Essential Oils as Antibiotic Agents

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Essential Oils as Antibiotic Agents

Alternatives to conventional Western medication take many forms from nutraceuticals to healing touch, from acupressure/acupuncture to aromatherapy.  They are thought to treat a variety of conditions and have been used over millennia and in many cultures.  This paper focuses on essential oils, specifically their antibacterial effects and usage as an alternative or adjunct to pharmaceutical antibacterials.

The Rise of Antibiotic Resistant Bacteria

More and more we are encountering drug and multidrug resistant (MDR) pathogens.  These pathogens, including bacteria, are becoming increasingly deadlier and costlier to treat as we exhaust of options to treat them (Allen, 2017).  The development of new antibiotics is always one route; however, concern about resistance to those new antibiotics is warrented (Hrvatin, 2017).  We need to look to alternatives, both singularly and in combination with traditional therapies to meet this challenge.  Essential oils are one method that have been around and are gaining in popularity and attention (Herbs uses, history, essential oils, n.d.; Yap, Yiap, Ping, & Lim, 2014).

Background and significance

Essential oils were the precursors to many medications.  They have been used for an indeterminant time (Aromatherapy: History and basics, n.d.; History of essential oils, n.d.).  They have been used in India in ayurvedic therapy, in China, in Egypt, in Greece and Ancient Rome, etc. (Aromatherapy: History and basics, n.d.; History of essential oils, n.d.).  For a time, in Catholic Europe, their use was considered witchcraft but was kept alive, it is thought, by monks who continued the science in secret (History of essential oils, n.d.).  By the 1700’s, their use was becoming more common and widespread again.  Even during the Indochine War, the French physician Jean Valnet used essential oils to treat war wounds successfully when antibiotics ran out (Aromatherapy: History and basics, n.d.; History of essential oils, n.d.).  They could be extracted from everyday plants such as clove, garlic, eucalyptus, and more to create effective medications for the everyday person.  Blends of essential oils were used to combat the bubonic plague, most notably, “thieves’ oil” which legend has it protected grave robbers from the plague while they were in contact with the infected bodies (Young Living Essential Oils).  Currently, in the United States, essential oils are available for use in inhalation and topical applications (PDQ® Integrative, Alternative, and Complementary Therapies Editorial Board, 2019).

We know that essential oils have many properties.  Clove oil, for instance, has a main component of eugenol which has pain relieving and antimicrobial properties (Yap, Yiap, Ping, & Lim, 2014).  Many know that aspirin was originally extracted from willow bark and used as an analgesic, frequently brewed as a tea for ingestion.  The applications of oils address a variety of needs.

Review of Literature

Many essential oils have antibacterial properties among other properties.  Among these are clove oil, rosemary oil, citrus oils, oregano oil, basil oil, and mentha oil (Chavez-Gonzalez, Rodriguez-Herrera, & Aguilar, 2016).  All of these have been shown to have properties effective against drug resistant bacteria, some against multidrug resistant bacteria (Chavez-Gonzalez, Rodriguez-Herrera, & Aguilar, 2016; Abdullah, Hatem, & Jumaa, 2015).  These are examples of some of the more recent studies that have been done on essential oils and their antibiotic effects. These look at essential oils and/or their components against more than one type of bacteria.

Oregano and thyme oils have as a major component the phenol carvacrol (Magi, Marini, & Facinelli, 2015).  Carvacrol has shown more effectiveness against gram-positive bacteria than against gram-negative in its bactericidal activities; its mechanism of action (MOA) is to damage bacterial membranes (Magi, Marini, & Facinelli, 2015).  It also has a synergistic effect with  antibiotics, including macrolides (Magi, Marini, & Facinelli, 2015).

Streptococcus pyogenes

is a Group A streptococci (GAS) bacteria that can have mild to severe consequences if an infection develops.  GAS can cause relatively mild disease such as impetigo all the way to necrotizing fasciitis and shock.  It can also have post-streptococcal sequelae like rheumatic heart disease, post-streptococcal glomerulonephritis, and more.  GAS has developed increasing resistance to the main macrolide that is used to treat it, erythromycin (Magi, Marini, & Facinelli, 2015).  While oregano and thyme oils showed inhibitory GAS bacterial growth, the best GAS growth inhibition was a combination of carvacrol and erythromycin (the tested strains were erythromycin-resistant GAS strains) (Magi, Marini, & Facinelli, 2015).  This shows potential for use in clinical applications and the development of safe drug combinations to administer to those who contract GAS (Magi, Marini, & Facinelli, 2015).

Rosemary and clove oils were tested against MDR strains of several bacteria, both gram-positive and gram-negative, as well as two standard strains (Abdullah, Hatem, & Jumaa, 2015).  The four strains of MDR bacteria were

Acinetobacter baumanni

,

Pseudomonas aeruginosa

,

Staphylococcus aureus

, and

Enterococcus faecalis

(Abdullah, Hatem, & Jumaa, 2015).  The two standard strains used were

Pseudomonas aeruginosa

ATCC 27853 and

Staphylococcus aureus

ATCC 29213 (Abdullah, Hatem, & Jumaa, 2015).  Rosemary oil showed inhibition in all six bacteria when in concentrations of five percent and greater but only in two bacteria when in weaker concentrations (Abdullah, Hatem, & Jumaa, 2015).  Clove oil showed inhibitory growth for all six strains at a much greater level, including in concentrations as low as 1.25%, and in three of the strains at a concentration of only 0.312% (Abdullah, Hatem, & Jumaa, 2015).  This leads to the conclusion that while rosemary oil can be used as an antibacterial agent (and is a potent option), clove oil is a more potent option (Abdullah, Hatem, & Jumaa, 2015).

Four components of several essential oils, carveol, carvone, cintronellol, and citronellal, were tested against

Escherichia Coli

and

Staphylococcus aureus

.  All provided some inhibition to bacterial growth with one notable exception: carvone to

Staphylococcus aureus

(Lopez-Romero, Gonzalez-Rios, Borges, & Simoes, 2015).  Citronellol had the highest inhibitory effect followed by citronellal against both pathogens (Lopez-Romero, Gonzalez-Rios, Borges, & Simoes, 2015).  Citronellol and citronellal are both components of

Eucalyptus citriodora

which is a varietal of eucalyptus (Lopez-Romero, Gonzalez-Rios, Borges, & Simoes, 2015).  Based on how these components affected the two tested bacteria, it was concluded that they would be useful in topical applications for skin infections (Lopez-Romero, Gonzalez-Rios, Borges, & Simoes, 2015).

Relevance to Advanced Practice

As advanced practitioners, we will encounter multidrug resistant bacteria often.  Advanced practitioners must educate themselves in alternatives to the traditional Western medicine.  Dealing with these bacteria will be something we cannot avoid, and we must look to alternatives and complementary therapies to combat them.  This can include essential oils.  Many oils (and their components) are generally recognized as safe (GRAS) for usage and are widely available (besides the fact that some are commonly used for cooking in their plant form) (Chavez-Gonzalez, Rodriguez-Herrera, & Aguilar, 2016; Boire, Reidel, & Parrish, 2013).  Information on how to use them can be found on the internet; much of it is unreliable as there are few sources or references for the claims listed.  This is a concern as an advanced provider as the patient might choose to use essential oils without considering them medicine (they may affect other medications) and they may be utilizing them in an unsafe way.  Arguably a reliable website that commonly comes up on searches is healthline.com; their articles are written and reviewed by professionals with sources listed (About us, n.d.).  This is not the case for many sites.  Being able to steer patients to reliable sources is important in educating them, be it about essential oils, diseases and conditions, and more.  Patients must also be cognizant of the fact that some forms of usage are better than others (indeed, some forms of usage may be deadly) and that use should be carefully considered.

Conclusions

Essential oils are a viable alternative and/or adjunct to traditional therapies in the treatment of pathogens, especially MDR ones.  Their application in not limited to antibacterial applications but also include other microbials such as fungus (Dagli, Dagli, Mahmoud, & Baroudi, 2015).  There should be concern that microbes will do what they have done since the beginning of time, evolve to withstand these additional agents. Research must continue developing ways to combat them.  It is necessary to discover the toxic levels (such as neurotoxicity) and side effects so that dosing can be safely determined (Dagli, Dagli, Mahmoud, & Baroudi, 2015).  In the meantime, as additional therapies are being developed, it is the wise primary care provider (and the acute care provider) not to dismiss essential oils as the province of those who distain Western medicine but to learn more about them, their uses, and their applications.

References

  • Abdullah, B. H., Hatem, S., & Jumaa, W. (2015). A Comparative study of the antibacterial activity of clove and rosemary essential oils on multidrug resistant bacteria.

    UK Journal of Pharmaceutical and Biosciences, 3

    (1), 18-22.

  • About us

    . (n.d.). Retrieved from Healthline.com: https://www.healthline.com/about
  • Allen, H. A. (2017).

    Alternatives to antibiotics: Why and how?

    Retrieved from National Academy of Medicine: https://nam.edu/alternatives-to-antibiotics-why-and-how/

  • Aromatherapy: History and basics

    . (n.d.). Retrieved from Alliance of International Aromatherapists: https://www.alliance-aromatherapists.org/aromatherapy
  • Boire, N. A., Reidel, S., & Parrish, N. (2013). Essential oils and future antibiotics: New weapons against emerging “Superbugs”.

    Journal of Ancient Diseases and Preventative Remedies, 1

    (2), 105.
  • Chavez-Gonzalez, M., Rodriguez-Herrera, R., & Aguilar, C. (2016). Essential oils: A natural alternative to combat antibiotics resistance. In K. Kon, & M. Rai,

    Antibiotic resistance: Mechanisms and new antimicrobial approaches

    (pp. 227-237). Elsevier, Inc.
  • Dagli, N., Dagli, R., Mahmoud, R., & Baroudi, K. (2015). Essential oils, their therapeutic properties, and implication in dentistry: A review.

    Journal of Internaltional Society of Preventative and Community Dentistry, 5

    (5), 335-340. doi:10.4103/2231-0762.165933

  • Herbs uses, history, essential oils

    . (n.d.). Retrieved from Master Gardner Mecklenbery County: https://www.mastergardenersmecklenburg.org/herbs-uses-history-and-cultivation.html

  • History of essential oils

    . (n.d.). Retrieved from Essential Oils Academy: https://essentialoilsacademy.com/history/
  • Hrvatin, V. (2017). Combating antibiotic resistance: New drugs or alternative therapies?

    Canadian Medical Association Journal, 189

    (37).
  • Lopez-Romero, J. C., Gonzalez-Rios, H., Borges, A., & Simoes, M. (2015). Antibacterial effects and mode of action of selected essential oil components against Eschericia coli and Staphylococcus aureus.

    Evidenced-based Complementary and Alternative Medicine, 2015

    . doi:10.1155/2015/795435
  • Magi, G., Marini, E., & Facinelli, B. (2015). Antimicrobial activity of essential oils and carvacrol, and synergy of carvacrol and erythromycin, against clinical, erythromycin-resistant Group A Streptococci.

    Frontiers in Microbiology, 6

    . doi:10.3389/fmicb.2015.00165
  • PDQ® Integrative, Alternative, and Complementary Therapies Editorial Board. (2019).

    PDQ Aromatherapy with essential oils.

    (A. a. PDQ® Integrative, Ed.) Retrieved from National Cancer Institute: https://www.cancer.gov/about-cancer/treatment/cam/hp/aromatherapy-pdq
  • Yap, P. S., Yiap, B., Ping, H., & Lim, S. (2014). Essential oils: A new horizon combating bacterial antibiotic resistance.

    Open Microbiology Journal, 8

    , 6-14. doi:10.2174/1874285801408010006
  • Young Living Essential Oils. (n.d.).

    The history of Thieves essential oil.

    Retrieved from Young Living Essential Oils: http://www.ylessentialoils.com/pdf/Thieves%20Essential%20Oil.pdf

Best wound care approach for patients with foot ulcers

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Best wound care approach for patients with foot ulcers

Topic: Best wound care approach for patients with foot ulcers

(Or it can be a different topic, but needs to be approved first)

During this lesson, you will use the PICOT questioning format/formula to develop an answerable research question. All elements are listed below:

• P: Population/disease (age, gender, ethnicity, disorder)
• I: Intervention or variable of interest (exposure to a disease, risk behavior, prognostic factor)
• C: Comparison (a placebo or “business as usual” such as no disease, absence of risk factor, or prognostic factor B)
• O: Outcome (risk of disease, accuracy of a diagnosis, rate of occurrence of adverse outcome)
• T: Time (the time it takes to demonstrate an outcome; e.g., the time it takes for the intervention to achieve an outcome or how long participants are observed)
prepare an evidence-based practice (EBP) presentation on a topic of your choice that is relevant to advanced nursing practice education, leadership, quality improvement, or change

Your presentation should include:
1. Identification of an advanced practice nursing issue or practice problem of concern
2. Design a research question using the PICOT format
3. A brief literature review and findings related to best practices with at least three scholarly resources cited in APA (6th ed.) format
4. Plan, Do, Study, Act Process that could be used
5. Any implications that the investigation might have for nursing practice

Rubric:

The presentation includes an appropriate topic identification related to an advanced practice nursing issue or practice problem of concern. The topic is clearly stated in the introduction, developed and explained well through the literature review, and there is an appropriate conclusion statement.

PICOT Question Design
Population is fully defined and present in the research question. Includes specific interventions, identifies comparisons, and presents appropriate outcomes in a timely manner for the question. Overall, a well-built question using the PICOT method.

Literature Review
Includes a brief overview of the literature in the presentation and includes relevant details.

Plan/Do/Study/Act Process
Presentation includes a description of the study, study design, rationale, and inclusion of sampling information that the student is using.

Implications to Nursing
The significance and applicability to nursing is included and well presented.

: It is important to understand how borrowed theory can help you in your everyday environment as a nurse. In the previous assignment, you identified a practical problem that emerged from the evidence in the extant literature or professional practice

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: It is important to understand how borrowed theory can help you in your everyday environment as a nurse. In the previous assignment, you identified a practical problem that emerged from the evidence in the extant literature or professional practice
PURPOSE:

It is important to understand how borrowed theory can help you in your everyday environment as a nurse. In the previous assignment, you identified a practical problem that emerged from the evidence in the extant literature or professional practice, and you explored how middle-range theory could be applied to solve the problem. In this assignment, you will explore and apply borrowed theory to solve the specific problem that you identified previously, and you will synthesize the applications of the middle-range theory and the borrowed theory into the most appropriate solution to the problem.

DIRECTIONS:

Consider the problem that you described in the previous assignments and the instructor feedback about those assignments.

Write a paper (1,750 to 2,000 words) that describes how borrowed theory can be applied to the identified problem. The paper should include the following:

A brief summary of the problem including the potential middle-range theory that could be applied.
A description of a borrowed theory that could be applied to the problem. Is this borrowed theory appropriate to your identified problem?
A brief history of the borrowed theory’s origins.
A discussion of how the borrowed theory has been previously applied.
A discussion of the application of the borrowed theory to the identified problem. How would your practice change by incorporating this theory?
A discussion of how application of both the borrowed theory and the middle-range theory can be integrated to create the most appropriate solution to the identified problem.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

Please read the previous 2 essay and apply it to this assignment, apa format, at least 1700 to 2000 word, 3 reference

1 previous essay

Neuman’s System Model and Use in Psychiatric Facilities

Student’s Name:

Institution Affiliation:

The problem description summary

Psychiatric and mental health nursing deals with the care of the patients with emotional and mental health problems that include and not limited to depression, anxiety, mood disorders, addictions, and stress and various developmental disorders (Phillips, 2016). In this case, the nursing professionals play a significant role in offering both nursing and medical care to the individuals, groups, communities, and even families to promote emotional and mental health. The primary problem experienced in a psychiatric nursing workplace setting is the patient violence that significantly affects the quality of care given and the nursing management outcome (Phillips, 2016). The patient violence particularly occurs in the acute setting of the psychiatric facilities and is believed to result from the nature of the patient condition. This problem remains a global concern and mainly affects the nurses because they remain the primary care givers in the psychiatric facilities and have long hours exposed to the mentally ill patients. A research conducted by Phillips (2016), indicates that over 20%of all psychiatric patients possess violent behavior in a variety of ways ranging from verbal to physical abuse. Various triggers are believed to precipitate the violent behavior and hence proper training, administration, policy making, and proper practice development remain pillars of early detection and prevention of patient violence (Phillips, 2016).

Betty Neuman’s systems model

Middle range theories are highly useful in addressing various nursing problems especially the vulnerable groups, families, or even individuals. In this case, the Betty Neuman’s system model gives a comprehensive system based and holistic approach to nursing with an element of flexibility. This theory primarily focuses on the patient’s response to the existing potential environmental stressors and the utilization of the primary, secondary and the tertiary nursing prevention interventions for maintenance of patient system wellness (Neuman & Fawcett, 2002).

The Neuman’s system theory has various assumptions to put into consideration in its application. The model assumes that a patient system is a unique with composite factors, existence of many universal stressors influencing the patient system stability, each patient has range of responses to the environment, and the interrelations of the patient with care givers at any time can affect the degree to which the client is protected (Neuman & Fawcett, 2002). The model also assumes that the client remains a dynamic system of interrelationships of the existing variables in either state of wellness or illness. In addition, a secondary prevention relates to the symptoms following a behavior or even a reaction and appropriate measuring of the priorities of the intervention and the treatment offered reduces their bad or noxious effects. The primary concepts applied in this model include a person, health, environment, and nursing. This model is highly useful in my identified problem of patient violence in the psychiatric facilities. In this case, the systematic nature of this theory can help the nursing team to do thorough patient management and help reduce the cases of mentally ill patient’s violence against nurses (Neuman & Fawcett, 2002).

Chronic Obstructive Pulmonary Disease Nursing Case Study

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This essay describes the nursing assessment and care planning provided to a patient with Chronic Obstructive Pulmonary Disease (COPD), as experienced during a clinical placement. In addition, the health breakdown of the patient is described, followed by the delivery of an appropriate intervention and how this will be evaluated. Firstly, a brief description of the patient is provided.

Patient Profile

The true identity of the patient will remain anonymous in adherence with the Nursing and Midwifery Code of Conduct on patient confidentiality (NMC, 2008). However, the patient will be referred to by the pseudonym ‘Sally’ for the purpose of this essay.

Sally is 50-years old and was diagnosed with COPD approximately 2-years ago. She lives alone and has no close family. Her health has been deteriorating rapidly over the last couple of months, with the primary problem being restricted mobility. She is finding it increasingly difficult to attend to activities of daily living or to maintain social contact. This is in part due to becoming easily out of breath as a result of the COPD. Her condition is exacerbated by her weight, as she is clinically obese. At 5ft 4inches and weighing 16 stones (224 pounds), Sally’s body mass index (BMI) is 38.4kg/m2. Sally mainly consumes a diet of microwave meals and convenience foods because she finds it too much effort to cook a meal for one. She is in a vicious cycle that perpetuates her mobility issues, whereby the less active she becomes, the more she gains weight and the more sever her symptoms of breathlessness become.

Holistic Assessment

A patient-centred holistic approach was taken in assessing Sally’s health and care needs. This approach is based on the belief that “in the treatment of medical conditions, all of one’s physical, mental, emotional and social conditions – not just physical symptoms – should be taken into account” (American Holistic Nursing Association, 2010, p.1). In line with this approach, Sally was placed at the centre of her own health care, providing her with active involvement in the assessment process and the development of her care plan. This approach is promoted by the Department of Health in their efforts to encourage self-management and self-responsibility in people with long-term chronic conditions such as COPD (Department of Health, 2008).

Historically, Sally’s assessment would have adhered primarily to the medical model and involved measures of airflow and lung volume in order to assess COPD severity. This would not have provided Sally with the appropriate level of care as important issues surrounding her diet, living circumstances, and psychological well-being might have been missed. In order for Sally to be provided with individualised care, her COPD and mobility issues require the holistic approach that has recently been advocated by the National Institute of Clinical Excellence (NICE, 2010).

Recognising that the assessment should not merely focus on Sally’s physical condition if an appropriate care plan is to be devised (Shapiro et al., 2007), the Roper, Logan and Tierney Activities of Living Model (Roper et al, 2000) was utilised (appendix 1). This is a holistic model based on the twelve activities of living (ALs) essential to health and well-being. The model comprises five components, which guided Sally’s assessment (Box 1):

1) Level of independence in each of the ALs is assessed.

2) Level of nursing intervention required relates to the patient’s level of dependence or on the nurse regarding these ALs.

3) Position on a lifespan continuum from birth to death has a bearing on levels of independence.

4) A range of factors influence ALs, including biological, psychological, socio-cultural, environmental and politico-economic factors.

5) Individualised nursing according to ALs, dependency levels, age, and influencing factors is required.

Box 1: Patient Assessment using the Roper, Logan and Tierney’s Activities of Living Model (Roper et al, 2000)

PATIENT ASSESSMENT

Date: 15/01/2011

Patient ID: 12569

Patients Name: Sally Johnson Height: 5ft 4in FEV1: 52% (Moderate)

Age: 50-years old Weight: 16st (224lbs) Blood Pressure: 116/79

Activities of Living (D=dependent; I=independent):

– Maintaining a safe environment D I

– Communication D I

– Breathing D I

– Eating and drinking D I

– Elimination D I

– Personal grooming D I

– Controlling body temperature D I

– Mobilising D I

– Working and playing D I

– Expressing sexuality D I

– Sleeping D I

– Dying D I

Comments: Sally shows dependency in four ALs: mobilising; breathing; eating and drinking; and working and playing.

Influencing Factors

Biological:

Sally is clinically obese.

Sally is 50-years of age.

Sally has reduced mobility due to COPD-related breathlessness and obesity.

Sally used to smoke, but quit 2-years ago when diagnosed with COPD.

Psychological: Sally expresses feelings of loneliness and is tearful, both of which indicate possible depression, which could be due to social isolation.

Socio-cultural: No current issues.

Environmental: Sally is finding it difficult to maintain a tidy house.

Politico-economic: No current issues.

The Roper, Logan and Tierney Activities of Living Model is particularly relevant to Sally’s circumstances as her greatest problems are in activities of daily living. This model provides specificity of where these problems are greatest. The core problem is mobility, which seems to exacerbate some of the other problems, including her COPD symptoms, weight, and social life.

Remaining patient-centred, Sally was asked if there was anything she felt might improve her mobility. Sally felt that the breathlessness had got worse with her weight gain and auggested that weight loss might assist. The assessment reached similar conclusions since weight loss is most often associated with worsening COPD, whilst weight gain is more likely in those without airway obstruction. This would indicate that the weight was impacting the COPD rather than vice versa.

The open-ended questioning approach used with Sally follows the theoretical framework offered within motivational interviewing, which has been found to be effective in motivating lifestyle-related behaviour change (Miller and Rollnick, 2009). It is often used alongside the stages of change model, as was the case here. According to this model there are five stages to lifestyle-related behaviour change (Prochaska, DiClemente, and Norcross 1992): 1) pre-contemplation (i.e. the individual is unaware of a problem and does not intend to change their behaviour; 2) contemplation (i.e. the individual is aware of the health risks of their lifestyle and is thinking about change; 3) preparation (i.e. the individual expresses serious intentions to change their lifestyle; 4) action (i.e. the first few weeks and months of actively taking steps towards behavior change; and, 5) maintenance (i.e. about 6-months to 5-years after initiation of the behavior change decision, when the individual takes action towards relapse prevention).

Sally was clearly at the preparation stage, but needed practical, medical, and emotional support to enter the action stage.

Self-Management Intervention

Medical interventions are limited for people with COPD and thus a key role for nurses is to promote healthy behaviours in people with COPD. A multidisciplinary intervention was required to meet Sally’s care needs. Firstly, NICE (2004) guidelines recommend that BMI is calculated for people with COPD and that if weight loss or gain changes over time they are referred to a dietician. Such a referral was made for Sally and would provide the initial provision of education, advice and support in terms of her dietary needs.

In addition, a self-management care plan was introduced to Sally, as developed by the British Lung Foundation (2011). The plan was designed to help people with COPD manage their condition effectively and includes sections on medication, oxygen status, symptom monitoring, breathing techniques, healthy eating, and exercise tips. Sally’s current problems with mobility resulting from excess weight and breathing difficulties are multifactorial and thus such a holistic approach is likely to be more efficacious than merely providing guidance on weight loss. Indeed, self-management education has been found to reduce hospital admissions, improve symptoms of breathlessness and enhance quality of life in people with COPD (Effing et al., 2007).

It was recognised that Sally’s isolation and loneliness might also be contributing to her problems and thus she was informed of the benefits of establishing connections with other people who have COPD. Sally did express some interest in this, especially in terms of meeting people via a programme of pulmonary rehabilitation, such as the local BreatheEasy programme (BLF, 2011). Pulmonary rehabilitation can reduce disability and improve quality of life. By improving physical fitness, breathlessness is reduced and independence increased. Whilst it doesn’t improve lung function, it can play a significant role in increasing exercise tolerance.

Sally was particularly interested in finding a local BLF Active (2011). This is a scheme set up by the British Lung Foundation, which supports people with COPD in remaining physically active. Sally decided to try this option, but was open to also exploring joining an Expert Patient course, designed to increase confidence to self-manage. She was keen to be actively involved in her care, but also expressed low self-efficacy and thus a need to gradually integrate social and lifestyle changes into her life. Group-delivered self-management programmes are notorious for increasing patient self-efficacy through the provision of vicarious experience (i.e. learning from others with the same condition) (Ashford, Edmunds, and French, 2010). Furthermore, many self-management groups are educational and based on setting achievable goals, both of which increase an individual’s sense of mastery.

Intervention Effectiveness

Changes in lung function as a result of interventions are often minimal for people with COPD. Thus, intervention effectiveness requires an assessment of other outcomes, such as improvements in activities of daily living and quality of life.

Regular monitoring and reassessment of Sally’s needs will be required in order to identify the effectiveness of the support provided to her, as well as to identify where changes might be needed. This will be achieved by regular assessments using the Roper, Logan and Tierney’s Activities of Living Model in order to monitor levels of dependency, especially in terms of mobility.

As part of her self-management plan, Sally will also be closely monitoring her symptoms, including levels of breathlessness and changes in cough sputum. Spirometry readings will be taken by the nurse during each assessment in order to monitor COPD severity in comparison to Sally’s current severity rating of moderate. Sally’s weight will be monitored through contact with the dietician who she has been referred to.

In line with government efforts to measure the quality of healthcare services via patient-reported outcomes (DH, 2009), Sally will also be asked to complete the Clinical COPD Questionnaire (CCQ) (Molen et al., 2003) before, during, and after the intervention. This 10-item questionnaire comprises the following domains: functional state; symptoms; mental state. This is instrument is easy to administer and complete for the assessment of patient-reported symptom severity, ability to partake in physical and social activities, and psychological well-being.

Appendix 1: The Roper, Logan and Tierney Nursing Model (Roper et al., 2000)

Level of dependence (D) or independence (I) on 12 Activities of Living (ALs):

Activities of Living:

– Maintaining a safe environment D I

– Communication D I

– Breathing D I

– Eating and drinking D I

– Elimination D I

– Personal grooming D I

– Controlling body temperature D I

– Mobilising D I

– Working and playing D I

– Expressing sexuality D I

– Sleeping D I

– Dying D I

The patient’s position on a lifespan continuum from birth to death:

Birth Death

Influencing Factors:

Biological (e.g. overall health, current illness or injury, anatomy and physiology, age)

Psychological (e.g. emotion, cognition, spiritual belief, ability to understand)

Sociocultural (e.g. societal and cultural experience, expectations, values)

Environmental (e.g. damp in the home, air pollution)

Politico-economic (e.g. government, politics, economy)

Individualised care according to these ALs, level of dependence or independence in regard to ALs, position on the life continuum, and the influencing factors of ALs. References

American Holistic Nurses Association., 1998. What is holistic nursing? Available from:http://www.ahna.org/Home/NewsRoom/AHNAFactSheet/tabid/1939/Default.aspx [cited 13 February 2011].

Ashford, S., Edmunds, J. and French, D.P., (2010). What is the best way to change self-efficacy to promote lifestyle and recreational physical activity? A systematic review with meta-analysis. Br J Health Psychol, 15(Pt 2), pp.265-88.

British Lung Foundation (BLF),, 2011. COPD Self Management Plan. Available from: http://www.lunguk.org/supporting-you/Publications/copd_self_management_plan [cited 13 February 2011].

British Lung Foundation (BLF)., 2011. BLF Active. Available from: http://www.lunguk.org/supporting-you/blf_active/ [cited 13 February 2011].

British Lung Foundation (BLF)., 2011. Breathe Easy. Available from: http://www.lunguk.org/supporting-you/breathe-easy [cited 13 February 2011].

Department of Health (DH)., 2009. Guidance on the routine collection of Patient Reported Outcome Measures (PROMs). Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_092647 [cited 13 February 2011].

Department of Health, 2008. Health, Your Way – A Guide to Long-Term Conditions and Self-Care.’ Department of Health, The Stationary Office, London.

Effing, T., Monninkhof, E., Van Der Valk, P. and Van Der Palen, J., et al., 2007. Self-management education for patients with chronic obstructive pulmonary disease [systematic review]. Cochrane Database of Systematic Reviews 4. Available from: http://ovidsp.tx.ovid.com. ezproxy.lib.uts.edu.au/spa/ovidweb.cgi [cited 13 February 2011].

Miller, W.R. and Rollnick, S., 2009. Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, pp. 129-140.

Molen van der, T., Willemse, B.W., Schokker, S. and Ten Hacken, N.H., 2003. Development, validity and responsiveness of the Clinical COPD Questionnaire. Health Qual Life Outcomes. 1:13.

National Institute of Clinical Excellence (NICE), 2010. Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). This guideline partially updates and replaces NICE clinical guideline 12. Developed by the National Collaborating Centre for Chronic Conditions, London.

Nursing and Midwifery Council (NMC)., 2008. Code of Conduct. London: NMC.

Prochaska, J.O., DiClemente, C.C. and Norcross, J.C., 1992. In search how people change: Applications to addictive behaviours. American Psychologist, 47S, pp. 1102-1114.

Roper N., Logan W.W. and Tierney A.J., 2000. The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Elsevier Health Sciences.

Shapiro, J.R. and Neuberg, S.D., 2007. From Stereotype Threat to Stereotype Threats: Implications of a Multi-Threat Framework for Causes, Moderators, Mediators, Consequences, and Interventions. Personality and Social Psychology Review, 11, pp. 107-130.

Also read: How to Write a Nursing Case Study Paper

Study on the Impact of Geriatric Medication Errors

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Abstract

The use of certain medications in geriatrics when potential risks outweigh the potential benefit and an effective alternative is available is called as Potentially Inappropriate medication. Because geriatrics are more sensitive towards adverse effects of medications. Beers criteria which is updated and reviewed by American Geriatric society list out 53 medications/therapeutic classes of drugs to be avoided in geriatrics.

Methodology

: A prospective observational study was conducted for 9 months in a 650 bed private corporate hospital, South India. All geriatric patients admitted in the hospital during the study period was included. Beers Criteria 2013 were used to identify potentially inappropriate medications.

Result:

The prevalence of PIM use (52%) was significantly higher in study population. An avg of 10 drugs were taken by the study population. A total of 215 medications were identified as PIMs. Among them 195(90%) medications should be avoided by the geriatrics independent of their condition (category I). 66(60%) of the study population had used more than one PIMs. 91(83%) of the PIM users had atleast one DRPs and the mean DRPs value of the PIM users were 1.591.3.

Conclusion:

High prevalence of PIMs in the study population signifies the need of monitoring geriatric prescriptions.

Key words: PIMs, Beers Criteria, Geriatrics


Introduction

In recent years proportion of geriatric hospital admission with comorbidity and polypharmacy has been increasing continuously (21, 2). Adverse drug events (ADRs) are the most common reason for hospital admission, but sometimes it’s not identified. Medication errors (MEs) or conventional adverse drug reactions (ADRs) are the common reason for adverse drug events which ends in clinical symptoms. Overall, elderly patients need greater attention to drug therapy and safety parameters (21, 3-5).

Greater attention is needed for geriatric population due to age related pharmacodynamics and pharmacokinetic changes. But appropriate pharmaceutical care for elderly are determined on the basis of clinical trial conducted with adult population.(6) The burden of harm resulting due to the use of multiple drugs in geriatric populations is a major health related problem in developed countries. A research study reveals that around one in four geriatrics admitted to hospitals are prescribed with at least one inappropriate medication and potentially preventable adverse drug reactions accounts for nearly 20% of all inpatient deaths (7).

The assessment of potentially inappropriate medication (PIM) in geriatric is a challenging work and there is a need for considering many factors which influences the prescribing as well as outcome. Eight well known tools are available to identify the PIMs and studies reports that Beers criteria is the best and easy one to assess the PIMs. Beers criteria also has the advantage over others because it is periodically updated (8).This study therefore aimed to investigate the prevalence of PIM use on geriatric population using Beers criteria 2012 and its association with Drug Related Problems (DRPs) .


Methodology

Study Site: The work entitled “A study on prevalence and impact of Potentially Inappropriate Medication use in geriatrics at a private corporate hospital” was carried out in a 640 bedded private corporate hospital, South India.

Study Design: Prospective –Observational study.

Study Period: Nine months.

Inclusion criteria: Patients above age of 65 yrs.

Exclusion criteria: The patients who are unwilling to participate in the study and out patients

METHOD: A regular ward rounds was carried out in all the wards of General medicine. Each patient’s medication profile was reviewed. Patients who met the inclusion criteria were briefed on the project with the help of patient information form and if they are willing to participate in the study their consent was obtained. The data from medical chart were recorded in customized data entry form.

The prescribed drugs were evaluated and PIMs use were identified with the help of Beer’s criteria. The drugs which are identified as PIM are categorized into following:

  1. Potentially inappropriate medications /classes to avoid in geriatrics,
  2. Potentially inappropriate medications /classes to avoid in geriatrics with certain pathological condition that the listed PIM use can exacerbate
  3. Medications to be used with caution in geriatrics.

ADRs associated with PIMs use were assessed. Drug interaction and ADR was monitored and reported. DRPs and Drug Risk Ratio (DRR) were calculated for PIMs. DRPs were the sum of ADR, drug interaction and drug allergy.DRR was calculated as the number of DRPs in relation to how often the drug was used (DRPS/number of times used).


Results and Discussion

In the study period, 212 patients were included in the study as per inclusion criteria and exclusion criteria. 110 (52%) patients were found to be prescribed with PIMs listed in Beers criteria (fig no: 01). A similar study conducted by Birader K et al (2013) (9) reported that PIM prevalence were 38% in their study population. Increased anxiolytics use as a prophylaxis for hospital related anxiety might be the reason for high prevalence of PIM than the later study. The total number of patients in study population were 110. Among them 62(56%) were males and 48(44%) were females.The study result reveals that PIMs user are mostly males. A similar study conducted by Birader K et al (2012) (9) reported that prevalence of PIM use is more among males than females.

The age categorization of PIM users was done. The maximum age of PIM users was 93 years and mean age of PIM users was found to be 70.2±5.77. The median age for PIM users was 68.5 years.

The result indicated that age group of (65-69) were commonly prescribed by PIMs. This results compared with a previous study carried out by Birader K et al (2012) (9) which also reports that PIMs were frequently prescribed in the age group of 65-69 years. The social habit of the PIM users shows that 8(7%) patients were smokers and alcoholics, 14(13%) patients were alcoholics, 21(19%) patients were smokers and 67(61%) patients were teetotalers in PIM users.

The comorbidities of the PIM users was analyzed. There were 52 (47%) suffering from hypertension and 32(29%) were suffering from DM. The results shows that most of the study group had comorbidities of hypertension followed by DM and CVDs. A similar study conducted by Fouquet A (11) also reported that most common diagnosis among their study population was hypertension and diabetes.

The number of drugs prescribed for the PIM users were calculated (fig no: 2). The mean number of drugs per prescription was 9.9±2 with the maximum of 16 drugs and minimum of 5 drugs prescribed. The above results signifies that all prescriptions were in polypharmacy category. A similar study conducted by Blozik E (12) concluded that one of the main factor for PIM use is “polypharmacy”.

The number of PIM drugs per prescription in the study population was calculated (Fig no: 3). The result reveals that 44(40%) were using one PIM drug, 50(45%) were using two PIMs, 14(13) were using three PIMs, 1(1%) were using 4 PIMs and the maximum of 5 PIMs use were found in 1(1%) of the study population. 66(60%) of the study population consumed more than one PIM. The mean was found to be 1.8±0.78 and an avg of 2 PIM was used by the study population. A similar study conducted by Dormann H (2013) (13) were reported that 87% of the study population consumed at least one PIM.

Among the PIM users the total number of PIM drugs was calculated and it was found to be 215 drugs. PIM users were categorized into three groups according to Beers criteria. (Table no: 2) There were 195(90%) belongs to category I, 12(6%) were in category II and 8(4%) were in category III.

The individual categories of PIM was analyzed. It was found that alprazolam 57(52%), clonazepam 17(15%), hyocyamine 10(9%), Lorazepam 10(9%), hydroxyzine 10(9%), zolpidem 10(9%), ketorolac 10(8%) were prescribed in category I (table no: 3). A similar study conducted by Birader K et al (2013) (16) reported that alprazolam and cimetidine were frequently used PIM among their study population.

Use of hyocyamine in constipation 3(25%) accounts for the most frequent inappropriate drug use in category II (table no: 4). Hydroxyzine in constipation 2(17%), cyproheptidine in constipation 2(17%), ketorolac in PUD 2(17%), clonazepam in frequent fall 1(8%), ketorolac in CHF 1(8%) and theophylline in insomnia 1(8%) were other category II inappropriate medication use.

Use of escitalapram 3(40%), mirtazapine 2(30%), fluoxetine 1(10%), sertraline 1(10%) and Duloxetine 1(10%) were the category III PIMs (table no:5).

The DRP among the PIM users were analyzed (fig no: . It was found that 19(17%) of the PIM users were free from DRPs. Majority of the study population had at least one drug related problems. The mean value of DRP in the study population was found to be 1.59±1.3. The minimum observed number of DRP per patient was one and maximum observed number of DRP per patient was six.

The ADR use was monitored in the study population. A total number of 40 ADR associated with PIM use (Fig no:5) and 14 ADR associated with nonPIM use were identified. The study result reveals that one among three PIM users were found to have at least one ADR. A similar study conducted by N. Nixdorff et al (2008) were also reported that PIM users were found to experience ADR most frequently than nonPIM users.

As a part of our study, screening of drug interactions were done. A total number of 131 major drug interactions were identified, in that 111 were unique. Among the drug interactions found 16(12%) were PIM-PIM drug interactions, 39(30%) were PIM-other drugs drug interactions and 76(58%) were caused by non PIM drugs (table no: 6).

Drug risk ratio were calculated for the study population (table no:7). It was observed that prochlorperazine had the highest DRR (4) followed by phenobarbitone (2), digoxine (2), pentazocine (2) and duloxetine (2).

The statistical analysis of obtained results has been done using statistical tools. The association of different variables are analyzed using 2 test.

On assessment of association between “number of comorbidities” with “number of drugs” and “number of PIMs” (table no:8), the result proved that “number of comorbidies” are statistically associated with “the number of drugs” at 0.001 level of significance and “number of PIMs” at 0.05 level of significance. It means that as number of comorbidity increases polypharmac and PIM use also increases.

On assessment of association between “number of drugs” and “number of PIMs” (table no: 9), the result proved that “number of drugs” are statistically associated with “number of PIMs” at 0.05 level of significance. This result proves that polypharmacy is one of the reason for PIMs.

On assessment of association between “number of DRPs” with “number of drugs” and “number of PIMs” (table no:10), the result proved that “DRPs” are statistically associated with “number of PIMs” at 0.01 level of significance but not associated with “number of drugs” at 0.05 level of significance.

This result proves that DRPs is more associated with PIMs than polypharmacy which means it not the number of drugs contributing to DRPs but the use of PIMs.


Conclusion

Our study identified a high prevalence of PIMs use and associated DRPs in the study population. DRPs due to PIMs is preventable. Development and implementation of new criteria or modification of already existing criteria such as Beers criteria, START STOPP criteria which will helps in safe prescribing practice can reduce the PIMs use.


References

  1. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011; 365: 2002–12.
  2. Budnitz DS, Shehab N, Kegler SR, Richards CL: Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007; 147: 755–65.
  3. Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG: Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 2005; 165: 68–74.
  4. Pirmohamed M, James S, Meakin S. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329: 15–9.
  5. Chrischilles EA, VanGilder R, Wright K, Kelly M, Wallace RB. Inappropriate medication use as a risk factor for self-reported adverse drug effects in older adults. J Am Geriatr Soc 2009; 57: 000–6
  6. Avorn J, Shrank WH. Adverse drug reactions in elderly people: A substantial cause of preventable illness. BMJ. 2008;336:956–7
  7. Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework. Ian A. Scott, MBBS, MHA, MEd,a Leonard C. Gray, MBBS, MMed, PhD,b Jennifer H. Martin, MBChB, MA (Oxon), PhD,c Charles A. Mitchell, MBBSd
  8. Opondo D. Inappropriateness of Medicationth Prescriptions to Elderly Patients in the Primary Care Setting: A Systematic Review, plos one, aug 2012, volume 7, issue 8
  9. Biradar K; assessment of potentially inappropriate medication in elderly patients at Basavehwar teaching hospital;IJPP 2012dec, vol 5,issue 4, 73-5
  10. Denys TL (2011) Functional Decline Associated With Polypharmacy and Potentially Inappropriate Medications in Community-Dwelling Older Adults With Dementia, Am J Alzheimers Dis Other Demen. 2011 December ; 26(8): 606–15. doi:10.1177/1533317511432734
  11. Fouquet A, Zegbeh H, Krolak-Salmon P, Mouchoux C. Detection of potentially inappropriate medication in a French geriatric teaching hospital: A comparison study of the French Beers criteria and the improved prescribing in the elderly tool. J Eurger 2012 3: 326-29
  12. Blozik E, Rapold R, von Overbeck J, Reich O. Polypharmacy and potentially inappropriate medication in the adult, community-dwelling population in Switzerland. Drugs & aging. 2013;30:561-8
  13. Dormann H, Sonst A, Müller F, Vogler R, Patapovas A, Pfistermeister B, Plank-Kiegele B, Kirchner M, Hartmann N, Bürkle T, Maas R. Adverse drug events in older patients admitted as an emergency the role of potentially inappropriate medication in elderly people (PRISCUS). Dtsch Arztebl Int 2013; 110(13): 213–9. DOI: 10.3238/arztebl.2013.0213
  14. N. Nixdorff et al. Potentially inappropriate medications and adverse drug effects in elders in the ED. AJEM 2008 26: 697–700


Tables and figures


NO. of PIM/prescription


Number of patients


N=110


Percentage

1

44

40

2

50

45

3

14

13

4

1

1

5

1

1

Table no:1 Number of PIM per Prescription

sl no

category

no. of PIMs

percentage

1

PIM drugs/classes to be avoid in geriatrics (category I)

195

90

2

PIM to be avoided in certain pathological condition (category II)

12

6

3

PIMs to be used with caution (category III)

8

4

Table no:2 Categories of PIM

sl no

Drugs

No. of Patients

sl no

Drug

No. of Patients

1

Alprazolam

57 (29%)

16

Nitrofurentoin

3(1.5%)

2

Clonazepam

17(9%)

17

Mirtazapine

2(1%)

3

Hyocyamine

10(5%)

18

Cyproheptidine

2(1%)

4

Lorazepam

10(5%)

19

Diazepam

2(1%)

5

Hydroxyzine

10(5%)

20

Piroxicam

2(1%)

6

Zolpidem

10(5%)

21

Prochloperazine

2(1%)

7

Ketorolac

10(5%)

22

Chlorphemiramine

2(1%)

8

Aceclofenac

9(4.5%)

23

Trihexylphenedine

2(1%)

9

Propoxyphene

8(4%)

24

Digoxin

2(1%)

10

Diclofenac

7(3.5%)

25

Phenobarbitone

1(0.5%)

11

Spironolactone

6(3%)

26

Naproxen

1(0.5%)

12

Prazosin

5(3%)

27

Clinidium-chlordiazepoxide

1(0.5%)

13

Clonidine

5(3%)

28

Indomethacin

1(0.5%)

14

Chlordiazepoxide

3(1.5%)

29

Metachlopramide

1(0.5%)

15

Amitriptyline

3(1.5%)

30

Pheniramine

1(0.5%)

31

Pentazocine

1(0.5%)

Table no: 3 Category 1(PIM drugs/classes to be avoid in geriatrics)


Sl no


Drug


Disease


No. Patients


Percentage

1

Ketorolac

CHF

1

8

2

Hydroxyzine

Constipation

2

17

3

Hyocyamine

Constipation

3

25

4

Ketorolac

PUD

2

17

5

Cyproheptidine

Constipation

2

17

6

Clonazepam

Frequent Fall

1

8

7

Insomnia

Theophyllin

1

8

Table no: 4 Category II (PIM to be avoided in certain pathological condition)


sl no


Drug


No of Patients


percentage

1

Mirtazapine

2

30

2

Fluoxetine

1

10

3

Sertraline

1

10

4

Duloxetine

1

10

5

Escitalapram

3

40

Table no: 5 Cateegory III (PIMs to be used with caution)


NO OF INTERACTION


PERCENTAGE

PIM-PIM

16

12

PIM- OTHER DRUGS

39

30

OTHER DRUGS

76

58

Table no:6 Categories of Drug Interactions


Sl No


Drug


DRPs


Total


Drug Risk Ratio

1

PROCLORPERAZINE

8

2

4.00

2

PHENOBARBITONE

2

1

2.00

3

DIGOXIN

4

2

2.00

4

PENTAZOCINE

2

1

2.00

5

DULOXETINE

2

1

2.00

6

NAPROXEN

2

1

2.00

Table no.7 Drug Risk Ratio

Sl no

Varience

No. of comorbidities

Chi squire value

P value

1

2

≥ 3

1

No. of PIMs

1

5

21

13

12.76*

0.05

2

10

12

15

≥ 3

7

15

12

2

No. of drugs

6-8

13

16

4

26.77*

0.001

9-11

8

25

17

≥ 12

1

7

19

Table no:8 Association of no. of comorbidities with no. of drugs and PIMs

.

varience

No. of Drugs

Chi squire value

P value

6-8

9-11

12-14

≥15

No. of PIMs

1

16

21

4

3

21.76*

0.001

2

14

24

8

4

≥ 3

2

5

5

4

Table no: 9 Association of no. drugs and no. PIMs

Sl no

Varience

No. of DRPs

Chi squire value

P value

0

1

2

≥3

1

No. of PIMs

1

11

21

10

2

21.76*

0.001

2

7

23

8

12

≥ 3

1

4

2

9

2

No. of drugs

6-8

9

15

11

1

11.77

0.05

9-11

4

25

6

12

≥ 12

6

8

3

10

Table no:10 Association of DRPs with no. of drugs and PIMs

Fig no:1 Prevalence of PIMs

Fig no:2 Number of Drugs Prescribed per Patient


Fig no:3 Number of PIM per Prescription

Fig no: 4 Adverse Drug Events and Its frequency

Fig no:5 Adverse Drug Events and Its Frequency

NUR505- REPLY TO DISCUSSION DANETTE

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Module 2 Discussion

The importance of effective communications between healthcare provider and patient are to ensure that the best evidence-based practices are being utilized to assist in the curative or preventative manner in which the patient is seeking medical assistance. The best way to do incorporate this in a manner that promotes cultural competence requires education. Education on the part of the healthcare provider as well as the recipient patient.

Effective communication between the participating parties would begin with acknowledging the differences in cultures that may be present, and giving due respect where those differences are concerned. Cultural differences can create barriers to providing and receiving quality, effective healthcare. With lack of knowledge of different cultures on the healthcare providers part, it can lend to a feeling of mistrust on the patient’s part. If an individual feels that their beliefs are not being respected and taken into consideration, it can add to any barriers and misconceptions felt on the patient’s part, and prevent the ability to participate in a trusting relationship between provider and patient (Purnell, 2013).

An individual’s culture defines the way that they make sense of the world and influences how they view illnesses and the healthcare experience, and how they make their decisions about accepting and utilizing provided information (Brown et al, 2016).  Brown et al (2016) states that in spite of the importance of culture competence in the healthcare field, traditional medical training is lacking in educating the importance of cross-cultural communication. Policies to improve cultural competence knowledge and skills are required to communicate more effectively between patient and provider. Cross-cultural communication includes strategies that acknowledge the individual’s cultural traditions, beliefs or values, and also take into account one’s own beliefs, experiences, and values, without generalizing about the patient (Brown et al, 2016). When the healthcare provider is more knowledgeable in the diverse cultures that he or she may come in contact with in their career, it can help set the basis of a strong, successful working relationship. Communication is key in setting the stage for this new relationship between the participants, and can help the provider learn even more about the patient, their backgrounds, beliefs and goals. Communication between the healthcare practitioner and the patient, and their family and social support, is key to reaching mutually agreed upon healthcare goals (Brown et al, 2016).  

Cross-cultural communication can also be seen as a hinderance with lack of knowledge on how to communicate efficiently. Within cultural groups, people learn their rules: like who is allowed to communicate with whom; when, where and how something may be communicated; and what to communicate about. Sometimes, language and personal beliefs can get in the way of successful communication. When people use slang in context with people outside of their own group, effective communication often fails and creates misunderstanding and barriers between the participants (Center for Disease Control and Prevention, 2020). This is more often seen when healthcare workers and providers are trying to communicate with individuals who may have limited healthcare literacy (Center for Disease Control and Prevention, 2020).  Health literacy is defined as the degree to which an individual has the ability to obtain, process, and comprehend basic health information and the services needed to make appropriate, informed healthcare decisions (Purnell, 2013).

By ensuring we are more open to the cultural differences of the patient in front of us, we can begin to be good stewards of the health they are entrusting us with. By showing respect for the multitude of cultures we will come in contact with in this career as advanced practice nurses, we can also earn the trust of those we seek to assist. Trust sets the basis for a more successful relationship, and should ideally lead to more positive healthcare compliance and outcomes.

References

Brown, E. A., Bekker, H. L., Davison, S. N., Koffman, J., & Schell, J. O. (2016). Supportive care: Communication strategies to improve cultural competence in shared decision making. Clinical Journal of the American Society of Nephrology, 11(10), 1902-1908. DOI: https://doi.org/10.2215/CJN.13661215

Centers for Disease Control and Prevention. (2020). Culture & Health Literacy. Retrieved from https://www.cdc.gov/healthliteracy/culture.html

Purnell, L. (2013). Transcultural Health Care: A Culturally Competent Approach (4th ed.). Philadephia, PA: F. A. Davis Co.

Uterine Cancer (UC): Disease Process- Risk Factors and Treatments

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Abstract

Uterine Cancer (UC) is the most common cancer in women in the United States. Both new cases and death increase yearly. In a normal uterus, the endometrium, or lining, thickens every month unless the woman is pregnant or postmenopausal. If an egg is not fertilized, the lining is shed in the form of menstruation. Progesterone and estrogen are produced in and released from the ovaries. Their release is triggered by the hypothalamus. The corpus luteum, a temporary gland in the ovary, releases progesterone that causes the endometrium to thicken as the egg moves through the fallopian tube towards the uterus. If the egg is not fertilized, the corpus luteum ceases to exist. Like other cancers, UC occurs when cells grow abnormally. The precise cause of UC is still unknown but various theories are presented. While various treatments exist, UC is often not diagnosed until a woman has symptoms and by then, the cancer may have metastasized. Unlike annual PAP smears that detect cervical cancer, no such routine test has been implemented. A current clinical trial may introduce a simple yet revolutionary method for women to collect intravaginal DNA at home to send to a laboratory for testing and early detection.


Uterine Cancer

Uterine cancer (UC), the most common gynecologic cancer, killed 10,733 women in the United States in 2016. The rate of new cases of UC for that year was 56,808. The age group with the most new cases (10,260 women) were between the ages of 65-69, though there were 61 women between the ages of 20-24 who also were diagnosed with UC that year. Of the new cases, 27.6% were White, 27% were Black, 24.6% were Hispanic, 19.4% were Asian or Pacific Islander, and 16.9% were American Indian or Alaskan Native (Centers for Disease Control and Prevention [CDC], 2019). But according to a recent study, Black women had the worst five-year survival rate (54%) of any ethnic group (Baskovic, Lichtensztajn, Nguyen, Karam, & English, 2018). Despite technological advances in medicine, new incidents of UC increased 0.7% each year from 1999 to 2015 and death rates also increased, at a rate of 1.1% each year from 1999 to 2016 (Henley, Miller, Dowling, Benard, & Richardson, 2018).


Normal Structure and Function of the Uterus

The uterus consists of three layers: the exterior layer is the serosa, the middle layer is the myometrium, and the interior layer is the endometrium. The endometrium has three layers: a basal layer, an intermediate spongiosa layer, and an epithelial cell layer. The top of the uterus is the fundus, the middle of the uterus is the body, or corpus, and the bottom of the uterus is the cervix. The function of the uterus is to house and protect the fertilized egg as it develops into an embryo and fetus. During childbirth, the uterus contracts to allow the baby to be born (Canadian Cancer Society, 2019).

There are two female reproductive cycles: the ovarian cycle and the endometrial cycle. The ovarian cycle begins with the follicular phase when the endometrium is at its thickest. If there isn’t a fertilized egg, there are low levels of the luteinizing hormone (LH) and the follicle-stimulating hormone (FSH) in the anterior pituitary gland and both estrogen and progesterone levels remain low.  and menstruation (shedding of the endometrium) occurs. The hypothalamus releases the gonadotropin-releasing hormone (GnRH) that allows the gonadotropic cells in the anterior pituitary gland to produce FSH followed by an increase of LH after one or two days. Ovarian follicles then produce exponentially more estradiol, which both inhibits the secretion of FSH and to a lesser degree LH, and stimulates their synthesis. Meanwhile, the endometrial cycle begins with the menstrual stage, when the endometrium is thin. The estradiol causes the basal layer of the endometrium to begin to thicken during the proliferative stage of the endometrial cycle

(Knudston & McLaughlin, 2019).

During the ovulation stage of the ovarian cycle, the follicle fills with fluid and hormone-secreting granulosa cells and inhibits FSH further.  The estradiol, as well as GnRH and progesterone, causes LH production to increase. This leads to lowered estradiol levels and higher progesterone levels. The LH stimulates enzymes to open the follicle to release the ovum and begin meiosis (Knudston & McLaughlin, 2019).

During the luteal phase of the ovarian cycle what is left of the follicle becomes the corpus luteum which secretes progesterone. This corresponds to the secretory phase of the endometrial cycle, and the progesterone prepares the endometrium for implantation by increasing glycogen and blood flow to the endometrium. LH and FSH levels drop and if implantation does not occur, the corpus luteum becomes the corpus albicans, estradiol and progesterone levels are lowered causing the spongiosa and epithelial layers to shed in the form of menstrual blood, leading back again to the menstrual phase. If implantation occurs, the corpus luteum does not degenerate but remains functional in early pregnancy, supported by human chorionic gonadotropin (HCG) that is produced by the developing embryo (Knudston & McLaughlin, 2019). Pregnancy tests detect high HCG levels. While the phases do not line up neatly, they overlap and influence each other.


Disease Process

The majority (more than 95%) of UC is endometrial carcinoma, or abnormal cell growth that starts in the endometrium. 75-80% of these cancers form in the endometrium glands, and are known as endometrioid carcinoma, which in turn may or may not include non-cancerous squamous cells. Other kinds of endometrioid carcinoma include villoglandular, secretory, and ciliated

cell (Canadian Cancer Society, 2019). Like other cancers, the exact mechanism that causes women to develop UC is still unknown. There are theories that UC may be caused by a number of factors, including “environmental factors, including estrogen, an

abnormal mismatch repair (MMR) system, genetic abnormalities, and aberrant methylation of DNA and microRNA” (Banno, Yanokura, Iida, Masuda, & Aoki, 2014, p. 1957).


The Estrogen Effect

If a woman produces too much estrogen and too little progesterone, she may develop atypical endometrial hyperplasia, or thickening of the endometrium, which may in turn make her more susceptible to endometrial carcinoma (Type I). But if a woman has already passed menopause (and no longer producing estrogen), the carcinoma may develop in a typical endometrium. Known as Type II Endometrial Cancer, the prognosis is worse in this case because the cells are not as differentiated as in Type I. (Banno et al., 2014)


Abnormal Mismatch Repair System

Errors may occur during DNA replication and an abnormal mismatch repair (MMR) system repairs these errors. Lynch syndrome is a hereditary cancer disorder which causes mutations in MMR genes. According to Zakhour et al. (2017), 2-5% of endometrial cancers are attributed to Lynch syndrome. They found that Lynch syndrome was associated with at least 50% of the young women they sampled with endometrial cancer. Unfortunately, they also found that these women were not screened for Lynch syndrome because their family histories did not meet the Amsterdam II criteria for testing (Zakhour et al., 2017), suggesting that screening criteria may need to be expanded so that women may be able to be diagnosed and treated sooner.


Aberrant DNA methylation

Normal DNA methylation (Tao & Freudenheim, 2010) occurs when methyl group bonds to cytosine residues with the help of DNA cytosine methyltranseferase enzymes to form methylcytosine, which is helpful in transcription, normal development, silencing some genes, and gene imprinting. Aberrant DNA methylation occurs when tumor suppressing genes are silenced, allowing tumors to grow. Tao and Freudenheim (2010) found that aberrant DNA methylation was present before diagnosis, suggesting that DNA methylation should be investigated to detect endometrial cancer early.


PTEN Mutations

One of the tumor suppressor genes, the phosphatase and tensin homolog gene (PTEN), is responsible for “the inhibition of cell migration and spreading and focal adhesion” (Tao & Freudenheim, 2010, p. 493). In other words, PTEN normally both stops cancer cells from attaching to healthy cells and stops the cancer cells from metastasizing. 26-80% of endometrial cancers are associated with PTEN mutations

(Tao & Freudenheim, 2010). This suggests that screening for PTEN may be informative in assessing risk for EC.


Tomaxifen

Segev et al. (2013) found that women who were given tamoxifen (for breast cancer) were four times more likely to develop UC after they reached menopause. Tamoxifen is a “selective estrogen receptor modulator” which is used both to prevent and treat breast cancer as it is antiestrogenic, meaning it blocks estrogen, in mammary (breast) linings by binding with the estrogen receptors. But tamoxifen is proestrogenic on the uterine lining; in other words, it acts like estrogen in the endometrium thus increasing the likelihood of endometrial cancer due to hyperplasia (Sporn & Lippman, 2003).


BRCA1/2

While women who are found to be carriers of mutations in the BRCA1 and BRCA2 genes are seven to twenty times more likely to develop breast and ovarian cancer than those who are not carriers, recent research has indicated that this genetic screening may also be valuable in terms of UC. Laitman et al. (2019) explored the rates of the UC in Jewish women in Israel who are carriers of the BRCA1/2 mutations with expected and actual rates of UC in non-carrier women. They found that BRCA1/2 carriers were 3.98 times more likely to develop UC compared to the general Jewish population. Regardless of type of UC and whether or not the woman also developed breast cancer, the increased risk remained significant. Current recommendations for BRCA1/2 carriers include undergoing risk reducing salpingo-oophorectomy (RRSO), or the removal of the ovaries and fallopian tubes. The authors suggest that given the significant risk increase for UC, undergoing a hysterectomy (removal of the uterus) may be considered. The study did not, however, take into account whether or not women received tomaxifen as that data was not available.


Obesity

Women with a high (over 30 kg/m²) Body Mass Index (BMI), are two times more likely to develop UC than women with a healthy BMI (Nunez, Bauman, Egger, Sitas, & Nair-Shalliker, 2017, 61). Adipose (fat) tissue contain the aromatese enzyme converts androgen into estrogen. Thus, women who are obese may have more estrogen than other women which may lead to hyperplasia and UC. According to Lee et al. (2018), “adiposity has been associated with other factors that may drive tumorigenesis in general, including increased inflammation, depressed immune function, and chronic insulin resistance and hyperinsulinemia.”  The insulin in turn, can both stimulate cell growth and act as an anti-apoptotic, protecting cells from cell death (Nunez, Bauman, Egger, Sitas, & Nair-Shalliker, 2017, 61). The use of Metformin for diabetic patients has shown promising results in decreasing the incidence of UC by causing apoptosis (cell death) and “inhibiting cell migration” (Lee et al., 2018).


Modifiers


Diet

Folate includes a methyl group that can be used for methylation and one carbon metabolism (the transfer of one-carbon groups), while methionine, vitamins B2, B6, and B12 are important for one carbon metabolism (Tao & Freudenheim, 2010). High levels of folate are found in dark green leafy vegetables, liver, legumes, asparagus, and avocado. Methionine is in meat, fish, and dairy. Vitamin B2, or riboflavin, is found in eggs, green vegetables, and grains. Chicken, fish, potatoes, and fruit are all sources of vitamin B6. Vitamin 12 is present in fish, chicken, eggs, dairy, beef liver, and clams (National Institutes of Health, 2019).

Soy and soy products, which contain phytoestrogens like genistein, may also help reduce endometrial cancer. The hypothesized mechanism of action involved is DNA methylation but more research is needed to examine the appropriate amount of soy needed to help reduce the risk (Tao & Freudenheim, 2010).


Hormone treatments

A combination of progesterone and estrogen may be given as hormone therapy or as oral contraceptive to reduce the risk of Type I EC. (Tao 2017) The rationale is that too much estrogen and not enough progesterone may cause the hyperplasia in Type I EC but if a woman is given an appropriate combination of the hormones, the thickening may not occur and therefore the risk of cancer is lowered (Tao & Freudenheim, 2010).


Lifestyle

Regular exercise may serve as a protective factor against UC. Women who engaged in high levels of physical activity (vigorous activity at least once a day) were 53% less likely to develop UC than women who did not engage in any physical activity (Nunez, Bauman, Egger, Sitas, & Nair-Shalliker, 2017, 61), suggesting that regular vigorous exercise may serve as a protective factor for women.


Pregnancy

Women who have been pregnant have reduced risk of developing EC and the risk is reduced as she has more children up to five or more. During pregnancy, a woman produces less estrogen and more progesterone. In addition, when a woman is pregnant, she does not menstruate, so her estrogen levels do not increase, and she has less estrogen buildup in her body. Pocobelli et al. (2011) found that women who gave birth for the first time after age 35 had decreased risk for EC. They hypothesize that this may be due to the fact that progesterone increases during pregnancy, which suppresses the estrogen production.


Breastfeeding

When a woman breastfeeds, her estrogen production is suppressed. Thus, her risk of developing EC may be reduced as well. In fact, Jordan et al. (2017) found that women who reported having ever breastfed had a 11% risk reduction for EC compared to women who did not ever breastfeed. In addition, they found that the risk reduction increased as a woman breastfed her baby for longer up to 6-9 months.


Bariatric Surgery

Roux-en-Y is the most common type of gastric bypass, which is the most common method of bariatric, or weight-loss surgery. In this procedure, the surgeon cuts off a small pouch of the woman’s stomach from the rest and attaches the middle of her small intestine to the small pouch. This prevents the woman from eating too much food or absorbing too many nutrients. Bariatric surgery may be an option for women who are extremely obese (BMI over 40) or are moderately obese (BMI 35-39.9) and have serious health problems related to their weight. Women who undergo bariatric surgery must be screened to qualify and may have to commit to adopting a healthier lifestyle and follow-up monitoring after surgery (Mayo Clinic, 2019).

According to a recent study, obese women who have had bariatric surgery were 71% less likely than obese women who did not have bariatric surgery to develop UC. When these women were able to maintain normal weight after bariatric surgery, their risk of developing UC was further reduced to 81% (Ward et al., 2014). Unfortunately, the study did not specify what types of bariatric surgery had been performed and this may have been a significant factor.


Detection

While women undergo routine annual pap smears which screens for cervical cancer, there is no comparable screening process for UC. Instead, women who have a family history of UC or another lynch syndrome cancer such as colon or ovarian cancer, may request genetic testing and regular check-ups. The most common symptom of UC is bleeding in post-menopausal women. Doctors may diagnose UC by doing a biopsy or ultrasound. Bakkum-Gamez et al (2015) investigated the use of tampons to detect EC. She found that tampons collected sufficient fluid compared to a Tao brush, which is usually used to collect samples from the endometrium. A woman would be able to insert the tampon at home to collect a sample of DNA from her endometrium, and then send it to a lab for testing. This would be especially helpful for early detection, repeated testing, and testing for women in inaccessible locations. Dr. Nicolas Wentzensen of the National Cancer Institute recently began a clinical trial (clinicaltrials.gov, NCT 03538665) testing the tampon hypothesis by having women aged 45 or older insert tampons for a half hour before undergoing a hysterectomy. The experimental group must have diagnosed EC or EC precursors, while the control group must have benign conditions such as fibroids or polyps.


Treatments

Depending on the type and stage of the cancer, treatments may include surgery, radiation, hormone therapy, or chemotherapy. Surgery involves a hysterectomy and possibly the removal of the fallopian tubes and ovaries as well. Lymph nodes removed during surgery may be examined to indicate the stage of cancer to better inform treatment (Mayo Clinic, 2019b).

Radiation therapy involves powerful energy beams directed at specific parts of the body either externally or internally through the vagina. Radiation therapy may be indicated before, after, or in place of surgery. Radiation may be used before surgery to reduce the size of the tumor by damaging the cancer DNA or after surgery to reduce the chances of recurrence. Women who are not healthy enough to have surgery may only have radiation therapy (Mayo Clinic, 2019b).

Hormone therapy involves taking medications to lower hormones such as estrogen that may be facilitating tumor growth in the uterus and beyond. Oral or intravenous chemotherapy may be indicated to kill cancer cells using chemicals. Like radiation therapy, it may be used before or after surgery. Targeted drug therapy may also be used with chemotherapy to weaken cancer cells. Immunotherapy assists the woman’s immune system to attack the cancer cells. In addition, palliative care is recommended to help with pain relief and managing symptoms of the disease as well as side-effects of the treatments

(Mayo Clinic, 2019b).


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Developing A Framework For Critiquing Health Research Nursing Essay

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As a matter of fact, the title of the study, according to Jeanfreau, should generally consist of a heading that provides insight into the reported research study by including reference to the research problem or concept studied the population, and the research design. Given such a view, the title of the present study correctly fits in as it contains the main keywords and refers to the learning experiences and the population consists of nursing students with dyslexia. This title consists of fifteen words, which is also a good point as it meets the requirements of research methods as suggested by Holloway (2010) and Polit and Beck (2010)

In qualitative research, the researchers are considered as data collecting instruments – as well as the creators of the analytic process (Onwuegbuzie, 2010). Therefore their qualifications, experience, and reflexivity are relevant in establishing confidence in the data. (Polit and Beck, 2011) The study under consideration was undertaken by two researchers, Jenny Child and Elizabeth Langford. Child is a senior lecturer in adult nursing, while Langford is also a senior lecturer and study skills adviser at the University of the West of England, in the Faculty of Health and Life Sciences in Bristol. The two authors are staff who teach nurse students, and have experience with nurse’s education. They are therefore competent and have the right qualifications to deal with the type of topics developed. One can also look at the notion of cultural competency of these authors. Lapan et al (2011) advocated such a view, and argued that “cultural competency is a crucial disposition that is related to the researcher’s or evaluator’s ability to accurately represent reality in culturally complex communities” (Mertens, 2009:89). Being lecturers in a British university, the authors of the article certainly meet this requirement, especially Langford who is a study skills adviser.

An abstract of an article can be defined as “a summary of what you are going to do, why and what its value is” (Hickson (2008:61). Several criteria can be considered to assess the quality of an abstract: length and content. With 183 words, the length of this abstract meets the requirements of an abstract as stated by Polit and Beck (2008) who advocate a length of between 100 to 200 words. As for the contents, it actually summarizes this article. It opens with the aim where the authors state why they undertake the study. Then it elucidates the research methodology with a clear statement about the phenomenological life world approach used. This is followed by the results of the research, where three main themes emerged, and ends it with a conclusion that supports the abstract’s data.

As for the literature review, it actually is a summary of existing literature, which develops an argument that supports the needs of the present study (Polit and Beck, 2008). In this research, not less than eleven recent documents have been assessed, and this search concentrated on computer based literature that was published between 2008 and 2011. The interesting point in this review is that it goes beyond a simple description of the sources to become “a critical summary and assessment of the range of existing materials dealing with the knowledge and understanding” of dyslexia (Blaxter, 2006). This literature review is up-to-date and comprehensive, because it searches, surveys and reviews what exists to place the research in the context of what was already done, and especially it points out the paucity of research in the domain of dyslexia for nursing students. However, one weakness of the article in general is that it contains many references dated prior to 2006. However this can be understood as most of those papers are secondary sources which were very helpful in the research.

From the above literature review, the rationale for the study is obvious. First there is a requirement by the Equality Act 2010, for reasonable adjustments of student health professionals in the educational institutions and workplace. Second the NMC (2006) requires that any nurse should have good skills in literacy and numeracy. Third the authors mention that there is a paucity of research in this problem. This is justified. While providing the reasons why the research is being conducted, the rationale of a research is normally developed alongside a review of some central ideas in the relevant literature (Van der Riet. et al. 2006).

Looking at the aims, it can be argued that there is a clear statement of the aims of the research, which mentions the research goal, its relevance and why the research is important. The authors explored the experience of such students in order to make recommendations that will support them in practice.

Talking about the ethical issues, Polit and Beck (2010) argue that “methods must be ethically appropriate, and must incorporate issues surrounding informed consent, the right to withdraw, sensitivity, confidentiality and anonymity of the participants”. In the article under scrutiny, one can discover several ethical issues addressed. The authors took care to enquire the authorisation of the university ethics committee. They also obtained voluntary informed consents from the participants who they invited by letters. The study itself addresses issues that would help the participants in their education. This means that principles such as respect, informed consent and justice have been taken into consideration. One would for example notice that the tape recording and the analysis were all coded, so not disclosing the identity of the participants. This is a very good system to keep the anonymity of the participants, which means confidentiality. Further, the participants were granted the freedom to take part in the research or withdraw from it without any problem. This is an aspect of respect (Kitchener and Kitchner, 2009). Finally, participants were given a consent form. This is also a form of freedom for the participant to accept or refuse to participle.

Dealing with the methods of a research, Cadwell et al (2005) proposed to examine several aspects. In this article, the researchers took the care of identifying the philosophical background and the study design as well as explaining the rationale behind their choice. They used a phenomenological life world approach, focused on the world as it is experienced before the formulation of any hypothesis to explain it. This is a suitable approach, because phenomenology is “a science whose purpose is to describe a particular phenomenon or the appearance of things, as lived experiences” (Carpenter 2007:43).

They also used the qualitative exploratory method, involving one tape-recorded semi-structured interview per participant, with an independent interviewer. The duration of the interview and the venue were determined. The method of analysis was also identified, a line-to-line and thematic analysis. It is also interesting to notice that there was a piloting study of the questions with professionals, and that the feedback obtained helped to refine the questions. This approach was properly selected, because the study is focussed on the human experience, and very little is known about the topic. (Burns and Grove, 2009) Further, the research gets more credibility not only because of the famous journal in which it was published, but also it went through a double-blind experiment before publication.

According to Cadwell et al (2005), a good research has to identify the major concepts and themes. In this article, three main themes were outlined, mainly the value of work-based learning days, the importance of the clinical placement mentor role, and the need for advocacy. Other themes also emerged, and the researchers put all of them in Box 2. Further, the authors included some excerpts from the interviews to point out what students said and thought about those themes. This makes things clear for any reader.

Dealing with the selection of participants, one would say that there is a flow in this area, because the study does not tell how the participants were selected, neither does it identify the sampling methods. All the present researchers say is that they had two groups of people selected, six students with dyslexia and six other students without dyslexia, and that they were third year adult nursing students. They do not say anything about their gender, the severity of the dyslexia. Could it be justified in that it was a « convenience, purposive and selective sample, grounded on the researchers’ will to have participants readily available and easy to contact, participants with specific characteristics, in this case dyslexia and the selection of cases was done prior to the conduct of research” (Higginbottom, 2002).

Talking about the findings, a number of aspects can be considered, and Cadwell et al (2005) talk in terms of credibility, confirmability and transferability. “Credibility refers to the confidence in the truth value or believability of the study’s findings” (Polit, Beck and Hungler, 2006). Actually in this study, there is a huge description of the participants’ responses in the form of verbatim transcripts that can lead the readers to draw their own conclusions as well. There is a good relationship between the multiple sources used such as the literature review, the interview’s data and the researchers, note, and this adds to the credibility of the study (Streubert-Speziale, 2007). However it would appear that the participant validation suffers, because not much is said about the participants’ views on the conclusions obtained.

As for the confirmability or auditability,” it refers to the degree to which the results could be confirmed or corroborated by others.” Several strategies were used to enhance confirmability in this research. The authors have documented the procedures for checking and rechecking the data throughout the study. They audited their data by examining the data collection and analysis procedures. There is an assessment of the methodology used through the presentation of the methods, research notes and records of coding of the interviews. The reference to such documentations enable the reader to understand the researcher’s decision making ( Streubert-Speziale, 2007).

Transferability or fittingness is established by creating thick descriptions, which, when read by other researchers, can be applied in other contexts (Stringer (2007). The authors of this research recognized that the sample was so small that their findings could not be generalized. However as said by Stringer (2007), they also went a step further to believe that “the data collected will be of interest and relevance to others nationally and internationally who are redesigning their structures for student support and mentoring.” It would also seem that this transferability is strongly enhanced by the relationship between the conceptual framework of their research and the data collection and analysis (Marshall and Rossman, 2010).

The findings were presented in an appropriate way and they are clear to anyone who reads the article. They are also interesting in that in addition to identifying the main themes, the authors looked at the personalised strategies developed by the students and developed a toolkit to help them in their placement. The main recommendations and shared responsibilities are clearly summarised in Figure 1, under three areas: the university, the practice placement and the students, showing also areas of overlapping. The only aspect that seems a bit ill-placed is the questionnaire used in the study. An appendix at the end of the study would be preferred, because the way it is presented creates a sort of digression within the study.

The discussion expanded the findings with ideas related to time pressure, more training for mentors to be able to support students with dyslexia, student’s personalised plans from the university, development of strong links between the two institutions, development of personal skills in the university curriculum, advocacy to help students disclose their disability, more time needed to adjust to placement routines. The conclusions run smoothly as they summarized the main points of the research.

To conclude, it can be said that this study was properly undertaken. The title gives insights into the topic, the population and the research design. The abstract presented a summary of the whole study, the way it was conducted including the data, the analysis and the results. The method was appropriate, including the collection of the data, analysis procedures, and reasons for its selection. The discussion of the evidence can be considered adequate, and the findings relate to the original research question. The results identified the main themes of the study and include quotes from the participants. It also points out the limitations of the study transferability due to its small sample. The validity of the research is obvious as it makes a contribution to current practice. Among the weaknesses, one has to mention the lack of clear selection criteria for the participants, a lack of participants’ views on the findings and a large portion of outdated bibliography.

I finally close this appraisal by saying that it has helped me to develop critical thinking as it led me to read a lot in order to have a reasoned argument when assessing a fact, seeking for alternatives, supportive and challenging evidence. This opened my eyes to think more about better evidence to use in my future career as a nurse.

Plan for Intimate Partner Violence (IPV) Prevention

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  • B.Trimble

Healthy People 2020 identified intimate partner violence (IPV) as an increasing public health issue. Previously thought of as a private matter, IVP has received little attention by the health care sector. IPV affects millions, both men and women; it crosses racial, ethnic, religious, economic, and educational groups. The financial effects of IPV are estimated at $ 5.8 billion annually in the U.S. alone. The incidence of IPV is a growing public health issue and to raise awareness and education is a goal of the Healthy People 2020 initiatives (Center for Disease Control and Prevention, 2020). This objective may be attainable by the increased number of physician offices, medical clinics, emergency room waiting areas, and health department clinics distributing the printed educational information (pamphlets, brochures, and posters), as well as the information distributed by in-office educational television. The goal is increasing collaboration with distribution and posting of printed materials in the waiting areas and strategic places in medical facilities. Evaluation of the increased awareness of the medical community will be based on the number of agreements, of the offices, to distribute educational material and information. Short term goals will be to raise awareness and dissemination of information and knowledge pertaining to IPV. Long term goals will be to continue the increase of information to inter-office television information and broadcasting for intimate partner violence, and future classes through the health department and schools for IPV prevention and interventions.

Articles reviewed from the CDC, American Association of College of Nurses, Crisis Prevention Centers, ENA, and American Family Physician agree that to inform and educate medical staff and patients about intimate partner violence, will help increase the community awareness of intimate partner violence. Key concepts include: healthcare professionals, domestic violence, interventions, education, and awareness.

The Information-Motivation-Behavior-Skills Model (IMB) will be utilized to develop the plan for intimate partner violence prevention. The IMB model provides a platform to design interventions, to help instigate change in the pattern of behavior, and to develop prevention measures. This includes three concepts:

1) Information: targeting the concepts that are used make behavioral changes and ways to achieve changes. Information generates knowledge, which shapes attitudes, which leads to behaviors (Mehta, 2010).

2) Motivation: deals with personal attitudes toward positive health behavior and uses existing social support systems to enhance motivation. Motivation is of two types: personal motivation, which is based on personal attitudes toward behaviors, and social motivation are to engage in prevention based on social responsibilities (Mehta, 2010)

3) Behavior: actions that allow the learning of skills required to make a change. Behavioral skills are the individual’s ability and self-efficiency to performing the action required to make the behavioral change (Mehta, 2010).

This framework is appropriate for the intended project as it includes the three elements needed to achieve practice and policy changes in most healthcare settings. Information targeting intimate partner violence, being displayed in medical facilities, will assist in making the employees of the facility, as well as the patients more aware. Motivation, even for well-informed individuals, is to undertake health promotion action and support the efforts toward awareness. Behavioral is based on if the individuals that have the knowledge and motivation, and have the required self-efficacy in carrying out a health promotion behavior plan (Mehta, 2010).

Interventions are designed and implemented based on the health behavior. Presenting the information to make changes is the first step to any behavior change. The evaluation or outcome is conducted to assess the impact of the intervention to produce the desired effect.

This model focuses on the individual by providing information and intervention on how to change the personal attitudes and behaviors, and the environmental by showing how health promotion may be affected by individual and social support systems (Gielen, 2003).

Placing awareness information or education in medical facilities, in strategic spots, such as bathrooms, examine rooms, and waiting areas, will allow the patients the opportunity to read and take the pamphlets, brochures, or resource cards with them when leaving the premises (McClure, 1996). It also lets the patients know that the staff is supportive and understand the importance of interventions and support for those that need assistance, or just want to discuss the issue (B.J.Walton-Moss & J.C.Campbell, 2002). Knowledgeable and supportive medical personnel may be able to refer the patient to the appropriate community resource or program. By displaying information openly, or discreetly, improves the chance of prevention and behavioral changes (Center for Disease Control and Prevention, 2013).

The plan for increasing the awareness of medical facilities and clinics will include discussions with physicians, nurses, advanced nurse practitioners, and all other medical care providers that provide care and assist in decisions related to patient education and information displayed in the offices, clinics, or clinical settings. The planned direction of the discussions will be on the increased awareness, and agree to place educational material related to intimate partner violence, available community resources, resource cards, and hotline numbers for help. The addition of inter-office television information related to IPV will be discussed, and information on obtaining this programming will be furnished (National Coalition Against Domestic Violence, 2013). Information pertaining to patient screening and staff training related to continued education credits for the medical staff will be furnished (CEU.Fast.com, 2014). There are many governmental agencies that have the instructional materials, screening programs, and programs for staff development available at nominal costs, as well as programs that are free for many medical facilities that agree to participate in clinical prevention (VAWnet).

When increasing the awareness of medical providers and their staff, on the public health issue of intimate partner violence, the added benefits of education and awareness of the public obtained through the medical office, may increase the community awareness and practice and attitudes toward IPV (Future Without Violence). The increased awareness may help in decreasing the incidence of IPV and the significant health issues related to IPV (Power).

As it is the responsibility of all medical professionals to improve the health of their communities and the people of the community, it is the responsibility of the APN to be involved in community education and awareness of fellow medical professionals, on the complications and long term medical issues resulting from IPV, measures to prevent IPV, and educational measures that may be implemented for the prevention and assessment of this public health issue (Rhodes & & Levinson, 2003).

References:

B.J.Walton-Moss, D., & J.C.Campbell, P. R. (2002, January). Intimate Partner Violence: Implication for Nurses.

Online Journal of Issues in Nursing, 7

(1). Retrieved February 2014, from

http://www.nursingworld.org/MainMenuCategory/ANAMarketplace/ANAPeriodical/OJIN

Center for Disease Control and Prevention. (2013, July).

National Intimate Partner and Sexual Violence Survey

. Retrieved from Center for Disease Control and Prevention:

http://www.cdc.gov/violenceprevention/nisvs/index

Center for Disease Control and Prevention. (2020).

Healthy People 2020

. Retrieved from Center for Disease Control and Prevention:

http://cdc.gov/nchs/healthy_people.htm

CEU.Fast.com. (2014).

Domestic Violence (Intimate Partner Violence)

. Retrieved from CEU.Fast.com:

http://www.ceu.fast.com/course/domesticviolence

Cronholm, P., Fogarty, C. M., Ambul, P. M., & & Harrison, S. M. (2011, May 5). Intimate Partner Violence.

American Family Physician, 83

(10), 1165-1172. Retrieved February 2014, from

http://www.aafp.org/afp/2011/0515/p1165

Emergency Nurses Association. (2013, September).

Intimate Partner Violence

. Retrieved from Emergency Nurses Association:

http://www.ena.org/SiteCollectionDocuments/PositionStatements

Future Without Violence. (2013).

Resource Material

. Retrieved from Future Without Violence:

http://www.secure3.convio.net/fopf/site/Ecommerce/1272334033?

FOLDER

Future Without Violence. (n.d.).

The Call To Action: The Nurse’s Role in Routine Assessment for Intimate Partner Violence

. Retrieved from Future Without Violence:

http://www.futurewithoutviolence.org/userfiles/files/healthcare/nursing

Healthy People 2020. (n.d.).

Leading Health Indicators

. Retrieved from Healthy People:

http://www.healthypeople.gov/2020/LHI/default

McClure, B. R. (1996). Domestic Violence: The Role of the Health Care Professional.

Michigan Family Review, 2

(1), 63-75. Retrieved February 15, 2014, from

http://www.hdl.handle.net/2027/spo.4919087.0002.15

Mehta, K. (2010).

Information-Motivation-Behavior Skill Model

. Retrieved from P500-FALL2010:

http://www.p500fall2010-wiki-wikispace.com/information-motivation-behavior+skill+model

National Coalition Against Domestic Violence. (2013).

Setup Collaborative Models of Care: HealthCare About Intimate Partner Violence

. Retrieved from National Coalition Against Domestic Violence:

http://www.healthcareaboutipv.org/gettingstarted/set-up-multidisciplinary-collaborative-models

Power, C. R. (n.d.).

Domestic Violence: What Can Nurses Do?

Retrieved from Crisis Prevention Interventions.

Rhodes, K. M., & & Levinson, W. M. (2003, February 5). Intervention for Intimate Partner Violence Against Women.

The Journal of the American Medical Association, 289

(5). Retrieved from

http://www.jamanetwork.com/article,aspx?articleid=195899

VAWnet. (n.d.).

Publications on Domestic Violence

. Retrieved from National Online Resource Center on Violence Against Women:

http://www.nrcdv.org/dvam/catalog

Critiquing Quantitative, Qualitative, or Mixed Methods Studies

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 Critiquing Quantitative, Qualitative, or Mixed Methods Studies

Critiquing the validity and robustness of research featured in journal articles provides a critical foundation for engaging in evidence-based practice. In Weeks 5 and 6, you explored quantitative research designs. In Week 7, you will examine qualitative and mixed methods research designs. For this Assignment, which is due by Day 7 of Week 7, you critique a quantitative and either a qualitative or a mixed methods research study and compare the types of information obtained in each.
To prepare:
Select a health topic of interest to you that is relevant to your current area of practice. The topic may be your Course Portfolio Project or a different topic of your choice.
Using the Walden Library, locate two articles in scholarly journals that deal with your portfolio topic: 1) Select one article that utilizes a quantitative research design and 2) select a second article that utilizes either a qualitative OR a mixed methods design. These need to be single studies not systematic or integrative reviews (including meta-analysis and metasynthesis). You may use research articles from your reference list. If you cannot find these two types of research on your portfolio topic, you may choose another topic.
Locate the following documents in this week’s Learning Resources to access the appropriate templates, which will guide your critique of each article:
Critique Template for a Qualitative Study
Critique Template for a Quantitative Study
Critique Template for a Mixed-Methods Study
Consider the fields in the templates as you review the information in each article.
Begin to draft a paper in which you analyze the two research approaches as indicated below.
Reflect on the overall value of both quantitative and qualitative research. If someone were to say to you, “Qualitative research is not real science,” how would you respond?
To complete this Assignment:
Complete the two critiques using the appropriate templates.
Write a 2- to 3-page paper that addresses the following:
Contrast the types of information that you gained from examining the two different research approaches in the articles that you selected.
Describe the general advantages and disadvantages of the two research approaches featured in the articles. Use examples from the articles for support.
Formulate a response to the claim that qualitative research is not real science. Highlight the general insights that both quantitative and qualitative studies can provide to researchers. Support your response with references to the Learning Resources and other credible sources.
As you complete this Assignment, remember to:
Submit your paper to Grammarly and Turnitin through the Walden Writing Center. Based on the Grammarly and Turnitin reports, revise your paper as necessary.
Reminder: The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The School of Nursing Sample Paper provided at the Walden Writing Center provides an example of those required elements (available from the Walden University website found in this week’s Learning Resources). All papers submitted must use this formatting.
Combine all three parts of this assignment into one Word document including both critique templates and the narrative with your references. Submit this combined document.
*** I have already done the paper- I need help with templates and I am at work and need this by tomorrow! I have attached the templates and my paper to guide you.

Attachments:
Nursing research projectcritiquing_quantitative_and_qualitative_research_methods.docx
Nursing research projectnurs_6052_week06_critiquetemplatequantitative.doc
Nursing research projectnurs_6052_week06_critiquetemplatemixedmethods_1.doc
Literature homework help