centred approach which is formed around listening.

The nurse must try to empathise or “tune in” to the client physically and psychologically, being aware of body language, listening actively and understanding their concerns contextually. As Egan (2009) says “listening is at the very heart of understanding.”

During the process of establishing this relationship with the client, the CMHN must also consider other disciplines that could have constructive input into the client’s care. In providing a service to person with dementia, collaboration with other mental health services, social services, family doctors and other support services is important. Recommendations by Cosgrove and Williams (2005) state that for half a million people with dementia in the UK a specialist multi-disciplinary team is justified, and that for a smaller population those who decide on service provision should prioritise the disciplines which would work most effectively. For example, when the diagnosis has been made and initial assessment done, Simone’s case would be discussed at a MDT including Simone, her daughter, an occupational therapist (OT,) a psychiatrist, the CMHN, social worker and other professionals that could have input. This would generally start with the CMHN who would have a central role being Simone’s first point of contact with the MDT (Cosgrove & Williams 2005.)

The Department of Health (2005) published the Ten Essential Shared Capabilities; A Framework for the whole of the Mental Health Workforce. These are values and principles that were issued so that every mental health worker would abide by them. The first is Working in partnership that advises mental health workers to “develop and maintain constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks” (Department of Health 2004.) Hall et al (2008) says that no one agency, profession or individual can provide the diversity required to successfully and efficiently provide a comprehensive care package for a service user. They go on to say that each discipline must overcome any barriers that may interfere with the goal of providing person-centred care planning (Hall et all 2008.)

Simone has spent the last ten years being the sole carer for her daughter who despite being described as very able will have put some strain on her independence. Kitwood (1997 cited in Woodrow 1998) has said that the stresses of life can contribute to the development of dementia which may have contributed to the development of Simone’s condition. Also, the anxiety she is feeling over her diagnosis will add to this stress as she worries about her ability to care for her daughter.

We also know that Simone has lost contact with many friends since starting to care for her daughter ten years ago and does not have any family locally that can support her. And so the stress of caring will be more pronounced without help and support. This absence of an emotional support network will also have contributed to Simone’s isolation. Previous studies have shown a correlation between social isolation, or having fewer interactions with others, and dementia and cognitive decline (Wilson et al 2007.) Thus we can deduce that reducing the strain of Simone caring for her daughter is likely to slow any deterioration in her condition. The CMHN can liaise with an agency such as Alzheimer’s Scotland to organise support for Simone and her daughter to help assist in this.

Information at this stage is very important. Simone must understand her condition, ways to keep herself safe and strategies for keeping herself healthy in order to delay the degenerative process of dementia.

Reduced appetite and food intake is closely associated with the ageing process. Studies have shown that the transition of food through the digestive system of an older person is significantly slowed causing a feeling of fullness that can lead to reduced appetite. A diminished sense of taste and smell occurs in the ageing process; in particular, alterations in these senses occur in AD and can affect a person’s food intake (Shepherd 2010.) This will lead to weight loss which is common in older people, and in particular, people with dementia, even more so for those in the later stages of the disease. Those with dementia will often lose additional weight due to a lack cognitive functioning regarding preparation and consumption of food such as use of cutlery, lack of co-ordination, difficulty in preparing food, loss of interest in eating and forgetting to eat. Under-nutrition increases the risk of a variety of physical health problems and will lead to a decline in functional and cognitive capabilities (Stanner 2007.) There is also the possibility of over-eating during the early stages of dementia due to memory problems. This does not rule out the possibility of malnutrition as the food consumed may not contain the balance of nutrients required to remain healthy (ADEAR 2010.)

Routine nutritional screening for malnutrition in high risk groups such as those with dementia should be a priority (Stratton & Elia 2007.) The standard screening tool used in Scotland is the Malnutrition Universal Screening Tool (MUST) is a simple five step tool that can be used for the screening and management of a client’s nutrition (Malnutrition Advisory Group 2008.) This should be administered to Simone initially and at every meeting thereafter to identify early signs if there is a decline in her nutrition.

She should also be asked about what food she eats and its nutritional value carefully considered. There is research to suggest that the biological processes involved in ageing may be due to damage to cells and could be caused by the generation of “free radicals.” Polyphenols are anti-oxidants known to tackle these free radicals and can be found naturally in tea, fruit and vegetables, some herbs and wine. Studies have shown that these polyphenols may also assist in the prevention of dementia which is thought to be caused partly by oxidative stress (Shepherd 2010.) There is also evidence to suggest that increasing omega-3 fatty acids and oily fish lessens the chances and possibly progression of dementia (Shepherd 2010.) Levels of these nutrients have also been found to be inversely related to the depression of severity. Concentrations of folate are also thought to be similarly related to depression (Williamson 2009.)

There is a wealth of further information on diet and it’s effect on dementia. Simone could benefit from a digestible form of this information from a source such as Alzheimer’s Scotland (www.alzscot.org) which can provide information in booklet form that is simple and accessible. The nurse should support Simone to go through this information, ideally with her daughter as well, so that they can plan a good nutritious diet that can be reinforced by them both.

Simone and her daughter both being involved in the preparation of food will also reduce the risks to their safety. Simone has already shown difficulty in cooking safely and this may cause her to stop this activity, impacting on her diet and nutrition. People with dementia may avoid doing an activity altogether, refusing to acknowledge the impact of the disease on their function (Howorth & Saper (2003.) This is something I will discuss later but for now I will concentrate on the risk that Simone’s condition presents and her insight into it.

Mitchell & Glendinning (2007) state that older people manage everyday risks in order to lead as “normal” a life as possible. In Simone’s case, she wishes to remain in her own home with her daughter and states that she does not need any help in coping there. However, she has yet to assess the risks with regard to her and her daughter’s long-term well-being with regards to her recent diagnosis. This may be due to a lack of insight into her condition at this early stage. As show by Howorth & Saper (2003) in their research into insight in dementia sufferers, the discrepancy between what patients report and carers report on an ADL (activities of daily living) scale seems to indicate a loss of awareness regarding cognitive and functional abilities for those in the early stages of dementia. They go on to suggest that this may highlight a distinction between implicit and explicit knowledge in the dementia sufferer, reflected in Simone’s belief that she does not need help (her implicit knowledge) despite her explicit behaviours having shown otherwise on more than one occasion (her burning food and becoming lost.)

Simone’s awareness of her difficulties may be hampered by short term frustration, worry and giving priority to another concern: her daughter (Howorth & Saper 2003.) In another study, people recently diagnosed with AD would discuss various aspects of their illness but would not us the term AD to label their experiences. This was while they would resist any movement towards categorisation of their symptoms as AD creating what MacQuarrie (2005) called a “paradox” that seemed to preserve the person’s sense of self, or agency, in the face of cognitive decline. Living with AD should not be termed as acceptance or denial of the condition but rather as this “paradox” of understanding that takes into account the acknowledgement of, and resistance to, the condition (MacQuarrie 2005.)

And so Simone’s desire to live a “normal” life may require her own assessment of risk to be subject to a process of constant reappraisal and adaptation depending on the progress of her condition if she is to live safely (Mitchell & Glendinning 2007.) She may, after having difficulties with certain ADLs, come to realise that she cannot live safely doing these activities. And, depending on her level of insight, she will more than likely require a great deal of input from the CMHN in doing this which is when the CMHN should assess risk.

Risk assessment is a major concern for any CMHN and they are encouraged to identify, manage and reduce risk. There is a preconception about those with dementia presenting a risk mainly to themselves through, for example, wandering or getting lost, as Simone did in a previously familiar place. However, as is evident from Simone burning food recently, this risk may affect others, in particular her daughter (Manthorpe 2003.)

Simone’s home is “well equipped for both of them” but the nurse should suggest to Simone that an OT come to review the equipment. In particular, the cooking equipment should be looked at and safety measures considered. An isolation valve for the cooker could be fitted, or the gas cooker replaced with electric. Gas detectors and smoke alarms may be used and these can be linked to external warning devices to alert others if necessary. These measures can ensure an adequate level of autonomy remains with Simone but that her safety is greatly increased (Alzheimer’s Society 2010.)

Other safety strategies could be discussed with Simone and her daughter around her likelihood of becoming lost or wandering again. Alzheimer’s Scotland’s (2010b) advice to carers, in this case Simone’s daughter, is to always have a recent photograph available with a list of identifying features. With this, a list of familiar places the person may go would be useful for the police in the event of Simone going missing. This will be particularly useful as her daughter may be limited in her ability to search for her mother herself.

Thus I have shown how a care plan could be initiated for Simone and with the underlying evidence, how it could be further developed in future depending on the progression of her condition.

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Factors Affecting Hand Washing Compliance

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Factors Affecting the Compliance of Hand Washing Among Healthcare Workers in a Long-term Care Facility in Los Angeles, California


  • Noela Gadingan

  • Samantha Tweeten, PhD

Healthcare workers deal with different types of patients every day. Every patient has their own microorganisms that contributed to the development of their diagnosis. Hand hygiene plays a critical role especially among healthcare workers as they deal with not only one but several patients. Hand washing is vital in the prevention of the different hospital acquired infections or also known as the nosocomial infections. The increasing incidence of nosocomial infection is very alarming knowing that there are many organizations such as the Joint Commission and Centers for Disease Control and Prevention who exert effort to implement the guidelines of hand hygiene among healthcare workers.

A research article on a survey on hand washing practices and opinions of healthcare workers shows that healthcare workers knew the importance and benefits of hand washing, but still, they tend to overestimate their own compliance. It also shows that healthcare workers were more concerned on the different interventions that would make hand washing easier (Harris et al., 2000).

Another research article on hand hygiene compliance rate in the United States of America presented a 12-month multicenter collaboration where researchers measured the product usage and provided feedback about hand washing compliance to assess the hand washing compliance rates in the United States of America. The result shows that the rate of hand washing among healthcare workers is still at or below 50%; the researchers suggest that with the combination of monitoring and providing feedback, compliance rate would increase (

http://ajm.sagepub.com.ezproxy.nu.edu/content/24/3/205)

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The researcher of this study chose this topic because there are many programs and organizations that exerted efforts, time, and money to implement hand washing, yet there are still incidences of non-compliance. The topic on hand washing seems is common and seems to be easy yet ignored by some individuals. As a result, there are a lot of unanswered questions on the aspects of hand washing compliance. The increasing incidence rate of nosocomial infections among the patients provides a significant reason to conduct this research study. Healthcare providers are expected to care, cure, and help patients achieve a quality of life; thus, hand washing should not be a want but rather a need.

However, there are some knowledge gaps that still need answers and limitations that may not have given a complete solution to address this issue. The purpose of the study is to know the different factors that affect the compliance among healthcare workers in a long-term care facility in Los Angeles California and to assess the knowledge and attitude of the healthcare workers concerning the practice of hand washing.

The hypothesis is that there are several factors affecting the compliance of hand washing among healthcare workers, such as lack of awareness, lack of education on the importance of hand washing, personal attitude of healthcare workers, and insufficient supply of hand washing materials. The researcher believes that through knowing the different factors that affect the compliance of hand washing among healthcare workers, it would give benefits not only among individuals but also to the community and society as a whole. Individuals, both patient and healthcare providers, protect themselves from different infectious diseases knowing that proper hand washing is the universal precaution. It would also help build a healthy community if there will be an absence or decrease incidence of infectious diseases. To the society as a whole, it would help in developing appropriate planning to identify the different solutions that would address the different factors identified. It would contribute to the different healthcare organizations and health policy makers to implement suitable actions and would hopefully achieve 100% compliance among healthcare workers and decreasing incidence rate of nosocomial infections among patients.


Review of Literature

A research study by assessed the knowledge, attitude, and practice of hand washing among healthcare workers in Ain-Shams University Hospital and had an inspection of 10 wards on that hospital for facilities needed for hand washing (Elaziz, 2009). A cross-sectional study was being conducted from the period of June until November 2006. For the data collection of this study, 10 infection control nurses were trained on how to carefully observe hand washing opportunities and to fill out forms needed for the study. There were three research instruments used: observation form on hand washing, form on ward inspection, and, to assess the knowledge and attitudes of healthcare workers regarding hand washing, a self-administered questionnaire was used. The results showed that doctors had a 37.5% compliance, which is significantly higher compared with the other groups of healthcare workers, but only 11.6% executed the proper hand washing correctly. Routine hand washing, which is 64.2%, was the most common type of hand washing that is being practiced among healthcare workers, compared with the antiseptic hand washing, which is only 3.9%. In addition, inadequate supply of paper towels was identified as another factor. Nurses were identified to have more knowledge on hand washing compared with doctors. They believed that to increase the compliance on hand washing, administrative orders and a continuous observation as well must be implemented. The researchers of this study suggested that to give solution to theses factors that affect the compliance of hand washing, there should be an implementation on multifaceted interventional behavioral hand hygiene program that would monitor and provide performance feedback, an increase in hand washing supplies, and an institutional support.

McGuckin, Waterman, and Govednik (2009) studied on hand hygiene compliance rates in the United States of America. Their study is a 1-year multicenter collaboration with the use of a product/volume usage measurement. All healthcare facilities were offered the measurement program. The only criteria for enrollment that was used in the study was the site’s willingness to submit the monthly summaries of the volume of the product usage and patient bed days to a more secure protected database that is important in generating, measuring, and benchmarking reports. The sites that were enrolled were encouraged to make use of the reports in giving feedback to the healthcare workers. They received as well an implementation manual, and they would also receive a support from the researchers of the study in implementing the program at their site. The researchers made use of three reported methods of measuring the hand washing compliance. These are as follows: direct observation, healthcare workers self-reporting, and an indirect calculation based on the product usage of hand washing. The results showed that hand washing compliance in an intensive care unit were 26% and 36% for non-ICUs. Meanwhile, after 12months of measuring the usage of product and giving feedback, the compliance rate increased to 37% for ICUs and 51 for non-ICUs. However, the compliance rate on hand washing among healthcare workers is at or below 50%. The researchers suggested that to give solution to this, there must be a combination of monitoring and feedback to increase the compliance rate.

Aziz (2013) studied on how availability of materials improved the hand hygiene compliance. The annual National Health Survey provides healthcare workers the opportunity to share their opinions on the availability on the materials used in hand washing. There were three community buildings and 31 wards that were reviewed to assess the availability of materials needed in hand washing, as well as alcohol hand rub located on wards and at entrances. The results showed based on the audit that in 30 out of 34 areas, the availability of hand washing materials was good. Both staffs in ward and in community emphasized what other materials were required for hand washing. After knowing the inadequacies, steps were made to provide these. The audit carried out made the practice of hand washing to be benchmarked across the trust and enhanced the awareness of the staff on the importance of hand washing. Therefore, as a result of this, compliance of hand washing among healthcare workers increased from 80% to 95%.

A survey on hand washing practices and opinions of healthcare worker was conducted (Harris et al., 2000). The research instrument that was used in this study is a 74-question survey that was given to healthcare workers in two tertiary care hospitals. The result of the study shows that healthcare workers knew the importance and benefits of hand washing, but still, they tend to overestimate their own compliance. It also shows that healthcare workers were more concerned on the different interventions that would make hand washing easier.

The different literature review from the four researches provide an explanation to conduct further studies to enhance the compliance rate of hand washing practices among healthcare workers. Alhough there are many studies conducted previously from different researchers, there is still a need to know more on the different factors why we cannot achieve a 100% compliance among the healthcare workers who were known to care and cure the sick.


Methods

The participants of the study are the healthcare workers, which includes the following: doctors, nurses, nursing assistants, and therapists. It will include both male and female, all types of ethnicity, and age. They must be a current employee in a long-term care facility.

This research study will make use of a cross-sectional study design that will be conducted in a long-term care facility in Los Angeles in a period of 2years. The researcher will conduct a study observation where different areas in the healthcare facility will be checked. The observation will be carried out where healthcare workers usually do invasive procedures, have personal contact with the patients, and perform non-invasive procedures such as taking the vital signs of the patients and obtaining specimen for the laboratory, during waste disposal.

For the data collection, it will make use of the same process that was carried out on the research study by Elaziz (2009). In collecting data, there will be two infection control nurses who will be trained on doing the hand washing observation and in filling out the observational and ward inspection form. In a covert manner, the nurses that were trained will fill out the observational form, which records whether hand washing was carried out or not and if it is carried out appropriately or not. He or she will also record the type of hand washing that was carried out by the person observed and note what type of errors that was committed when it was done incorrectly. In checking the availability of the hand washing materials, which include soaps, sinks, towels, drying materials, and hand washing posters and guidelines, a ward inspection form will be filled up.

There will be three research instruments that will be used in gathering the data for this research study. The same research instruments that were used by Elaziz (2009) in her study will be used. The three research instruments are observation form of hand washing, form for ward inspection, and, to know whether there is lack of awareness and education and whether a problem on healthcare workers attitude is a factor, a self-administered questionnaire will be used as part of the research instrument. The self-administered questionnaire would assess whether lack of awareness and education, and personal attitude among healthcare are factors affecting the compliance on hand washing. The questionnaire to assess for lack of awareness and education will include different questions covering different aspects of hand washing practices, including the use of time, proper execution, and materials needed for hand washing. A Likert scale will be used in assessing the attitude of healthcare workers. The program that will be used for data entry, checking, and analysis will be the Statistical Package for Social Science.

For the ethical consideration, the approval of the design and the different steps of the study were conducted with the different members of the infection control unit in a long-term care facility in Los Angeles, California. This study will prepare informed consent forms that will provide prospective study participants information regarding the research. The observation of hand washing practices among healthcare workers is already considered as a routine checking of infection control activities by the infection control nurses.

The bias that may include in this study is information bias because participants may not provide honest answers to appear in compliance to the guideline on proper hand washing. Another bias that might happen is the measurement bias when a research cannot control for the effects of the data collection and measurement, knowing that self-administered questionnaire is one of the types of the research instrument used in this study

The limitation of the study will include the possible biases that might be present especially in the data collection process, which will affect the credibility and reliability of the result of the research study, and the time and resources in conducting this research study.


References

Aziz, A. (2013). How better availability of materials improved hand-hygiene compliance.

British Journal of Nursing

,

22

(8), 458–463.

Elaziz, K. (2009). Assessment of knowledge, attitude and practice of hand washing among health care workers in Ain Shams University hospitals in Cairo.

Journal of Preventive Medicine and Hygiene

, 50(1), 19–25.

Harris, A. D., Samore, M. H., Nafziger, R., Rosario, K. D., Roghmann, M. C., & Carmeli, Y. (2000). A survey on hand washing practices and opinions of healthcare workers.

Journal of Hospital Infection

. doi: 10.1053/jhin.2000.0781

McGuckin, S., Waterman, R., & Govednik, J. (2009). Hand hygiene compliance rates in the United States—A one-year multicenter collaboration using product/volume usage measurement and feedback.

American Journal of Medical Quality

. doi: 10.1177/1062860609332369

. Identify one quality improvement strategy to improve health. How could you apply it to your current nursing practice? Currently working in ICU. Discussion prompt 2

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. Identify one quality improvement strategy to improve health. How could you apply it to your current nursing practice?
Currently working in ICU.

Discussion prompt 2
2. How does the assimilation of quality improvement strategies enhance leadership?

. Identify one quality improvement strategy to improve health. How could you apply it to your current nursing practice?
Currently working in ICU.

Discussion prompt 2
2. How does the assimilation of quality improvement strategies enhance leadership?

Identify the major benefits offered under the Medicare Program.

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Identify the major benefits offered under the Medicare Program.

processes in your response.

5. ” Insurers believe there is a high correlation between an applicant’s credit record and future claim expense”. Do you agree or disagree with this statement. Support your answer with information from the text or outside source.
6. Define the term facultative reinsurance. In what situations would this term be applicable?
7 Why have so many insurers had to increase their risk-based capital requirements?

1. Explain the law of agency and how it affects the actions of insurance agents.
2. What are the three general rules of agency that govern the actions of agents and their relationships with insured’s?
3. Define the concept of coinsurance and deductible as each relates to health insurance policies.
4. Why are other insurance provisions necessary in insurance contracts?
5 Describe the coordination of benefits provision that is included with most group insurance plans. In what situations is it utilized? Provide examples with your response.

1. Explain in detail the fundamental legal principles that are reflected in insurance contracts. (Requires one page).
2 Discuss the required components of an insurance contract. (1 page)

1. Define the term POS. Give examples of such plans.
2. Describe the basic characteristics of a cafeteria plan. Describe the ways insurance companies use the coordination of benefits provision in their payments to providers of health care.
3. Discuss how self-insured health plans are operated. Do employers save money with these type of plans?
4. Explain the evolution of the Patient Bill of Rights. Compare and contrast how it is utilized in different health care settings.
1. What is managed care? How do managed care plans differ from the traditional group health insurance plans? (1 page)
2. What is a PPO? How do PPO’s differ from EPO’s? Give examples of each with your answer. (1 page)
3. How are preexisting conditions provisions and coordination of benefit provisions often used in group health insurance plans?
4. What coverage is typically provided through group basic medical expense plans?
5. What are the four major health care problems in the United States? Identify each of these and include examples with your response.

1. Identify the major benefits offered under the Medicare Program.
2. What is Medigap insurance? Describe the development of such plans and the reasons they came about.
3. Describe the primary objectives of unemployment insurance. How is eligibility determined under this program?
4 Discuss the Medicare Advantage program alternatives to Medicare Part A and Medicare Part B.

1. Discuss the basic benefits offered under the Part B side of the Medicare program. How are these benefits paid for?
2 Identify the basic characteristics of Social Insurance.

1. What are the three categories of torts? Be sure to differentiate between each type of tort in your response.
2. Describe the common defenses against negligence?
3. What are the primary elements of a negligence?
4. Explain the concept of compensatory damages. Differentiate between special damages and general damages.
5. Define the term Res Ipsa Loquitur, expounding on the background of this legal concept. Give examples with your answer.
6. What is a personal umbrella policy? Name the exclusions normally present in this type policy.
7. In your opinion, what is the cause of the medical malpractice crisis in the health care industry. Support your answer and include appropriate examples.

1. Describe the common elements of a casualty insurance contract.
2. Identify the purpose of a claim’s made malpractice insurance policy and compare andcontrast the claims made and the standard malpractice insurance policy.
3. Describe the typical commercial umbrella policy and identify it’s major policy provisions.
4. What is the purpose of business interruption insurance? Compare and contrast the business interruption insurance with business casualty insurance policies.

Accounting is the study of how businesses track their income and assets over time. Accountants engage in a wide variety of activities besides preparing financial statements and recording business transactions.

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Accounting is the study of how businesses track their income and assets over time. Accountants engage in a wide variety of activities besides preparing financial statements and recording business transactions.

These activities include computing costs and efficiency gains from new technologies, participating in strategies for mergers and acquisitions, quality management, developing and using information systems to track financial performance, tax strategy, and health care benefits management.
Use the Internet or the Strayer Online database to research career options within the accounting field and accounting job postings in your local area to respond to the questions in the assignment.

Describe at least two (2) career options someone with an accounting education can pursue. Be sure to reference sources such as the Bureau of Labor Statistics and the American Institute of Certified Public Accountants.

Describe one (1) researched accounting position, and explain the essential skills that would make a candidate successful in the position. Articulate the primary manner in which the researched accounting positions could add value to the company seeking candidates.